Because Hinds County’s contract arrangement with its emergency medical service provider can make response times seem shorter than they actually are. The agreement Hinds County made with Colorado-based American Medical Response requires that the ambulance company responds to all emergency calls within eight minutes. The contract does not include exceptions like high volume periods or inclement weather, which would affect the company’s response time. A Mississippi Today/WLBT analysis on statewide contracts revealed that these exceptions do not impact the company’s response time. Hinds County was the most populous county in the state, with more than 32,000 calls for emergency services in 2018. An average trip time of one hour and half was determined by a review of the calls. This includes the time from dispatch to the moment the ambulance arrives at the hospital to allow the ambulance to return to service. Half of the calls last year were exceptions. This includes delays due to weather or construction and what is considered excess volume. Excess call volume in Hinds County refers to calls that exceed the company’s capacity. It is when eight or more active trips are made at once. One-third of emergency calls, or more than 10,000, were exempted from AMR’s response times performance in 2018. This was due to “unusual systems overload” Rick Narad, a professor at California State University at Chico and national emergency medical service researcher, said that the agreement was unusual and similar to a card that allows you to get out of jail. You’ve got a combination between a very friendly contract, and inadequate oversight,” as excluded response times are not included in the contract’s accountability mechanisms. “That makes me nervous because it implies that we don’t know the provider’s true intentions. We have given them an exclusive contract, but we are not holding them responsible.” Jim Pollard is a public affairs manager at the Mississippi office of the company. He defends the Hinds County deal as a good deal to taxpayers. The contract stipulates that Hinds County will pay AMR 15 cents per Hinds County resident, which amounts to approximately $36,000 annually to provide emergency services. Hinds County also agreed to permit certain exceptions and to grant AMR exclusive rights for non-emergency call such as the transport of nursing home patients to scheduled doctor’s visits. These calls are the main source of revenue for emergency medical services providers. Pollard wrote that the government officials should select one contractor to transport all emergency and non-emergency patients in their community. Pollard wrote that if local governments allow multiple companies to transport non-emergency patients, the contractor for 911 transports would be financially impaired. This is just one example of the many challenges facing emergency medical services in the United States. According to a report by the National EMS Advisory Council in 2016, $2.9 billion is spent annually on uncompensated emergency care. According to the report, total loss includes charity care and under-reimbursement by Medicare. 911 calls that don’t result in hospital visits are not included. Pollard explained that exclusivity agreements such as the Hinds County clause provide stability in an otherwise volatile business environment. Emergency medical services providers can lose money if patients don’t have health insurance. Even insured patients have different reimbursement rates. Many ambulance trips are not covered in areas where there is high poverty and uninsured rates, such as Jackson. Kyle Greer, Hinds County’s emergency services coordinator, who authorizes AMR’s response time and excludes calls, said that the long waits and high volumes of uncompensated care are systemic throughout the country. It’s not an ambulance issue. It’s not a hospital issue. It is a whole-of-the-board problem. It’s a Catch-22 in many ways. Greer stated that the whole system is broken, but no one can fix it all. Hinds County is the only county in the state that has a contract for ambulance response times. The county demands that the company responds to 85 percent of Jackson and Clinton emergencies within eight minutes. AMR must respond to calls from outside-Hinds County in 18 minutes or less. A 911 dispatcher receives a call from a person calling for help. The time it takes to get an ambulance to a patient can vary depending on the distance from the hospital and how many ambulance companies are involved. Paramedics should be able to quickly get to patients, take them to the nearest hospital and then hand off paperwork to make it easier for the next patient. Paramedic reports, research, and our analysis show that there is another factor to consider when calculating response time. Wall time is what paramedics call it. It refers to how long it takes to transfer a patient from an ambulance stretcher to a bed in a hospital. Emergency medical service providers claim that wall time has plagued providers of all sizes for years. It could be hours without an ambulance provider in smaller counties. Experts agree that the response time for ambulances will be longer than they are now. Consolidation among ambulance providers in Mississippi is increasing the number of calls. In addition, the infrastructure is deteriorating and rural hospitals are closing more frequently. Wall time is responsible for half of all emergency calls in Hinds County. It takes approximately 45 minutes per call when a paramedic picks-up and drops off a patient. Wall times increase over time, according to data. Call volume spikes between 11 a.m. to 3 p.m., creating a backlog at emergency departments and making it difficult for them to resume service. AMR, which contracts with 19 Mississippi counties, has a large fleet and can absorb some losses better. They also work with counties to make exceptions in their contracts. It is not an option for smaller companies, as they will have to eat it. However, many small operators worry that this could cause them to lose their business and weaken the public safety of ambulance providers. We’re the duck that can paddle like a duck under water to stay afloat. We are actually in crisis, and it will hit critical mass. It’s hard to predict what it will look like, but I do know it won’t be healthy for people. “If we ever remove this veil, people will see that it’s really scary,” Tyler Blalock, Rural Rapid Response’s founder in Lawrence and Franklin counties. Blalock, who was an AMR paramedic and started his own business in 2012, also calls for greater oversight. The question of who should be responsible for oversight has been a long-standing debate. These life-and death matters in Mississippi and across the country are decided by a large, unregulated network of private EMS providers who make deals with local counties and emergency medical providers that create unregulated, unenforceable agreements amongst each other. The National Highway Traffic Safety Administration maintains a federal database that tracks response times. However, no state agency regulates them. The U.S. Department of Transportation supervises and pays emergency medical service providers. They were created in response to increasing car accidents in the 1960s. The Mississippi State Department of Health inspects, regulates and licenses emergency medical technicians and paramedics across the state. Other than that, each county is responsible for enforcing their contracts and acting in their best interests. The long-running dispute between hospitals and emergency service providers over who is responsible to provide patient care at the hospital emergency department has led to the state attorney general’s office advising the health department that hospitals are legally responsible for the care of patients on hospital grounds. Experts in emergency services agree that this clarity is necessary. As pressures increase on ambulance service providers, so does patient risk. Ryan Kelly, director for the state’s rural task force on health said that it is important to not have a third heart attack in your county. Otherwise you will be waiting a long time. If you have a serious condition, there are two ambulances on call. You’ll be waiting for hours. It’s scary to think that depending on your position in the queue, you could live or die. This is Part 1 of an occasional series about Mississippi emergency medical services. Part II will examine the problems faced by rural providers. Our Methodology: We requested 2018 Hinds County emergency transports. To calculate the “wall time” of each trip, we used the total time from dispatch to returning in service. We also calculated the average and the median time spent treating/transporting patients as well as wall time. The same data also included the total number omitted from monthly overall response times. This data was used to calculate the average number of calls for each month that were not used in AMR’s Hinds County contract performance metrics. After sorting the data chronologically, we created a formula that counted how many calls were received each day. We were able to count how many trips were ongoing each time a new call was received. This was used to determine AMR’s performance metrics. References to “unusual system overload” are based on the number and frequency of calls received in 2018. To calculate the number of trips from their region to seek treatment in Jackson, we also requested total wall times for transfers from Mississippi State Department of Health.