Sure, firefighters still want to get your cat out of the tree. But they'd much rather check your blood sugar, vaccinate your kids, take you to the hospital and - best of all - send you the bill.
In the past two years, dozens of fire departments nationwide have tried to grab a piece of the ambulance and paramedic business before it is devoured by a merger-crazed health care industry.For the firefighters, it's a matter of necessity. Thanks to more than two decades of wildly successful fire prevention programs, firefighters spend less time fighting fires and much more trying to keep city councils from slashing their budgets.
Since 1992, four monolithic corporations have emerged from the ether of investment capital, swallowed 75 of the nation's biggest local ambulance companies in 33 states and positioned themselves as cheaper alternatives to public paramedics.
At least once a week, one of these behemoths buys a local ambulance company. In two years, they have taken control of one quarter of what analysts conservatively estimate to be a $4 billion business.
The private sector, once dominated by moonlighting morticians who slapped flashing red lights on their hearses, now uses satellites to position its ambulances, Wall Street to bankroll its acquisitions and courts and local governments to fight bruising turf battles with a firefighting lobby trying desperately to preserve its place in American culture - not to mention city budgets.
"Fire departments nationwide have made it clear the only way they're going to remain in operation is if they go into the ambulance business," said Dan Smiley, chief deputy director of California's Emergency Medical Services Authority.
"This is survival for both sides, public and private," Smiley said. "Only one can get the call, and both want it."
What they want most is the Medicaid, Medicare and private health insurance reimbursements for a trip to the hospital. Both also want to expand into EMS' logical extension: using those well-equipped vehicles to deliver non-emergency care for profit.
"You're going to see a lot of change in EMS. You're going to see them provide more diabetes screening, medication delivery for the elderly, vaccinations," said Dr. Scott Zietlow, medical transportation chief for the Mayo Clinic.
A new nationwide effort by the firefighters to seize EMS from private ambulance companies is being encouraged by national lobby groups who fear the private ambulance industry is getting too big, too powerful and, most of all, too efficient to withstand.
"What rang our bell is there seemed to be a concerted effort by several large EMS companies in this country to dominate the industry," said Doug Brown, top lobbyist for the International Association of Fire Chiefs.
"If they can knock away EMS from the fire service, they will knock away the fire department."
A brief tour of the battlefield:
- Private ambulance companies have gone to court in at least eight California communities in the past two years seeking to stop the local fire department from taking over the paramedic business.
- Last month, Boca Raton, Fla., fired its private ambulance company so the fire department could get the insurance reimbursements.
- Firefighters are livid in Louisiana, where a regional ambulance company is advertising a "311" emergency service to compete with the publicly staffed 911.
- In Fresno, Calif., last July, the city decided its public paramedics were superfluous to the private sector and eliminated their budget.
- Ambulance giant American Medical Response Inc. earlier this year tried to buy the ambulance company serving Rochester, Minn., home of the Mayo Clinic. Mortified Mayo, worried about losing its local ambulance provider to a giant national firm, stepped in and matched the bid.
- In March, Portland, Ore., narrowly rejected this year a measure to let firefighters handle ambulance service in life-threatening cases.
- In Albany, N.Y., the common council last month settled a feud by giving firefighters a cut of ambulance company insurance reimbursements.
Experts say it's unclear, yet doubtful, whether the tumult has caused any sharp rise in deaths. If anything, the competition has led to vast improvements in response times.
Still, EMS in general is a muddled mix of public, private, volunteer, hospital-based and hybrid systems that veer crazily in quality nationwide from the good to the bad to the extremely ugly.
"There is no uniformity in this country. In some places, you can dial 911 in New York state and get an ambulance that was illegal in Arkansas in 1973," said Jack Stout, who has designed private systems for Kansas City, Fort Worth, Texas, Tulsa, Okla., and the former Israeli-occupied West Bank.
It's still far from decided whether EMS will be dominated by the health care industry or the public safety sector, but it's clear that the private side is creeping up on the guys in the red hats and galoshes.
Among the nation's 100 most-populous cities, the portion relying on the fire department for EMS has dropped from 48 percent in 1981 to 40 percent last year, according to the industry's Journal of Emergency Medical Services.
Cities relying solely on the private sector rose from 17 percent to 19 percent, and those using a combination of both went from 6 percent to 15 percent. The rest used volunteer services, hospital paramedics or a public agency unaffiliated with the fire department.
Firefighters now typically spend only about 20 percent of their time fighting fires, mainly because of better building construction, tougher codes and mandatory smoke detectors.
Perhaps the most bitter case is in Sacramento, where firefighters won a lawsuit last year allowing them to compete with private ambulance companies. Now, the city is considering taking over the entire market.
Its main competitor, Boston-based American Medical Response, has filed a federal antitrust suit.
AMR chief executive officer Paul Verrochi, who previously helped consolidate national sanitation and environmental services companies before moving into ambulances two years ago, said he isn't trying to put firefighters out of work.
He said it's clear, however, that "firefighters are trying to expand their scope of business in order to protect their jobs."
With $350 million in annual revenues and dominant stakes in 17 states, AMR is the biggest of the four national ambulance companies that have transformed the industry.
Two others formed within the past two years: Careline of Irvine, Calif., and MedTrans, a division of Laidlaw, a $2 billion Ontario transportation company.
Rounding out the big four is Rural-Metro of Scottsdale, Ariz., a regional ambulance company that went national last year. It already runs the fire department in Scottsdale - the traditional firefighter's worst nightemare.
The merger mania in the ambulance business has coincided with the trend toward managed care in the health industry. The theory is that being big and regional is more cost-effective than being small and local.
The whole trend toward regionalized health care has threatened to take EMS out of the hands of local communities.
"Once the managed care providers get control of a region, they are going to force everyone to work together," said Tom Scott, director of the Emergency Care Information Center, a consultant group in Carlsbad, Calif. "They don't want to deal with several fire departments and ambulance companies."
Firefighters are clearly rattled. Like the cowboy and the cop, the firefighter is an American icon.
"Hey, we do rescue stuff," Brown said. "We get your cat out of the tree."