In May 2023, Door County Emergency Services and Door County Medical Center entered into a unique partnership that has improved patient care and the county’s 911 service, according to an annual report from organization representatives.
Door County EMS Director Aaron LeClair and Door County Medical Center CEO Brian Stephens gave a report on the status of the partnership in its first year to the Door County board of supervisors at their regular meeting on December 17.
The interfacility transport agreement was approved in May 2023 by the county board of supervisors, but the program did not “go live” until February 1, according to LeClair. The county had to hire staff and purchase an additional ambulance to fulfill the agreement, which took some time, he said.
If Door County Medical Center has a patient that needs additional or specialized care beyond what it can provide, the patient is transported to another hospital. In Wisconsin, the transferring facility, Door County Medical Center in this case, is responsible for patient care and safety until they reach their destination.
Typically, hospitals contract with private ambulance companies to provide medical transport, Stephens said, and up until about six years ago that is what DCMC was doing. When the local private company it was working with went out of business, the hospital filled the gap with a private company in Green Bay.
Door County EMS agreed to help and transport critical cases, as long as those services did not conflict with its 911 response. This arrangement continued for almost four years, but wait times for medical trans were averaging 105 minutes, Stephens said.
“That is not the quality we want for our patients,” he said.
Now, response time is averaging 68 minutes and for transfers provided specifically by Door County EMS, the average wait time is 47 minutes.
Patients in rural hospitals like DCMC are more likely to need medical transfers from one facility to another. Wait time data for 911 transports is more readily available than for interfacility transfers and can give some insight into how wait times in rural areas can be higher than in urban areas.
According to a study by the Journal of the American Medical Association in 2017, the average wait time for an ambulance after calling 911 is seven minutes in urban areas, and 14 minutes in rural areas.
According to the agreement, when DCMC needs a medical transport, emergency room staff calls county EMS and they provide the ambulance service. If all available EMS crews are on 911 calls, or if the transport is going further than Green Bay, DCMC will contact a private company in Green Bay.
The cost of the program for the county, including about eight additional staff members and another ambulance was projected to be $1,058,386, with revenue anticipated at $711,000. Door County Medical Center subsidizes the difference with a monthly payment of $28,943.83.
Some numbers were surprising however, Stephens told the board. Transfers for patients with Medicare or Medicaid were higher than expected. This is significant because “government payers” only reimburse for about half of service costs, he said.
DCMC had projected that 58 percent of transfers would be Medicare or Medicaid patients, Stephens said, but the actual number is 62 percent for 2024. The increase is seen on the Medicare side, he added.
The county still receives 100 percent of the costs for the transfers, with the deficit coming out of DCMC’s pocket, he told the board.
Stephens pointed to demographics as the reason behind the uptick in Medicare patients. Door County has a high retiree population and the retirement and the average age in the county is increasing.
“It’s not a negative, but a reality we have to work with,” he said, and DCMC has changed their focus from a growth mentality of adding more services to one of developing better efficiency.
“We want to work within those Medicare reimbursements,” Stephens said.
The partnership with the county is more expensive than using a private company, Stephens said, but less expensive than if the hospital were to operate its own medical transport service.
Both county EMS and DCMC are paying close attention to the numbers this year, as the agreement calls for regular cost analysis, or a “true up” of actual versus estimated costs.
So far, the county has not experienced any negative financial outcomes, and LeClair does not expect it to. “When I built the expenses out,” he said, “we covered every expense there possibly could be so I could assure that the taxpayers were protected.”
The partnership has strengthened the county’s 911 response, according to LeClair, by having more EMS personnel and another vehicle. Many of the patients who are calling 911 are also the ones needing transport later, he added. “They’re all local people we are supposed to be serving.”
As of February this year, Door County EMS is fully staffed. It’s a good thing, LeClair said, as 911 calls have doubled since he started working in Door County in 2004. In the first year of the partnership with DCMC, 495 of 4,387 ambulance calls were hospital transfers.
“Being fully staffed is uncommon in any area of healthcare,” Stephens commented.
The agreement itself is also uncommon, he said, and may be the only one of its kind in Wisconsin. “Public/private partnership is unusual,” Stephens said, “especially when it’s going well.”
Collective bargaining contract approved
After a “very respectful” negotiation process, according to Todd Thayse, board vice chair and District 2 supervisor, the board unanimously approved the county emergency services contract up for renewal.
The EMS’s collective bargaining team negotiated with county corporation counsel for these primary changes:
- Go from two year to three year contract terms for personnel
- Amended vacation and compensation schedules
- A mechanism to recognize years of experience for part time department members coming into full time so they are eligible for commensurate vacation time
- Recognizing part-time members for experience retroactively back to 2022 and commensurate wage adjustment.
Getting the contract approved was “huge”, according to LeClair, and speaks to a healthy public safety community in Door County as a whole.
Fully staffed rural EMS departments are an anomaly these days, he said. He credited the crews for building a culture that is respectful and attractive to employees. “No better recruiting tool than your workers recruiting for you,” he said in a phone interview after the county board meeting.