City of Rochester, NY

EMS System Evaluation

Page 1 February 27, 2023

Executive Summary Top Five Priorities

T
he City of This executive Once fully 1. Stabilizing and
Rochester’s summary highlights implemented, the
Fire the most substantive citizens and visitors
improving EMS
Department has recommendations of the City of response times and
completed an and alternatives Rochester would capacity
evaluation of the developed for the receive improved
EMS system utilizing Department. EMS response
5 years of historical capability, reduced
2. Evaluating and selecting
data between 2017 Overall, there were reliance on large re the desired system
and 2021. The six main themes that apparatus for EMS design presented
evaluation included were utilized to incidents, and
comprehensive evaluate potential maintain or improve
quantitative data EMS system response time
3. Optimizing sta ng and
and Geographic con gurations. performance for the deployment
Information System These included most critical EMS
(GIS) analyses to various incidents. 4. Developing objective,
determine the con gurations of the
distribution, Rochester Fire Substantive
transparent, and
concentration, and Department (RFD) alternatives would accountable
reliability of xed providing or include creating an performance criteria
and mobile response supplementing EMS EMS overlay
forces for re and services that are provided by the
emergency medical currently provided RFD, providing
5. Adopting a longer
services (EMS). by a private patient response time criteria
contractor. Finally, transportation for the private contractor
A comprehensive options for services by RFD, if the desire is to remain
assessment of the preserving the status improving the
available revenues quo and improving performance
an unsubsidized patient
within the city’s EMS the performance management transport system
system demand was management of the oversight for the
completed so that private contractor to contract with the
the city and ensure highly private provider, 2021 Total Number of Incidents: 38,807
department transparent and and updating
leadership can accountable the contract
consider policy services. language to 0.0% 1.6%
EMS

options to meet support an Fire

Hazmat

expectations and objective and Rescue

introduce a high transparent 41.2%

degree of contract
transparency with oversight that is 57.2%

the public. fair to the City

and the provider.
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Rochester EMS System Evaluation
Page 2 February 27, 2023

Evaluating the Current EMS System

T
he current system design includes having RFD respond to
approximately 25% to 30% of the total community demand for
EMS incidents. Nearly all EMS incidents are responded to by
the current contracted provider, American Medical Response (AMR)
as AMR provides 100% of the patient transport services unless
mutual or automatic aid is required when resources are constrained.
Historically, RFD did not provide any patient transportation services. Recommendation
12 EMS Responses
11 EMS Responses with Transports 1. Better align turnout time
10
performance with best
Average Number of Responses per Day

practices
9

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Hour of Day

In 2021, a total of approximately 82,264 EMS responses occurred within the City of Rochester that
resulted in 46,332 patient transports, or a transport rate of 56.3%.

The average total time on task for a patient transport provided by AMR was 77.6 minutes and 24 minutes
for a non-transport. The average total time on task for RFD responses on all EMS incidents was 16.2
minutes.

2021 90th Percentile Response Time

RFD EMS Performance
Dispatch Response
Turnout Time Travel Time Sample RFD travel time to EMS
Program Time Time
Size1 incidents was 4.6 minutes at
(Minutes) (Minutes) (Minutes) (Minutes)
the 90th percentile.
EMS 1.6 2.1 4.6 7.0 20,549
Fire 1.6 2.1 4.8 7.3 12,718 RFD total response time to
Hazmat -- -- -- -- 3 EMS incidents was 7.0
minutes.
Rescue 2.6 1.9 4.4 7.5 584
Total 1.6 2.1 4.7 7.1 33,854
AMR response time was
AMR EMS Performance aggregated for all responses
regardless of priority at a 12
Dispatch Time Turnout Time Travel Time Response Time minute travel time. This is a
high level analysis and
should not be scrutinized as
10.5 0.3 12.0 20.7 the contractually required
performance is provided
separately.
 Rochester EMS System Evaluation
Page 3 November 23, 2022 February 27, 2023

Contractual Obligation for Ambulance Performance

T
he contract executed on October 31, 2020 includes
performance objectives for the contractor based on the clinical Recommendations
severity of the incident as triaged through the 911 emergency
communications center (ECD). It is understood that the medical
director and the ECD migrated from priority types to event types in 1. Utilize the MPDS
Appendix B of the current contract. However, for simplicity, the determinants and priorities
performance objectives are described below based on the historical for contractor performance
priority values. and contractual compliance

Priority 1 Priority 2 Priority 3 Priority 4 2. Priority 2, at 12:59, should

be utilized for all
8:59 12:59 14:59 17:59 uncategorized incidents

The current contractual compliance for response time could not be 3. It is recommended that the
evaluated during this study. The timing of the changes between contractor meet the
legacy priority de nitions and the updated event types has contractual obligation by
introduced su cient ambiguity that the contractor has to expend priority irrespective of
considerable manual e ort to eliminate the myriad of exclusion whether the city re or police
criteria. Overall, this leaves the city with limited transparency for department co-responds
oversight and relies on the contractor to manage their own
compliance. Therefore, it is recommended that the contractual 4. City should provide oversight
language and processes are better aligned to allow the city to for contractual compliance
provide contractual oversight and compliance.
5. Update the contractual
It is recommended that the language accordingly
City update the contract
language to either utilize
the Medical Priority
Dispatch System (MPDS)
determinants and/or the
associated response time
priorities for each of the
determinants. The Observations
migration to event types 1. The process of utilizing event
provided a more types appeared to have
consolidated approach, introduced more ambiguity
but an unintended into the ability to
consequence is that it lost transparently measure
granularity for the nuances contract performance
of how calls are processed
and categorized. In 2. Utilizing co-response as a
addition, if calls do not determining factor in
work through the priority contract compliance in not
dispatch process, then all su ciently distinct to be
non-categorized calls e ective
should be measured for
compliance as a Priority 2,
or 12:59 at the 90th percentile.
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 Rochester EMS System Evaluation
Page 4 November 23, 2022 February 27, 2023

Primer on Data Challenges with Contract Compliance

F
itch facilitated a data retreat with ECD, RFD, and AMR to
discuss the ongoing challenges with contractual compliance and Recommendations
the accuracy of information. This was a productive meeting and
shed light on some cross-user concerns from the di ering
perspectives. Overall, the following recommendations and 1. Utilize the MPDS
observations are provided to improve the contractual relationship and determinants and
speci cally the City and RFDs ability to transparently manage the
contractor and system. priorities for contractor
performance and

F
irst, is the challenge that has been introduced with the new CAD contractual compliance
system. Within the changeover to the new CAD the collective
bodies collapsed the MPDS determinants to a comparatively
small handful of “event types” within CAD. While the process made 2. The contractors’
the transition easier, it introduced ambiguity where event type response time for
descriptions could reside in more than one MPDS determinant with staging calls should not
di erent response parameters. It is recommended that the ECD, begin until a PD unit
RFD, and contractor (currently AMR) agree to use the MPDS
determinants and priority system for compliance measurement and noti es EMS that the
the event types for dispatching, if desired. This will require a table scene is “all clear” or
relationship in CAD to attach the MPDS determinant to the call. “clear to enter”

S
econd, the frequency of police related and/or staging calls has
introduced times that are con ated at best, and highly 3. ECD should create
inaccurate at worst. For example, when a call comes through “dummy AMR units”
PD and then escalates to an EMS incident, the recommendation may within CAD to allow
be to stage for PD. The time appears to begin at the moment of the AMR to assign and
request, but the ambulance unit could be staging for long-durations
where they may be more e ciently utilized within the system. unassigns units as
Compounding the problem, is the contractual obligation of the needed without closing
response time for a co-response with a city resource. Therefore, it is the call
recommended that the ambulance’s compliance “clock” doesn’t start
until a PD unit noti es EMS that the scene is “all clear” or “clear to
enter”. 4. It is recommended that
the City and RFD update

T
hird, it was observed that the bi-directional CAD interface the contractual language
allows an incident to be closed in the ECD CAD when AMR to re ect
assigns, then unassigns a unit. It is recommended that ECD
needs to prevent that from occurring. Therefore, it is recommended recommendations and
that the ECD creates “dummy AMR units” within CAD. Utilizing this ensure a transparent
processes, AMR can simply do unit swap commands to handle an and more closely
assign/unassigned actions without closing the call. automated process to

F
inally, the current compliance process is nearly universally a manage contractor
manual evaluation that is completed by the contractor. The compliance
process is highly labor intensive, cumbersome to complete, and
largely opaque to the City and RFD. In other words, the contractor is
monitoring the contractor’s performance and the city receives the
reported compliance.
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 Rochester EMS System Evaluation
Page 5 November 23, 2022 February 27, 2023

System Valuation and Establishing Performance

T
he current system is built to handle the most restrictive
performance for Priority 1 (and their equivalent event types) at 8 Observations
minutes and 59 seconds for 90% of the events. The 1. Establishing performance at 8:59 may
contractual measure includes both turnout time, de ned as once the threaten the sustainability of any
units are noti ed of an incident until driving to the call, and travel contractor to provide services in an
unsubsidized environment
time, de ned as the time it takes to actually drive to the incident.
Therefore, assuming an industry best practice of a 1-minute turnout 2. The 12-minute aggregate performance in
time, an 8-minute travel time was tested to determine the relative 2021 is well-aligned with these analyses
sustainability of the system in a non-subsidized environment. 3. The system valuation is the minimum
necessary deployment and was utilized to
The analyses suggest that an 8-minute travel time (8:59) is not demonstrate the limited available revenue.
sustainable in an unsubsidized environment within the current 4. Actual operations may require additional
sta ng schema and available revenues. AMR reported that the deployed hours to control for workload
actual 2021 911 related collections was $13,907,581. Similarly, that may introduce the need for a 12:59
minimum standard
FITCH estimated a system value of $14,493,276 for 911 related
incidents prior to billing costs. Therefore, if the policy desire is to
continue with an unsubsidized patient transport system, it is
recommended that the city consider migrating performance to 10:59
or 12:59 at the 90th percentile. RFD can respond to the highest Recommendations
acuity incidents in under 5-minutes to begin either Basic Life Support
1. It is recommended that the City
(BLS) or Advanced Life Support (ALS) care. consider adjusting the desired
Unit Hour Cost 8-Minute 10-Minute 12-Minute performance to maintain a non-
subsidized environment
Minimum Hours -
System No Control for Unit Hours Cost Unit Hours Cost Unit Hours Cost
Design UHU
2. Fiscally, a response time of 10:59
ALS $160.44 (ALS) 100,037 $16,049,635 91,301 $14,648,063 82,565 $13,246,491 or 12:59 provides for more
$141.57 sustainability
ALS/BLS Tier 100,037 $14,161,915 91,301 $12,925,193 82,565 $11,688,470
(ALS/BLS)

The current sta ng matrix would be challenged to cover 90% of all incidents within 8:59.

The current sta ng matrix is better aligned to cover 90% of all incidents within 12:59.
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 Rochester EMS System Evaluation
Page 6 November 23, 2022 February 27, 2023

Comparative Analyses with Similar Communities

T
he City of Rochester was compared with other like agencies to
determine the per capita rate for re protection services Observations
between 2016 and 2021. This was accomplished through the
research of a benchmarking advocacy group. No information was 1. Rochester’s per capita
available for 2022 at the time of the completion of this report. The spending on re protection,
information was consistently reported across the communities; which includes rst response
therefore it is assumed that the methodology may have been more for EMS, is well aligned with
uniformly applied than typical peer surveys. While the information the comparator cities
was not independently validated, the information is still bene cial for
comparative purposes. 2. Rochester exercised
considerable cost avoidance
Overall, the benchmarking results found that the City of Rochester for EMS services
had an average per capita expense on re protection of $240 over
the 6-year period. The $240 is median per capita value across the 3. Currently, reducing or
comparators. eliminating RFD EMS
responses would not reduce
Year Albany Bu alo Rochester Syracuse Yonkers
the current re protection
Population 99,224 278,349 211,328 148,620 211,569
resource allocation or needs

2016 $218 $232 $233 $224 $329 4. However, there could be

some cost avoidance for
2017 $208 $253 $235 $248 $348 reinvestment due to growing
EMS demands
2018 $247 $232 $238 $244 $364

2019 $236 $239 $243 $259 $369

2020 $248 $226 $244 $244 $354

Recommendation
2021 $250 $246 $247 $258 $345 1. The City and RFD need to
select a desired service delivery
6-year $235 $238 $240 $246 $352 model for the future
Average

RFD EMS Related Expenditures

I
t is common in New York to provide EMS services through
a public-private partnership similar to the current system in 6.5
5.8 5.8 5.8 5.9 5.9 5.8
EMS Fire Other

Rochester. Within these systems, the patient transport 6.0

5.5 5.2
5.6 5.6
5.4 5.4
5.2

ambulance services are largely unsubsidized systems. In 5.0 4.8 4.8

Average Number of Calls per Day

other words, the contracted providers for patient transport 4.5

3.9
4.3

operate within their cost recovery e orts through patient

4.0 3.7

3.5 3.1
billing. Therefore, Rochester has not historically invested 3.0 2.8
2.4
2.9

heavily into the provision of EMS that wouldn’t already be 2.5 2.2
1.9 2.0

considered a sunk cost for re protection readiness. RFD is

2.0

1.5

responding to approximately 25% to 30% of the total 911- 1.0

related EMS incidents and has done a good job of cost 0.5

avoidance as it relates to EMS activity.

0.0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Hour of Day

https://seethroughny.net/benchmarking/local-government-spending-and-revenue/#
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 Rochester EMS System Evaluation
Page 7 November 23, 2022 February 27, 2023

RFD System Resiliency and Deployment

S Recommendations
tation E2 has highest rate of call concurrency at 18%. In other
words, approximately 82% of the time a call can occur within
E2’s rst due area and it can be completed before a second or
1. Under the current deployment
greater call occurs. E2, E10, E9, E5, and E19 all have a call
strategy Stations E2 and E5 are
concurrency rate of approximately 15% or more.
in need of reinvestment of a
second unit
20
2. Stations E17/R11 and E9 will
require reinvestment in the near
15 future as call volume increases
Percentage of Overlapped Calls

10
3. It is recommended that the
additional resources are 2-
person EMS units
5

1. Squad, or;
2. Ambulance
0
E2 E10 E9 E5 E19 E17/R11 E16 E1 E7 T10 E12 E13 E3 T5 T2 T4 T6 E8 T3

Demand Zone
(First Due Station)

U nit Hour Utilization (UHU) is an objective

measure of time on task for deployed
resources. RFD is as busy as other large
metro departments that provide rst response
0.30

0.25
UHU

IAFF

EMS. Considering that RFD only responds to a 0.20

fraction of the overall EMS workload that occurs

Utilization Rate

0.15

within the city is of import. Fire departments that

do not provide patient transportation services very 0.10

rarely exceed 0.2, or 20% workload on 911 related 0.05

activity. Understanding where the department is

today, reinvestment is needed to maintain the 0.00
/G RT

DC
E3 OR1
T1 2

R1 B1

1
E1 6

/G 1 2

3
E1 E5

E1

E9

T5

T6

E7

T2

T4

E8
1
2

2
R1

OR
M
HM

R9
TR

TR

HM
E1

E1

E3
P
E
/W

status quo and signi cant investment would be

OA
3/

0/

CA

AT
AT
7/

1/
E2

/F

H1
T3

R US

required to provide a greater role in the delivery of

/B

Unit
9
E1

EMS.

S
tations E2 and E5 could use additional resources to
0.9 EMS Fire Other
overcome the average hourly call rate. It would be
recommended that these units are either 2-person
0.8

0.7 0.66
0.64 0.65

quick response vehicles (Squads) or Ambulances.

0.64
Average Number of Calls per Day

0.62
0.60 0.61 0.62
0.59
0.6 0.56 0.56 0.57
0.55
0.53
0.47
0.5
0.44
0.41

Stations E17/R11 and E9 would follow the same strategy as

0.39
0.4
0.33
0.29
0.3
0.24
0.19
0.24 0.26
the call volume continues to increase. Stations E17/R11 and
E9 are right at the threshold for reinvestment.
0.2

0.1

0.0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of Day
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 Rochester EMS System Evaluation
Page 8 November 23, 2022 February 27, 2023

Maintaining the Status Quo

P
revious analyses validate that the current deployment strategies Recommendations
from RFD are generally su cient for the current percentage of
EMS calls for which they are responding. However, as 1. Adjust contractual compliance
previously identi ed, Stations E2 and E5 should each receive an and performance objectives to
additional resource, followed by Stations E17/R11 and E9. When maintain an unsubsidized
referring to the available data, the post Covid rebound was nearly environment
15% increase in call volume in one year. The year-over-year growth
was 2.1%. 2. At a minimum, maintain current
deployment
Projected Growth
600,000
3. Reinvest in Stations E2 and E5
500,000
in the short-term
400,000
NO. of Incidents

300,000
4. Reinvest in Stations E17/R11
200,000 and E9 as call volume dictates
100,000

0
2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040

"Low 1.1%" High 14.9% YoY Average 2.1%

R
einvestment in one Units Personnel Personnel Capital Costs Total Costs
station at a time is Costs
e ective at reducing
workload and reliability issues 2 BLS 20.8 $1,774,630 $242,500 $2,017,130
within that station’s rst due
response area. However, the 2 ALS 20.8 $1,954,578 $321,500 $2,276,078
investment provides little
citywide or system bene t as
the reinvestment would be a single area at a time resulting in a more robust investment and deployment
plan than creating a system bene t such as as an EMS overlay program. The squad concept discussed
subsequently will provide a more
cohesive systemwide strategy.
Opportunities Finally, preserving the status Challenges
quo of a public-private
1. Preserves the quality of services as they partnership includes 1. Investments may become incremental
are provided today maintaining an unsubsidized and lack a system wide bene t

2. Improves response capacity and system

environment for the City. This 2. Sensitivity to relaxed response time of
resiliency will require reasonable the private contractors
adjustments to the contractual
3. Reduces workload in assigned areas compliance methodology and
response time objectives for
4. Requires limited RFD reinvestment
long-term sustainability.
5. Stabilizes the performance and scal
sustainability for the private contractor
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 Rochester EMS System Evaluation
Page 9 November 23, 2022 February 27, 2023

RFD Provides ALS First Response

T
his alternative evaluated whether RFD could provide ALS rst
response through an ALS engine/truck program. Currently, the
Recommendations
department has 8 paramedics, but does not have a speci c 1. Transition at least 16 of the large re
classi cation for paramedic. So, the increased costs for FF/PMs is apparatus to ALS
modeled at a 20.28% increase over FF/EMT based on other large
2. Consider a shift deployed EMS
metropolitan re departments and applied to the 4th person on each supervisor and one additional EMS
apparatus. Depending on the policy choice, 1 unit at each station administrative person
could upgrade to ALS (16 units) or the full total of 20 units.
3. Reinvest in Stations E2 and E5 in the
Upgrading from BLS response to ALS response does not alter the short-term
total call volume or need for reinvestments. Therefore, as previously 4. Reinvest in Stations E17/R11 and E9 as
identi ed, Stations E2 and E5 should each receive an additional call volume dictates
resource, followed by Stations E17/R11 and E9 as the increasing call
volume dictates. All personnel estimates utilized a sta ng multiplier of 5. Adjust contractual compliance and
5.21 for the shift deployed 10/14 personnel. performance objectives to maintain an
unsubsidized environment

I
ntroducing ALS clinical care
will require the department
Units Personnel Personnel Costs Capital Costs Total Start-
to provide a greater depth Up Costs
of oversight, logistics,
pharmaceuticals and other 16 ALSFR 83.4 (upgrade) $1,439,580 $780,000 $2,219,580
supplies, and quality
assurance and quality 20 ALSFR 104.2 (upgrade) $1,799,475 $975,000 $2,774,475
improvement. Therefore,
expanding the administrative 2 ALS 20.8 $1,954,578 $321,500 $2,276,078
capacity may be required. It
ALL ALS 20.8 (New) $3,754,053 $1,296,500 $5,050,553
is recommended that there is
Total 104.2 (Upgrade)
one EMS supervisor per shift
and a second EMS person
on a M-F day shift for QA/QI and assistance in training. Additionally, the fact that the department would have
ALS capacity may introduce
some future policy discourse on
Opportunities the percentage of the totality of Challenges
EMS calls that they choose to
1. May require a long-term implementation
1. Preserves rst-due response time respond. Increasing call as the 104 personnel are trained and
volume would ultimately require deployed (96 with the current 8)
2. Improves the response time for ALS
care
another strategy such as an
2. FF/PM classi cation will have to be
EMS overlay or full patient negotiated
3. Reduces workload in assigned areas transport services.
3. ALS capability may lead to a choice to
4. Requires limited reinvestment respond to a greater proportion of EMS
Finally, the department
calls that is misaligned with this strategy
5. Stabilizes the performance and scal providing ALS would have as a singular solution
sustainability for the private contractor synergy with relaxing the
contractor compliance to 4. Sensitivity to relaxed response time of
the private contractors
ensure sustainability.
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 Rochester EMS System Evaluation
Page 10 November 23, 2022 February 27, 2023

RFD Provides BLS/ALS First Response with Squads

T
his alternative evaluated whether RFD could provide BLS and/or ALS rst response through an ALS
quick response vehicle (QRV) or Squad concept. Currently, the department has 8 paramedics, but
does not have a speci c classi cation for paramedic. So, the increased costs for FF/PMs is
modeled at a 20.28% increase over FF/EMT based on other large metropolitan re departments. All
squad sta ng is one FF/EMT and one FF/PM.

This alternative would require 6 Squads to cover the current EMS workload within an 8-minute travel time
while keeping the UHU under the recommended threshold at 11.3%. Understanding that the crews work
a split 10/14 schedule, these units could be deployed with 4 Squads and a 10-minute travel time with a
UHU of 17%. Utilizing this strategy would provide a system wide bene t to the current EMS workload on
the large re apparatus. This deployment strategy would account for nearly 100% of the workload for
EMS incidents that can be responded to within 8-minutes travel time. Working in concert with the medical
director, RFD could decide which call types still would require and bene t from a 4.6-minute response
from the closest engine or ladder truck.

The gure on the left

is an 8 minute travel
time with 6-Squads
from a minimum of
four locations.

The gure on the

right is a 10 minute
travel time with 4-
Squads from a
minimum of two
locations.
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 Rochester EMS System Evaluation
Page 11 November 23, 2022 February 27, 2023

RFD Provides BLS/ALS First Response with Squads

T
he projected costs for a BLS and/or an ALS rst responder
Squad concept is presented below. The personnel count Recommendations
would be synonymous whether BLS or ALS was provided, 1. Create a 6-Squad deployment from at
however, the personnel costs and capital needs are greater with the least four locations that delivers an 8-
ALS service delivery model. minute travel time

2. Consider a shift deployed EMS

As previously presented the FF/PM value is suggested as 20.28% supervisor and one additional EMS
above FF/EMT based on our national experience with other large administrative person
metropolitan size re departments. BLS sta ng would be 2 FF/
EMTs and ALS sta ng would be 1 FF/EMT and 1 FF/PM. 3. No need to reinvest in Stations E2, E5,
E17/R11, and E9 as this deployment will
solve the workload issue
Finally, at the city’s sole discretion, the re department could deploy
single-certi cation personnel that were only EMTs or PMs. In other 4. Adjust contractual compliance and
words, there could be added EMS depth, but not sworn re ghters. performance objectives to maintain an
The deployment plan would be the same, but the personnel costs unsubsidized environment
would be less of a barrier to entry.

W
hen Squads Personnel Personnel Capital Total Start- Net
considering Costs Costs UP Costs Operating
this model it Costs
is important to
consider the BLS Sworn 62.5 $5,323,891 $727,500 $6,051,391 $5,427,819
necessary eld
supervision and the ALS Sworn 62.5 $5,863,733 $964,500 $6,828,233 $6,001,519
administrative
BLS Single- 62.5 $3,642,038 $727,500 $4,369,538 $3,745,966
position previous
Certi cation
described. The model
will have a positive ALS Single- 62.5 $4,762,298 $964,500 $5,726,798 $4,900,083
impact on reducing Certi cation
the reliance on large
re apparatus to
respond to EMS incidents and
reintroduce availability for re
Opportunities protection and other services. Challenges
This alternative essentially 1. May require a long-term implementation
1. Preserves rst-due response time creates an EMS overlay on top as the 63 personnel are either hired or

2. Improves the response time for ALS

of the base re protection trained and deployed

care (if an ALS model is chosen) services provided by RFD. 2. FF/PM classi cation will have to be
While the system will work very negotiated
3. Reduces workload on large apparatus e ectively and accomplish
many of the desired elements, 3. Costs are very similar to a full re-based
4. Provides cost avoidance strategies for
the future
it is important to note that the transport model but without access to
cost recovery
level of investment is similar to
5. Stabilizes the performance and scal migrating to a full transport 4. Sensitivity to relaxed response time of
sustainability for the private contractor model and introducing the cost the private contractors
recovery elements associated
with patient billing.
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 Rochester EMS System Evaluation
Page 12 November 23, 2022 February 27, 2023

RFD Provides Only ALS or BLS Patient Transports

T
his alternative evaluated whether RFD could provide either ALS patient transport or BLS patient
transport and continue with a public-private partnership for the residual work. In other words, this
would allow both RFD and the contractor to co-exist within the EMS system. The model utilized a
50% split between ALS to BLS requests for service.

This alternative would require RFD to sta 11 ambulances to cover either the ALS or BLS workload within
an 8-minute travel time while keeping the UHU under 50%. Understanding that the crews work a split
10/14 schedule, these units could be deployed with a system UHU of 38.4%. However, if crews routinely
swap to, or create, a 24/48 schedule, then this would not be recommended. It would require 4 additional
units, for a total of 15 units, to control for workload on a 24-hour schedule with a UHU of 28%.

U
tilizing this strategy would provide a system wide bene t to the current EMS workload on the large
re apparatus. This deployment strategy would account for nearly 100% of the workload for either
ALS or BLS incidents that can be responded to within 8-minutes travel time. Working in concert
with the medical director, RFD could decide which call types still would require and bene t from a 4.6-
minute response from the closest engine or ladder truck.

The gure on the

left is an 8-minute
travel time with 11
ambulances from a
minimum of four
locations (move-up
plan)

The gure on the

right is a 10 minute
travel time with 9
ambulances from a
minimum of two
locations (move-up
plan)
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 Rochester EMS System Evaluation
Page 13 November 23, 2022 February 27, 2023

RFD Provides Only ALS or BLS Patient Transports

A
n important consideration of this model is if the tiered
approach of a public service responding to 50% of the EMS Recommendations
incidents and a private provider partnering for the other 50% 1. Create an 11-ambulance deployment
of the EMS incidents within the city is e cient and scally model if 10/14 schedule is adhered to
sustainable for either agency. with delity as a single-tier model
(Primary)

Private Unit Hour

8-Minute 10-Minute 12-Minute 2. Create a 15-ambulance deployment if
Contractor Cost
utilizing 24-hour shifts
System
Unit Hours Cost Unit Hours Cost Unit Hours Cost
Design
3. It would be recommended that RFD
ALS $160.44 50,019 $8,024,817 45,611 $7,324,031 41,283 $6,623,246 invest in ALS services
BLS $122.70 50,019 $6,137,294 45,611 $5,601,341 41,283 $5,065,387
4. Consider 2 shift deployed EMS
supervisors and two additional EMS
An analysis of the private market would indicate that 50% of the administrative personnel
available revenues of $6,953,790 would likely be insu cient for a
5. Ensure that the program manager has
private contractor to provide ALS services without subsidy. BLS su cient expertise and experience
services are more sustainable.

W
Ambulances = 15 Single Tier BLS Single Tier ALS Single-Tier BLS Single Tier ALS
hen considering Assumption of 24/hr Sworn Sworn Single-Certi cation Single-
this model it is Schedules Certi cation
important to
Revenue $6,953,791 $6,953,791 $6,953,791 $6,953,791
consider the necessary eld
supervision and the Personnel 156.3 156.3 156.3 156.3
administrative positions $13,309,727 $14,659,333 $9,105,094 $11,905,744
Personnel Costs (DL)
necessary for oversight,
training, QA/QI, and pre- DM and OH $4,057,810 $4,692,953 $3,829,600 $4,464,743
billing review. Similarly, it Total Operating Costs $10,413,746 $12,398,495 $5,980,904 $9,416,697
will be important to ensure
that the program manager Capital Start-up $3,895,875 $8,341,875 $3,895,875 $8,341,875

has su cient experience

and expertise with a large
EMS transport model.

Opportunities The transportation models Challenges

introduce a more robust
1. Provides the city more control and
nancial assessment that 1. May require a long-term implementation
includes Direct Materials (DM) as the 156 personnel are either hired or
transparency over service delivery trained and deployed
and Overhead (OH) which
2. Preserves rst-due response time includes asset depreciation 2. FF/PM classi cation will have to be
over 7 years. Initial capital negotiated
3. Improves the response time for ALS
care (if an ALS model is chosen)
purchases are identi ed
separately and includes a 3. Costs may be a barrier to
implementation
4. Reduces workload on large apparatus factor of 1.5 of peak
deployment to provide for 4. Sensitivities to unintended
5. A ords the city some cost recovery reserve capacity. consequences for the existing
workforce with the long-term contractor
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 Rochester EMS System Evaluation
Page 14 November 23, 2022 February 27, 2023

RFD Provides All Patient Transport Services

T
his alternative evaluated whether RFD could provide an all ALS single-tier or ALS/BLS tiered patient
transport services. In other words, this alternative would largely reduce a private provider’s 911-
related EMS foot print to automatic and mutual aid for large events and additional surge capacity.
Currently, the department has 8 paramedics, but does not have a speci c classi cation for paramedic. So
the increased costs for FF/PMs is modeled at a 20.28% increase over FF/EMT based on other large
metropolitan re departments.

This alternative would require 18 ambulances to cover the city’s total EMS workload within an 8-minute
travel time while keeping the UHU under 50%. Understanding that the crews work a split 10/14 schedule,
these units could be deployed with a system UHU of 46.8%. However, if crews routinely swap to create a
24-hour schedule, then this would not be recommended. It would require 10 additional units, for a total of
28 units, to control for workload on a 24/48 schedule with a UHU of 30%.

U
tilizing this strategy would provide a system wide bene t to the current EMS workload on the large
re apparatus. This deployment strategy would account for nearly 100% of the workload for EMS
incidents that can be responded to within 8-minutes travel time. Working in concert with the
medical director, RFD could decide which call types still would require and bene t from a 4.6-minute
response from the closest engine or ladder truck.

The gure on the

left is an 8-minute
travel time with 18
ambulances from a
minimum of four
locations (move-up
plan)

The gure on the

right is a 10-minute
travel time with 16
ambulances from a
minimum of two
locations (move-up
plan)
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 Rochester EMS System Evaluation
Page 15 November 23, 2022 February 27, 2023

RFD Provides All Patient Transport Services

T
he projected costs for an all ALS or an ALS/BLS tiered re-
based patient transport service is presented below. As Recommendations
previously noted, the personnel costs and capital needs are 1. Create a single-tier ALS model on 12-
greater with the ALS service delivery model. hour shifts with civilian personnel.
1. 33 12-hours shifts
2. 42 hour workweek with scheduled
It is important to recognize that workload was the limiting factor and OT included
a tiered ALS/BLS model could work as long as it was understood
that ALS resources may respond to BLS calls, but BLS calls would 2. Create a 28-ambulance deployment
be distributed to BLS resources rst to maintain ALS availability. model if it is customary to allow
employees to swap or trade shifts to
This model would best be utilized if members were working 24-hour work a 24-hour schedule
schedule and additional resources were utilized to control for
workload. Otherwise, it is recommended to deploy a single-tier all 3. Consider 2 shift deployed EMS
ALS system. supervisors and two additional EMS
administrative personnel

4. Ensure that the program manager has

W
hen considering this model, it is important to consider the su cient expertise and experience
necessary
eld Ambulances ALS/BLS Tier Single Tier ALS ALS/BLS Tier Single Tier ALS Single Tier
supervision and the Sworn - 28 Sworn - 18 Single-Certi cation Single- ALS Single-
Ambulances - Ambulances - - 28 Ambulances - Certi cation - 18 Certi cation -
administrative 24-hours / Day 24-hours/ Day 24-hours / Day Ambulances - 33 12-hour
positions necessary (24/72) (10/14s) (24/72) (10/14s) Shifts / Day
for oversight, training, Revenue $13,907,581 $13,907,581 $13,907,581 $13,907,581 $13,907,581
QA/QI, and pre-billing
Personnel 291.8 187.6 291.8 187.6 155.7
review. Similarly, it will
be important to ensure Personnel Costs (DL) $26,464,350 $17,591,199 $20,356,956 $14,286,893 $12,065,337
that the program
DM and OH $5,356,512 $4,943,796 $5,101,210 $4,709,334 $4,702,952
manager has suf cient
experience and Total Operating Costs $17,913,281 $8,627,414 $11,550,585 $5,088,647 $2,860,708
expertise with a large
Capital Start-up $12,607,500 $10,010,250 $12,607,500 $10,010,250 $10,010,250

Opportunities EMS transport model. Challenges

1. Provides the city more control and
1. May require a long-term implementation
transparency over service delivery The transportation models as the 156 to 292 personnel are either
introduce a more robust hired or trained and deployed
2. Preserves rst-due response time
nancial assessment that
3. Improves the response time for ALS includes Direct Materials (DM) 2. FF/PM classi cation will have to be
negotiated
care (if an ALS model is chosen) and Overhead (OH) which
includes asset depreciation 3. Costs may be a barrier to
4. Reduces workload on large apparatus over 7 years. Initial capital implementation
5. A ords the city some cost recovery
purchases are identi ed
separately and includes a 4. Sensitivities to unintended
consequences for the existing
6. Operating costs are reasonable for the factor of 1.5 of peak
workforce with the long-term contractor
level of services provided deployment to provide for
reserve capacity.
7. Allows additional government-based
cost recovery
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 Rochester EMS System Evaluation
Page 16 November 23, 2022 February 27, 2023

Single Contract Provider - No RFD EMS Response

A
s previously discussed during the system valuation, the current
system is built to handle the most restrictive performance for
Priority 1 (and their equivalent event types) at 8 minutes and
Observations
59 seconds for 90% of the events. The contractual measure includes 1. Establishing performance at
both turnout time, de ned as once the units are noti ed of an 8:59 would likely require an
incident until driving to the call, and travel time, de ned as the time it annual subsidy of at least
takes to actually drive to the incident. Therefore, assuming an $1.4 million
industry best practice of a 1-minute turnout time, an 8-minute travel
time was tested to determine the relative sustainability of the system 2. The need for subsidy would
in a non-subsidized environment. increase exponentially if the
contractor was asked to
The analyses suggest that an 8-minute travel time (8:59) is not replicate current RFD
sustainable in an unsubsidized environment within the current performance
sta ng schema and available revenues. Therefore, if RFD elected to
not respond to EMS calls any longer, it would be assumed that the
policy option would want the contractor to respond in the most
restrictive timeframe of 8:59 (8-minute travel time). FITCH estimates Recommendations
that a tiered ALS/BLS system would cost approximately $14.2 million
dollars to operate. This is considered cost neutral, so it would be
safe to assume that a subsidy of approximately $1.4 million would be 1. It is recommended that the
required for the contractor to provide 8:59 service. Any subsequently City carefully consider policy
faster response times would exponentially add subsidy obligations options that would eliminate
and it would be unrealistic to replicate RFDs rst-due response time responding to community
of 4.6 minutes. requests for service
Unit Hour
8-Minute 10-Minute 12-Minute
Cost

System
Unit Hours Cost Unit Hours Cost Unit Hours Cost
Design

ALS $160.44 100,037 $16,049,635 91,301 $14,648,063 82,565 $13,246,491

ALS/BLS Tier $122.70 100,037 $14,161,915 91,301 $12,925,193 82,565 $11,688,470

T
he re department would not realize any immediate e ciency or reduced costs by discontinuing
responses to the EMS calls at the current frequency. In other words, the sunk costs for the readiness
of the re protection model is providing su cient capacity to respond to EMS incidents.
Opportunities However, it is recognized that Challenges
some cost avoidance would be
available as reinvestment would 1. May be perceived as a reduction in

1. Reduces workload on large apparatus

be delayed. services

2. There will be limited scal bene t for

2. Introduces some cost avoidance for a The public policy calculation is decisions that may be highly scrutinized
growing call volume the balance between the real or
perceived reduction of services 3. The perception of increasing subsidies
while increasing the specter of for a private contractor at the expense
subsidizing the system. of public employees

4. There would be no reduction in current

re protection resource allocation
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 Rochester EMS System Evaluation
Page 17 November 23, 2022 February 27, 2023

RFD Provides Supplemental Patient Transport

T
his alternative evaluated whether RFD could provide BLS and/or ALS rst response and
supplemental transport within the city. Therefore, the model will follow precisely the previous
Squad alternative, but the capital costs would increase to provide for transport capable units.

This alternative would require 6 rst response and transport capable units to cover the current EMS
workload within an 8-minute travel time while keeping the UHU under the recommended threshold at
11.3%. Understanding that the crews work a split 10/14 schedule, these units could be deployed
with 4 Squads and a 10-minute travel time with a UHU of 17%. Utilizing this strategy would provide a
system wide bene t to the current EMS workload on the large re apparatus. This deployment
strategy would account for nearly 100% of the workload for EMS incidents that can be responded to
within 8-minutes travel time. Working in concert with the medical director, RFD could decide which
call types still would require and bene t from a 4.6-minute response from the closest engine or ladder
truck.

Essentially, this alternative is to provide for the rst response component, similar to the squads, but
maintain the capability to transport patients in times of high demand when the private contractor may
not be available or when there is a clear clinical need to transport immediately. If the contract
compliance is managed well, this should occur relatively infrequently.

The gure on the left

is an 8-minute travel
time with 6
ambulances from a
minimum of four
locations.

The gure on the

right is a 10-minute
travel time with 4
ambulances from a
minimum of two
locations.
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 Rochester EMS System Evaluation
Page 18 November 23, 2022 February 27, 2023

RFD Provides Supplemental Patient Transport

T
he projected costs for a BLS and/or an ALS rst responder
supplemental ambulance concept is presented below. The Recommendations
personnel count would be synonymous whether BLS or ALS 1. Create a 6-ambulance deployment from
was provided, however, the personnel costs and capital needs are at least four locations that delivers an 8-
greater with the ALS service delivery model. minute travel time

2. Consider a shift deployed EMS

As previously presented the FF/PM value is suggested as 20.28% supervisor and one additional EMS
above FF/EMT based on our national experience with other large administrative person
metropolitan size re departments. BLS sta ng would be 2 FF/
EMTs and ALS sta ng would be 1 FF/EMT and 1 FF/PM. 3. No need to reinvest in Stations E2, E5,
E17/R11, and E9 as this deployment will
solve the workload issue
Finally, at the city’s sole discretion, the re department could deploy
single-certi cation personnel that were only EMTs or PMs. In other 4. Adjust contractual compliance and
words, there could be added EMS depth, but not sworn re ghters. performance objectives to maintain an
The deployment plan would be the same, but the personnel costs unsubsidized environment
would be less of a barrier to entry.
5. Develop clear contractual parameters
for when RFD units could be utilized

W
hen considering this
model it is important
Ambulances Personnel Personnel Costs Capital Costs Total Start-UP
to consider the
Costs
necessary eld supervision
and the administrative position BLS Sworn 62.5 $5,323,891 $1,558,350 $6,882,241
previously described. The
model will have a positive ALS Sworn 62.5 $5,863,733 $3,336,750 $9,200,483
impact on reducing the BLS Single- 62.5 $3,642,038 $1,558,350 $5,200,388
reliance on large re Certi cation
apparatus to respond to EMS
incidents and reintroduce ALS Single- 62.5 $4,762,298 $3,336,750 $8,099,048
availability for re protection Certi cation
and other services.

This alternative essentially

Opportunities creates an EMS overlay on top Challenges
of the base re protection 1. May require a long-term implementation
as the 63 personnel are either hired or
1. Preserves rst-due response time and services provided by RFD. trained and deployed.
adds transport capable surge capacity While the system will work very
2. Improves the response time for ALS
effectively and accomplish 2. FF/PM classi cation will have to be
many of the desired elements, it negotiated.
care (if an ALS model is chosen)
is important to note that the 3. Costs exceed a full re-based transport
3. Reduces workload on large apparatus level of investment is similar to model
4. Provides cost avoidance strategies for migrating to a full transport
4. Sensitivity to relaxed response time of
the future model and introducing the cost the private contractors
recovery elements associated
5. Stabilizes the performance and scal
with patient billing. 5. Potentially incentivize contractor to
sustainability for the private contractor
decrease resources and leverage RFD
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Rochester EMS System Evaluation
Page 19 February 27, 2023

Adopting a System of Measures

A
s the RFD contemplates taking a greater role in managing and operating EMS services, it is
important to measure and manage the e ciencies of a well-run operation using a system of
measures as presented in the table below. In this manner, the daily management continues in place,
but the strict adherence to system design performance is secondary, to the outcome measures. For
example, if response time increases and there is no change in outcomes then it would be purely a policy
choice to act. Conversely, if the outcomes change, then the Department leadership will turn to the system
of measures and attempt to discern which of the variables or combination of variables may be
contributing to the change in outcomes.

The summary of measures provided below include all aspects of time, apparatus sta ng by type, relative
risk ratings, and system resiliency measures such as reliability, call concurrency, workload, and unit hour
utilization. The system of measures provided are not intended to be overly prescriptive. RFD should adopt
the system performance objectives internally and update as needed.

Similarly, the following is recommended as a contract compliance adjustment.

Priority 1 Priority 2 Priority 3 Priority 4

10:59 12:59 14:59 17:59

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 Rochester EMS System Evaluation
Page 20 November 23, 2022 February 27, 2023

Summary of Alternative System Designs

M
ultiple alternative EMS models were evaluated in this study.
If the City’s desire is to ensure a high quality and sustainable Observations
EMS system, then there are several pathways to achieve this 1. The options with the greatest ease of
goal. implementation, and the least risk and
disruption, are associated with
reinvesting in rst response capability
For example, the current ambiguity associated with compliance and simultaneously ensuring that the
monitoring of the contractor can be xed with the recommendations contractor is scally sustainable and
contained herein. Additionally, any actual di culties in meeting compliant
compliance may be associated with the available revenues and the 1. Status Quo - ALS
reasonableness of the desired response times. Recommendations 2. ALS FR with Status Quo - ALS
to re-establish sustainable response time parameters of 10:59 and/ 2. Options with the greatest direct control
or 12:59, in concert with a transparent compliance process, can over the provision of services is a re-
ensure scal and operational sustainability in a non-subsidized based transport model
environment. Therefore, options that improve rst response
capacity and simultaneously address the contract compliance, will 3. Variations of implementation strategies
may be costly throughout the transition
introduce the least risk.
4. The 12-hour civilian-based model would
Finally, RFD patient transportation options will provide the City with provide the most operationally and
the greatest control over the service provision as a direct provider. scally sustainable city provided option
This can be accomplished with a moderate level of net investment
1. Annual cost of $2.8 million to
after cost recovery of approximately $2.8 million. The deployment operate
strategy is provided below.
2. Improves response times for all
In addition, through the Ground/Public Emergency Medical service as well as ALS services
Transportation (GEMT/PEMT) program it is estimated that an
5. Additional GEMT/PEMT cost recovery
approximate annual value of $738,831 would be available to the city of approximately $738,831 would be
as a government provider that is not currently available to private available to the city if they were the
providers. The cost recovery varies by year based on participation. provider of services
Therefore, it is not recommended to operationalize the revenue, but
it may be very bene cial in purchasing capital and other one time
costs as needed or to build up an EMS reserve fund balance.

However, it would be a large organizational endeavor to both develop an ALS system and a transport
system simultaneously. If that is the ultimate policy goal, a long-term strategy of di erent levels of public-
private partnership may be a substantive consideration. For example, a public-private partnership could
be utilized for the next ve years, while implementing an all ALS rst response department, and then
reassess for the next contract period.
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 Rochester EMS System Evaluation
Page 20 November 23, 2022 February 27, 2023

Primer on Financial Assumptions and Modeling

T
he nancial models began with market
research on the costs of civilian EMTs and
Classi cation Total Annual Cost per Hour
Paramedics. The highest 3 (EMT) and 4 (PM) Compensation
salaries were identi ed and utilized within the base
assumptions. A total of 35% was added for the
rollup on bene ts as well as an increase of 5% over FF/EMT $85,155.00 $40.94
market for a reasonable competitiveness in a FF/PM $102,424.43 $49.24
di cult labor market. Supervisory positions were
Civilian EMT 2080 $58,253.96 $28.01
estimated at 10% over the corresponding rank of
paramedic. Civilian PM - 2080 $94,090.82 $45.24

F
Civilian EMT 2184 $59,281.37 $28.50
ire ghter paramedics are not currently a
classi cation within the Rochester collective Civilian PM - 2184 $95,750.27 $46.03

bargaining agreement, therefore, market EMS Chief $192,750.00 $92.67

research of other large metro re-based agencies Civilian EMS Supervisor $103,499.90 $49.76
established that the average increase was 20.28%
over the classi cation of FF/EMT. It is understood Sworn EMS Supervisor $112,666.88 $54.17
that this would be a negotiated item for the QA/QI and Prebilling $50,000.00 $24.04
interested parties, but this value was utilized as a
reasonable industry estimate for the creation of a
FF/PM classi cation for the nancial modeling.
Transport Units - Capital Estimates

C
apital costs were estimaed based in industry
Capital Item BLS ALS
experiences working with other clients and
managing current ambulance systems. Vehicle $121,900 $280,000
However, it is understood that within the current Striping/Decal $2,600 $2,600
Stretcher w/autoload $30,000 $30,000
environment in ation, green initiatives, and lingering
Cardiac Monitor $38,000
supply chain delays have creates an understandable Stair Chair $4,000 $4,000
degree of instability within the market. Therefore, Backboard/Scoop $1,500 $1,500
the capital estimates are provided with con dent for Bags and Supplies $3,000 $4,500
today, but may change considerably year of year Suction $750 $750
and should be reevaluated following policy ePCR $2,000 $2,000
direction. Understanding the limitations, BLS units Electronics $4,400 $4,400
Radios $3,000 $3,000
require less speci c equipment than the ALS service Total Capital Costs $173,150 $370,750
will provide. Similarly, civilian models may allow a
less expensive apparatus type than a re-based
model that has to account for the re ghting
personal protective equipment. Estimated DM and OH Description

D
irect materials and overhead (DL & OH) were Fuel Costs $537,817.50
estimated utilizing costs for fuel, uniforms, Varies by Plan
Uniform Per Employee $200 / year
consumable medical supplies, and capital $400 / year for Sworn
depreciation. All scenarios had a DM & OH cost
between $3.4 million and $4.7 million. The most Medical Supplies $1,434,180.00
operationally and scally e cient plan had a DM &
OH cost of $4,702,952.24. It is understood that 7-year Depreciation Varies
there may be additional costs allocated to EMS in Capital Depreciation
by Plan
the future such as intergovernmental transfers. Recommended plan is
$1,430,035.71
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