Orange County authorities shelved a proposal last month aimed at expanding the use of paramedics, and in doing so, preserved a longtime wall in the local health care industry.
The proposal would have allowed private ambulance companies to use paramedics for transporting patients between health care facilities. Today, the county only allows paramedics to fully perform in the public sector.
Unlike many counties in the state, paramedics have been effectively relegated to fire departments in Orange County. They can technically work for private companies but then can't do the advanced medical procedures that distinguish them as state-licensed paramedics.
Dr. Sam Stratton, the county emergency medical services director, pushed for expanding the use of paramedics at an Emergency Medical Care Committee meeting Dec. 14. The group is composed of political appointees and area emergency response officials, and advises the county supervisors on health care policy.
As EMS medical director, Stratton basically oversees the county's regulation of ambulance companies and non-hospital medical professionals. He said he has been working to expand paramedics to the private sector, though for a limited purpose, for nearly a year.
He argued paramedics could be a better fit for transporting patients between health care facilities than the current options. Ambulance companies normally use emergency medical technicians, known as EMTs, or nurses.
Paramedics fall between EMTs and nurses in terms of medical training and average pay. They can perform trickier procedures than EMTs and usually cost less than nurses to employ. Stratton wants to explore whether they can fill a niche where patients want higher-quality care at a lower price.
"I had expected that it would be embraced," Stratton said. "It's back at ground zero now."
Stratton said the loudest opposition to his proposal came from the Orange County Firefighters Association. Aside from paramedics working for fire departments, many firefighters in the county are also licensed paramedics.
The union's argument is particularly interesting because it provides a window into a much bigger territorial battle over who should handle medical emergencies in the county: the public or private sectors?
Stratton's proposal didn't draw a line in this battle directly. He only proposed allowing paramedics where firefighters almost never go: Transporting patients between health care facilities is left to EMTs and nurses.
But if the county allowed ambulance companies to start using paramedics for that service, what would be next? A foothold for potential competitors might emerge in the firefighters' domain down the road.
"It's just the old proverbial foot in the door," said Barbara Penland, the longtime program director of paramedic training at Saddleback College. "The problem is when you open the door and there's a flood outside, the water is going to come in faster and faster."
Consider part of the union's argument, which cited the nonexistence of paramedics in the private sector today. Under Stratton's proposal, association president Dave Rose said ambulance companies would need to hire greenhorn paramedics and their learning curve would result in worse patient care.
The same argument could be made against allowing ambulance companies to use paramedics for emergencies, the fire department's main service area.
As long as private paramedics don't exist in Orange County, firefighters can warn people about the potential side effects of a transition period.
But if the county were to adopt Stratton's proposal, the argument would weaken.
Local ambulance companies would have an environment to gain experience in the industry and potentially challenge firefighters' exclusive domain. The public sector wouldn't have the only trained paramedics to offer local governments.
Rose insisted the union's position wasn't about money but rather patient care. He said ambulance companies should transport patients with nurses, who receive more training than paramedics.
"We're opposed to lowering the level of care," Rose said.
Bill Weston, president of a local ambulance association, said he opposes Stratton's proposal. He argued that allowing paramedics to handle the service instead of nurses would worsen the quality of patient care and wouldn't even save money.
Weston said the cost of most transports is reimbursed by Medicare or Medical, and those programs charge the same fixed rate for paramedics and nurses. Patients and taxpayers, he said, would be billed the same as they are today under the proposed setup.
"The only savings that would be achieved is how much an ambulance company would save on their staff," Weston said. "We should be advocating for reducing labor but not at the sake of patient safety."
The Orange County Fire Authority hasn't taken a position on Stratton's proposal.
Battalion Chief Scott Brown, who oversees EMS services, said the agency is focused on emergency calls and its only concern in the current debate is making sure ambulances remain available to handle 911 calls.
Brown said the Fire Authority doesn't view the proposal as a "foot in the door."
Area officials have long debated the use of private vs. public paramedics. The current system is sometimes criticized as inefficient because firefighters and paramedics are dispatched to medical calls. Gas-guzzling fire engines zip through Orange County's streets in response to heart attacks and accidents.
Penland said she's heard complaints about "overkill" many times before, but she endorses the system. Like many firefighters, she prefers a model that responds to emergencies with more resources than likely necessary in case the situation deteriorates.
"I like the fact that in Orange County that two licensed paramedics will show up at a minimum and they will be backed up by EMTs," she said. "If something goes wrong with your chest pain, then you'd be real glad all those people are here."