Paramedic Program Operational Plan

Paramedic Program Operational Plan February 2000 Prepared for the Blaine County Board of Commissioners & The Wood River/Sawtooth EMS Region Council by The Abaris Group Sponsored by Teresa and H. John Heinz III Foundation

Paramedic Program Operational Plan Page 2 TABLE OF CONTENTS OVERALL OBJECTIVE 3 Overview 3 Study 3 Program Differences 5 Conclusions 6 PARAMEDIC PROGRAM NEEDS 9 Historical 9 Blaine County and the Region 13 PARAMEDIC OPERATIONAL PLAN 16 Paramedic Operational Planning 16 Operational Plan 17 Cost Considerations 20 Revenue Considerations 20 Downside Risk 22 RECOMMENDATIONS AND ACTIONS NEEDED 24 Recommendations 24 Action Steps Needed 25 APPENDIX A 26

Paramedic Program Operational Plan Page 3 Overview: OVERALL OBJECTIVE The Wood River/Sawtooth EMS Region Plan calls for the development of an improved EMS system for the Wood River/Sawtooth EMS region. One of the objectives of the plan is to improve prehospital clinical services and the skill set of the first-responder and ambulance staff. An essential goal of the EMS Plan is the development of a paramedic for the region and developing a consistent Advanced EMT (A-EMT) service in all other regions not served by the paramedic program. Study: Since the approval by the Wood River/Sawtooth EMS Council of the EMS Plan in December 1998, significant study has been underway relative to the options, costs and delivery systems for advanced life support programs including A-EMT (current status), EMT Intermediate (EMT-I), and EMT Paramedic (EMT-P). The study has included site visits to several paramedic programs (Portland area and Ada County). The Wood River/Sawtooth EMS Council has also extensively discussed the relative merits of enhanced skills at the EMT I and EMT P levels. Detailed studies were also conducted of training options for both types of programs. Key questions raised during this study phase were: Is there a need for an advanced life support (e.g. EMT-I or EMT-P) program in the region? What are the differences between EMT-I and EMT-P programs?

Paramedic Program Operational Plan Page 4 How can staff skills be maintained in low-volume programs? How have these issues been addressed by other rural programs? What is the impact of the Hailey Hospital closing on an enhanced program? What are the cost issues and can either type of program be financially sustained for the region?

Paramedic Program Operational Plan Page 5 Program Differences: The following chart illustrates the differences in the various categories of basic and advanced life support programs: Advanced Life Support Program Options Skill Category A-EMT (current) EMT-Intermediate EMT-Paramedic Basic EMT Skills Yes Yes Yes Airway Management Basic Endotracheal intubation only Basic Endotracheal intubation only Basic Endotracheal intubation Rapid sequence induction (RSI) Paralytic agents Cricothyrotomy Intravenous Lines Normal saline only Normal saline Ringers lactate Multiple options for entry Cardiac Assessment Skills & Drugs None 2 lead EKG Core medication list Normal saline Ringers lactate Multiple options for entry Interocceous IVs (children) Other pediatric entry options 12 lead EKG Core medication list Additional comprehensive list designed for field use

Paramedic Program Operational Plan Page 6 Advanced Life Support Program Options Skill Category A-EMT (current) EMT-Intermediate EMT-Paramedic Trauma Assessment Skills & Drugs Other Advanced Medical Assessment Skills & Drugs Basic assessment. No drugs None Basic assessment Advanced assessment No drugs Additional core list of assessment and drugs (e.g. diabetes, drug overdose, etc) Estimated Training Hours 60 hours (above EMT-B) 500 hours 1,200 hours Basic assessment Advanced assessment Limited advanced injury treatment drugs Special trauma resuscitation devices (e.g. chest decompression) Additional core list of assessment and drugs (e.g. diabetes, drug overdose, etc) Additional extensive list of assessment and drugs that allow advanced assessment, treatment and pain management Additional skills and drugs per local medical director approval Conclusions:

Paramedic Program Operational Plan Page 7 It is the ultimate goal of this effort is to improve the skills of prehospital staff to assure optimal services in the field and the reduction of mortality and morbidity. The Wood River/Sawtooth EMS Council has concluded that EMT P services in the core area, with EMT P intercept services for those areas not served (with the eventual development of consistent A-EMT or EMT P throughout the region) would best serve the residents and visitors of the region. The Wood River/Sawtooth EMS Council has concluded that an EMT-P program would improve the knowledge and skill base of the ambulance service and be the best match for service and cost effectiveness for the region. These conclusions were reached for the following reasons: The region is impacted by geographical (e.g. significant time-to-scene, to the hospital factors and traffic delays) and the potential for improved medical outcomes (e.g. reduced patient mortality and morbidity in heart attacks); Time to definitive care is the key factor to reducing morbidity and mortality. Blaine County s current A-EMT skills set have very limited approved definitive-care skills; Advanced skills necessary to stabilize, resuscitate patients and provide advanced assessment, stabilization and pain management skills are needed for these purposes in the region; EMT-I and EMT-P skill sets are similar but not identical; There are no current approved EMT-I skill lists and operational and training programs of the caliber that would be required for the region (e.g. national curriculum);

Paramedic Program Operational Plan Page 8 Ongoing costs for the EMT-I program would be essentially the same as the EMT-P; Other comparable rural areas have EMT-P services and have not experienced issues of extraordinary cost and have appropriately responded to concerns about skill decay commonly raised about rural areas; and, There are EMT-P training programs in place (Ada County) or planned (e.g. Boise State, College of Southern Idaho) in the state.

Paramedic Program Operational Plan Page 9 Historical PARAMEDIC PROGRAM NEEDS EMS programs across the country have been undergoing a steady improvement in quality and consistency. During 1966, the so-called EMS "White Paper" titled "Accidental Death and Disability: The Neglected Disease of Modern Society", identified deficiencies in providing emergency medical care in the country. 1 This paper was the catalyst to spurring federal leadership toward an organized approach to EMS. Through the enactment of the 1966 Highway Safety Act, the states' authority to set standards and regulate EMS was further reinforced and encouraged. Many communities across the country evaluated and implemented paramedic programs in response to the White Paper along with their desire to bring advanced life support services to the patient. Cardiac arrest and the related opportunities to reversing particular rhythms (ventricular fibrillation) formed one of the focuses for the development of prehospital advanced life support. Early work on advanced life support programs by Pantridge using physician and nurse staffed mobile intensive care units in 1966-67. In the United States similar programs were developed. Instead of using scare and expensive physicians in prehospital settings, the EMT-P position was created to provide advanced life support. Many of the early programs based this premise on the scientific fact that cardiac-arrest victims were more likely to survive if they had certain drugs and treatment protocols brought to them in the field. 1 National Committee of Trauma and Committee on Shock. Accidental Death and Disability: The Neglected Disease of Modern Society, Washington D.C., National Academy of Sciences/National Research Council, 1966.

Paramedic Program Operational Plan Page 10 Early studies by Eisenburg, et al 2 describe cardiac-arrest survival rates in suburban populations before and after the addition of paramedic level services. Paramedic services decreased the time from arrest to the delivery of advanced care from an average of 27.5 minutes to 7.7 minutes. The rate of admission to an intensive care unit of successfully resuscitated patients went from 19 percent to 34 percent and for those discharged from the hospital, an improvement from 7 percent to 17 percent. Many other authors have identified the success factors 3, 4, 5, 6, 7, 8 of paramedic programs on cardiac arrest survival. 2 Eisenburg MS, Berger L., Hallstrom A: Paramedic programs and out-of-hospital cardiac arrest: Factors associated with successful resuscitations. Am J Public Health 1979;69:30-38. 3 Eisenberg MS, Copass MK, Hallstrom A, Cobb L, Bergner L. Management of out-of-hospital cardiac arrest. Journal of the American Medical Association 243:1049-1051, 1980. 4 Roth R, Stewart RD, Rogers K, Cannon GM. Out-of-hospital cardiac arrest: Factors associated with survival. Annals of Emergency Medicine April 1984; 13:237-243. 5 Cummins RO, Eisenberg, MS, Hallstrom AP. Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. American Journal of Emergency Medicine 1985; 3:114-118. 6 Weaver WD, Cobb LA, Hallstrom A, Copass MK, Ray R, Emery M, Fahrenbruch C. Considerations for improving survival from out-ofhospital cardiac arrest. Annals of Emergency Medicine October 1986; 15:1181-1186. 7 Nichol G, Detsky AS, Stiell IG, O Rourke K, Wells G. Laupacis A. Effectiveness of emergency medical services for victims of out-ofhospital cardiac arrest: A meta-analysis. Annals of Emergency Medicine June 1996; 27:700-710. 8 Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: A graphic model. Annals of Emergency Medicine November 1993; 22:1652-1658.

Paramedic Program Operational Plan Page 11 Cummins et al 9 compiled a list of survival rates for all discharged cardiac arrest rhythms by system type. For those that employed merely EMT defibrillators (EMT-D) with automatic defibrillators, the survival rate was 16 percent compared to 29 percent for those systems employing both the EMT-Ds and EMT-Ps combined. Studies have further shown that the addition of citizen CPR, can further improve survival of cardiac arrest victims. This adds to the important components for a successful EMS system. Other studies have shown the effectiveness of EMT-P services on the diagnosis and treatment of acute heart attack, pulmonary edema, serious trauma, and seizure management. In all, there have been 51 articles written on the efficacy of paramedic programs. The following are conditions where the medical community agree that paramedic level skills have distinct advantages over EMT and EMT-I skills: 9 Cummins RO, Ornato JP, Thies WH, et al: Improving survival from sudden cardiac arrest: The chain of survival concept. A statement for health professions from the advanced life support subcommittee and the emergency cardiac care committee. American Heart Association. Circulation. 1991;83: 1832-1846.

Paramedic Program Operational Plan Page 12 Paramedic Program Efficacy Amongst The Medical Community (partial list) Conditions where the medical community agree that paramedic level skills have distinct advantages over EMT and EMT-I skills: anaphylactic shock (allergic reaction) cardiac arrests cardiac arrhythmia child birth complex medical assessments complex traumatic assessments difficulty in breathing drug overdose moderate to complex fractures moderate to serious trauma pain management pulmonary edema respiratory arrest status asthmaticus stroke

Paramedic Program Operational Plan Page 13 Blaine County and the Region The EMS system in Blaine County responds to approximately 1,160 emergency responses per year of which 1,000 are transports. There are an estimated additional 150 responses outside Blaine County (in Camas and Custer Counties) that are also included in the Wood River/Sawtooth EMS Council planning area as well. Approximately 878 patients are transported by Blaine County ambulance providers each year of which 655 are for prehospital EMS (non-transfer calls). Data from Blaine County demonstrates that approximately 13 percent (84) of all Blaine County-transported patients need the emergency resuscitation skills of a paramedic (e.g. called in this report: extreme calls). From national data we know another 5 percent (35) will need advanced life support intervention skills (e.g. IVs, drugs, etc) and another 27 percent (175) of the calls will need the advanced assessment skills of a paramedic but not necessarily paramedic- level intervention. The following two charts demonstrates the overall call breakdown for Blaine County ambulance providers and a more detailed breakdown of the extreme paramedic calls.

Paramedic Program Operational Plan Page 14 Blaine County and Region Total EMS Responses 1999 Category # % Total Transports (non tranfer) 655 100% Paramedic level skills required - extreme 84 13% Paramedic level skills required - general 35 5% Paramedic assessment only skills required 175 27% Total Paramedic Level Calls 294 45% Total ambulance transports 878 Interfacility Transfers* 223 Total Calls 878 Source: Data from providers, Special Blaine County Study - Jan. 2000, Scott Bourn, RN, EMT-P Paramedic Research Institute, Boulder CO * some interfacility calls may require some minor ALS skills.

Paramedic Program Operational Plan Page 15 Blaine County Extreme Paramedic Calls Unconsc. diabetic Unk. Unconsc. Allergic reaction Cardiac arrrest Unconsc. seizure Unconsc. stroke Trauma Hypothermia Cardiac symp Extreme Level Calls for 1999: Allergic reaction 8 Cardiac arrrest 14 Cardiac symp 26 Hypothermia 2 Trauma 6 Unconsc. stroke 4 Unconsc. seizure 10 Unconsc. diabetic 12 Unk. Unconsc. 2 Total 84

Paramedic Program Operational Plan Page 16 PARAMEDIC OPERATIONAL PLAN Paramedic Operational Planning Planning for a paramedic program by the Wood River/Sawtooth EMS Council has been underway for nearly a year. Training program alternatives, costing models, revenue studies and candidate screening have all been conducted. The goal of the program is to implement the EMT-P program in a manner that can serve the greatest needs for the region in the most cost effective way. Research was conducted on options for the paramedic training programs. All potential entities that have experience or an interest with paramedic training were invited to submit proposals to a Wood River/Sawtooth EMS Council review committee for consideration. After considerable debate and onsite interviews of candidate entities, the Ada County program was selected for the first phase of the program. Their selection was based on: extensive background and expertise with EMT-P training programs existing program scheduled to begin in February 2000 (rescheduled for April 2000) significant willingness and flexibility on course timing, clinical and field training requirements willingness to provide technical guidance on candidate screening and prerequisites historical high pass rate of previous candidates ability to extensively assist with field training including potential for an employee swap during the training sessions

Paramedic Program Operational Plan Page 17 It remains the ultimate goal of the Wood River/Sawtooth EMS Council to establish local paramedic training program within the Blaine County region to the extent that it provides the most cost-effective and relevant educational modality to the community. This may be done collectively with any or all entities including Ada County, Boise State and the College of Southern Idaho (CSI) College. Operational Plan The operational plan for the Wood River/Sawtooth EMS Council EMT-P program is to have an operational paramedic unit in service by early 2001. To achieve this important goal, sufficient candidates will be trained to field an intercept unit. An intercept unit is a unit that may respond directly to the scene of an emergency or may intercept an ambulance already transporting a patient. One single intercept unit would be staffed cooperatively by both Ketchum and Wood River Fire and Rescue staff and intercept the ambulance enroute to calls or perhaps enroute from the scene to the hospital. Final details on operations of the intercept program (e.g. location, dispatch, staffing and billing) will be completed in the next 60 days. The first phase training class in Ada County would initially train four candidates. Two from each jurisdiction. While the first class is in session, a careful analysis will be conducted of the second phase training options. It is generally felt that the second program could be initiated in Blaine County with an affiliated entity (e.g. Ada County, CSI, Boise State) during late 2000 or early 2001. The second program would train another four candidates or more if parties from other Wood River/Sawtooth EMS jurisdictions are interested. The cooperative intercept unit would be used until sufficient candidates (eight at full staffing) are trained to field a total of two transport units, one in Ketchum and one in Hailey to serve the Wood River Fire and Rescue service area. This would likely occur sometime the latter part of 2001.

Paramedic Program Operational Plan Page 18 A milestone chart is provided below documenting important milestones for the implementation of the program.

Paramedic Program Operational Plan Page 19 Wood River/Sawtooth EMS Region Paramedic Program Timetable Task/Month 2000 2001 Activity Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 1. Research alternatives, costs and revenue sources 2. Prepare plan of action 3. Obtain Wood River/Sawtooth EMS Council approval 2. Obtain sponsoring entity approval Ketchum City Council Wood River Fire and Rescue Blaine County Board of Commissioners Revise plan and submit final version 4. Begin Ada County paramedic class. 5. Initiate startup plans. Draft and obtain approval on protocols Order paramedic supplies Define response patterns and backup procedures. 6. Field paramedic intercept unit. 7. Initiate second paramedic class (Blaine or Ada County). 8. Initiate program review and evaluation process.

Paramedic Program Operational Plan Page 20 Cost Considerations The cost of the paramedic program has been calculated and divided into startup and ongoing costs. As with any paramedic program, the most significant cost is the startup or implementation costs. Ongoing costs are nominal and are limited to paramedic salary adjustments (recommended at 10 percent), continuing medical education and equipment replacement. A detailed listing of costs and revenue assumptions have been provided in Appendix A. Revenue Considerations The implementation costs are expected to be entirely paid through the generous donations of The Heinz Foundation and the fund raising efforts of The Moritz Auxiliary of Wood River Medical Center. No county tax dollars will be required for startup costs. As noted in the separate report EMS Program Cost and Revenue, Blaine County has been very conscientious about the charges to the public to the extent that the charges have lagged behind so that now they are below what insurance companies will pay for ambulance service. Changes to the ambulance charges coupled with improvements to the billing process provides sufficient revenue to support the ongoing costs of the paramedic program. No county tax dollars will be required to offset the ongoing costs for the paramedic program. This assumes the Board of Commissioners adopts the revenue recommendations of this report. It should be noted that the changes to the billing process and charge master are needed irrespective of the decision to move ahead with the paramedic program.

Paramedic Program Operational Plan Page 21 Therefore, it is anticipated that the ongoing annuals costs will be covered through one or a combination of the following steps: improved present billing and collection systems; adjustments to the charge system by the Blaine County Board of Commissioners; the development of an ambulance membership program; and, cost-reduction efforts to be achieved through study by the two EMS ambulance provider chiefs already underway. The improved billing and collection system expectation is based on the observations and recommendations made in the Wood River/Sawtooth EMS Cost/Revenue Report available under separate cover. Ambulance charge system changes are also detailed in the other report but consists of revising charges to be consistent with payer profiles and removing artificial barriers to payment built in the current charge system (e.g. resident and non-resident fees). It should be noted that there are a variety of ways to achieve the increased revenue assumptions. Models provided in this report provide one set of options but others could be available as well. Ambulance membership programs are popular in other areas of the country. There are programs whereby a residence pays an annual fee (typically $35 $55) to provide coverage for out-of-pocket expenses that may be associated with an ambulance event (e.g. co-pays and deductibles). These out-of-pocket expenses borne by the patient are far in excess of the membership fee and are allowed by Medicare. The program is very popular with those of high risk of using an ambulance service such as the elderly and chronically ill as it provides a fixed cost for the potential user to absorb. This revenue is not expected to achieve immediate results, as such programs typically take two to three years to mature. However, a properly run membership

Paramedic Program Operational Plan Page 22 program can offer a fixed income source and protect the program against the unknown effects of future payment policies. Downside Risk The recommendations of this operational plan are based on research and the assumptions used on that research. The factors that could contribute to key concerns about these assumptions include higher costs and lower revenue resources. The Wood River/Sawtooth EMS Council believes that they have taken into consideration these risks and the risks have been neutralized to the extent possible. It is important to recognized that the EMS Council has been using the services of a nationally-recognized EMS consultant and that much of the premise of the new program is based on the consultant s input and feedback from other successful Idaho programs. On the cost side, the ambulance providers have begun to evaluate cost savings and have already reported that their the discussions have been fruitful. We anticipate their preliminary recommendations within the next 60 days. Some of the unanticipated costs may be offset by these planned cost savings. Unanticipated costs above these costs savings may be offset by new revenue sources suggested in this report. Relative to revenue, much is unknown. Medicare fee schedules and managed care contracting could have an effect on revenue assumptions but these are both expected to either not have an effect (managed care s penetration into rural areas has been only slight) or possibly be positive. Preliminary information on the new Medicare fee schedule indicates that rural areas such as Blaine County may be substantially helped by the fee schedule.

Paramedic Program Operational Plan Page 23 A summary of cost and revenue considerations are provided below. Please note that revenue assumptions used demonstrate but one method of new revenue that relies on increased charges and billing, Other models are available as well. Wood River Sawtooth EMS Region Paramedic Program Cost/Revenue Estimate Category # Estimated Estimated Cost Revenue Number of paramedics at maturity 8 Start-up Costs: Tuition, meals, lodging and staff $ 378,526 $ 380,000 replacement costs Ongoing Costs: (annual) Paramedic staff incentive pay, equipment $ 85,000 $ 89,622 replacement and continuing education Total $ 463,526 $ 469,622

Paramedic Program Operational Plan Page 24 Recommendations RECOMMENDATIONS AND ACTIONS NEEDED The planning process for the development of a paramedic program for the region is a step in a process that is designed to implement a comprehensive EMS system. This planning process has been careful and deliberate and has taken two years to date The development of a paramedic program is but one part of the entire EMS plan. Other elements of the EMS systems development includes medical direction, a consolidated dispatch center, and public education. It is recommended that the Board of Commissioners join the Wood River/Sawtooth EMS Council, The Moritz Auxiliary and The Heinz Foundation and demonstrate their endorsement and support for this lifesaving program by approving of the paramedic program and including the EMT-P scope of service in the ambulance agreements. The Board of Commissioners should also request the ambulance providers provide more detail on their response to the billing and collections recommendations (separate cost/revenue report) and be asked to report back to the Board with implementation procedures. The ambulance fee schedule will also need to be adjusted to assist with revenue. It is also recommended that an ambulance membership program be implemented. Details on all three of these items will be forwarded within 30 days of final approval of this plan the Board. In addition, cost efficiencies by the existing ambulance providers are also being studied and a report on results and actions needed will be forwarded within 60 days.

Paramedic Program Operational Plan Page 25 Action Steps Needed: (1) Approve the plan of action to establish the paramedic program as requested in this report. (2) Authorize the EMS ambulance provider chiefs to meet and report back within 30 days on: review billing and collection needs and recommend a plan of action; and, review and make detailed recommendations on the ambulance fee schedule. (3) Study and recommend an ambulance membership program with details to be brought back to the Board (4) Request that the EMS ambulance provider chiefs to meet and prepare a plan of action on existing program cost efficiencies to report back within 60 days.

Paramedic Program Operational Plan Page 26 APPENDIX A The following are tables further describing the financial impact of the paramedic program and details on the programs costs and charges.

Paramedic Program Operational Plan Page 27 Startup Ongoing Category Estimated Revenue* # Unit Estimated Transports Average Revenue Cost Cost Cost Charge Start-up Costs: Tuition, meals, lodging and staff $ 410,488 $ 420,000 replacement costs Ongoing Costs:(annual) Paramedic incentive pay/year 8 $ 4,000 $ 32,000 Paramedic CME 8 $ 3,500 $ 28,000 Equipment replacement 2 $ 5,000 $ 10,000 Miscellaneous 1 $ 15,000 $ 15,000 Revenue Sources Current Number of transports/average charge 878 $ 351 $ 308,178 Net Collections (both agencies) 75% -- $ 231,357 Future** Wood River Sawtooth EMS Region Paramedic Program Cost/Revenue Estimate Number of transports***/average charge**** 778 $ 570 $ 443,460 Net Collections (both agencies) 85% -- $ 376,941 Total $ 410,488 $ 420,000 $ 85,000 Net Difference (future from current) $ 145,584 * From Heinz Foundation and The Moritz Auxiliary ** Assumes one model (rectified charge master and payments from payers). Other models are available. *** Transports reflects reduced number of transfer during 2001 due to new hospital opening. **** The new average charge reflects adjustments to the existing charges per recommendations made in a previous report. For more detail on the start up costs and new charges, please see Tables A and B.

Paramedic Program Operational Plan Page 28 Table A Wood River Sawtooth EMS Region Paramedic Program Startup Costs Category # Unit Total Candidates - Initial Ada County Program 4 Candidates - Second Training Program 4 Total 8 Training Costs - Ada County Program Tuition 4 $ 6,000 $ 24,000 Meals (per trip) 84 $ 60 $ 20,160 Mileage (@$.27/mile) 84 $ 300 $ 6,804 Lodging (rooms @$60/night - one nite per 84 $ 120 $ 40,320 trip - where possible) Replacement Staff - Ketchum 1 $ 31,987 $ 31,987 Replacement Staff - WRFR 1 $ 31,987 $ 31,987 Training Costs - Blaine County Program Paramedic Instructor 1 $ 55,000 $ 55,000 A V Support/Materials/Misc 1 $ 50,000 $ 50,000 Tuition (e.g. CSI) 1 $ 2,500 $ 10,000 Meals (clinical and field training only) 30 $ 70 $ 8,400 Mileage (clinical and field training only) 30 $ 300 $ 2,430 Lodging (clinical and field training only) 30 $ 120 $ 14,400 Replacement - Ketchum 1 $ 15,000 $ 15,000 Replacement - WRFR 1 $ 15,000 $ 15,000 Other Startup Costs Equipment 2 $ 30,000 $ 60,000 Miscellaneous 1 $ 25,000 $ 25,000 Total Cost $ 410,488 Startup Revenue Heinz Foundation $ 270,000 Moritz Foundation $ 150,000 Total Startup Revenue $ 420,000

Paramedic Program Operational Plan Page 29 Table B Wood River Sawtooth EMS Region Paramedic Program New Charges Current Charges Activity Volume Charge Total $ Total transports - 1999 878 Average Mileage 12 Charges: BLS Base Rate - Resident 699 $ 265 $ 185,298 BLS Base Rate - Non-resident 95 $ 400 $ 38,140 ALS Base Rate - Resident 73 $ 345 $ 25,323 ALS Base Rate - Non-resident 10 $ 480 $ 4,804 Mileage 878 $ 5 $ 52,680 Other charges (e.g. supplied) 933 $ 2 $ 1,866 Total Charges $ 308,112 Current average charge $ 351 Current Profile: ALS/BLS Mix: ALS 10% BLS 91% Resident 88% Nonresident 12% Proposed Charges Activity Volume Charge Total $ Total transports - 2001 778 Average Mileage 20 Charges: ALS Base Rate 778 $ 450 $ 350,100 Mileage 778 $ 6.00 $ 93,360 Other charges (e.g. supplied) 778 $ - $ - Total Charges $ 443,460 Future average charge $ 570 Current Profile: ALS/BLS Mix: ALS 100% BLS 0% Resident 0% Nonresident 0%