Sunday 26 March 2017

Costs of Emergency Response: Comparing Ambulance in Vancouver with the Vancouver Fire Department.

Image Source: http://www.bcehs.ca/PublishingImages/BCAS_VAN_033012_113.jpg
A while ago I stumbled across this dataset which outlined the call volumes and types of calls which BCAS (BC Ambulance Service) responded to in the lower-mainland. Although I have plans to use this dataset for some future analysis. At an initial glance, what popped out at me was that the fire department responds on average to about 5% of BC Ambulances calls in the entire lower mainland but, close to 50% of calls in Vancouver itself. (in 2014)

This piqued my interest and got me wondering. What is the cost structure of the fire department? what is the cost structure of BCAS?

From a cost perspective, I have always wondered how cost effective it is to send 6 firefighters and the large fire truck to that many calls - both from a wage and capital cost perspective. Keep in mind, both BCAS and the Fire Department are paid for with public funds, just at different levels of government, provincial and municipal respectively.

Now, luckily the Vancouver fire department provides an extremely detailed breakdown of their previous years' activities in each municipal budget, these can be found here.  Unfortunately, BCAS provides a much less detailed public budget, as a result, I have had to do my best, scrounging together information from the above dataset, the BCAS 2014 annual report, which can be found here, and the BCAS 2014 Vancouver demand analysis which can be found here.

Compiling all this information I obtain the following table, which has also been augmented with wage data from workbc.ca



The big disclaimer here is that the BCAS expense data for Vancouver and the Lower mainland is entirely estimated at 25% and 50% based off of call volumes in relation to the provincial level. As such these are entirely arbitrary and may have no bearing on reality, but at least provide an insight into these areas.

While the expenses are estimated, the call volumes and labour information is accurate and obtained from the above-noted BCAS reports.

The second disclaimer is that Vancouver Fire provides their staffing information in terms of FTE, while BCAS provides it in terms of regular full-time, irregular full-time and part-time.

Through hear-say I understand that many of these "part-time" paramedics in Vancouver can, and often do, work more than a full-time schedule. But, at the risk of underestimating, I assign each part-time employee only 0.5 FTE while each full-time 1 FTE in calculating the FTE for BCAS in each region.

Finally, for the per crew information, BCAS generally operates in crews of 2 while I understand Vancouver Fire generally operates in crews of 4. (thank you, Brian, for this update! Also recognizing that Vancouver Fire will operate with as little as 2 for some medical calls. While this changes the number of FTE crew, this does not change the total expenses/call)

Now some discussion of the actual results of the above table.

My first surprise was that only 3% of the Vancouver fire departments calls are actually to deal with fires. Another 25% of their calls are fire inspections, to finish off with 72% of their calls being medical in nature, supporting BC ambulance. That means despite being a fire department (with their budget being about twice the estimated Vancouver BC ambulance budget) they primarily act in a capacity of being first responders to medical calls.

Now in a bit of preliminary research on this topic. I looked into the importance of first-responders, and empirically it appears that having a fast response time, all else equal, greatly increases the viability of the patient. My question then; does society benefit more when the first responder is from the fire department? or given the cost of fire response, would a modified response structure with BCAS be more cost effective and provide the same patient benefit?

Clearly, the Fire Department provides an extremely valuable service, especially in cases of vehicle accidents and hazardous materials. Unfortunately, I have not yet worked out from the above dataset, what percentage of Fire calls are due to hazmat or MVI (Motor Vehicle Incident), or just medical, with the request of a first-responder (Fire) crew. This will definitely, be the area of future follow ups! (followed-up here)

To finish off this post, as it has gotten a little long, If we evaluate the cost per call and the wage cost per call between calls in Vancouver for BCAS and the Fire Department we see that:
  • Vancouver Fire has a wage cost per call almost 8 times larger than BC ambulance.
  • Vancouver Fire has a total cost per call almost 3 times larger than BC ambulance. 
Although this data is already 3 years old and pre-fentanyl crisis, I find it fascinating that most of the news coverage on the crisis comes from the fire department, resulting in calls for more department funding when perhaps a more cost effective solution would be to increase ambulance funding and staffing.

But then again, these observations are just from a quick back of the envelope calculation. Perhaps there is much much more to the story. 

As I said my interest has been piqued and I now have a good chunk of data to pour over. 

Move over real-estate market, I have found a new topic for the next little while.

What are your thoughts? feel free to comment below.

EDIT: In retrospect, this article may seem like I have decided to pick a side in an emergency services battle for supremacy. This is not the case! Rather the above article is purely motivated by my curiosity and surprise based on the results and through this hopefully stir some thought on how these essential services may be provided in a more cost-effective manner!




27 comments:

  1. Hey Keith,

    Vancouver Fire rolls with 4 man crews on the fire apparatus, and several halls have medic units which are just pickup trucks. They can be staffed with as little as 2 members up or up to 4. Medic 8 (yaletown) usually only has 2 members, and medic 23 (DTES) only has 3. If you adjust your calculations from 6 man crews to 4, your numbers should become more accurate.

    Cheers,

    Brian

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    1. Hey Brian thanks for the information! I'll update my numbers and see how everything updates as a result! Thanks for the correction!

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    2. About 40 years ago the argument was what can we get the fire guys to do while they're waiting for a fire? Get patients out of wrecked cars, was one thing. Then 20 years ago, hey these fire guys are doing some first aid at car accidents maybe they can help the ambulance service, some of the calls are right close to the fire hall anyway. Now it's, boy it costs allot for these guys to fill in their spare time helping out.

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  2. Looking forward to an update on this topic because, regardless of what you think you know, its best to wait for the facts!

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    1. I have had one follow up posts on this. Unfortunately given the nature of both BCEHS and fire there is very little publicly available data (despite being taxpayer entities) - as a result I think I've almost hit the end of what I can do with the information available!

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  3. Now consider that BCAS brings transport capability and licensing at the ITT, ACP, and PCP level, while fire brings EMR-FR and no ability to transport. Data also shows that fire department responses only make a difference to patient outcome on about 3% of the calls they go to (cardiac arrests and motor vehicle accidents).

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    1. Would love to see the source on this! I was looking for information on patient outcomes from FR involvement but could not find anything relevant. Especially helpful would be FR "usefulness" by call type ... But I doubt such detailed data is publicly available.

      In what I could find FR usually meant a 1 man ACP responder not fire as we have here.

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    2. Look to the Pomax report from Toronto, paramedic Chiefs white paper or contact the Ontario paramedic association. The facts do exist.

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  4. I think what you should be looking at is not how many responses they do but how many they actually do a protocol on. You can do a million responses but if you do nothing on those then are you really doing anything? The recent claims that fire wants to use their PCP trained crew more is just a joke. They have to have time and experience to actually initiate a protocol and once that protocol is done have followup to make sure what they did was appropriate. As it stands many fire departments barely get a complete FR form done and this is a legal document of assessments and treatments done. Fire will never be able to keep a budget even close to the ambulance service since BCAS is provincial and all fire is municipal. There are no boundaries for ambulances. There is no need for mutual aid agreements. THere is no territory boundaries. One team..one goal.

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    1. The problem is data access - with the exception of Vancouver call information collected by a journalist after a bit of a legal fight -- all other information is from published annual budgets - which are at best limited with the information they provide and highly political.

      ie: if you want to justify your budget you may inflate call volumes, response times, and patient outcomes to make it look like public money is being really well spent! Never maliciously of course - but perhaps you record # of call outs rather than # of patient contacts. From what I understand these can vary substantialy.

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  5. Large amounts of peer reviewed evidence proves rather conclusively that the only measurable benefits to sending first responders at all is in cases of cardio respiratory arrest. A call that makes up less than 5% of overall responses to which fire resources are currently sent. Deployment and finding of fire resources is guided purely by manipulation of public perception, not by evidence.

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    1. Made this comment to a previous poster - would love to see this information on benefits of FR response! So far I have been unable to find any conclusive information on this.

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    2. Thats because there is no such evidence. It is a PR ploy by fire departments with no medical evidence to back it up.

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    3. So I want to clarify, an FR response is NOT an ACP response. When Fire responds, they respond with the EMR-FR license level (look up the legislation on this) which is a 2 week study. PCP in Canada is now a two year program, and ACP is another year.
      There are no Fire responses that are operating at the ACP license level.
      You also need to look into the equipment (which is related to license scope) that each group brings.
      I have passed your website in to "Send Paramedics" who will have peer reviewed evidence for you.

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    4. Much appreciated!

      On the note of First Responders - I'm aware that here in BC it is a licensing level under EMR, however in many peer-review articles I have read on the subject (focused in either the US, UK, EU, or Australia) when they speak of first responder, they are often referring to a one man motorcycle or SUV ACP which responds first to asses and stabilize. Given the lack of consistent terminology across provinces, countries, etc. it is often difficult to ascertain the actual scope of practice which is being referred to when you start looking at these global articles.

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    5. Be ware that the term "first responder (FR)" is sometime used to describe all emergency services including police, fire, ambulance. Regarding the articles, even when considering the different scope of practices of fire dept in different countries, the clinical and statistical evidence still points out that fire FR response is beneficial for code blue/arrests and when extraction/rescue is needed.

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    6. Yes, I realized this very quickly while looking at the literature - depending on the country in which the study was conducted "First Responder" (FR) means very different things!

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  6. I have questioned the costs on numerous different variations.
    First though we must look at what budgets are paying the largest portion of the costs.
    Fire hall costs fall to the municipal levels, and therefore make up to almost 50% of a municipal budget. BCAS budgets fall within the provincial budget, and probably the main reason the actual cost of emergency services in general get downloaded to the cities.
    However, should we not really be placing a large portion of these costs where they belong, which should be on the insurance industry. Car accidents are a prime example. Why should a property owner be paying for a 4 man crew to show up at a car accident, when the cars involved in the accident should be covered by insurance? Should the insurance company, not be paying the true cost of the accident?

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    1. This is always the interesting talk with services like ambulance. Technically (from an economic point of view) these types of services would be most efficiently provided by the free market (private). However, as a society (in Canada at least) we often have notions of fairness that perhaps all Canadians should have access to emergency medical care irrespective of their ability to pay - thus it becomes a publicly provided service and subsidized by the provincial government.

      The question then, if we maintain ambulance as a publicly provided service, who should pick up the costs?
      (A) do we split the cost equally across the whole province through our provincial taxes (current method as far as I can tell).
      (B) do we offset some of the cost to the user, implementing a cost recovery pricing scheme for each call out (social issues exist with this obviously).
      (C) do we offload some of the costs of ambulance to insurers (auto, home, health, life insurance? which one?) (if we do, we still end up paying for this, as an already stressed insurance industry responds by increasing insurance premiums)
      (D) Does BCAS adopt an approach like the RCMP, where they provide ambulance services on contract to municipalities, thus it comes down to individual municipalities to determine how much resources to commit to providing ambulance services (What happens in rural areas under this model though?)

      Obviously each scheme has its fall backs - the question is, has this question been asked and has it just been dismissed? or has a proper comparison of the costs and benefits of the above (and other) schemes been evaluated?

      End of the day, any time we publicly provide a service which the free market could provide, we will do it inefficiently - so really what do we value more - Economic efficiency or our values of equal access, equity and fairness within society? different provinces, nations have different answers to this obviously.

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  7. I like this topic. But, I have a few comments.

    A previous comment was about costs associated to FD budgets and the suggestion was that “fire hall costs” are large. This is a false claim. Metro Fire dept. wages and benefits take up in the low 90% of the total FD budget. Also, Fire stations are on land owned by the municipality and land in the Metro area has been an appreciating asset for many years.

    Referencing back to FD wages and the impact to their budget. If we promote the labour costs difference of FD vs BCAS, aren’t we justifying the ridiculous low wages of paramedics in the Province? The FD unions have fought hard for a liveable wage in a province that has an extremely high cost of living. It is tough for us to want parity, with our First Responder partners, when we constantly promote how cheap we are.

    When you were costing out BCAS numbers, how did you calculate when outside regions are used to prop up the service in the Metro area? IE Sea to Sky corridor resources being sucked into Metro or resources from far away as Hope, that are sucked into Abbotsford, because those resources are in Surrey.

    Lastly, Burnaby has close to a billion dollars in cash from their extensive land acquisitions and deals. It’s very un-Canadian, but shouldn't a Burnaby resident have the opportunity to have better levels of service in terms of Pre-Hospital care from their Fire Department when they belong to a community that has the resources.

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    1. Thanks for your comment, but I think my point in this post was misunderstood. I am not criticizing the FD wages, as you are right they have a great union which has successfully fought hard for great wages and working conditions (something which has not been done by the union representing paramedics as far as I know). Rather this article was more pointing out the differential in cost per call between Fire and Ambulance, and as a tax payer asking the question "is it worth the extra tax-payer dollars to send fire to all these calls? or are there other more cost effective ways to deal with this?"

      In costing out the BCAS numbers, I did not incorporate the fact that BCAS will often cross municipal boundaries in providing their service (where I assume fire does not typically do this).

      This was simply calculated by finding the 2014 budget information from BCEHS annual reports, and assuming that 50% of the BCEHS budget went to the lower mainland, while 25% of the budget went to Vancouver alone (this is roughly supported by call volumes - but simply a convenience, this is only a blog).

      Once the proportion of the budget was determined for Vancouver and the lower mainland, I next had to find an estimate of how many paramedics BCEHS employs in Vancouver and the lower mainland and how many calls originate in each respectively. then just a process of splitting up the allocated budget between wages (variable costs) and overhead (fixed costs). Finally, dividing each respective budget item (total, variable and fixed) by call volume to determine ($/call, wage/call and fixed cost/call).

      As a result there is no adjusting to include the fact that crews can be sucked into metro areas - as a result if we assume that calls can be uniformly distributed across the whole lower-mainland, the comparison of average costs between Vancouver fire and lower-mainland BCAS may be a more realistic comparison of average costs (cost per call). Of course one would have to recognize the short-comings of such an assumption - but such is the nature of having access to limited data.

      hope that clears things up and answers your question.

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  8. Also too.... here in Ontario the fire dept assigns a different run number for each truck dispatched to the same call. Example... 4 trucks to one event = 4 call numbers. For an ambulance it's one call number for each event. Example... 10 ambulances on a 401 mvc = 1 call number. This system inflates fire numbers and deflates ambulance response numbers. Another variance between the 2 is that ambulance measures its response times from the 911 call received. Fire measures theirs from the time the truck rolls out on the call. Apples and oranges. Fire's stats are designed to show more benefit than what really occurs. Having worn both hats at one time this is how it is currently.

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    1. Not surprising - the one thing I always tell my students when I have them look at government or crown corporation budgets is that "These are political documents".

      That is, while they are trying to convey some legitimate information - the way in which the information is presented and how they have chosen to define certain bits of information (IE what is a call) is extremely important and can influence the results.

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  9. Here is the Toronto Pomex Report on the paramedic and Fire services. Some great info.

    https://www.google.ca/url?sa=t&source=web&rct=j&url=http://www.toronto.ca/legdocs/mmis/2013/ex/bgrd/backgroundfile-59903.pdf&ved=0ahUKEwjqxZOK0P_VAhWFx4MKHSSUB8sQFggjMAA&usg=AFQjCNHwoOUrQ0F9gudz1nyd7qvM4bAgYA

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    1. Thanks! I'm excited to see what I can piece together from this, perhaps enough for a future post.

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  10. As a Dtes Vancouver resident and someone who has done front line work, I would love to know 1 - How much it costs per incident for firemen to respond to overdose calls? and stats on number of those calls. 2 - How much does it costs for firemen to respond to false fire alarms e.g. individuals smoking in apartment hallways causing alarms to sound requiring firemen to disable alarm. Which if you live BC Housing Dtes it can happen multiple times a week, especially during summer time.

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