Read the headlines around the country about competitive ambulance bid processes and it sounds like a train wreck. Spokane, Wash., is considering reopening its bid process after community members questioned its fairness after only receiving one bid. The Alameda County, Calif., bid award resulted in a major lawsuit between bidders. Merced, Calif., had to start over after a bidder protested what they claimed was a “flawed process.” Two bidders protested the Napa County, Calif., process claiming bias and scoring discrepancies. These are newspaper stories and not representative of all the facts, but there are enough of these stories to question the legacy process in place and look to modernize it for today’s EMS.
Communities have used the request for proposals (RFP) process for ambulance service for decades. Back in 1987, former EMS consultant Jack Stout and JEMS founder James O. Page famously facilitated a “Battle of the Bids” preconference at EMS Today in Anaheim, Calif. Stout advocated that competitive bidding was good for communities because it introduced entrepreneurial competition, and good for the profession because it raised the bar and encouraged providers to innovate and improve.
Cities and counties across the U.S. that use the private sector for the provision of ambulance services are the primary producers of RFPs. California is unique and has a requirement in its health and safety code that demands a competitive process unless the existing provider is grandfathered, having been in service prior to 1981 and there have been no significant provider changes.
RFPs are traditionally produced by a community’s purchasing office, legal counsel or through the engagement of an EMS consultant. The American Ambulance Association advocates for the engagement of an EMS consultant, theorizing that this will support creating standards and performance expectations that are evidence-based and reasonable.1
Assessment of the issues with RFPs
Last year, professor Richard A. Narad at California State University, Chico studied the most recent RFPs released in California.2 He presented his findings to the EMS Administrators’ Association of California and is currently preparing a paper for peer-reviewed publication. Without giving away the meat of Narad’s findings, here are some key issues identified in his work and our own analysis. These are the same issues expressed to me by ambulance service providers who regularly produce proposals in response to these RFPs.
• RFP documents produced in-house are not custom designed for each procurement. Attorneys and purchase officers often start with boilerplate templates and then add the ambulance specifications. EMS consultants reuse the same core template from previous engagements and change the specifics for each client. There is little or no improvement over time.
• The RFP process mixes legal, pass/ fail and competitive criterion. Criterion may not be clearly stated and the relationships within the RFP scoring process are not always defined.
• RFP review scoring systems range from highly subjective to semi-objective, with little potential for inter-rater reliability. This leaves them open to contesting. Weighting and prioritization of criterion don’t always match the stated aim of the RFP. For example, the RFP may state that quality is important, but then weigh price higher.
• RFPs ask bidders to produce performance and services that exceed the known or predicted collections of the service area and no tax subsidy is provided. Rarely is validation presented that the performance can be achieved.
• RFPs criterion for the future contract are heavily weighted on strict response time goals (e.g., 8 minutes and 59 seconds at 90th percentile compliance) that are not supported by peer-reviewed evidence or cost (e.g., zero tax subsidy), which may limit the potential services available to communities.
• Communities are required to go out to bid, but some may not have the will to change or improve, resulting in an RFP for which only the incumbent bidder will submit a proposal.
• The RFP constraints and bidding burden limit potential bidders to only a few companies, hindering competition and resulting in a small number of proposals. This can be due to the lack of a viable or sustainable system.
• RFPs are absent of focus on the clinical care quality, patient experience and innovation that reduces the overall cost per capita.
Recommendations for improving the RFP process
RFPs remain an important process for communities and should drive the innovation so badly needed in the ambulance service market. It is not the 1980s anymore and modern competitive bid processes need to reflect the state of the current science and the design of today’s EMS.
The following recommendations help the process evolve.
RFP Design: Reviewing RFP documents is painful and really makes you feel for the proposal writers and the evaluators who have to read them. RFP documents should be lean and incorporate only what’s necessary to clearly describe the requirements, define the proposal specifications and explain the scoring criteria. Legal requirements and pass/ fail criterion should be clearly identified. Competitive criteria should include clear objectives and constraints, and map directly to a defined scoring rubric.
Standardized RFP documents are acceptable, but the authors must ensure the criterion matches the local context. Carbon copy RFPs don’t serve anybody. Inclusion of local data to assist potential bidders to conduct analysis and produce proposals is strongly preferred.
Research & System Design: While it’s well known that peer-reviewed research on prehospital care and EMS system design is not as robust as we hope, there are papers that should influence RFP design.3 Response time goals are frequently the sole performance standard and evidence is growing that the 8 minute 59 seconds is an antiquated target .4,5,6 There is evidence that the pre-hospital role in key clinical pathways such as ST-elevation myocardial infarction, stroke, cardiac arrest, trauma and sepsis can influence outcomes.7
Criterion should also reflect guidance from the EMS Agenda for the Future, the Institute of Medicine EMS at the Crossroads report and the Baldrige Criteria for Performance Excellence.
Finally, EMS systems are supposed to be for the patient’s benefit, but there is rarely mention of patient experience.
Economics: When developing an RFP, it’s important to understand what the service area can sustain on its own. With a historical call volume and payer mix, it’s possible to calculate the reasonable revenue the system can expect. If the desire is to provide ambulance service without providing tax subsidy, then this number becomes the key calculation to accurately predict a system budget. This calculation is important to informing what is possible for a private provider to accomplish within the constraints of reimbursement. If a community wants more, it needs to be prepared to contribute tax subsidy. Zero subsidy is achievable for many, but it may not be desirable.
Competition: Harnessing the entrepreneurial creativity of the private provider in a competitive process is one of the essential attributes of an RFP. The RFP should provide the specifications and constraints to ensure communities get professional, experienced and reliable service providers, but should limit extraneous requirements that may limit the pool of possible bidders and the number of eventual proposals.
Assessment & Scoring: Evaluation of proposals should be transparent with a clear scoring rubric and inter-rater reliability that reduces the risk of the outcome being contested or overturned.
Conclusion
It’s 2014 and the future opportunities and constraints for EMS systems have changed since the 1980s—so should the RFP process. Creating evidence-based, efficient and reliable system designs that leverage entrepreneurial creativity in a fair RFP process is possible by following a few common sense steps.
Disclosure: The author is an EMS consultant.
References
1. American Medical Response (2008). EMS structured for quality: Best practices in designing, managing and contracting for emergency ambulance service. McLean, VA; American Ambulance Association.
2. Narad, R.A. (2013). California Ambulance RFPs: Evaluation and Scoring. Presented May 30, 2013 to the EMS Administrators’ Association of California.
3. EMS Research agenda for the future.
4. Blackwell, T. H., & Kaufman, J. S. (2002). Response time effectiveness: comparison of response time and survival in an urban emergency medical services system. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 9(4), 288–295.
5. Pons, P. T., Haukoos, J. S., Bludworth, W., Cribley, T., Pons, K. A., & Markovchick, V. J. (2005). Paramedic response time: does it affect patient survival? Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 12(7), 594–600. doi:10.1197/j.aem.2005.02.013.
6. Blackwell, T. H., Kline, J. A., Willis, J. J., & Hicks, G. M. (2009). Lack of association between prehospital response times and patient outcomes. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 13(4), 444–450.
7. Myers, J. B., Slovis, C. M., Eckstein, M., Goodloe, J. M., Isaacs, S. M., Loflin, J. R., et. al. Pepe, P. E. (2008). Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS – Benchmarking. Pre-hospital Emergency Care, 12(2), 141. doi:10.1080/10903120801903793.
David M. Williams, PhD, is a researcher and consultant at the international ambulance service consulting practice Medic Health (@Medic_Health, medichealth.com). He is also an improvement advisor with the Institute for Healthcare Improvement and is the lead prehospital emergency care faculty. He advises organizations to apply improvement science to improve patient access, enhance quality and reduce per capita cost.
