Fifty years ago, the ambulance business in Washtenaw County was up for grabs. Almost anyone with a vehicle big enough for a person to lie down in provided emergency patient transport. That included hospitals, gas stations, taxi companies, and undertakers.
Times change. Regulatory agencies spring up, standards are created, and licensure becomes required. For the past twenty-six years, one community-owned nonprofit, Huron Valley Ambulance (HVA), has been the county’s sole 911 provider of emergency medical services (EMS). It’s also been the only company supplying nonemergency stretcher transport.
But now a would-be rival company, Care Transport, alleges that HVA’s solo status represents an unfair monopoly, a monopoly supported by the Washtenaw/Livingston County Medical Control Authority (MCA)—the agency whose approval is the first step toward licensing by the state.
“They change protocols, add new conditions—we feel there’s been gross bias and deliberate obstruction,” says Therle Dregansky, Care Transport’s quality assurance manager. “There was never any intention to license us.”
Not so, says the MCA’s medical director, Robert Domeier. Domeier prefers a one-provider EMS model, but he insists that if any rival service meets the board’s standards, he and his fellow board members will approve it. “Care Transport didn’t do that,” he says.
Care Transport, headed by Sabah Rabiah, has been providing wheelchair transport for seventeen years. The company first applied for an ambulance license two years ago, after clients—including nursing homes, hospitals, and adult foster care homes—said they wanted an alternative to HVA for nonemergency transport. “For wheelchair transport, we have many options,” says Jody Josephson, who runs an adult foster care home in Dexter. “But for stretcher transport we have one, and there is a very, very long wait. I think citizens have a right to have a choice. Isn’t that how our economy is meant to work?”
HVA says it’s not that simple. “The revenue from our nonemergency calls supports our emergency ambulance service,” says spokeswoman Joyce Williams. The argument is that Care Transport will come in and “cherry pick” the nonemergency calls, most of which are paid for by Medicare, private insurance, or nursing homes themselves, and HVA will be left to cover all the 911 calls, many of which go unpaid. “We write off about a million dollars in emergency care every year,” Williams says. Without the nonemergency call revenue to offset those losses, HVA argues, it will have to ask taxpayers for subsidies to stay operational.
The losers, according to HVA president Dale Berry, will be residents of western and southern Washtenaw County. HVA currently has one ambulance based in Manchester, two in Chelsea, and one advanced-life-support ambulance apiece in Saline and in Dexter. The Dexter ambulance loses $250,000 annually just by itself, says Berry.
Care Transport is unimpressed with that argument. “The idea that we could end up costing them more money—I’m sorry, but one or two ambulances are not going to put them out of business,” says Dregansky. Care Transport says it has no interest in competing with HVA for emergency transport, but the licensing system is one-size-fits-all: the law says that if a company wants to do stretcher transport, it also has to be ready to answer 911 calls.
Among the standards the MCA says Care Transport has been unable to meet are having the right equipment, having enough trained personnel, and being insured as a 911 provider. Dregansky counters that until Care Transport is a licensed ambulance service, neither 911 equipment providers nor insurers will do business with his company. He says it’s a catch-22, designed to keep competitors out of the market. As for personnel, Dregansky says the process has dragged on so long that Care Transport has been unable to keep staff.
“We’ve done nothing but comply with each and every new demand that’s been made,” he says. “But were it not for the fact that a time limit has been placed on this process, I think they would simply come up with new conditions until we ran out of funding or patience or will.”
At the heart of Care Transport’s allegation of bias is the fact that Domeier, the MCA board’s medical director, is also the medical director of Huron Valley Ambulance. The rest of the nineteen-member board is made up of representatives from area hospitals, health departments, and patient transporters, including Roger Simpson, one of HVA’s vice-presidents.
Simpson has abstained from all votes regarding Care Transport. The company argues that Domeier should also abstain. But the system is set up so that Domeier automatically becomes the medical director for any EMS agency in Washtenaw or Livingston county—including HVA and any newcomer like Care Transport—because he is the MCA’s medical director.
“In the end, we [the MCA] are just a bunch of doctors and nurses and service providers trying to do our best,” Domeier says.
On February 22 Care Transport asked the Michigan Department of Community Health, which oversees the state’s EMS commission and the county medical control authorities, to determine whether it is being deliberately kept out of the market. Department spokesperson James McCurtis says the review could take up to a month.