A dulcet but definitive voice scratches on the loudspeaker, echoing through the multi-bay garage ground floor of Colorado Springs’ oldest, busiest firehouse.

“Truck respond, medical assist.”

And so the firefighters of Station 1 do.

In one of the few major U.S. metro areas that still contracts with a private company for ambulance services, the first emergency medical technician or paramedic assessing and treating patients on scene nonetheless usually arrives on a fire engine.

With 24 (soon 25) fire stations strategically located around a sprawling and growing city, a fire EMS crew is simply often closer when crisis occurs. Their crews can respond quickly and are fully qualified and equipped to begin basic or advanced life support services while awaiting the arrival of an ambulance from American Medical Response, and patient transport to the hospital.

“Whoever gets there first, your care level is going to be the same, whether it’s AMR or fire,” said Curt Crumb, president of Colorado Springs Professional Firefighters union Local 5 and a firefighter in the Springs for almost 30 years. “The one difference is we have more people on a truck than they have in an ambulance.”

To be fair, there are other differences between the private ambulance company, which earns its revenue from insurance reimbursements, and the equally qualified crews, funded primarily by local tax dollars, tasked with responding to the breadth of emergencies, fire, traffic and medical, in a city of almost 500,000.

When delays can mean the difference between life and death, seconds count — and cost.

According to its contract with the city, when AMR responds to calls after certain established maximum response times, the company must pay “damages.”

Data show the company paid the city more than $5.7 million — largely for delayed response times — between April 2020 and January 2024.

In just 12 months in 2022, the company racked up nearly $3.5 million in damages.

With AMR’s contract due to expire in 2025, city leaders have been quietly exploring — again — the feasibility of launching a government-run ambulance service.

The plan has a number of fans, including Crumb, Colorado Springs Mayor Yemi Mobolade and Fire Chief Randy Royal.

“We do fully believe (an in-house ambulance service) is the right thing for our system, to make it more efficient and effective. … We do believe that contract can be met and we’re 100% confident we can meet it,” Royal said.

For others, the reality begs a number of questions, including about longer-term budget math they say just doesn’t add up.

AMR’s performance in Colorado Springs

For its part, American Medical Response, the nation’s largest private ambulance service company, would prefer things stay as they are.

Monthly performance and compliance reports provided by the Colorado Springs Fire Department from April 2020 through January 2024 show AMR largely met performance requirements for emergent and non-emergent calls from April 2020 through July 2021, and generally in the year between January 2023 and January 2024.

Data show the company failed to meet its required performance in urban and suburban areas almost every month beginning in August 2021 and throughout 2022.

The company in a written statement attributed the “significant impacts” in AMR’s operations to staffing shortages and “other challenges that were beyond our reasonable control” throughout the COVID-19 pandemic in 2020, 2021 and most of 2022.

Under its contract, AMR must respond 90% of the time to emergent calls using lights and sirens within 8 minutes to 16 minutes, depending whether the call is made to an urban, suburban or rural area.

For varying types of non-emergent calls that do not use lights and sirens, AMR must respond 90% of the time within 15 minutes to 25 minutes, depending on the type of call and the area type.

As to the parts of its record that are harder to defend, the company promised to improve.

The company said it has taken “significant steps” in the last two years to enhance its operational ability, including implementing a program where AMR pays to send its EMTs to paramedic school; implementing mandatory overtime and pay raises; offering sign-on and retention bonuses; and changing its leadership structure.

The switch in Manitou Springs

For Manitou Springs, promises to improve weren’t enough. Last year, it joined a growing number of Colorado Springs’ near neighbors, including Black Forest and Falcon, to switch to an in-house ambulance service.

When its contract with AMR expired in early 2023, Manitou responded to years of concerns and complaints about delayed response times by creating the Emergency Medical Services Transport Division.

In March 2023, that division’s rotating, 24/7 staff of four — two of whom are dedicated to EMS transport each shift — took over as the city’s emergency medical responders, with AMR on call as backup should local crews be busy with other emergencies.

Response times immediately dropped more than 50%, from an average of more than 11 minutes to five minutes and 23 seconds, according to annual reports from the city.

“I can tell you unequivocally, without any doubt in my mind, that because of the faster response times we have saved lives,” said Manitou Springs Fire Chief John Forsett.

Forsett said his department was “lucky” to have resounding support from city leaders and residents, as well as guidance from municipalities that had faced similar inflection points, including some “peers” in his larger and more populous neighbor to the east.

Transitioning a city of roughly three square miles and 4,700 residents to an in-house ambulance service didn’t happen overnight, and it wasn’t cheap.

Start-up and recurring costs “were and are quite substantial for our small community,” said city spokesman Mitchell Carter.

In 2023, Manitou Springs supported a line-item budget of $768,000 for personnel and equipment, with an additional $155,000 budgeted for capital expenses for initial start-up costs for ambulances and equipment. Ongoing funding for Manitou’s EMS Transport Division comes from the city’s general fund, currently as part of the annual budget, with costs offset by revenues recovered from patient billing, largely from insurance providers.

What would it cost in the Springs?

According to Colorado Springs Fire Department financial projections, the new enterprise could cost the city just over $11.5 million to start up. The department expects those expenses to be covered by a loan and by possible donations from local philanthropic groups, Royal said.

Financial projections for the years 2025 to 2033 show the enterprise would cost between about $14.1 million annually to about $30.8 million annually, with costs generally growing each year. Colorado Springs projects it will make a profit each year, expecting the enterprise to bring in a range of about $2.6 million to about $7.4 million a year, after expenses.

Rather than earnings going to a private ambulance service contractor, that’s money that benefits the city and “increases resources and lowers response times,” Royal said.

Under the current contract, AMR reimburses ambulance-related costs the city incurs to the tune of $1.4 million a year. That money goes into Colorado Springs’ general fund and pays for services like medical direction and oversight, first responder assistance, contract administration and dispatch services, among others.

“We would no longer receive that $1.4 million from AMR, but with the amount of profit we would be receiving (from an in-house ambulance service), it wouldn’t be needed,” CSFD’s Fire Chief of Operations Jayme McConnellogue said.

Some department positions paid for in the general fund will be moved to the new enterprise, “so there is no loss to the city’s general fund,” Royal said.

City Councilman Brian Risley, however, said he is concerned the Fire Department is over-projecting what it will receive in net revenues per transport, a key financial component of predicted revenues. It is the amount an ambulance service provider receives, on average, for each patient ambulance transportation.

Colorado Springs Fire Department projects it will receive about $755 per transport in 2025, with that amount steadily growing to a projected $969 in 2033.

AMR did not provide an exact figure, but said the city’s projected revenue per transport is way off.

“With decades of experience in operations and billing, AMR Colorado Springs realizes a net revenue per (transport) significantly below what Colorado Springs Fire Department is proposing,” AMR said in a written statement.

Risley said his own analysis, using financial data AMR provided to him, showed the company is currently receiving a net revenue per transport that is 30% less than what the Colorado Springs Fire Department projects it will receive.

“My concern is if (a city ambulance enterprise) is not viable, and if it’s not viable by a significant factor, it means in a few years the general fund or some other fund is going to have to start backfilling the losses or potential losses,” Risley said.

A provider of 911 billing services in Colorado, who wished to remain anonymous due to “potential conflicts of interest,” called CSFD’s expected ambulance transport revenues “aggressive.”

“It’s not realistic for any large municipality in the state to collect that kind of money, not just Colorado Springs,” he said.

Apples to apples?

Richard Buchanan, a project manager and independent consultant working with Colorado Springs, who has consulted on fire-based ambulance services across the country, said private emergency medical service entities like AMR and public enterprises such as the one Colorado Springs is exploring aren’t comparable.

“They are very, very different, so it’s almost impossible to compare the finances of one to the other,” he said.

Colorado Springs determined its financial projections using the same national models Buchanan uses to determine payer mix, or the amount of Medicare, Medicaid, commercial insurance or self-payers in a community; reimbursement rates; and costs for services, he said. The city’s projected costs also don’t include another $6 million Buchanan expects it will receive in federal subsidies designed to cover the gap between what a publicly owned ambulance service bills Medicaid for transports and what it actually receives.

“Financially, this isn’t a big question. … The projections Colorado Springs has are pretty conservative,” Buchanan said.

AMR said its transport calculation includes the total number of transports, payer mix, charged rates and reimbursement rates, as do Colorado Springs’ calculations.

“These variables remain consistent regardless of an organization being public or private for the city service area,” AMR’s statement said.

What’s next?

Of course, AMR has a dog in this fight. And, it’s been here before.

Complaints about the company and delayed responses led Colorado Springs to try to change providers ahead of the current contract cycle, which began in April 2020. That plan fell through late in the game.

Not having ambulance service wasn’t an option, so AMR was back.

The Fire Department hopes to bring forth an ordinance proposing a city-run ambulance service in the coming weeks or months, Royal said in a written statement.

The Colorado Springs City Council must then vote on the proposal to create a new enterprise.

Mayor Mobolade made it clear last week, in an interview with The Gazette, where his feelings on the issue lie.

“This provides us a very good opportunity to put this responsibility completely in the hands of our public servants (the Fire Department) who are the best at doing this, and who are also tasked by (city) code with doing this,” Mobolade said. “As we come to the end of this contract, we’re asking the question, ‘Who is the best entity to take this on?’ Really, it’s the city of Colorado Springs and our fire department.”