By Jim Doyle
The San Francisco Chronicle

SAN FRANCISCO — San Francisco's public health director has decided to invite additional private ambulance firms to help the Fire Department cover 911 emergency medical calls on the city's streets.

The decision by Dr. Mitch Katz to establish a "nonexclusive zone" for emergency ambulance services follows a recent state ruling that advised the city to put those services to competitive bid.

But the health czar has balked at preparing a bid package for 911 medical services, a move that experts warned could create logistical problems and lower the quality of services, with private firms vying to serve neighborhoods where there are fewer homeless and uninsured patients.

"This is the worst of all the solutions they could pick," said Richard Narad, a professor of health and community services at Chico State University who is an expert on California ambulance law.

"You will have a system that will cost more, that will be less accountable and provide a lower level of service. And I don't understand why Katz would decline to put it out to bid, which would result in a provider who meets county standards and is accountable to the public and is likely to cost less."

Narad said such competition for patients creates a highly expensive dispatch dilemma of determining which ambulance is closest, and will also result in an increasing number of ambulances flooding into the system — which will lead to higher costs that will be passed on to consumers.

But Katz said dispatching the closest available ambulance to 911 calls will help reduce response times, especially in outlying areas that are not close to a fire station.

On July 31, the state's Emergency Medical Services director, Dr. Steve Tharratt, ruled that San Francisco's 911 ambulance services, which have been dominated by the Fire Department since 1997, do not qualify for antitrust protection from the state because of a lack of competition among the city's emergency ambulance providers.

Tharratt said private ambulance firms handle fewer than 2.4 percent of the city's 911 ambulance services.

The state ruling has sparked consternation among Fire Department administrators, fire and paramedic union leaders and two private ambulance firms that already provide backup emergency ambulance services in the city.

"Effective immediately, San Francisco will no longer maintain an exclusive ambulance zone," Katz wrote in an Oct. 3 letter to Fire Chief Joanne Hayes-White. "If there are additional EMS providers who meet the requirements for advanced life support ambulance services, we will welcome them into our system ... Having additional providers may enhance our system by providing additional capacity."

Katz said in a telephone interview Monday that the city was in "a weak position" to challenge the state's ruling. He also said that, with his creation of an open system for qualified ambulance providers, the state has no grounds to require a competitive bid process.

"Providing pre-hospital care is part of our core mission, and we're devoted to it," Hayes-White said. "We're not going to change the way we do business at all."

David Nivens, president of the California Ambulance Association, said that he was unaware of another urban area in California that has successfully operated a nonexclusive zone for emergency ambulance services. But, he added: "I would think that San Francisco would be an attractive market ... It's small and there's a large population there."

David Andersen, a quality improvement expert in 911 ambulance services who worked previously for the San Francisco Fire Department, said that private ambulance firms may resort to "cream skimming" — only responding to calls in neighborhoods where patients are more likely to afford these services.

John Hanley, president of firefighters union Local 798, questioned the qualifications of outside ambulance firms and the impact Katz's decision will have on the city's revenues.

"We have extremely high standards on patient care," he said. "Do the ambulance companies that will be doing this work have our standards on patient care?"

Private ambulance firms were skeptical about Katz's latest move.

"We'd hate to go back to the ambulance wars of years gone by," said Jerry Souza, general manager of American Medical Response, which already provides backup 911 ambulance services in the city. "Ultimately, we're concerned about quality and a dilution of levels of competencies by new providers who might come in."

Copyright 2008, The San Francisco Chronicle