8-0900-8458-2
STATE OF MINNESOTA
OFFICE OF ADMINISTRATIVE HEARINGS
FOR THE MINNESOTA DEPARTMENT OF HEALTH
In the Matter of the Norman County
Ambulance, Ada, Minnesota.
FINDINGS OF FACT,
CONCLUSIONS OF LAW
AND RECOMMENDATION
The above-entitled matter came on for hearing before
Administrative Law Judge Jon L. Lunde commencing at 7 p.m. on
Tuesday, January 18, 1994 at the Dekko Community Center, 4th
Avenue East, Ada, Minnesota. The hearing was held pursuant to a
Notice of Completed Application and Notice of and Order for
Hearing dated December 7, 1993.
William W. Larson, R.N., director of the Norman County
Ambulance Service, Ada Municipal Hospital, 405 East 2nd Avenue,
Ada, Minnesota 56510, appeared on behalf of the Norman County
Ambulance Service. No one petitioned to intervene in this
proceeding and no public testimony was presented in opposition to
the application by interested persons at the hearing. However,
written comments were submitted to the Administrative Law Judge
in opposition to the application after the hearing but before the
January 20, 1994 deadline for submitting written comments set by
the Commissioner of Health. Because the Norman County Ambulance
Service did not have an opportunity to respond to comments
submitted to the Administrative Law Judge after the hearing was
held, copies of those comments were provided to Norman County
Ambulance Service, and it was given an opportunity to respond.
The record closed on February 4, 1994, the last day allowed by
the Administrative Law Judge for the Applicant to respond to
public comments submitted after the hearing but before the
January 20, 1994 deadline.
This Report is a recommendation, not a final decision. The
Commissioner of the Minnesota Department of Health will make the
final decision after a review of the record which may adopt,
reject or modify the Findings of Fact, Conclusions, and
Recommendations contained herein. Pursuant to Minn. Stat.
14.61, the final decision of the Commissioner shall not be made
until this Report has been made available to the parties to the
proceeding for at least ten days. An opportunity must be
afforded to each party adversely affected by this Report to file
exceptions and present argument to the Commissioner. Parties
should contact Mary Jo O'Brien, Commissioner, Minnesota
Department of Health, 717 Delaware Street Southeast, Minneapolis,
Minnesota 55414, telephone (612) 623-5000, to ascertain the
procedure for filing exceptions or presenting argument.
STATEMENT OF ISSUE
The issue in this case is whether the ambulance service
operated by the Ada Municipal Hospital should be upgraded to
authorize it to provide advanced life support ambulance services
throughout Norman County under Minn. Stat. 144.802, subd. 3(g)
(1992).
Based upon all of the proceedings herein, the Administrative
Law Judge makes the following:
FINDINGS OF FACT
1. The Ada Municipal Hospital, located in Ada, Minnesota, is
the only hospital in Norman County, Minnesota. It owns and
operates the Norman County Ambulance Service (NCAS). The NCAS is
currently licensed to provide BLS ambulance service throughout
Norman County, its primary service area (PSA). Ambulance
services are provided from the hospital, which serves as its base
of operation. NCAS operates no substations.
2. Norman County is rectangular in shape. It abuts the state
of North Dakota on the west, Polk County on the north, Mahnomen
County on the east, and both Clay and Becker Counties on the
south. Ada is situated in the northeast corner of the southwest
quarter of the county.
3. The Ada Municipal Hospital took over NCAS approximately
three years ago at the request of the Norman County Board of
Commissioners. Since then, its call volume has increased from
197 calls in 1990 to 565 in 1993.
4. NCAS is the only ambulance service available in most of
Norman County. However, two other ambulance services serve part
of the County: County EMS and Mahnomen Ambulance. County EMS
serves six towns in the northeast corner of Norman County:
Lockhart, Spring Creek, Sundal and Bear Park, which are bounded
on the north by Polk County, and the Towns of Strand and Waukon,
which abut Sundal and Bear Park Towns on the north. County EMS,
based in Fertile, Minnesota, is licensed to provide ALS ambulance
services in Polk County and the six towns in the northeast corner
of Norman County. Fertile is close to the boundary line between
Polk and Norman Counties and is located just north of the Town of
Sundal in Norman County. Mahnomen Ambulance is licensed to
provide BLS ambulance services in the eastern part of Norman
County. The record does not show the precise areas within Norman
County served by Mahnomen Ambulance.
5. The six towns in Norman County served by County EMS
represent one third of County EMS's primary service area. NCAS
has only received approximately four calls from the towns served
by County EMS in the last two years. See, Application Section
VI, Part II, Question 3. There is no evidence in the record that
the services County EMS provides in the six towns is, in any way
inadequate, or that there is a need to license NCAS in that area.
6. County EMS has formed working relationships with
individuals and rescue squads in the six towns and within the
City of Gary. It provides education and training to rescue squad
members. These rescue squads, being first responders, provide
basic life support emergency care until County EMS's ambulance
arrives.
7. The Gary Rescue Squad and County EMS recently established
an early defibrillation program within the rescue squad. The
program requires a physician to serve as the medical director.
County EMS's medical director provides the controls, education
and oversight for that program. Due to County EMS's medical
director's participation in the early defibrillation program, any
patient treated by the Gary Rescue Squad with early
defibrillation equipment must be transported by County EMS. The
Gary Rescue Squad and County EMS jointly purchased a
defibrillator for the program. It uses a data card for recording
the entire patient event. The recording is used by the medical
director for program evaluation and oversight. The
defibrillator's data card is compatible with the data card and
collection system in the medic ambulance so the transfer of care
from the rescue squad to County EMS and the transfer of data is
not interrupted.
8. NCAS has mutual aid agreements with the F-M Ambulance
Service, Inc. of Fargo, North Dakota; Polk County Ambulance in
Crookston, Minnesota; and Mahnomen Ambulance, Mahnomen,
Minnesota. Under these agreements, the other ambulance service
have agreed to provide back-up coverage in Norman County for
NCAS.
9. In 1993, NCAS filed an application to upgrade its license
to the ALS level in order to provide more comprehensive services
to the citizens and visitors of Norman County. There are
approximately 7,975 residents and 4,000 visitors in the county.
The most distant point in Norman County from the Hospital's base
of operations in Ada is 30 miles, and it takes approximately 30
minutes to respond to calls from that point. However, the
average response time for NCAS is 8 minutes. In most areas of
Norman County which are served by County EMS, County EMS can
respond sooner than NCAS. One exception is in the area of Gary,
Minnesota where NCAS can respond about as quickly as County EMS.
10. In Norman County, ambulances are dispatched through a 911
public safety answering point.1 The public safety answering
point in Norman County apparently is the sheriff's office in Ada.
The sheriff either directly dispatches public services, such as
ambulances, or extends, transfers or relays 911 calls to them
under Minn. Stat. 403.02, subd. 5. The record does not show
what the 911 service areas in Norman County are.
11. NCAS does not propose to change existing 911 districting
or dispatching. In those portions of the county served by County
EMS, County EMS will continue to serve persons requesting its
service if existing practices continue; also law enforcement
personnel would only call NCAS if no ambulance
-------------------
1. The emergency telephone system in Minnesota is governed by
Minn. Stat. 403.01 et seq. and rules promulgated by the
Department of Administration. See, Minn. Rules, pt.
1215.0100 et seq. (1991). Under the statute, each county
is required to design a 911 system for police,
firefighting and emergency medical and ambulance
systems.service is requested and NCAS is closer. If the
County EMS is requested or is closer, it would be called
under existing practices. Even when NCAS is called, it
notifies County EMS that it is responding, and County EMS
can respond if it wishes.
12. The Ada Municipal Hospital has specialists in family
practice and internal medicine, but not in cardiology, surgery
and neurology. Therefore, patients needing tertiary-level care
must be transported to Fargo, North Dakota. NCAS seeks an ALS
ambulance license in order to provide these tertiary patients
with a higher level of care en route to the hospital and during
interhospital transfers. From three to five tertiary patients
weekly need ALS ambulance service.
13. NCAS currently has 15 attendants and drivers: eight of
them are Minnesota certified Emergency Medical Technicians
(EMTs), five are Minnesota Paramedics, and two are registered
nurses. Exhibit 4. The compensation paid to NCAS staff will not
increase if NCAS's license is upgraded to the ALS level. NCAS
already staffs the ambulance like an ALS service with at least
two paramedics on call. Although NCAS is a BLS service at this
time, it has received variances for monitor/defibrillation, IVs
and advanced airways. It does not, however, have any
authorization to administer medication.
14. Licensure will not result in equipment changes and no cost
or subsidy increases are anticipated. The public health
generally will benefit from the higher level of care ALS
licensure will enable NCAS to provide, and cost savings should
result because tertiary patients will not have to be transported
by air to Fargo, North Dakota. Also, in cases of cardiac arrest,
for example, NCAS will be able to provide mere vigorous field
treatment if ALS licensure is granted.
15. The Norman County Board has set up an emergency medical
services steering committing that monitors NCAS's overall
management. The steering committee consists of two county
commissioners, the mayor of Ada, a city council person, the Ada
Municipal Hospital's administrator, and the director of emergency
medical services. One of the steering committee's objectives is
to guard against unfair or extreme pricing for ambulance
services.
16. Notice of the completed application and a Notice of and
Order for Hearing were published in the State Register on Monday,
December 20, 1993 and published in the Norman County Index on
Tuesday, December 28, 1993 and Tuesday, January 4, 1994. Also,
the notices were mailed to the Norman County Board of
Commissioners, the Community Health Boards in Rochert and Detroit
Lakes, Minnesota; the governing body of the Regional EMS System
in East Grand Forks; the ambulance services in the Crookston,
Detroit Lakes, Fertile, Fosston, Mahnomen, Red Lake Falls, and
White Earth, Minnesota and Fargo, North Dakota. The notices were
also sent to the mayors of Ada, Borup, Gary, Halstad, Hendrum,
Perley, Shelly, and Twin Valley, Minnesota.
17. The board of Directors of the Northwest Minnesota
Emergency Medical Services Corporation has determined that NCAS
is in compliance with the regional emergency medical services
plan and that the number of its runs which could be classified as
ALS support its license request.
18. The application filed by NCAS is supported by the Norman
County Board, and businesses, individuals and municipalities in
Norman County. Letters of support were filed by the mayor of
Ada, the NCAS steering committee, Twin Valley Women of Today, Ada
Police Department, Multi-County Nursing Service, Ada Medical
Clinic, Ada Municipal Hospital, Halstad Rescue Squad, Wild Rice
Conservation Club of Twin Valley, Twin Valley Rescue Squad, Twin
Valley Lioness Club, Lutheran Memorial Home Corporation (a
nursing home operator in Twin Valley and Halstad), Twin Valley
Booster's Club, Schep's Clothing in Twin Valley, Norman County
Agricultural Society, Volunteer Homemakers Club of Ada, Norman
County Fire Department Association, Jubilee Homemakers of Ada,
Modern- aires Home Study Club of Ada, First State Bank of Ada,
Ada Garden Club, Prairie Dental Centers of Ada, Twin Valley and
Lake Park, Ada Veterans of Foreign Wars, Ada Fire Department,
Norman County Sheriff, City of Perley, City of Hendrum, and the
Shelly Rescue Squad.
19. County EMS objects to the license application insofar as
it would authorize NCAS to provide advanced life support within
the six townships where County EMS is now licensed to provide
those services. The Towns of Waukon, Bear Park, Strand and
Sundal all filed comments indicating their desire to continue
receiving ambulance services from County EMS.
Based upon the foregoing Findings of Fact, the Administrative
Law Judge makes the following:
CONCLUSIONS
1. The Commissioner of the Minnesota Department of Health and
the Administrative Law Judge have authority to consider the
license application filed by Norman County Ambulance Service
under Minn. Stat. 14.50 and 144.802 (1992).
2. Proper notice of the application and of the hearing were
given in full compliance with the provisions of Minn. Stat.
144.802, subd. 3 (1992).
3. The Notice of and Order for Hearing was proper in form and
content and the Department and NCAS have complied with all
relevant substantive and procedural requirements of statute and
rule.
4. NCAS has the burden of proof under Minn. Rules, pt.
1400.7300, subp. 5 (1991) to show that an upgraded license is
needed and will not have a deleterious effect on the public
health. Matter of Rochester Ambulance Service, 500 N.W.2d 495,
498-99 (Minn. Ct. App. 1993).
5. Under Minn. Stat. 144.802, subd. 3(g), the
Administrative Law Judge is required to review and comment upon
the City's application and make written recommendations regarding
its disposition to the Commissioner. In making those
recommendations, the Judge must consider and make written
comments concerning the need for the service proposed based upon
a consideration of the following factors:
(1) the relationship of the proposed service, change in
base of operations or expansion in primary service area to
the current community health plan as approved by the
commissioner under section 145A.12, subdivision 4;
(2) the recommendations or comments of the governing
bodies of the counties and the municipalities in which the
service would be provided;
(3) the deleterious effects on the public health from
duplication, if any, of ambulance services that would
result from granting the license;
(4) the estimated effect of the proposed service, change
in base of operation or expansion in primary service area
on the public health;
(5) whether any benefit accruing to the public health
would outweigh the costs associated with the proposed
service, change in base of operations, or expansion in
primary service area.
5. The ALS ambulance service license NCAS proposes to obtain
is consistent with Norman County's current community health plan
and is supported by the Norman County Board of Commissioners and
many communities to be served.
6. NCAS established that upgrading its BLS license to an ALS
level will enhance the public health in those areas of Norman
County not currently served by an ALS ambulance service.
7. NCAS failed to establish that any need exists for
licensing it at an ALS level in those portions of Norman County
currently provided with ALS services by County EMS, but showed
that a need exists for upgraded services in other parts of Norman
County.
8. Licensure of NCAS in those areas of Norman County
currently served by County EMS could have a deleterious effect on
the public health by jeopardizing the financial viability of
County EMS or fostering competition.
9. The benefits accruing to the public health of citizens in
Norman County outside the areas currently served by County EMS
would outweigh the costs associated with NCAS's proposed upgrade
in its license from BLS to ALS.
Based on the foregoing conclusions, the Administrative Law
Judge makes the following:
RECOMMENDATION
IT IS HEREBY RECOMMENDED: That the Commissioner of Health
grant NCAS an advanced life support ambulance service license for
all of Norman County except that portion currently served by
County EMS.
Dated this day of February, 1994.
JON L. LUNDE
Administrative Law Judge
Reported: Taped
MEMORANDUM
Under Minn. Stat. 144.802, subd. 1, the Commissioner of
Health is empowered to license ambulance services within the
state of Minnesota. When a licensee desires to provide a new
type of service, it must obtain a new license from the
Commissioner. The purpose of the statute was addressed by the
Minnesota Supreme Court in Twin Ports Convalescent, Inc. v.
Minnesota State Board of Health, 257 N.W.2d 343, 348 (Minn. 1977)
where the court stated:
We interpret Minn. St. 144.802 to manifest a legislative
intention to protect the public welfare against
deleterious competition in the ambulance services field.
The provision embodies a legislative determination that
the ambulance service business is one in which the public
welfare is not promoted by free enterprise. Ambulance
service is essential to a community. It is also a service
for which demand is inelastic and expenses largely fixed.
Where the demand is insufficient to support additional
services, either quality is sacrificed or rates and public
subsidies are increased, but in either event, the
taxpayer-consumer suffers.
Accord Matter of Rochester Ambulance Service, 500 N.W.2d 495, 499
(Minn. Ct. App. 1993).
The application filed by NCAS to provide advanced life support
ambulance services in all of Norman County should not be granted
because NCAS failed to show that its proposed level of service is
needed in those areas of Norman County currently served by County
EMS. County EMS already provides ALS ambulance services in its
primary service area. There is no evidence that County EMS is
not meeting the needs of the public in those portions of Norman
County where it is licensed to provide ALS ambulance services or
that NCAS can provide better services to those areas. In fact,
the contrary is true. County EMS can serve the areas it is
licensed to serve quicker than NCAS can serve them. Moreover,
the demand for NCAS's services in the areas served by County EMS
is virtually nonexistant as is evidenced by the fact that it
receives only two requests for ambulance services annually in
those areas.
Although the application filed by NCAS received widespread
support, it did not receive support from those areas of the
county currently served by County EMS. In fact, the towns served
by County EMS have requested that their ties to County EMS not be
disrupted. Also, NCAS has indicated that it does not intend to
change existing use patterns in those areas served by County EMS.
In other words, in its view, County EMS would still be dispatched
to those areas of Norman County it is licensed to serve. If NCAS
does not intend to provide any significant ambulance service in
those areas of the county served by County EMS, there is no
reason to conclude that it should be licensed to provide services
in those areas. If County EMS needs backup, it can enter into a
mutual aid agreement with NCAS or NCAS can provide services under
Minn. Rules, pt. 4690.3500 (1991) without a license.
NCAS failed to establish that its county-wide licensure will
not have a deleterious effect on the public health. The record
indicates that one third of County EMS's service area consists of
six towns in Norman County. If NCAS started competing with
County EMS to serve those six towns, if the sheriff changed the
manner in which emergency calls are relayed, or if the public
began to use NCAS instead of County EMS in those areas,
deleterious competition could result. This could threaten the
economic viability of County EMS, increase costs, or result in
unnecessary duplication of services. For all these reasons, the
Administrative Law Judge is persuaded that NCAS has failed to
establish that its license should include those areas of Norman
County currently served by County EMS.
Apart from the areas currently served by County EMS, NCAS
showed that it should be authorized to upgrade its current BLS
license to an ALS level. The upgrading it seeks is supported by
the Norman Board of Commissioners and municipalities in the
County as well as a significant number of rescue squads, business
organizations, social organizations, and citizens. Apart from
those areas currently served by County EMS, granting an ALS
license to NCAS would enhance the public health because it will
enable NCAS to provide timely medical services it cannot now
provide. Without a variance, BLS ambulance services cannot use
esophageal obturator airways, cardiac monitors or difibrillators,
establish or maintain intervenous therapy or intervenous
infusion, and cannot administer drugs other that oxygen, syrup of
ipecac and nonprescription drugs. Minn. Rules, pt. 4690.0800,
subps. 2 and 4 (1991). NCAS has variances for intervenous
therapies, esophagealobturator airways, and cardiac
monitors/defibrillators, but not for the administration of drugs.
The ability to administer drugs to persons experiencing heart
attacks, chest pain, strokes, insulin shock, asthmatic problems,
chronic obstructive pulmonary disease, and injuries, will clearly
enhance the public health. This is especially true in an area
like Norman County which has only one hospital and where it may
take up to an hour or more to get an ambulance to a patient and
return the patient to the hospital for treatment. The ability to
administer drugs to those patients under detailed protocols and
oversight by qualified medical personnel will be an obvious
benefit to citizens in the county. Prompt and thorough treatment
will not only help save lives but will also help to reduce the
seriousness of some injuries which, in the long run, will save
costs.
The proposed licensure will not involve any significant cost
increases. NCAS is currently staffing at ALS licensing levels
and is providing many of the services ALS licensed ambulance
services can provide to patients. Furthermore, no new equipment
purchases will be required. Therefore, it is concluded that the
benefits to the public health of citizens in Norman County
outside the area served by County EMS substantially outweigh the
costs associated with the higher level of service NCAS proposes
to provide.
On the basis of the entire record, the Administrative Law
Judge is persuaded that the license application filed by NCAS to
provide advanced life support ambulance services in Norman County
should be granted but that the primary service area should be
limited to those parts of Norman County not currently served by
County EMS.
JLL