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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 833

1 BEFORE THE OFFICE OF ADMINISTRATIVE HEARINGS

2 IN THE MATTER OF: )

3 ) Hellsgate Fire District ) No. 2017A-EMS-0006-DHS

4 dba Rim Country Fire and ) Medical Service, ) (EMS No. 4163)

5 ) Applicant. )

6 ____________________________)

7

8 At: Phoenix, Arizona

9 Date: December 15, 2016

10

11

12

13 REPORTER'S TRANSCRIPT OF PROCEEDINGS

14

15 VOLUME 4 (Pages 833 through 1116)

16

17

18

19 COASH & COASH, INC.

20 Court Reporting, Video & Videoconferencing 1802 N. 7th Street, Phoenix, AZ 85006

21 602-258-1440 [email protected]

22 Prepared By: JODY L. LENSCHOW, RMR, CRR

23 Certified Reporter Certificate No. 50192

24

25

COASH & COASH, INC. 602-258-1440 www.coashandcoash.com Phoenix, AZ

2017A-EMS-0006-DHS VOLUME 4 12/15/2016 834

1 INDEX TO EXAMINATIONS

2 WITNESS PAGE

3 EDWARD RACHT, M.D.

4 DIRECT EXAMINATION BY MS. FICKBOHM 841 CROSS-EXAMINATION BY MR. RAY 895

5 CROSS-EXAMINATION BY MR. MEYERSON 902 REDIRECT EXAMINATION BY MS. FICKBOHM 931

6 RECROSS-EXAMINATION BY MR. MEYERSON 935

7 DOUG JONES

8 DIRECT EXAMINATION BY MS. FICKBOHM 936

9 CROSS-EXAMINATION BY MR. RAY 958 CROSS-EXAMINATION BY MR. MEYERSON 970

10 REDIRECT EXAMINATION BY MS. FICKBOHM 993 EXAMINATION BY ALJ SHEDDEN 994

11 RECROSS-EXAMINATION BY MR. MEYERSON 996

12 ALAN MAGUIRE


14 CROSS-EXAMINATION BY MR. MEYERSON 1008

15 RICHARD BARTUS


17 CROSS-EXAMINATION BY MR. RAY 1051 CROSS-EXAMINATION BY MR. MEYERSON 1056

18 REDIRECT EXAMINATION BY MS. FICKBOHM 1070

19 JIM ROEDER


21 CROSS-EXAMINATION BY MR. MEYERSON 1084

22 JOHN VALENTINE


24

25


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 835

1 INDEX TO EXHIBITS

2 NO. DESCRIPTION OFFERED ADMITTED

3 Exhibit LLA-3a "Prevalence of 878 878 Hyperventilation in

4 Intubated Patients with Closed Head

5 Injuries in the Prehospital Setting"

6 Exhibit LLA-3aa Chest Pain - Pain 877 877

7 Decrease Chart

8 Exhibit LLA-3cc AMR World CPR Challenge 876 876 Summary (2016 results)

9 Exhibit LLA-3dd "Do EMS Providers 868 868

10 Accurately Ascertain Anticoagulant and

11 Antiplatelet Use in Older Adults

12 with Head Trauma?"

13 Exhibit LLA-3ee AMR Infographics (2016) 861 861

14 Exhibit LLA-3ff CDC-SOP for patient 865 865 handoffs (ground

15 ambulance)

16 Exhibit LLA-3gg CDC-SOP for patient 866 866 handoffs (air to

17 ground ambulance)

18 Exhibit LLA-3j 2013 Poster, Mobile 855 855 Integrated Healthcare

19 Practice

20 Exhibit LLA-3k "Mobile Integrated 856 856 Healthcare Practice:

21 A Healthcare Delivery Strategy to

22 Improve Access, Outcomes, and Value"

23 Exhibit LLA-3l "EMS at the Healthcare 858 858

24 Table"

25


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 836

1 INDEX TO EXHIBITS CONTINUED


3 Exhibit LLA-3n "An Evidence-Based 881 881 Prehospital Guideline

4 for External Hemorrhage Control"

5 Exhibit LLA-3p Medtronic 858 858

6 Philanthropy's "Principles for

7 Establishing a Mobile Integrated Healthcare

8 Practice"

9 Exhibit LLA-3r PIM & PIT description 864 865

10 Exhibit LLA-3u What Really Matters - 864 864 Bourn article

11 Exhibit LLA-3w 2013 SCA Facts AMR 871 871

12 (2012 Data)

13 Exhibit LLA-3x 2014 SCA Facts AMR 874 874 (2013 Data)

14 Exhibit LLA-3y 2015 SCA Facts AMR 875 875

15 (2014 Data)

16 Exhibit LLA-3z 2016 SCA Facts AMR 875 875 (2015 Data)

17 Exhibit LLA-5c ADHS's Director's 1093 1093

18 Final Decision dated 01-26-2016

19 Exhibit LLA-13a Doug Jones Resume 940 940

20 Exhibit LLA-13b Rich Bartus Resumé 1019 1019

21 Exhibit LLA-13e Dr. Racht Resumé 849 849

22 Exhibit LLA-13g Jim Roeder Resumé 1075 1075

23 Exhibit LLA-13h John Valentine Resumé 1091 1091

24 Exhibit LLA-13k Alan Maguire Resumé 1001 1001

25


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 837

1 INDEX TO EXHIBITS CONTINUED


3 Exhibit LLA-14 CON 58 and City of 1077 1078 Payson Response Times

4 Exhibit LLA-20 IAE&P letter to DHS 1103 1103

5 10-13-16

6 Exhibit LLA-27 Hellsgate ARCR 1041 1041 Comparative Analysis

7 12/9/16

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 838

1 BE IT REMEMBERED that the above-entitled

2 and numbered matter came on regularly to be heard

3 before the Office of Administrative Hearings, 1400 West

4 Washington Street, Suite 101, Phoenix, Arizona,

5 commencing at 8:31 a.m. on the 15th day of December,

6 2016.

7 BEFORE: Administrative Law Judge Thomas Shedden

8

9 For the Applicant:

10 THE MEYERSON LAW FIRM, P.L.C. By Mr. Jeffrey Meyerson

11 2555 E. Camelback Road, Suite 140 Phoenix, Arizona 85016


13

14 For the Intervenor:

15 FLETCHER, STRUSE, FICKBOHM & MARVEL, PLC Ms. Ronna L. Fickbohm

16 6750 N. Oracle Road Tucson, Arizona 85704


18

19 For Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System:

20 OFFICE OF THE ATTORNEY GENERAL

21 Education and Health Section Mr. Kevin D. Ray

22 Ms. Molly Bonsall Assistant Attorney General

23 1275 W. Washington Street Phoenix, Arizona 85007-2926


25


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 839

1 ALJ SHEDDEN: All right, good morning.

2 We are on the record in the matter of Hellsgate Fire

3 District dba Rim Country Fire and Medical Service,

4 applicant. This is Docket No. 2017A-EMS-0006-DHS.

5 Today is December 15, 2016. It's about 8:30 a.m. My

6 name is Administrative Law Judge Thomas Shedden. I've

7 been assigned by the Office of Administrative Hearings

8 to preside over this matter.

9 This is our fourth day of hearing, so

10 I'll just remind you that I've got the recording

11 device on. We're creating a transcript as well as

12 we go forward, so we've got to avoid interrupting

13 each other or talking over one another, that sort of

14 thing. We don't get a clear recording or transcript

15 if we don't adhere to that. So be aware of that,

16 please.

17 Also, the only food or drink allowed in

18 the hearing room is water. And I'll remind you there

19 should be some evaluation forms around if any or all of

20 you want to give our Director feedback on how we're

21 doing.

22 Let me just again ask if there's anyone

23 with you today you would like to introduce who you

24 haven't previously and/or if there are any preliminary

25 issues that you feel we need to address?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 840

1 No? All right.

2 Where we left off, we were going to go

3 to Life Line's presentation, so it looks like it will

4 be Dr. Racht first, correct?

5 MS. FICKBOHM: That's right, Your Honor.

6 ALJ SHEDDEN: All right. Why don't you

7 come on up.

8 THE WITNESS: Good morning.

9 ALJ SHEDDEN: Good morning. Let me go

10 ahead and get you sworn in, so if you would raise your

11 right hand.

12

13 EDWARD RACHT M.D.,

14 called as a witness on behalf of the Intervenor herein,

15 having been first duly sworn by the Administrative Law

16 Judge to speak the truth and nothing but the truth, was

17 examined and testified as follows:

18

19 ALJ SHEDDEN: All right. Go ahead and

20 state and spell your name for our record, please.

21 THE WITNESS: It's Edward Racht,

22 R-A-C-H-T.

23 ALJ SHEDDEN: All right. And I don't

24 know that you've been here the last few days, but

25 you've participated in our hearings before, I do know


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 841

1 that. Kind of do a round-robin, starting with

2 Ms. Fickbohm's questions, and then going to the

3 attorneys for DHS and the applicant here, Hellsgate,

4 give them a chance to ask you whatever questions they

5 may have.

6 So do you have any questions or concerns

7 about how we're going to go forward this morning?

8 THE WITNESS: I do not.

9 ALJ SHEDDEN: All right. Whenever

10 you're ready, Ms. Fickbohm.

11

12 DIRECT EXAMINATION

13 BY MS. FICKBOHM:

14 Q. Good morning, Dr. Racht.

15 A. Good morning.

16 Q. Could you please tell the Judge what your

17 current professional position is?

18 A. So I'm the Chief Medical Officer for American

19 Medical Response and the Associate Medical Officer for

20 Evolution Health, which is an entity under Envision

21 Healthcare.

22 Q. I would like to talk to you about the career

23 path that led you to where you are today. So tell me

24 when you first became involved in emergency medical

25 services.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 842

1 A. So I had my first role in emergency medical

2 services in 1987; was involved in the Richmond

3 Ambulance Authority and had a faculty position at the

4 Medical College of Virginia and became medical director

5 for a multitude of volunteer and career Fire Department

6 and EMS entities in Virginia.

7 My path took me west to Texas, where I became

8 the full-time medical director for the City of Austin,

9 Travis County EMS system. I served in that capacity

10 for 13 years.

11 Q. And let me interrupt you there for a second.

12 I forgot the preliminary for that.

13 You are a licensed physician?

14 A. I'm a licensed physician.

15 Q. And in what states are you licensed?

16 A. Currently licensed in Texas and Virginia.

17 Q. And when you started the position in Virginia

18 that you first told us about, were you a licensed

19 physician at that time?

20 A. I was a licensed physician at that time.

21 Q. Okay. So after your Austin position, you

22 went there?

23 A. After Austin I took a Chief Medical Officer,

24 Vice-President of Medical Affairs position at -- in

25 Piedmont Healthcare in Atlanta at Piedmont Newnan


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 843

1 Hospital in Georgia. And then from there joined

2 American Medical Response in 2010.

3 Q. 2010.

4 And can you tell us, generally speaking, what

5 your duties involve?

6 A. So my role involves, really, clinical

7 advocacy, facilitation. We have 130-plus medical

8 director -- physician medical directors throughout AMR

9 nationally, actually internationally, now. So I work

10 with those individuals. I work with healthcare systems

11 to really take the medical literature, the evidence,

12 the practice in emergency medical services, and

13 together formulate good operational approaches to

14 managing patients in a multitude of environments.

15 So facilitation, clinical conscious might be

16 a good term, advocacy for patient care, the science,

17 the evidence, oversight of our research efforts. So

18 we've got several -- have had several research projects

19 in the past as well.

20 Q. And is this all prehospital medicine?

21 A. So it has historically been prehospital

22 medicine. So the overwhelming majority is. Now some

23 of that is posthospital medicine. So in the newer

24 arena it's the EMS entity, the term mobile integrated

25 healthcare, where paramedics, EMTs, nurses and


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 844

1 practitioners would see patients in conjunction with

2 the healthcare system after they've been discharged, so

3 out of hospital.

4 Q. And with regard to mobile integrated

5 healthcare, which we also refer to as community

6 paramedicine, correct?

7 A. They are similar.

8 Q. Similar.

9 What has American Medical Response's role in

10 the national mobile integrated healthcare/community

11 paramedicine program discussions been?

12 A. So we've been very involved in that. As a

13 matter of fact, there's a JEMS article that we

14 published with the terminology of mobile integrated

15 healthcare group of AMR and non-AMR and practitioners

16 that talked about mobile integrated healthcare.

17 We have been very involved with exploring the

18 metrics associated with it, the credentialing, the

19 practices, the approaches, deployment strategies, level

20 of practitioner that's appropriate for level of care.

21 We offer some form of mobile integrated

22 healthcare program in about 38 or 39 AMR practices

23 nationally. We have published with the Medtronic

24 Foundation the guidebook, the playbook for mobile

25 integrated healthcare implementation. We've partnered


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 845

1 with the International Association of Fire Chiefs on a

2 webinar on mobile integrated healthcare.

3 So we're very involved in its evolution, in

4 its beginnings and kind of working with our colleagues

5 to figure out what works best in kind of the changing

6 world of healthcare.

7 Q. And is that evolution still underway?

8 A. That evolution, Counselor, will be underway

9 till all of our families are long, long gone. So it

10 will constantly be changing.

11 Q. I want to back up and just pin down a couple

12 terms you used.

13 When you say "a JEMS article," what is that?

14 A. I'm sorry. It's Journal of Emergency Medical

15 Services.

16 Q. And is that an important journal in your

17 field of medicine?

18 A. It's one of two journals that are very

19 commonly referred to for kind of current practices in

20 emergency medical services. EMS World is the -- EMS

21 Magazine is the other one.

22 Q. And you referenced the Medtronic Foundation

23 Playbook. What is that?

24 A. So the Medtronic Foundation Playbook is a --

25 it's a published document, a consensus document of a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 846

1 group of providers, again, within AMR and outside of

2 AMR, who came together to really try and encapsulate

3 and summarize principles of mobile integrated

4 healthcare, practice approaches, and clinical metrics

5 that were important.

6 And Lynn White, one of our colleagues in

7 American Medical Response, was the principal author of

8 that document.

9 Q. You testified that 38 to 39 AMR practices

10 nationwide are currently doing mobile integrated

11 healthcare, correct?

12 A. That's correct.

13 Q. Are you aware of any organization or entity

14 that's doing more than AMR is?

15 A. I am not aware of any organization that does

16 more mobile integrated healthcare sites than AMR.

17 Q. I'm going to come back to mobile integrated

18 healthcare in just a second, but I want to finish with

19 your background and experience.

20 I have up in front of us what's been marked

21 for purposes of identification as Life Line Ambulance

22 LLA-13e, even though it says AMR-13 at the top. And

23 this is your professional qualifications?


25 Q. And at the end of Page 1 we have your


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 847

1 certifications, and then on Page 2 your education and

2 then a long list of awards and honors, correct?


4 Q. And then after that is followed by -- well, I

5 want to go just back to the awards and honors for just

6 a second.

7 In 2015 you received the Pinnacle Dr. Joseph

8 Ornato Award for Clinical Leadership. Tell me what

9 that is.

10 A. So Dr. Joe Ornato is the chair of emergency

11 medicine at Virginia Commonwealth University. He was

12 my mentor. He hired me into emergency medicine when I

13 was a little puppy at the time. And he has been

14 instrumental in resuscitation research, in emergency

15 medical services. And the Fitch & Associates Group for

16 Pinnacle established an award in his honor, with his

17 contributions to emergency medicine, and I was the

18 first -- very honored to be the very first recipient of

19 that award in 2015.

20 Q. I'm not going to have you detail any of your

21 other awards. It would just take all day.

22 You've already summarized your professional

23 path.

24 You also have held a variety of academic

25 positions, as detailed beginning on Page 3, correct?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 848


2 Q. Some continuing to today.

3 And then you have other background in

4 emergency medical service that starts on Page 4 of your

5 CV, correct?


7 Q. You also have listed for us your work in

8 international medical care. And starting on Page 6,

9 maybe -- what did I do? I went all the way to the end.

10 Sorry. We have the committees and boards that you have

11 served on and continue to serve on, correct?


13 Q. And that includes the Institutional Review

14 Board for the National Academies of Emergency Dispatch,

15 correct?


17 Q. And after that, starting on Page 9, we have

18 your publications that you have either authored or been

19 involved in the authoring of, correct?


21 Q. And I think that takes up about five pages,

22 if I'm right.

23 On here it says "Poster Presentation." Can

24 you explain to us what that is?

25 A. Poster presentations are academic approaches


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 849

1 where a study or a message is encapsulated in a poster,

2 a single poster, in abstract form, that usually at

3 professional meetings individuals will present their

4 poster. It's often a precursor for a fully published

5 article.

6 Q. And this includes one you did in 2001 for a

7 comparison of ambulance driving times with and without

8 lights and sirens, correct?


10 Q. Because not every ambulance response requires

11 a lights and sirens -- lights and siren utilization,

12 correct?


14 Q. I'm not going to ask you to go through that.

15 Your resumé, I believe, speaks for itself.

16 MS. FICKBOHM: I would move for

17 admission of LLA-13e, Your Honor.

18 ALJ SHEDDEN: Is there any objection on

19 13e?

20 MR. MEYERSON: No objection.

21 ALJ SHEDDEN: 13e is admitted.

22 BY MS. FICKBOHM:

23 Q. Going back to mobile integrated healthcare,

24 tell us what the challenges are associated with putting

25 a mobile integrated healthcare program in place,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 850

1 particularly in a small or rural community.

2 A. So if I could, I would start with kind of the

3 global challenges of mobile integrated healthcare.

4 Q. Sure.

5 A. And then maybe drill down to different

6 venues.

7 The concept behind mobile integrated

8 healthcare, it's a funny terminology, but it fits best.

9 It's kind of the 910 and the 912 of 911. So it is

10 designed to use the skill set, the resources, the

11 deployment, the availability of a traditional EMS

12 system to prevent utilization of 911, Emergency

13 Department visits, to try and manage patients before

14 they deteriorate to the point that they need an acute

15 level of care.

16 On the flip side, the 912 part, the concept

17 is that those same individuals, with the right

18 training, with the right credentialing, would provide

19 postacute care. So they would go to the patient's

20 home, to wherever the patient was. In some communities

21 they would reach out to find homeless patients to try

22 and manage them postevent, but to try and create a

23 transition that improves their health.

24 So the idea is to use the brain power, the

25 skill set, the resources of an EMS system to help


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 851

1 prevent the use of the acute side.

2 It depends on many, many factors, and I've --

3 in my career, short time that MIH has been around,

4 there are no two mobile integrated healthcare programs

5 that are the same, but they are designed to be able to

6 manage a certain population.

7 In an urban environment, the volume of

8 patients would allow for that mobile integrated health

9 component to be relatively busy if it's a dedicated

10 approach.

11 In an urban -- sorry. In a rural or frontier

12 environment, the challenges that many see are being

13 able to access patients. There is a lot of drive time

14 in between. That's personnel time. So there's drive

15 time in between, and there's often difficulty in

16 getting other practitioners involved in their care.

17 That said, there are advantages in both

18 sides. So there are advantages in the urban side to be

19 able to rapidly get to patients to prevent 911; and on

20 the rural and frontier side, to be able to decrease the

21 need for them to travel great distances to emergency or

22 acute healthcare.

23 Q. When you say "a frontier environment," what

24 do you mean by that?

25 A. I'm sorry. That's probably a Texas term. My


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 852

1 apologies. I'm surprised you guys don't. It's the

2 Texas equivalent, so it's a -- it is not wilderness,

3 but it is --

4 Q. Super-rural?

5 A. It is super-rural. It is very difficult

6 access because of distance or ability to reach that

7 patient.

8 Q. Are these programs easier to set up if you

9 have a community where the ownership of the EMS

10 resources is vested in one entity or organization, such

11 as a City that runs a hospital runs the ambulance, runs

12 fire?

13 A. So the very -- the very purpose of mobile

14 integrated healthcare, the I part of integrated, is

15 that there is no single practitioner, whether he or she

16 is a physician, a case manager, dentist, a paramedic,

17 who can manage all of the components of a patient that

18 they may need over a spectrum of time.

19 So by definition, mobile integrated

20 healthcare means that that process has to integrate

21 with the hospital side, the healthcare system side, the

22 municipal side, governmental side, ambulance side. The

23 best mobile integrated healthcare programs are programs

24 that essentially bring those different players together

25 in an integrated way.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 853

1 Q. And given the fact that AMR is the leader in

2 this field and there's 37 to 38 operations and AMR has

3 hundreds and hundreds of operations, what's the

4 challenge of having it everywhere? Why isn't it just

5 everywhere?

6 A. So mobile integrated healthcare, again, from

7 a clinical standpoint, is a fabulous idea. It is a

8 healthcare -- it's a healthcare strategy that would

9 potentially improve the health of patients. It would

10 decrease deterioration. It would improve their

11 transition back after an acute admission or acute

12 episode.

13 So clinically, I think the mobile integrated

14 healthcare strategy is ideal for helping to manage an

15 historically tough population.

16 Logistically, part of the challenge and

17 really a big part of the challenge -- and the National

18 Association of EMTs published a survey about a year and

19 a half or two years ago. The challenge has been

20 funding it. So funding a mobile integrated healthcare

21 program, if you look at what it does, mobile integrated

22 healthcare says I'm going to decrease your -- I'm going

23 to decrease your ambulance transports, I'm going to

24 decrease your Emergency Department visits, I'm going to

25 decrease your hospitalizations, I'm going to decrease


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 854

1 everything that in today's fee-for-service world is

2 generating revenue. So it essentially takes that

3 patient out of the current system and puts it into this

4 mobile integrated healthcare system.

5 The challenge with that is that there is no

6 direct -- consistent direct way to fund mobile

7 integrated healthcare at that level. So it often

8 becomes a program that's done as part of a routine

9 response. So keeping mobile integrated healthcare

10 sustainable is probably the number one challenge.

11 The number two challenge is, unfortunately --

12 and I would underline unfortunately. -- the U.S.

13 emergency medical services, emergency healthcare really

14 haven't come together to define credentials,

15 competencies, practices, approaches, metrics,

16 documentation requirements. So there could be a mobile

17 integrated healthcare program that essentially used

18 on-duty practitioners, paramedics and EMTs, that had no

19 additional training in things like the continuum of

20 care or postacute care, who may use the emergency

21 medical services tools, but not do what the patient

22 needs.

23 On the flip side, there are mobile integrated

24 healthcare programs that are using more advanced

25 diagnostics, that are using diagnostics to obtain -- or


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 855

1 to facilitate imaging, to facilitate blood and specimen

2 drawing for laboratory analysis.

3 So the spectrum is wide, and there's not

4 consensus on exactly what those entities should be

5 doing.

6 Q. Thank you.

7 I'm going to show you what's been marked as

8 LLA-3j, and this is a poster on the mobile integrated

9 health practice, correct?


11 Q. And AMR was involved in the authoring of

12 this?



15 admission of 3j.


17 Life Line 3j?


19 ALJ SHEDDEN: All right. 3j is

20 admitted.

21 BY MS. FICKBOHM:

22 Q. I'm showing you next LLA-3k. And just for

23 purposes of the record and ease of reference, all of

24 the exhibits I'm going to refer in Dr. Racht's

25 testimony are going to be LLA.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 856

1 So can you tell us what this is,

2 Dr. Racht?

3 A. So this was an article in Modern Healthcare

4 on mobile integrated healthcare practice that was

5 published as an overview of some of the potential

6 solutions of the strategies that I just described.

7 And the group of authors on this particular

8 article are reflective of -- so not all of those are

9 AMR or Envision Healthcare providers; and that was

10 purposeful, to bring in experts from both within and

11 outside of AMR to discuss that.

12 Q. Scott Bourn, yourself, Lynn White are all AMR

13 people?

14 A. So at the time of publication of this

15 article, Eric Beck, Alan Craig, Scott Bourn, myself,

16 and Lynn were AMR.

17 Q. And this goes into additional detail about

18 what you just testified about?



21 admission of 3k?

22 ALJ SHEDDEN: Is there --

23 MR. MEYERSON: I'm sorry. No objection.

24 ALJ SHEDDEN: All right. 3k is

25 admitted.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 857

1 BY MS. FICKBOHM:

2 Q. This one is a little harder to look at

3 because of the way it prints out, but I'm showing you

4 3l, "EMS," and the next page is going to say "at the

5 Healthcare Table. As the Community Paramedicine

6 Concept Evolves, EMS Will Play an Integral Part."

7 Who was involved in the publication of this?

8 A. So that particular article, the individuals

9 that were -- that participated in the Modern Healthcare

10 article were also involved in this concept.

11 This particular article is of note, if you

12 scroll down, Ronna, in the -- I'm sorry. Scroll back

13 up. Stop.

14 Q. Okay.

15 A. So if you -- we struggled for a significant

16 amount of time trying to define your question earlier,

17 community paramedicine and the new term, "mobile

18 integrated healthcare." So this article was the first

19 article published in the literature that used the term

20 "mobile integrated healthcare," and we spent

21 significant time to be thoughtful in trying to define

22 what an entity could be who delivered that kind of

23 care.

24 Q. And so this is from April of 2013, correct?

25 A. That's correct. I -- yes, that's correct.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 858

1 Q. Demonstrating how new this concept and goal

2 really is, correct?



5 admission of 3l.


7 ALJ SHEDDEN: All right. 3l is

8 admitted.

9 BY MS. FICKBOHM:

10 Q. And my last one on mobile integrated health,

11 Dr. Racht, is AMR or LLA-3p. Do you recognize what

12 this is?

13 A. Yes. So if you'll scroll down just a little

14 bit more to the bottom of that page.

15 So this is the Medtronic Philanthropy's

16 Guidebook, Playbook that I referred to earlier in

17 testimony, on building and maintaining a mobile

18 integrated healthcare program.


20 admission of 3p.


22 ALJ SHEDDEN: 3p is admitted.

23 BY MS. FICKBOHM:

24 Q. Let's talk for a minute about AMR, what it is

25 and what it does.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 859

1 And I want to tell you that you have a mouse

2 right in front of you, and you have everyone's

3 permission to use that mouse as much as you want. And

4 I'm happy to do it for you, but if you want to take it

5 yourself and move it around.

6 A. All right.

7 Q. Can you tell us what 3ee?

8 A. So 3ee is an infographic that we created

9 three years ago. It's a summary document that just

10 takes our -- some of our response statistics, some of

11 our metrics, and puts them into one infographic.

12 Q. And so can you tell us what this summarizes

13 with regard to what AMR does?

14 A. Yes. So this particular infographic

15 obviously -- and I won't read through all this, unless

16 you would like for me to.

17 Q. No, no, no. You can just scroll through.

18 A. It looks at vital signs. It looks at

19 critical intervention. Just a quick note. We don't

20 deliver 3 babies a day. It's 2.8-something, but a .2

21 is a very awkward baby to categorize. 4.4 million

22 patients, 87 pediatric patients transported every hour.

23 Part of what we use this for is to remind

24 ourselves, our practitioners, that if -- because we are

25 big, we have to be good. And I know that sounds very


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 860

1 corny. But this illustrates that we really have to

2 have an impact on clinical care that's thoughtful,

3 that's evidence-based. If we're transporting

4 87 pediatric patients an hour, we should be very

5 comfortable, confident in that patient population.

6 6,275 vehicles.

7 Q. And I just want to stop you for a minute.

8 You said this was from a few years ago. Have these

9 numbers increased since then?

10 A. These numbers have increased with every

11 publication, yes.

12 And, again, this is probably the -- this is

13 the number of communication centers. We are the

14 national FEMA provider for emergency medical response

15 for all four FEMA regions, and we have two national

16 interprofessional command centers. They are medical

17 command centers that are actually licensed practices of

18 medicine that are community -- or they're based on the

19 mobile integrated healthcare environment and then

20 emergency medical dispatch. We have more

21 CAAS-accredited ambulances.

22 Q. What's CAAS?

23 A. I'm sorry. The Commission on Accreditation

24 of Ambulance Services.

25 We're proud of this one, or I'm proud of this


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 861

1 one. I think we all are. We are the second largest

2 training center for the American Heart Association in

3 the country.

4 Q. What's the first?

5 A. The VA, interestingly. So the VA is number

6 one. We are number two.

7 We're also the largest provider of

8 prehospital education in the U.S.

9 This particular metric -- and I think you

10 might be talking about it later.

11 Q. We have more specifics on that one, yes.

12 A. Talks about our CPR Challenge. And I believe

13 that's it in this document.

14 MS. FICKBOHM: Move for admission of

15 3ee.


17 ALJ SHEDDEN: All right. 3ee is

18 admitted.

19 BY MS. FICKBOHM:

20 Q. I want to talk to you about AMR's core

21 philosophies.

22 Did there come a point in time where the

23 leadership at AMR got together and actually reduced

24 those core philosophies, pulling -- and core attentions

25 to writing?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 862

1 A. Core attentions as in the --

2 Q. As in what --

3 A. Clinical focus, so the Things that Matter?

4 Q. Yes, clinical focus, right.

5 A. If you're referring -- there we go.

6 So we --

7 Q. And I've got up on the screen Exhibit 3u.

8 A. So we, several years ago -- actually, more

9 than several years ago. Four and a half or five years

10 ago, as we looked nationally at what we were doing and

11 looked at our quality and performance approach, we

12 realized that we had a ton of data and very little

13 information. So we were able to capture a lot of

14 metrics. We had a lot of data. But we weren't very

15 good at being able to take that data and assimilate it

16 into an effort, a practice, and improvement.

17 So it took us a little more than a year,

18 again, with experts from within and outside of AMR, to

19 sit down and create the clinical metrics that we felt

20 were the most important clinical metrics to focus on as

21 a national organization at the individual local level,

22 so that we could study them, improve them, and do what

23 we could to improve patient outcome in those metrics.

24 So we created the metrics, and we,

25 interestingly, struggled in what to call them and


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 863

1 landed on the very scientific "Things that Matter"

2 phrase.

3 But the concept was that we would, as a

4 national organization, in addition to all the reporting

5 elements and quality improvement and performance

6 efforts at the local level, from a national standpoint

7 every AMR practice would focus on patient safety,

8 cardiac arrest and resuscitation, pain/discomfort,

9 respiratory distress, STEMI/stroke, which are

10 time-dependent, and then effective management of

11 significant trauma.

12 So our metrics surrounding that, our

13 education surrounding that, our focus surrounding that,

14 our data definitions surrounding that at the national

15 level all became uniform so that we could track our

16 performance and what our efforts were to improve those

17 things.

18 Q. And is this definition also important to a

19 concept we're going to talk about a little later called

20 benchmarking?


22 So part of the principle behind Things that

23 Matter is, if I am an AMR practice in one environment

24 and I have a pain relief rate of improving pain in

25 72 percent of the patients who present with pain, I can


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 864

1 benchmark myself against what the national numbers are.

2 If the national numbers are that's 96 percent, then

3 that would lead me to believe that I had some room to

4 grow and improve that.

5 So the idea behind that within AMR was to

6 identify the high performers, so that they could be the

7 teachers for the rest of us, and to identify those that

8 needed improvement or, frankly, had to have a pretty

9 aggressive effort to come in and focus on a particular

10 clinical condition.


12 admission of 3u, Your Honor.


14 ALJ SHEDDEN: All right. 3u is

15 admitted.

16 BY MS. FICKBOHM:

17 Q. Well, and I'm showing you -- that's not the

18 one I want to go to. Sorry. Sorry.

19 Showing you what's been marked as 3r, is this

20 a companion document to 3u?

21 A. Yes, it is.

22 Q. With additional detail?

23 A. Yes, it is.

24 MS. FICKBOHM: Move for admission of 3r.



2017A-EMS-0006-DHS VOLUME 4 12/15/2016 865

1 ALJ SHEDDEN: All right. 3r is

2 admitted.

3 BY MS. FICKBOHM:

4 Q. I would like to have you talk briefly and

5 from a high level about an example of each of these

6 points on what really matters.

7 So let's talk first about ensuring safe

8 patient care and transport. I'm going to turn to 3ff,

9 and can you tell us what this is?

10 A. So this was a joint effort between -- really,

11 led by Alex Isakov, who is one of our medical directors

12 and a physician at Emory University in Atlanta. This

13 was a result of the Ebola, the U.S. Ebola crisis.

14 So a group of us -- the organizations and

15 agencies are listed on the document. A group of us put

16 together standard operating procedures for patient

17 handoff. It's patient population that's obviously

18 highly infectious. It was a different population that

19 EMS had not seen before. So this group provided this

20 through the efforts of the Centers for Disease Control

21 and Prevention, and this was published as guidance.


23 3ff.


25 ALJ SHEDDEN: All right. 3ff is


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 866

1 admitted.

2 BY MS. FICKBOHM:

3 Q. 3gg, can you tell us what this is?

4 A. So this is the same approach as I described

5 previously. This happens to be air to ground because

6 of the -- at least in the early phases of the potential

7 Ebola crisis in the U.S., there was a lot of discussion

8 about moving patients by air to designated, qualified

9 and appropriate centers nationally. So the question of

10 moving them from air to ground and how to safely do

11 that for providers and for patients is addressed in

12 this.

13 Q. Who transported the infamous identified

14 Patient 1 for Ebola in the United States?

15 A. So we transported two. So the two nurses

16 that were at Texas Presbyterian we transported from the

17 hospital to Love Field in Dallas.


19 admission of 3gg.


21 ALJ SHEDDEN: 3gg is admitted.

22 BY MS. FICKBOHM:

23 Q. And I have in front of you 3dd. And can you

24 talk about how the concepts in this article address

25 safe patient care and transport?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 867

1 A. So this is an interesting article, in some of

2 our AMR practices and with medical directors who we

3 work with, that looked at identification of patients

4 that had an anticoagulant or antiplatelet therapy and

5 who also had head trauma.

6 So there's a real interest in --

7 appropriately, in identifying patients who have head

8 trauma who may be at risk for intracranial or inside

9 the head hemorrhage. Those patients have a much higher

10 mortality. They are much more acute and often need to

11 go to a higher level of care.

12 So this was the first study in this group

13 that really looked to try and ascertain whether, during

14 the management of these head trauma patients, medics

15 were able to accurately identify the presence of one of

16 those or any of those anticoagulants or antiplatelet

17 drugs, which could then be used to make better

18 decisions about either destination or acuity of that

19 patient.

20 Q. And this is from September of 2016?


22 Q. And in general, is this level of patient

23 analysis and treatment something that's done by first

24 responders or by ambulance transport providers?

25 A. So it can be done by the spectrum. Something


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 868

1 of this level is often done in the more intensive deep

2 dive of patient assessment. So any patient that's

3 assessed anywhere gets -- by all of us, whether in the

4 Emergency Department or in the field, that initial

5 assessment is essentially to figure out what's going to

6 hurt me, what's going to hurt them, what's acutely in

7 need of intervention for lifesaving skills; is the

8 patient breathing, not breathing, et cetera. And then

9 from there, continued evaluation, examination,

10 assessment, to figure out other variables that would

11 impact their care.

12 So in this particular case, this is one of

13 those secondary levels of assessment to then further

14 drill down and identify whether a patient may need a

15 higher level of care or different level of care to be

16 more appropriate or would be at higher risk.


18 3dd.


20 ALJ SHEDDEN: 3dd is admitted.

21 BY MS. FICKBOHM:

22 Q. Let's talk about cardiac arrest

23 resuscitation, the second point on the list.

24 First of all, I want you to tell me, like,

25 you know, how big a problem is -- or how big an issue


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 869

1 is this in the United States?

2 A. So it's huge. Let me clarify that. It is

3 a -- it's a large issue for acute healthcare providers,

4 because without the appropriate intervention, the

5 outcome is clear. The patient will not survive the

6 event. With inappropriate intervention the patient

7 could potentially survive, but be neurologically

8 impaired.

9 It's a time-dependent, resource-dependent,

10 very, very specific illness that EMS has historically

11 used as kind of the benchmark of performance and

12 success of an EMS system historically.

13 So we know what makes a difference. We know

14 how to impact that. We know how important time is, and

15 we know how important an integrated system is to manage

16 them to the best possible outcome.

17 Q. So with regard to what AMR has directed its

18 time and attention and resources to to address this

19 point of interest and focus, you have something known

20 as the CARES program?

21 A. Yes. So CARES is the Cardiac Arrest Registry

22 to Enhance Survival. It was initially a federally

23 funded program through the Centers for Disease Control

24 and Emory University in Atlanta. It is now -- it now

25 lives at Emory University in Atlanta.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 870

1 The principle behind CARES, it's a tremendous

2 principle, is that anyone who's involved in managing a

3 cardiac arrest patient -- "anyone" meaning the 911

4 communication piece, the first response piece, the

5 ambulance piece, the healthcare system piece. -- would

6 enter data into a National Registry to be able to look

7 at survival, to be able to track what interventions,

8 what intervals could make a positive or, conversely, a

9 negative difference in survival, and to serve as a

10 national benchmark in performance of a system, a

11 healthcare system, in this particular problem.

12 Q. And so this one dated 2013 collects data

13 from --

14 A. 2012.

15 Q. Is this 2012 data or is this --

16 A. It's 2012.

17 Q. Yeah. So this is national data for January

18 through December 2012, correct?

19 A. Correct.

20 Q. And on Page 2, AMR as a group is benchmarking

21 itself against national users of the sys -- national

22 entities that are participating in the program?

23 A. So that's correct.

24 So this summary document is a document that

25 we send to all of our colleagues in AMR as kind of the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 871

1 assessment of the year before. I think it's important,

2 this data comes through the CARES Registry program. So

3 hospital outcomes, the hospitals report those outcomes.

4 This isn't self-reported. But we use this to benchmark

5 what AMR CARES participant survival and other metrics

6 are versus what the overall national group data is.

7 Q. And so this allows you to look and see, if we

8 look at everyone and then we look at just us, are we

9 doing it worse, are we doing it better or the same?



12 admission of 3w, Your Honor.


14 ALJ SHEDDEN: All right. 3w is

15 admitted.

16 BY MS. FICKBOHM:

17 Q. 3x is the same collection of information for

18 calendar year 2013?

19 Yes?

20 A. I'm sorry. Yes.

21 Q. And so here we see that with regard to the

22 Utstein Survival and Bystander Survival, AMR as a

23 national group has a slightly lower rating than the

24 national --

25 MR. MEYERSON: I'm going to object, just


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 872

1 because counsel is testifying about this instead of

2 letting the witness testify to it.

3 ALJ SHEDDEN: All right. I'll just have

4 you go ahead and ask a question, Ms. Fickbohm.

5 BY MS. FICKBOHM:

6 Q. The last two categories, AMR as a national

7 group has lower percentages than CARES as a national

8 group. Are you able to comment on that?

9 A. Yes. So there are -- if you look at how

10 CARES reports their data, they report it in a variety

11 of different formats. So Overall Survival to Hospital

12 Discharge, which tends to be the practical approach;

13 the Overall Survival with Good or Moderate Cerebral

14 Performance, so those are patients who survive the

15 event who have -- who are neurologically intact.

16 And then the three metrics that are listed

17 below, Bystander CPR, Utstein, and Utstein Bystander

18 CPR, break down these populations into very distinct

19 subsets.

20 So we would expect to see, for example,

21 Utstein Survival, which are patients who are the

22 definition below, they are witnessed by a bystander and

23 they're found in a shockable rhythm. That's a very

24 distinct subset of patients, as is the Utstein

25 Bystander. So I may have mixed those up, but they are


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 873

1 both the same. They are defined as patients who are

2 witnessed by a bystander. They are found to be in a

3 shockable rhythm, historically the most treatable and

4 survivable rhythm.

5 So this a good example. This particular year

6 was a very good example. So our overall survival and

7 our neurologically intact survival was higher than the

8 national average. In looking at the subpopulations, it

9 allowed us to focus on -- to improve even more, it

10 allows to focus on those patient populations with

11 shockable witnessed rhythms and sent the message about

12 the importance of getting out to the community, educate

13 the community to call us rapidly and learn

14 compression-only CPR.

15 Q. And is that something that AMR, in fact, did?

16 A. So we did do that, and we very aggressively

17 did that. As a matter of fact, we modeled our efforts

18 after the landmark paper that the state of Arizona did.

19 So Ben Bobrow and Dan Spaite and his colleagues really

20 published the first paper that said that bystander

21 compression-only or hands-only CPR, when that program

22 is rolled out to a community, you can substantially

23 improve survival.

24 So we took that concept, and every year since

25 '13 we've done what we call the AMR World CPR


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 874

1 Challenge. So our practices nationwide will

2 essentially choose a day -- this coming year it will

3 actually be a week. -- that we -- our efforts are to

4 get in the community in any way we can to show the

5 community the importance of compression-only CPR. It's

6 aimed at the data that you see in the bottom two

7 segments here, to get the public more comfortable with

8 doing compression-only CPR and being able to activate

9 911 quickly in the case of an unconscious pulseless

10 patient.

11 Q. And using that kind of benchmarking analysis,

12 did you actually end up seeing improvement?

13 A. So we did see improvement. So I would love,

14 I would love to be able to say it was a direct result

15 of that effort. Cardiac arrest is a process that's

16 dependent on a multitude of things, but what it is --

17 what it does show us is that we have been able to

18 improve survival and to maintain survival higher than

19 the national average over our CARES journey.

20 MS. FICKBOHM: Move for admission of 3x.


22 ALJ SHEDDEN: 3x is admitted.

23 BY MS. FICKBOHM:

24 Q. I'm not going to have you go through it, but

25 I just want to ask you to confirm that 3y is the same


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 875

1 data for calendar year 2014 as reported in 2015?


3 Q. And 3z, the following year?


5 MS. FICKBOHM: Move for admission of 3y

6 and 3z.


8 ALJ SHEDDEN: All right. 3y and 3z are

9 admitted.

10 BY MS. FICKBOHM:

11 Q. And I'm showing you 3cc, and is this document

12 related to what you just talked to with regard to CPR

13 Challenge?

14 A. It is. This is a document that we created as

15 almost a newsletter document to our own colleagues, as

16 well as to the outside world, that said this is why we

17 do this and this is what we can accomplish in terms of

18 numbers of patients or folks who are trained and then

19 the potential increases in utilization of bystander

20 CPR.

21 Q. And since I know you don't have the numbers

22 memorized, could you just state for the record how many

23 people AMR trained through its CPR World Challenge in

24 2013, 2014, 2015, 2016, and total since the program was

25 initiated?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 876

1 A. So per the document, in 2013 we trained

2 54,885; in 2014, it was 61,883; 2015, 67,047; and then

3 this past May, 50,591. So our total was 234,405.


5 3cc.


7 ALJ SHEDDEN: 3cc is admitted.

8 BY MS. FICKBOHM:

9 Q. I would like to move through the remaining

10 points perhaps in a little quicker fashion.

11 Reduction of pain and discomfort is next on

12 the list. I'm showing you what's been marked as 3aa.

13 Could you tell us, generally speaking, what this is?

14 A. This is a graph that showed nationwide our

15 ability to decrease pain. So pain and discomfort was a

16 thing that mattered. We needed to measure it to see

17 how we were impacting it. What we quickly found,

18 unexpectedly, was that we were not -- we were often not

19 identifying two points of time of a pain assessment.

20 So if we had one pain score, we couldn't measure

21 improvement because we didn't have a second pain score.

22 So you can see in the middle, September 2014,

23 our efforts focused -- we shifted to an education that

24 said you have to get two pain scores in order to

25 identify that there is improvement or not.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 877

1 So this is twofold. One is it improved our

2 ability dramatically to assess what we do, and the

3 other is it showed that we were able to improve pain in

4 that patient population.

5 Q. And that was an effort done nationwide?

6 A. It was an effort done nationwide. It was

7 done at the local level and choreographed from a

8 national perspective.


10 3aa.


12 ALJ SHEDDEN: 3aa is admitted.

13 BY MS. FICKBOHM:

14 Q. The next item on the list of Things that

15 Matter is relief of -- I'm sorry, safe and efficient

16 management of airways and ventilation. Can you tell us

17 how 3a relates to that?

18 A. So this was, again, a study that essentially

19 looked at the prevalence of hyperventilation, meaning a

20 ventilation rate or a breathing rate which was higher,

21 in patients with a closed head injury.

22 Dan Spaite, Uwe Stolz, the entire University

23 of Arizona team has been very involved internationally

24 in looking at traumatic brain injury, head trauma. We

25 have, obviously, a large patient population nationally,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 878

1 so putting the two of those together has been, we

2 think, collectively beneficial in investigating what

3 makes a difference and doesn't.

4 Q. And do any of these studies -- you do the

5 studies and then you're like, wow, we shouldn't be

6 doing something we've been doing?

7 A. If studies don't identify that, then you're

8 not looking at the right thing. So the purpose of

9 investigation is to identify what makes a positive

10 difference and what makes a potential negative

11 difference, so that that negative difference can be

12 identified and changed.

13 Q. When we talk about relief of respiratory

14 distress, your next point, would this also be an

15 example of AMR's efforts in that regard?

16 A. This is a component of that.


18 admission of 3a.

19 MR. MEYERSON: 3a. No objection.

20 ALJ SHEDDEN: 3a is admitted.

21 BY MS. FICKBOHM:

22 Q. With regard to recognition and treatment of

23 STEMI and stroke, can you just orally give us an

24 example of AMR's efforts, studies, investigations?

25 A. So we've been -- we very aggressively


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 879

1 provided educational tools. We look at intervals.

2 We've worked with one of our partners, Physio-Control,

3 on monitors to identify compression intervals,

4 appropriate data and reports to manage how we

5 effectively respond to two very time-dependent

6 processes.

7 Stroke is really interesting, because the

8 world of stroke management has changed dramatically

9 even in the past six months. So there's an evolving

10 new concept of not just identifying a stroke, but

11 identifying a stroke that occurs in a large vessel as

12 opposed to a small vessel.

13 The difference being that these patients may

14 need to go to a different kind of a center. So there

15 are a lot of efforts nationally to figure out what

16 identifies those patients so that they can be taken to

17 the right level of care, and we've been involved in

18 many of those.

19 Two days ago I spoke to the California

20 medical directors about stroke CT ambulances. So there

21 are now ambulances that have CT scanners in them that

22 can respond to strokes.

23 Q. And the last point is effective and timely

24 trauma care.

25 Well, first, before we go there, could you


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 880

1 please, for the record, define what STEMI is,

2 S-T-E-M-I, the acronym?

3 A. I'm sorry. ST segment elevation myocardial

4 infarction.

5 Q. Heart attack?

6 A. Heart attack.

7 Q. I won't ask you why you guys always have to

8 have these big, long, complicated terms for things,

9 but...

10 A. Lawyers don't.

11 Q. Exactly.

12 So the last point on the What Matters list is

13 effective and timely trauma care. I have Exhibit 3n up

14 in front of you. Can you tell us how this relates to

15 that concept?

16 A. Yes. This -- and, unfortunately, this has

17 become an important paper, given what's happening

18 nationally. This was an evidence-based guideline in

19 conjunction with the American College of Surgeons to

20 identify principles of hemorrhage control. Lynn White

21 from AMR was a participant in this consensus process.

22 This particular article lays out an

23 evidence-based approach to managing hemorrhage and

24 bleeding. We've now incorporated, as many entities

25 have, the principles in this for managing active


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 881

1 shooter/hostile events. And, unfortunately, it's our

2 changing world. But it provides some good guidance on

3 managing this patient population.

4 MS. FICKBOHM: Move for admission of 3n.


6 ALJ SHEDDEN: All right, 3n is admitted.

7 BY MS. FICKBOHM:

8 Q. Can you talk for a couple minutes about how

9 the national attention and efforts you're involved with

10 benefit local operations, you know, individual

11 operations, whether it's CON 58, it's a Maricopa County

12 AMR operation, it's an AMR operation in Florida? How

13 do your national efforts benefit the local operations?

14 A. So I think the best way to summarize it is

15 that we have -- it's the Buzz Lightyear/Uni-Mind.

16 Sorry for the analogy, but the concept that you have so

17 many minds, so many folks who had experience and

18 expertise, who can contribute to potential solutions.

19 I think as an organization, AMR nationally, I

20 think we're stronger because we can identify who

21 understands certain things the best. They can then

22 help us provide those tools, those resources, those

23 educational principles nationally.

24 An example is Ebola. So the first -- when we

25 received the phone call to transport the first Ebola


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 882

1 patient, really very few clinicians, myself included,

2 were familiar with the management of Ebola patients,

3 the transmission of disease, the appropriate

4 protection.

5 We reached out to Alex Isakov at Emory

6 University and the CDC, who is one of our medical

7 directors. His team helped our team nationally put

8 together principles, practices, protocols, educational

9 materials in a very short period of time. He did a

10 nationwide, what we call, E grand rounds. So he did a

11 webinar for our folks nationally on what the Ebola

12 patient population, how it should be managed, and we

13 then made that available to anyone that wanted it.

14 So it allowed us to be smarter and to

15 understand and to be our own resource. We've done the

16 same thing with active shooter and hostile events.

17 We've done the same thing with cardiac arrest

18 management, mobile integrated healthcare. It's a

19 better way, I think, to implement the art of the

20 science.

21 Q. And the information that you're accumulating

22 nationally, is that available to local medical

23 directors?

24 A. So that's available to anyone that wants it.

25 And we made a strategic decision five years ago that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 883

1 medicine is not proprietary. So they are -- this is

2 all posted on our website. During the Ebola crisis,

3 any organization that wanted our materials could take

4 our materials, search for AMR, replace with the name of

5 their organization. And all we asked was if they had,

6 obviously, better data, then we would upgrade ours. So

7 it is available to anyone that needs it.

8 Q. Do you also have outreach efforts

9 specifically to medical directors working for AMR

10 operations? You just mentioned meeting with the ones

11 in California.

12 A. We do. So we -- if there are specific topics

13 that come up, the most recent being, again, active

14 shooter/hostile events, Dr. Rich Carmona, who is based

15 here in Arizona, is one of our strategic consultants.

16 He's been working with us on the active shooter events;

17 the same thing with Ebola, mobile integrated

18 healthcare, cardiac arrest, and actually things like

19 TXA, which is a drug that's given in trauma patients.

20 Q. Your information, is that available to local

21 operations for benchmarking?

22 A. Yes, it is.

23 Q. And let's say that -- I mean you're obviously

24 the top clinical person at AMR, correct?

25 A. I believe so.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 884

1 Q. So if somebody running a little operation in

2 Northern Arizona had a clinical question, do they have

3 to go through a chain of command to get to you, or are

4 you directly available?

5 A. So my cell phone is out there everywhere. I

6 am happy to answer directly or to find the right

7 resource.

8 Q. Could you speak for a moment about the

9 evolution of ambulance transport medicine from the

10 19 -- just how medicine used to be done 10, 20 years

11 ago versus how it's done now?

12 A. In EMS?

13 Q. Yes.

14 A. So when I was first getting involved in the

15 late '80s, early '90s, there was a real big focus, as

16 EMS developed, on rapid transport. The concept being

17 that the acutely ill or injured patient needed to be in

18 a hospital setting as quickly as possible.

19 Over the years, with articles like this and

20 exploration into the literature and the evidence, we've

21 identified that there are certain things that require

22 more than rapid transport, or actually don't require

23 rapid transport and may require a focused effort not

24 being transported for stabilization. So the terms we

25 use are stay and play or load and go to identify how to


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 885

1 best manage that patient to maximize their positive

2 outcome.

3 So we've moved from driving fast to a mobile

4 practice of medicine; assessment, appropriate

5 intervention, appropriate risk stratification,

6 intervention and reassessing those patients.

7 Q. And the interval between a patient being

8 loaded onto an ambulance and getting to the facility

9 it's being transported to, is that an important

10 interval?

11 A. That's a very important interval. All the

12 intervals are important. I'll say that. The ambulance

13 transport interval is important because that tends to

14 be a highly -- in the acutely ill and acutely injured

15 patient, that tends to be an intensive time of trying

16 to correct physiology and protect anatomy, so diving

17 deeper into the illness or to the injury and

18 stabilizing that illness or injury.

19 It's also a time to reassess. So what we

20 know in trauma, for example, is that trauma is a

21 continuum, and if a patient deteriorates rapidly, that

22 may be an indication for surgical intervention in and

23 of itself because of the deterioration. So that

24 ongoing reassessment becomes critical in helping to

25 define the next step.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 886

1 Q. During his examination, I asked Hellsgate's

2 Chief Bathke about his approach and perceptions on the

3 management of sepsis. He testified this is a shock

4 situation that should be approached with oxygen and IV

5 and patient monitoring.

6 Do you agree with that?

7 A. So sepsis is a pretty evolving new concept;

8 probably, I would say, two years now that we've

9 understood sepsis more. It is, interestingly -- and I

10 didn't know this until three or four years ago. It has

11 a higher mortality than patients with STEMI, higher

12 mortality than patients with stroke, higher mortality

13 than patients who have significant trauma. So it is a

14 major life-threat event.

15 The way that we manage sepsis today in most

16 contemporary EMS systems is to identify that the

17 patient potentially has sepsis. If that's the case,

18 then the healthcare system is integrated immediately

19 with that, just like with a STEMI or trauma or stroke,

20 so that they can be prepared to rapidly draw blood

21 cultures, assess what's going on with the patient,

22 stabilize the patient, and get the patient the right

23 antibiotics.

24 There's several things that have changed

25 pretty dramatically in the past six or eight months.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 887

1 There are systems that are now drawing lactic acid.

2 It's a finding in the blood that may indicate that the

3 patient has an overwhelming infection. There are now

4 systems that are administering antibiotics in the

5 ambulance in the field, again, because of the high

6 mortality. Almost all those patients need very

7 high-volume fluid resuscitation during the initial

8 phases of managing.

9 So it's a pretty -- it's a high mortality,

10 unfortunately, high mortality, but very complex event

11 that's getting a lot of clinical attention

12 internationally.

13 Q. The Chief also told us that Hellsgate

14 benchmarks its EMS employees three ways; quality checks

15 of patient records, annual review of employees, and

16 what I think you EMS folks call tape and chart, a peer

17 review of patient condition, treatment, outcomes, and

18 evaluation of how that went.

19 Can you speak to that?

20 A. Yeah, so obviously, I mean I don't know the

21 processes that Hellsgate goes through. Those are

22 appropriate processes. A lot of EMS systems, we do

23 those things as well; that we review our practitioners,

24 we reviewer our documentation, we review auditory

25 files, anything that we have involved with the patient.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 888

1 We think, in terms of looking at quality in

2 performance, that's the beginning of an assessment

3 piece. So our benchmarking, we think it's important to

4 really dive down into what happened. Outcomes are

5 important for us, so having an external entity, whether

6 it's a registry or it's a hospital outcome, are

7 important; for example, did the blood vessel get opened

8 in the hospital, did we identify the STEMI

9 appropriately, and then activities related to that that

10 either improve findings that aren't acceptable or

11 communicate those findings that are.

12 Q. So is there a step beyond those three things

13 that your protocols would indicate should be done?

14 A. So we do, in AMR, pretty much across the

15 board, and that's how we get our Things that Matter

16 metrics, we take that, we benchmark that, and then we

17 try and match the literature, the evidence, with what

18 the best practices are and then provide education.

19 So those documents of sudden cardiac arrest

20 that you saw, we actually call those prescriptions for

21 improvement, and they're based on the science, they're

22 based on our review, they're based on the registry, in

23 an effort to improve.

24 Q. And does AMR compare itself, local

25 operations, compare themselves to AMR nationally as a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 889

1 whole, national providers as a whole? What's the

2 comparison?

3 A. Yes. So we like comparing ourselves with any

4 like practitioners and like circumstances. CARES

5 Registry compares us to EMS systems and healthcare

6 systems across the country.

7 It's important for us in some areas to

8 compare ourselves with a very narrow window. So, for

9 example, in Las Vegas we have two operations in

10 Las Vegas. It's very interesting for us to compare the

11 two different organizations that are geographically in

12 the same place.

13 So we embrace that. We have found in that

14 process that there are areas that need improvement by

15 expanding that net, and that's been really valuable to

16 us.

17 Q. Chief Bathke also told us that when it comes

18 to ambulances, even in the nonemergency, what I'll call

19 interfacility or convalescent setting, faster is always

20 better.

21 Do you agree with that? And more

22 importantly, does the national literature agree with

23 that also?

24 A. So -- and, again, I wasn't here for the

25 testimony, so if okay, I'll express my opinion on that.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 890

1 There is a lot of discussion about -- and

2 I'll use the term "fast" to be a lights and sirens

3 response to a request for service, if that's a broad

4 enough category.

5 It's pretty clear from the literature that

6 about 10 percent, give or take, depending on the study,

7 about 10 percent of what EMS responds to is an actual

8 life-threatening emergency where patients need an acute

9 intervention. The other 90 percent may still need EMS

10 or need an evaluation, but aren't necessarily in that

11 time-dependent deterioration.

12 One of our biggest challenges nationally in

13 lights and sirens responses are motor vehicle crashes.

14 And so we have to be thoughtful as an EMS system when

15 we send any apparatus, law enforcement, fire, EMS. In

16 a priority lights and sirens scenario, we have to be

17 thoughtful and accountable to the fact that we're

18 creating a little bit more of a chaotic environment and

19 could potentially cause a car crash that could hurt

20 folks.

21 So there is a lot of -- a lot of interest in

22 defining better what needs most rapid and what needs a

23 lower level of response. Our colleagues in Charlotte,

24 North Carolina have published several papers on

25 response intervals and how they -- the 8-minute,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 891

1 historical 8-minute response interval is not predictive

2 of survival or mortality.

3 That said, my assessment is, no, not every

4 ambulance or engine, or law enforcement for that

5 matter, needs to immediately and rapidly get to a

6 person or patient's side. But every system has to have

7 a way of identifying those that potentially need it and

8 absolutely focus on getting that resource to that

9 patient's side rapidly.

10 Q. With regard to the 90 percent that are not

11 time-dependent, if you have two different ambulance

12 providers and one is theoretically able to arrive

13 30 seconds faster than the other or even a minute

14 faster than the other, will it always be better to use

15 that faster one, or are you going to look at things

16 other than speed?

17 A. So let me make sure I understand your

18 question.

19 Q. Okay.

20 A. So is the question if -- if you have two

21 responding entities, one gets there 30 seconds before

22 the other, would you --

23 Q. Or a minute before the other, is -- in

24 evaluating which one is the preferred responder --

25 A. Oh, I see.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 892

1 Q. -- is the speed going to be what is most

2 important to you from a clinical aspect?

3 A. Speed is one of the variables, but

4 potentially not the most important variable.

5 The right level of resource has to get to the

6 patient's side. So I'll use the analogy of an academic

7 Medical Center. If a patient in an academic Medical

8 Center needs an emergent surgical intervention, it may

9 be the resident or the fellow, a lower level of

10 training, that gets to that patient's side the fastest.

11 He or she may be there. The patient may need the

12 expertise of the faculty surgeon in order to have the

13 best available outcome for that particular condition.

14 So it is just as important, maybe more

15 important, to have the right trained, competent,

16 equipped entity respond to that patient's side. In the

17 90 percent, where the timing is not as critical in

18 terms of patient outcome, that resource becomes more

19 important.

20 Q. And in the interfacility transport scenario,

21 does faster is always -- let's say you're picking up a

22 patient at a hospital and taking it to another

23 hospital. Does faster is always better apply?

24 A. So I'll answer that with no and a caveat.

25 Q. Okay.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 893

1 A. So no. As a matter of fact, in the

2 interfacility world it's probably the least important.

3 The caveat is, there are several conditions that make

4 it just as high priority as in the field.

5 So if I happen to be a hospital that

6 identifies a patient that has a STEMI in my Emergency

7 Department and I don't have a cath lab, I'm taking that

8 patient from Facility A to Facility B. Because of the

9 time sensitivity of that heart attack, that patient

10 needs to be moved very, very quickly to be

11 appropriately cared for.

12 But the overwhelming majority of

13 interfacility transports, unless the patient's

14 deteriorating, are not as time-sensitive.

15 Q. Based upon your resumé, you're obviously

16 interacting with other prehospital medical service

17 providers on a regular basis, correct?


19 Q. What's your perception and opinion about the

20 quality of the AMR organization's attention to clinical

21 excellence in that context?

22 A. So I'm obviously very biased, but I feel very

23 strongly, and it was a big part of my decision to join

24 the organization in the first place. I feel very

25 strongly that the AMR attention to clinical


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 894

1 performance, excellence, and accountability is probably

2 the best in an EMS system I've seen.

3 I would support that with the fact that our

4 numbers, our metrics, our performance, again, good, bad

5 and ugly, is open for folks to see. We put our cardiac

6 arrest survival rate in our RFPs, and there are some

7 communities nationwide that exceed and there are some

8 that do not; but we feel very comfortable with our

9 approach at managing our clinical care and our

10 performance.

11 And probably just as important, two years ago

12 we launched a just culture initiative. A just culture

13 initiative basically says we don't -- we don't

14 discipline or penalize for clinical issues. We'll

15 remediate. We want our folks to bring up questions,

16 challenges, problems, so that we can make things

17 better.

18 So I -- your question about our clinical

19 care, I'm extraordinarily proud of it. We have reams

20 of data that can support an assessment or an assumption

21 on my part objectively, and I think the organization

22 really prides itself in being in the clinical arena.

23 MS. FICKBOHM: I don't have any other

24 questions for this witness, Your Honor.

25 ALJ SHEDDEN: All right. Mr. Ray, do


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 895

1 you have any questions?

2 MR. RAY: Yes, I do.

3

4 CROSS-EXAMINATION

5 BY MR. RAY:

6 Q. Good morning, Doctor.

7 A. Good morning.

8 Q. So the applicant in this case is a first

9 responder, first on the scene the high majority of the

10 time, and they have applied to do the ambulance service

11 as well.

12 Does AMR have any first responder assets or

13 resources in Arizona, that you're aware of?

14 A. I would defer to one of my Arizona

15 colleagues. I don't know specific.

16 Q. So nationally they do?

17 A. So I was going to answer nationally, we do.

18 Q. Okay.

19 A. So we do in a variety of different ways. So

20 with our acquisition of Rural/Metro, obviously, we have

21 fire apparatus with medical responders in some

22 communities. We, in a multitude of communities, will

23 use non-transport vehicles to first respond. We also

24 will use transport-capable vehicles, who will respond,

25 but not transport unless necessary. So we have a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 896

1 variety of different components.

2 Q. Okay. One of the issues that has been raised

3 as part of the application is the need for continuity

4 of care between the first responder on the scene and

5 the later arriving --

6 A. Right.

7 Q. -- in normal circumstances, the ambulance

8 service.

9 Has AMR studied that issue on a national

10 perspective?

11 A. So I would -- if I can, I'll bump it up to

12 our parent, Envision Healthcare. So Envision

13 Healthcare includes EmCare Physician Practices, most

14 recently another group, Sheridan. So we have emergency

15 physicians, critical care physicians, surgeons,

16 hospitalists. We have ambulances, obviously. In some

17 states we have prehospital nurses. We have the

18 communications center. So the issue within our own

19 walls becomes an issue of discussion of making sure

20 that transition or handoff of patient care in our own

21 organization is done appropriately and correctly.

22 So your question is spot on, which is we know

23 from the medical literature, and Joint Commission makes

24 a big deal, appropriately, of making sure that if one

25 provider hands a patient off to another provider, the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 897

1 right communication, the right handoff is provided to

2 assure that patient's safety.

3 Any patient in emergency services goes

4 through several, gazillions of handoffs. So,

5 theoretically, the handoff is from the 911

6 communication specialist, who is doing prearrival

7 instructions, to first response to ambulance to the

8 Emergency Department triage nurse to the Emergency

9 Department physician, to the surgeon, to the

10 radiologist, to the ICU.

11 So everyone in medicine, everyone who pays

12 attention to your question in medicine knows that those

13 handoffs are important and it's an important part of

14 clinical practice. They'll never go away and they're

15 always going to be there, which is why we focus on them

16 within our own organization. So...

17 Q. So what -- so let's assume that you have a

18 scenario like we do here in Gila County, where we have

19 a Fire-based EMS first responder, who gets on the

20 scene, initiates assessment, care, treatment, and then

21 needs to transfer that patient to an ambulance service

22 that arrives subsequent to the first responder.

23 A. Uh-huh.

24 Q. So you've got two different organizations

25 treating the patient at this stage of the continuum of


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 898

1 care.

2 Do you have any statistics that would suggest

3 that results in a higher continuity of care issue than

4 if you had a unified employer; i.e., the first

5 responder and the ambulance service are one and the

6 same?

7 A. So I am -- and help me if I don't answer your

8 question directly.

9 Q. Sure.

10 A. I am unaware of any document, publication

11 that's demonstrated that the employer or the agency of

12 record or the entity that is responsible for the

13 practitioner, that a difference in employer or agency

14 or organization has a negative impact at a handoff in

15 patient care.

16 And I would take that all the way up to

17 the ICU, because those same questions are asked in

18 the hospital, where an emergency physician would

19 hand off to a critical care physician, so does it

20 make a difference if the emergency physician is an

21 EmCare physician and the critical care physician is

22 the hospital physician. So we are unaware of any

23 literature that suggests that there is a worsening

24 of patient outcome or patient care in that

25 scenario.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 899

1 That said, that goes along with the same

2 focus, which is all of us in medicine, regardless of

3 where we are, have to focus on that transition. So if

4 I'm one organization, if it's Acme Emergency Healthcare

5 and I'm the dispatch, I'm first response, I'm the

6 Emergency Department, I'm Acme, those same transition

7 issues are between two practitioners. So if you're

8 Acme first response and I'm Acme ambulance, you and I

9 have the same accountability and responsibility.

10 And I would take it one step further, which

11 our medical colleagues do in the hospital, which is if

12 a patient is critical enough or unstable enough to

13 require additional resources, hands, or to have the

14 emergency physician travel with them up to the

15 operating room, as opposed to the nurse, the collective

16 interaction of that team and working together and

17 saying, "I'm going with you" or "You come with me," all

18 focused on what the patient needs, is what helps

19 decrease any change in mortality in that patient.

20 Q. Okay. You did answer my question. So

21 congratulations. It was a long question.

22 A. And a long answer.

23 Q. So does AMR have specific training protocols

24 that it establishes at a national level and pushes down

25 to, for instance, ambulance providers that says you


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 900

1 have some critical elements to establish good

2 continuity of care and these are our recommendations?

3 Does AMR do that?

4 A. So we do, and we have -- as part of our

5 Things that Matter initiative, part of -- part of our

6 recent addition was the patient documentation piece, so

7 the patient continuity piece, making sure that

8 information we either get from families or get from

9 other organizations is managed by us and then

10 subsequently appropriately communicated to the

11 receiving facility. So it's part of our patient safety

12 initiative, part of the Things that Matter component of

13 what we do.

14 Q. Okay. Does training -- would training

15 between first responders who are not the same

16 employer-based entity as the ambulance service, would

17 that improve -- is there any data, research that

18 suggests that improves patient outcomes or lessens

19 continuity of care issues --

20 A. So I am --

21 Q. -- on a national level?

22 A. Sorry. So I'm -- I know that that probably

23 exists. I am not prepared to be able to tell you what

24 those documents are. But I will say that I think the

25 general sense in medicine as a whole, public safety


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 901

1 medicine specifically, is that joint training, joint

2 education, joint drilling, joint exercises always,

3 always, always improves our ability to respond together

4 and effectively with a patient.

5 There's a subtlety in there that I think is

6 also important, which is, there are sometimes tensions

7 between organizations. The fact that we're in meetings

8 like this, there are tensions between organizations

9 that sometimes could be very harmful at a patient's

10 side if those same tensions impacted patient care.

11 So if you and I train together, I get to know

12 you more, I get to understand that what we do is fairly

13 similar, we have different challenges, but we develop a

14 relationship that's better.

15 September 11th did that for public safety

16 across the board. And if you look back at what we do

17 with law enforcement and fire and EMS and the

18 healthcare system, we are much better buddies. We

19 trust each other. We focus on things that we never

20 focused on before because of the fact that we had to

21 get together to train together to understand to do our

22 jobs, what our patients expect us to do.

23 Q. All right. Thank you, Doctor.

24 A. Thanks.

25 MR. RAY: I don't have any other


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 902

1 questions. Thanks.

2 ALJ SHEDDEN: Let me ask, Mr. Meyerson,

3 you're going to have questions, I assume?

4 MR. MEYERSON: Yes.

5 ALJ SHEDDEN: All right. Why don't we

6 take our break, and that way you'll not be interrupted.

7 We're about four minutes of. Why don't we meet back up

8 at about 11 or 12 after 10:00, in 15 or 16 minutes.

9 (A recess was taken from 9:56 a.m. to

10 10:11 a.m.)

11 ALJ SHEDDEN: All right. We're back on

12 the record. I don't know if you've met Mr. Meyerson,

13 the attorney for Hellsgate.

14 THE WITNESS: Good morning.

15 ALJ SHEDDEN: But I'm going to turn it

16 over to him for whatever questions he has.

17

18 CROSS-EXAMINATION

19 BY MR. MEYERSON:

20 Q. Good morning, Dr. Racht.

21 A. Good morning.

22 Q. Can you tell us whether you specifically

23 provided services for CON 58?

24 A. So me, specifically?

25 Q. Have you specifically provided services


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 903

1 directly to CON 58?

2 A. So as part of our national initiative?

3 Q. No, directly for CON 58.

4 A. Have I practiced in --

5 Q. Correct.

6 A. No, I have not.

7 Q. Have any of your previous positions been

8 focused exclusively in Arizona?

9 A. No, they have not.

10 Q. Do you have any direct input on the

11 operations and services provided by CON 58?

12 A. Yes, I do.

13 Q. Where you are talking to operators on the

14 ground in CON 58?

15 A. So let me make sure I understand your

16 question. By "operators on the ground," clinical --

17 Q. The EMTs and paramedics on the ground in

18 CON 58.

19 A. Actually out on patient care?

20 Q. Correct.

21 A. No, I do not.

22 Q. What do you know about Arizona's treat and

23 refer program?

24 A. The treat and refer initiative?

25 Q. Yeah.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 904

1 A. So the initiative, the treat and refer

2 initiative, is an initiative by the State as part of a

3 mobile integrated health approach. I think it's the

4 beginning of a pretty innovative, actually, initiative

5 to look at a different level of care.

6 Q. And has Life Line CON 58 filed for an

7 application specifically for that treat and refer

8 program?

9 A. I would have to defer to the Life Line

10 leadership.

11 Q. Have you -- isn't it true that you've never

12 attended an ADHS treat and refer meeting, have you?

13 A. No, I have not.

14 Q. In CON 58 there's a HALO program. Are you

15 aware of that?

16 A. No, I am not.

17 Q. And what is your current board certification?

18 A. Medicine, internal medicine.

19 Q. Would you agree with me that you've never

20 been certified as an emergency room physician?


22 Q. Agree with me that you've never been

23 certified in Arizona as a physician?


25 Q. Isn't it true that every one of the programs


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 905

1 you testified about, that no one from CON 58 has

2 actively participated in those programs?

3 A. I don't know that that is correct.

4 Q. But you don't have any evidence that would

5 show that they have?

6 A. I don't have evidence one way or the other,

7 correct.

8 Q. Are you aware of CON 58, has anything been

9 done about -- with the initiative you talked about in

10 reference to obtaining blood cultures or administration

11 of antibiotics?

12 A. I don't believe that's the case. Again, I

13 would defer to their leadership if they have had local

14 discussion about that.

15 Q. Can you re -- you've mentioned the Medical

16 College in Wisconsin. Can you -- do you remember what

17 you said about the Medical College in Wisconsin? I

18 think --

19 A. I don't believe I've mentioned that --

20 Q. Oh, you did not?

21 A. -- in testimony.

22 Q. Are you aware of the Medical College in

23 Wisconsin?

24 A. So I have had -- I just had social discussion

25 with the Chief about Medical College of Wisconsin


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 906

1 off --

2 Q. Correct. And you know of some of the

3 physicians that are there?

4 A. Yeah, I do.

5 Q. And would you agree that they have a very

6 high level of contribution to the EMS conversation

7 nationally?

8 A. So I'm not sure I understand you.

9 Q. Well, are they a leading contributor to the

10 EMS standards of care and innovation nationally?

11 A. So there are several clinicians at the

12 Medical College of Wisconsin who have done a lot for

13 emergency medical services and have contributed a lot

14 to the evidence in the literature.

15 Q. You testified about community paramedicine

16 and actually went over community paramedicine quite a

17 bit in your testimony. Would you agree that a

18 community paramedicine program requires an availability

19 of resources to be successful?

20 A. Yes, I would agree.

21 Q. Would you agree with me if I said if a

22 provider is already relying on another provider outside

23 its system, that it would be difficult for that

24 provider to successfully operate a community

25 paramedicine program?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 907

1 A. I would not agree with that.

2 Q. You would not agree that if a resource --

3 from a resource standpoint, they don't have enough

4 resources to serve their own CON operationally, that it

5 would be difficult to implement a community

6 paramedicine program?

7 A. So I would not agree with that.

8 Q. Okay.

9 A. Can I --

10 Q. No.

11 A. -- expand?

12 Q. Would you agree with me that the challenges

13 facing community paramedicine are the same across the

14 country?

15 A. I would not agree with that.

16 Q. You testified earlier that there are a number

17 of community paramedicine issues and that they are

18 being addressed nationwide and looked at nationwide.

19 The challenges are not the same, necessarily, on a

20 micro level; but on a macro level, are they the same?

21 A. So maybe I'm -- and I apologize if I

22 misunderstood your question. So what I responded to

23 was the last part of your question there. So the

24 challenges are not the same in each individual

25 community, but there are some global challenges which I


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 908

1 think impact all programs.

2 Q. But you would agree that available resources

3 are an important part of that program for any of those

4 communities?

5 A. So any mobile integrated healthcare or

6 community paramedicine program has to have the

7 resources that are specific to that program in order to

8 provide that care. Those resources aren't necessarily

9 the same resources as the emergency response resources.

10 Q. Would you agree with me that the research on

11 the mobile integrated health has little impact on the

12 current provision of services being provided by Life

13 Line in CON 58?

14 A. Could you clarify your question a little

15 more?

16 Q. Yeah. There's a lot of research, and we saw

17 a lot of research on the exhibits, about community

18 paramedicine or mobile integrated healthcare. And my

19 question is, does it directly impact the current

20 services being provided in CON 58?

21 A. So a direct impact today, no. The

22 implication of mobile integrated healthcare in any

23 community, including this community, could have an

24 impact on patient management and strategy.

25 Q. And that goes to your comment about our


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 909

1 families for years to come will shape the mobile

2 integrated healthcare model.

3 A. Right.

4 Q. But it still comes down to the resources with

5 a certain community to be able to provide those

6 services?

7 A. Correct.

8 Q. The infographic, I'm going to pull up 3ee

9 that was shown. Does it kind of go out of order?

10 Yeah, okay, there it is.

11 3ee, this infographic, is this something

12 that's produced by AMR?

13 A. Yes, it is.

14 Q. Is that infographic something that I, as a

15 consumer, would be able to access through the website

16 or other means?

17 A. I don't know specifically if it's available

18 on the website, but its intent is that it's -- it is

19 accessible.

20 Q. You said it's a reminder to employees of AMR

21 that we need to maintain a high level or high quality

22 of care to see all of these numbers. But you would

23 have to agree with me that this exhibit actually talks

24 more to the size of the company. It really says

25 nothing on here about quality of care.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 910

1 A. So the intent of this, in my use of this

2 infographic, is to remind all of our practitioners of

3 our size and how important it is for us to be

4 accountable and to provide care that's appropriate

5 because of the huge impact that we have. So this is a

6 motivator of sorts, I guess, and a reminder that we

7 have a big responsibility.

8 Q. So this is sent out to your paramedics and

9 EMTs on a monthly basis as a reminder?

10 A. No, it's not.

11 Q. Would you agree with me that the CPR training

12 program that was mentioned -- and as you were talking

13 about it, I didn't write down it fast enough, but

14 there's the -- we'll go with the 3t. I think this is

15 kind of the same idea.

16 There was one that was done in May of 2016.

17 Would you agree with me that that CPR training was not

18 provided in CON 58?

19 A. I would have to defer to my colleagues in

20 that organization.

21 Q. And I'm going to open up a couple of other

22 exhibits that were used. These standard handoffs, you

23 would agree that these address transfer of care of a

24 patient to another -- either a facility or another

25 entity of some kind?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 911

1 A. This particular document is a very specific

2 population, which is the highly infectious Ebola

3 patient population.

4 Q. And the next one here --

5 ALJ SHEDDEN: I'm sorry, let me just

6 jump in. That was 3ff we were just looking at.

7 MR. MEYERSON: Yeah. Sorry.

8 BY MR. MEYERSON:

9 Q. And 3gg as well is this -- but it's again

10 talking about transfer of care from one entity to

11 another?


13 Q. And would you have developed these studies if

14 transfer of care wasn't a concern?

15 A. Well, this is a very specific patient

16 population, so the concern that led to this initiative

17 and this documentation is that this is a different --

18 this is a different approach to transferring a patient.

19 This isn't a standard patient transfer. This is

20 outside of what we do day-to-day. It requires very

21 specific and different logistical approaches, and it's

22 a higher risk population because it can create harm to

23 the rescuers themselves. So this is very specific to

24 the highly infectious patient population.

25 Q. But you have written protocols within AMR


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 912

1 regarding transfer of care from ambulance to ambulance

2 or ambulance to healthcare facility; they're written

3 protocols that are provided to your paramedics and EMTs

4 and that are expected to be undertaken when they

5 transfer a patient, correct?

6 A. So every AMR practice nationwide, their

7 medical director will develop those protocols, in

8 concert with the leadership in that organization, and

9 address those things that are specifically required by

10 the medical director or by State regulatory entities or

11 by that individual practice.

12 Q. So the answer to the question is, yes, there

13 are written protocols?

14 A. So we have in many of ours -- again, we're in

15 thousands of communities, so we do have written

16 protocols that address transfer of patients from one

17 entity to another.

18 Q. So there's care taken to minimize the impact

19 of the transfer of care between each healthcare system,

20 let's say, that is included in that transfer?

21 A. Yeah, so I think the focus is, there is an

22 effort to make all providers aware of how to facilitate

23 that transfer in the most appropriate way.

24 Q. And you would have to agree that to some

25 extent, every transfer of care creates another level of


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 913

1 potential miscommunication between providers and could

2 impact patient outcomes?

3 A. So every transfer of a patient from one

4 practitioner or one caregiver to another has the

5 potential to impact care, both negatively and

6 positively. So there's also the opportunity to ask

7 questions, reassess, did you do this, did you do that.

8 So, yes, there is that risk, and that's what

9 we focus on. Your previous question is very important,

10 but there's also the opportunity to go through and to

11 confirm, much as happens in the aviation industry, to

12 confirm that certain things were or were not done.

13 Q. You mentioned a specific condition -- I can't

14 remember what it was. I was trying to write it

15 down. -- that was a benchmark for overall service

16 delivery. Was it a --

17 A. Cardiac arrest.

18 Q. Okay.

19 A. Right.

20 Q. And it was your testimony that the response

21 time in that situation is a critical aspect of a

22 patient outcome; is that correct?

23 A. So it is critical that -- in that particular

24 patient population, it's critical that the right

25 resources get to the patient's side quickly. So that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 914

1 may be -- in many communities that's a bystander

2 resource with an app that will send an individual who

3 knows how to do chest compressions. It may be a

4 publicly available AED. It may be a first responder

5 defibrillator. It may be a law enforcement

6 defibrillator. It may be an ambulance defibrillator.

7 But it is critical to get the right level of care to

8 that patient as quickly as possible.

9 Q. So the question I would have then is, the

10 time from the call to getting to the patient is

11 critical, whether it's a bystander -- I mean presumably

12 the bystander isn't receiving the dispatch call.

13 A. Right.

14 Q. But --

15 A. It would be interesting if they were.

16 Q. But --

17 A. Your next --

18 Q. -- what we're saying is, essentially, that

19 the time of the occurrence of the heart attack to the

20 point where the first person can get there is critical

21 to the patient outcome?


23 Q. There were 3w, x, y and z. So I'll just pull

24 up one of these, because I think they're in subsequent

25 years. I'll pull up the latest one just for our


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 915

1 purposes. So this is Life Line Exhibit 3z, and these

2 are the cardiac arrest facts. And then down below

3 there's the national group data and the comparison of

4 how AMR as a whole did compared to the national group

5 data.

6 How does CON 58 compare specifically against

7 those benchmarks?

8 A. I don't have their specific data to compare

9 to there at this point.

10 Q. There was also studies that determined

11 protocol and we talked about benchmarking, and

12 Ms. Fickbohm said that the Chief testified the three

13 ways that they benchmarked, and then asked you if

14 anything beyond that was something that AMR did. And

15 you mentioned that you would go another step and do

16 studies to determine whether or not protocols needed to

17 be changed or addressed.

18 Aren't those really addressing -- that's not

19 really benchmark. That's what you're doing with the

20 benchmark information, correct?

21 A. So I'm sorry if I didn't convey that

22 appropriately. So the additional evaluation of that

23 data, so once we review charts, review -- have the

24 data, the evaluation of that data, looking at that data

25 will help us determine what we need to do moving


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 916

1 forward.

2 So let me make sure. I'll try and describe

3 it, and please tell me if I don't.

4 So there's studying our own data, which is

5 looking at our own data, which is taking this and

6 saying if our -- if our bystander CPR rate is low and

7 our survival in the Utstein bystander CPR category is

8 low, there's a clear message there. And the clear

9 message is, we've got to focus on bystander CPR to

10 improve survival.

11 It's not a study. So we wouldn't do, for

12 example, a research study to look at -- we would use

13 evidence from studies to guide this, but we wouldn't

14 initiate a research study routinely from that kind of

15 information. So it's evaluating the data, looking at

16 what that data means, and then sorting through the most

17 appropriate way to improve on the patient management

18 side.

19 Q. But you would agree that --

20 MS. FICKBOHM: Excuse me, Counsel. I

21 just want to have clarity of the record that when

22 Dr. Racht was just giving his answer, he was pointing

23 to the exhibit that's up in front of all of us,

24 Exhibit 3z, LLA-3z, just for clarity of the record.

25 Thank you. Sorry to interrupt, Counsel.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 917

1 ALJ SHEDDEN: All right.

2 BY MR. MEYERSON:

3 Q. But this is all on a national level. You're

4 collating massive amounts of data for a national review

5 of protocols, not specifically CON 58; would you agree

6 with that?

7 A. So let me describe, which may help. So from

8 a national perspective -- and I think you'll hear

9 testimony in a little bit about some of our other

10 metrics that we gather at a national level and then

11 provide to the local level.

12 So from a national perspective, our data, our

13 overall care survival is the benchmark of all of AMR,

14 everything else. All of our other performance metrics,

15 so relief of pain, Trauma Center destination time

16 intervals, those data elements, we have that on a

17 national level to benchmark, and then each individual

18 practice has their ability to look at what their

19 performance is and compare it to this.

20 Based on that, we can provide national

21 resources. Dr. Betz, the local medical director, can

22 go in and make changes in the protocol, processes, or

23 education. Our folks can do that. We provide, for

24 example, for this, a national -- series of national

25 webinars that go through educational approaches to be


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 918

1 able to guide and direct this.

2 So the national supporting structure is

3 similar, in a way, to the advanced cardiac life support

4 program from AHA. It's developed nationally, but it's

5 administered at the local level.

6 Q. So how, specifically, has it been

7 administered at the local level in CON 58?

8 A. So, again, I would ask those questions of the

9 local leadership for the specific details on that.

10 Q. You said that the rapid response model is no

11 longer the model for 911/emergency calls?

12 A. So let me clarify. I don't believe I said

13 that. I said or responded that responding,

14 essentially, lights and sirens as rapidly as you can to

15 every request for service is no longer the perceived

16 model.

17 Q. But there are some indications or some

18 conditions and emergencies that response time --

19 A. Oh, absolutely, and I think I testified to

20 that, that there were conditions that require that very

21 quickly.

22 Q. There was some questioning that Ms. Fickbohm

23 asked and mentioned about Chief Bathke's testimony on

24 treatment of sepsis, and were you here for his

25 testimony on that?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 919

1 A. No, I was not, and I believe I tried to

2 convey my opinion on that and not to comment on any of

3 the previous testimony that I was not there.

4 Q. So you weren't trying to criticize Chief

5 Bathke's response?

6 A. Not at all. I was trying to specifically lay

7 out what our response would be to that, and I tried to,

8 hopefully, make that very clear. I was commenting on

9 our approach.

10 Q. On the benchmarking, the three items, there

11 was a comment by Ms. Fickbohm about the outside entity

12 and whether there's a review with an independent third

13 party.

14 Were you here for Chief Bathke's testimony on

15 how they do their benchmarking?

16 A. I have not been here for any of the Chief's

17 testimony.

18 Q. So his comments about having the other

19 facilities and working with the hospital to assist with

20 the outcomes and reviewing the actual outcomes of

21 certain transports, would you understand that, if he

22 had mentioned that, would you understand that to be an

23 independent third party going through and reviewing

24 specific outcomes?

25 A. Yes, so I believe -- and, again, I wasn't


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 920

1 here for the testimony; but if the hospital or

2 healthcare system is a participant in reviewing the

3 care independently, that that is an appropriate

4 approach.

5 Q. There were a lot of studies that you pointed

6 to or that your counsel -- that counsel pointed to that

7 you've been involved in, and I certainly applaud

8 anything that improves the healthcare system. Is that

9 information available to the general public?

10 A. So that information on our -- either on our

11 website, if those are appropriate documents, are. That

12 information is also available in a variety of venues,

13 so through the National Library of Medicine, through

14 the individual journals, through whatever the

15 individual publication uses to make that available.

16 Q. And do EMS Associations, let's call them,

17 ever use those studies to provide training at

18 conferences or seminars?

19 A. Yes.

20 Q. And so the general public, including

21 Hellsgate and its staff, could attend those and

22 implement those protocols into their own procedures at

23 the local level?

24 A. That is correct.

25 Q. You stated that 10 percent of interfacility


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 921

1 transports are -- would be life-threatening. Would you

2 agree with me that that number is highly dependent on

3 the number of hospitals or healthcare facilities within

4 a certain community?

5 A. So let me clarify. I believe I testified

6 that 10 percent of 911 calls are life-threatening. I

7 don't know what the number of interfacility

8 life-threatening calls are. I don't know that the

9 literature knows that.

10 Q. Okay. I thought you testified that a vast

11 majority of interfacility transports can wait a long

12 period of time and have no impact on patient outcomes.

13 A. So I did testify to the fact that there are a

14 large number of interfacility transports, and we

15 provide tens of thousands of them per year, that don't

16 require the same time sensitivity, that same rapidity.

17 Q. But you don't have any data to support the

18 large number?

19 A. Other than experience, correct. That's

20 correct.

21 Q. So going to the interfacility transport then,

22 the large number that you just described, would you say

23 that in a situation or in a community where there are

24 many hospitals, that interfacility transports for

25 critical care needs because one hospital can't provide


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 922

1 a certain service, so they need to transfer to another

2 hospital, are far less than a community where there's

3 one hospital that doesn't have the highest level of

4 trauma care?

5 A. So it would be intuitive to me, I think, to

6 say that if there are -- in an urban environment, with

7 higher levels of care facilities, the availability of

8 critical care resources would be greater than in a

9 rural or a suburban environment in that regard. So I

10 don't know that I can comment specifically, but it

11 intuitively makes sense that if you have a density of

12 resources, there's going to be more availability.

13 Part of the component of interfacility

14 critical care transports and time dependency, and I

15 think it's important in any system that all of us are

16 participating in, is, a hospital is considered a stable

17 place for a patient. It might not be the right stable

18 place for a patient.

19 So there are patients who are sick that need

20 to go to a different level of care. There are patients

21 that are sick or injured that need go to a higher level

22 of care with a time-dependent problem, and that's, I

23 think I referred to, if a STEMI comes into a facility

24 that doesn't have a cath lab, that's a quick, high

25 acuity that needs to go to a higher level of care.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 923

1 Q. And so the response time in that case would

2 be extremely important?

3 A. Correct.

4 Q. There was a -- and I'm going to ask you to

5 clarify, because I was writing quickly. There was a

6 comment that you made about the survival and mortality

7 rates not being impacted by response times, and I

8 missed the setting that you were talking about. Can

9 you remind me of that?

10 A. Absolutely. So Dr. Tom Blackwell, who at the

11 time was the medical director of Medic in Charlotte,

12 North Carolina, did a series of studies on response

13 intervals and outcomes in the Medic system in

14 Charlotte, North Carolina. And what they were able to

15 demonstrate in those studies was, through a range of

16 3 to 4 minutes of a difference in response interval,

17 there was no statistically significant impact on

18 mortality.

19 So many in medicine and in public safety

20 medicine use those studies to look at the ambulance

21 transport time. Now, remember, this is the ambulance

22 piece, not the initial responding entity. But they

23 used that to evaluate which response interval is most

24 appropriate. So --

25 Q. And was -- I'm sorry. Go ahead. You --


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 924

1 A. So we don't know -- in EMS medicine we don't

2 know -- as a profession, we don't know what the ideal

3 response interval is for the ambulance to get to the

4 patient's side.

5 We do know that the ideal response interval

6 to get a defibrillator, compressions, hemorrhage

7 control, airway management, those things to a patient's

8 side is as short, rapid and fast as we can. And we

9 often do that with engines, police cars, QRVs, quick

10 response vehicles, and ambulances in that community.

11 Q. So the context, I guess, to summarize my

12 question based on that information, which was very

13 helpful, is, so we're talking about a 911/emergency

14 call, not interfacility transports?


16 Q. Okay. In that case then, we're talking about

17 a 3 or 4-minute difference creating a statistically

18 significant difference in outcomes in an emergency

19 call; is that correct?

20 A. So I would --

21 Q. Is that what the study said?

22 A. So I would reverse it --

23 Q. Okay.

24 A. -- and say in that 4 -- and I apologize, I

25 don't have the paper in front of me; but in that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 925

1 4-minute difference in response interval, there was not

2 a significant difference in patient outcome.

3 Q. So do we know then the number of minutes

4 where it would be significantly impacted?

5 A. So that's the question that everyone in EMS

6 struggles with, and those studies were designed to

7 start evaluating that exact issue. And so as I just

8 alluded to, we don't know what the ideal response

9 interval is from the ambulance perspective side.

10 Q. So if we don't know what the ideal response

11 time interval is, wouldn't it make sense that we want

12 to respond as quickly as possible?

13 A. So if resources weren't an issue, if patient

14 safety wasn't an issue, if there weren't motor vehicle

15 crashes, if we didn't want to pay attention to whether

16 I could take an ambulance and move it to a higher -- or

17 an engine, for that matter, a higher acuity call, it

18 wouldn't be an issue; but all of those things are

19 important to a community. So just as surgeons who are

20 on call who have a surgical backup schedule and the

21 anesthesiologist, based on their cases, all those

22 moving parts have to be able to be functional.

23 If an EMS system could simply -- could

24 improve patient outcome and do it with the right

25 community resources by going hot, lights and sirens, as


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 926

1 quickly as possible, closest ambulance to every single

2 call, every community in the United States would be

3 doing that. There are almost none that do that now.

4 There are very few that still respond to every request

5 for care through 911 with a lights and sirens response.

6 So that's changed substantially over about the past

7 five years.

8 Q. So I wasn't suggesting that an ambulance go

9 10 miles per hour faster in order to get there.

10 A. Right.

11 Q. I was saying that if you had a model where --

12 and using the same assumptions, you had a model where

13 the response was X and then you had a model where the

14 response -- based on the same assumptions, but you had

15 a model where the response was X minus 3 minutes,

16 wouldn't it be preferable, with all things being

17 roughly the same, that the X minus 3 minutes would

18 provide better outcomes? Or not necessarily provide

19 better outcomes, but because we don't know what the

20 appropriate response time is, if it's 3 minutes faster,

21 that that would be better?

22 A. So I'll answer -- I hope I'll answer, and if

23 I don't, let me know. I'll answer based on emergency

24 medicine, trauma surgery and what they've done. So

25 it's the same principle as you've described. So you


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 927

1 have -- you have an unknown, but acutely evolving

2 patient.

3 So the Emergency Department doors open. You

4 have ambulance traffic. You have walk-in patients who

5 are all coming in. Ideally, per your analogy -- and I

6 don't disagree with this. Ideally, it would be great

7 to have as many rooms in that Emergency Department as

8 you needed to have, to have as many physicians

9 available so that when you came in, I would see you, as

10 a physician, first. We'd sort things out. We'd get

11 you over to one of six CT scanners quickly. I mean you

12 get my analogy.

13 Q. Yeah.

14 A. So from a utopian standpoint, if we could get

15 every patient into an acute treatment room with a

16 physician right away, get them imaged, I don't think

17 anyone would disagree with the fact that that was --

18 certainly felt better to the patient.

19 The flip side is the CEOs, the insurers,

20 everybody else on the planet, the logistics folks,

21 would say that's impossible for us to do. We can't

22 make that work. And even when we do, there will be a

23 day that one more patient will come in and we're one

24 room short. So we have to figure out -- and we're one

25 doctor short. So we have to figure out how to best


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 928

1 manage them.

2 So I think EMS, like emergency medicine, like

3 trauma surgery, has done a pretty nice job of trying to

4 understand what the potential acuity is and match our

5 resources, system resources, engines, ambulances, quick

6 response vehicles, match those resources to what the

7 patient may need based on our ability to predict that

8 and based on our ability to quickly change midstream

9 and get a resource to someone that needs that resource

10 quickly if their condition changes.

11 Q. So that's a very real-world example, and I

12 guess I want to go back to my question specifically,

13 which is, not knowing specifically whether a response

14 time at X or X minus 3 minutes is going to impact the

15 patient's outcome in a particular situation, would

16 we -- can you agree with me that the X minus 3 minutes

17 would be preferable?

18 A. So it's a hard question to answer, right,

19 because you want me to answer in a --

20 Q. I do want you to answer.

21 A. -- in a box. And I'm going to try, all

22 right. I'm going to try and answer in the box.

23 So I think anyone, myself included, would

24 agree that if everything else was equal, that someone

25 being at my side that was equally qualified as the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 929

1 other entity that got there earlier, I would want that,

2 and the community would want that.

3 In the scenario that's described, there's so

4 many things outside of that box that influence that,

5 that it could actually not give us the desired result.

6 So if I had -- back to my analogy, the box

7 would be do I get to see my physician quickly. If in

8 that community I have to bring ophthalmologists in to

9 see the patient, then I've not -- they've seen a

10 physician, but I've not necessarily given them the

11 right level of care. And I know it's a weird part of

12 the analogy, but I just want to make sure I'm answering

13 the question based on what you need; but it is a

14 boxed-in question.

15 Q. Okay. Well, let me tweak the question

16 slightly.

17 If the ambulance unit that is coming at

18 X minutes is coming without a paramedic, and the

19 ambulance that's coming at X minus 3 minutes is coming

20 with a paramedic, and assuming whoever's on board is

21 qualified in their positions, but there's a paramedic

22 on the one arriving sooner, which ambulance would you

23 prefer to get to you quicker?

24 A. So I promise I'm not trying to dance around

25 your questions. Our colleagues in the Houston Fire


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 930

1 Department have published data suggesting that too many

2 paramedics is actually harming our patients, in the

3 literature. So the concept of skill dilution; it

4 depends on what that paramedic is doing. We know that

5 EMTs have a specific role. We know that paramedics

6 have a specific role. There are circumstances where

7 either an EMT or paramedic may not be the right person

8 for the patient's needs.

9 So if they were both equal, again, to your

10 question, I would want one that was there more rapidly.

11 I think anyone would.

12 Q. Okay. That study that we were just talking

13 about talked about mortality and survival rate,

14 correct?

15 A. Which study? I'm sorry.

16 Q. I think it was the study about 3 to

17 4 minutes --

18 A. Tom Blackwell's.

19 Q. -- whether it impacts survival or mortality.

20 A. Correct.

21 Q. But there are other things that you can

22 measure besides whether the patient dies or not,

23 correct?


25 Q. Would you describe to me the joint training


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 931

1 programs that AMR has implemented in CON 58?

2 A. Joint training programs, joint between AMR

3 providers and other providers?

4 Q. Correct.

5 A. I would, again, defer to the operational

6 folks in that CON.

7 Q. Okay. Thank you, Doctor. I appreciate

8 it.

9 A. Thanks.

10 ALJ SHEDDEN: That's it?

11 MR. MEYERSON: That's all I have, yeah.

12 ALJ SHEDDEN: Ms. Fickbohm, any

13 follow-up questions?

14

15 REDIRECT EXAMINATION

16 BY MS. FICKBOHM:

17 Q. I need some acronyms clarified here.

18 ADD, capital A, capital D, capital D, you

19 referenced that in talking about cardiac arrest, I

20 think.

21 A. Yeah, so ADD is attention deficit disorder.

22 Q. Besides that.

23 A. I think I said AED.

24 Q. Thank you. My notes are bad.

25 A. Which is automated external defibrillator.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 932

1 Q. That's exactly what it was, because I was

2 wondering what ADD had to do with it.

3 A. My ADD doesn't allow me to pronounce the E as

4 appropriate.

5 Q. You referenced to training done by AHA. Is

6 that the American Heart Association?

7 A. American Heart Association, correct.

8 Q. When you were asked about resources for

9 allowing implementation of a mobile integrated

10 healthcare program, all of that is going to take

11 significant cash above and beyond and separate and

12 apart from the ambulance transport operation, correct?

13 A. So it is our experience in all of our mobile

14 integrated healthcare programs that it is a substantial

15 investment, and that it is best implemented as separate

16 from the 911 system, but often becomes integrated with

17 those resources.

18 Q. When you were discussing the criticality of

19 response time for a cardiac arrest situation and you

20 were being asked questions in the context of a call for

21 ambulance transport, I think that we've got the person

22 who called 911 to get the ambulance transport in the

23 first place, correct?

24 A. Correct.

25 Q. We've got the first responder, correct?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 933

1 A. Correct.

2 Q. And we've got the ambulance, correct?

3 A. Correct.

4 Q. Of those three, which are you going to expect

5 to be first able to provide the continuous chest

6 compression that we want to see now for survive -- to

7 increase survivability?

8 A. So our hopes would be the very first person

9 that has contact with that patient, whether he or she

10 is a bystander. It's the very first person that's able

11 to do that.

12 Q. Because people who have heart attacks don't

13 usually pick up the phone and say, "I'm lying

14 unconscious on the ground"?

15 A. So as a clarification, heart attacks can.

16 Cardiac arrests cannot.

17 Q. Cardiac arrest, that's right. Thank you.

18 Cardiac arrest.

19 And so is that one of the reasons for AMR's

20 focus on doing continuous chest compression training?

21 A. Absolutely.

22 Q. And is it your experience that most competent

23 dispatch systems in this country are set up to talk

24 people who don't know continuous chest compression

25 through it?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 934

1 MR. MEYERSON: I'm going to object,

2 leading the witness.

3 ALJ SHEDDEN: All right. Again, with

4 the leading questions, alls I can do is determine what

5 weight to give.

6 So you can answer, Doctor.

7 THE WITNESS: So the -- there's still

8 some question about how many 911 centers provide

9 prearrival chest compression instructions, because

10 there are so many small dispatch centers. But the

11 majority -- it is the general sense in our profession

12 that the majority of 911 centers now provide prearrival

13 chest compression instructions.

14 BY MS. FICKBOHM:

15 Q. And with regard to the Hellsgate Fire

16 District, you don't have any reason to believe that

17 their EMTs and paramedics aren't carrying the necessary

18 equipment as a first responder to do chest

19 defibrillation or other CPR -- or other emergency

20 measures required immediately for a cardiac arrest?

21 A. I have no reason to believe that.

22 Q. Those are the only points of clarification I

23 had, Dr. Racht. Thank you so much.

24 ALJ SHEDDEN: Mr. Ray, anything?

25 MR. RAY: Nothing further. Thank you.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 935

1 ALJ SHEDDEN: Anything else,

2 Mr. Meyerson?

3 MR. MEYERSON: Yeah, just one question

4 on the paramedic/EMT.

5

6 RECROSS-EXAMINATION

7 BY MR. MEYERSON:

8 Q. Would you agree that in a prehospital

9 response, that a paramedic has a greater ability to

10 perform a more in-depth initial assessment of a patient

11 than an EMT?

12 A. I think in general that's correct.

13 Q. Okay.

14 MR. MEYERSON: That's all I have.

15 Thanks.

16 ALJ SHEDDEN: Anything else?

17 MS. FICKBOHM: No, thank you, Your

18 Honor.

19 ALJ SHEDDEN: No. All right. Thank

20 you, sir. We appreciate your time.

21 THE WITNESS: Thank you.

22 ALJ SHEDDEN: All right. Who will be

23 the next witness then?

24 MS. FICKBOHM: Doug Jones.

25 ALJ SHEDDEN: All right. Come on up.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 936

1 All right, let me get you sworn in.

2

3 DOUG JONES,





8



11 THE WITNESS: Douglas, middle initial

12 K., Jones. Last name is J-O-N-E-S.



15 MS. FICKBOHM: Thank you, Your Honor.

16


18 BY MS. FICKBOHM:

19 Q. Mr. Jones, what's your current position?

20 A. I'm the vice president of analytics and

21 operations research with AMR.

22 Q. And at what point in your career did you

23 start working in emergency medical systems, services

24 systems?

25 A. Back in probably 1988ish, ballpark. I was a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 937

1 volunteer on a small Fire Department in a suburban

2 community. I had finished my college degree. I got my

3 Bachelor's in electronics engineering and was working

4 in that field and kind of accidentally got into EMS as

5 a way of getting involved in the community and getting

6 to know people, and I accidentally discovered what I

7 was supposed to be doing.

8 Q. So was your family disappointed when you

9 didn't stick with electrical engineering?

10 A. Well, disappointed; they were concerned, I

11 think is a fair way of doing it. But I wasn't married

12 or had kids or anything, and was in a position to

13 follow my heart, and so I traded that off for a very

14 small hourly wage to do something I was more happy

15 doing.

16 Q. And where did that initial volunteer position

17 with a small Fire Department in 1988, where did that

18 take you?

19 A. Where did it take me?

20 Q. Professionally.

21 A. So I fell in love with the medical side.

22 Went to EMT school. Turned around and went to

23 paramedic school. About halfway through paramedic

24 school, got hired at a small private ambulance service

25 in Pueblo, Colorado, and started doing that full time.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 938

1 Through that, ended up leaving that organization for A1

2 Paramedics in Colorado Springs, Colorado, and as a

3 paramedic, who was eventually bought out by AMR, and

4 then basically worked my way through different levels

5 of management, most --

6 Q. Tell us what different things you've done in

7 your manager capacity with regard to ambulance

8 transportation.

9 A. Well, so field training officer, field

10 supervisor, operations manager, assistant director,

11 both with Pueblo and Colorado Springs operations,

12 primarily; and the operations manager piece was

13 probably the highest level at the operations level that

14 I attained, where I was running the ambulance service,

15 administering all aspects of the operations.

16 Q. And what other functions have you performed

17 within an ambulance transport entity?

18 A. So data, started working with data a lot,

19 largely out of an absence of anybody else being able to

20 do it. With my educational background, was kind of

21 drawn into it and decided to dive into it. Learned a

22 lot, studied under a couple different people

23 historically, kind of got my legs under me in that

24 category, and I started working on deployment planning,

25 demand analysis, geospatial analysis, and developed it


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 939

1 so I could improve the systems that I was managing.

2 Q. And have there been any major technological

3 improvements or shifts at AMR as a result of your

4 efforts?

5 A. Yeah. So when I was brought into my first

6 corporate position as a national director, my job was

7 to be able to develop the tools, not only that I was

8 using, but were commonly available in the industry and

9 try to pick from the best of everything that's

10 available and put that into a system that was able to

11 do that, a lot of that functionality, for all of our

12 operations in the country. And that's what we did.

13 Over a period of a couple of years, designed

14 a system that we called OPAP, which is a --

15 Q. Another acronym.

16 A. Another acronym. I don't know why we do it

17 so much. But it stands for operations planning and

18 analytics platform, and it's a web-based application

19 that we take and we do all the heavy lifting,

20 basically, for the local operations with their data

21 that we basically take from all the different CAD

22 systems in the country.

23 Q. CAD being?

24 A. Computer-aided dispatching. Sorry.

25 And we build -- my team builds the business


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 940

1 rules on the front end to make sure that we accurately

2 interpret all the specific things for each area, so we

3 can understand what is on time in this market, you

4 know, for this contract with these response times and

5 when's the clock start and when's it end and all the

6 little nuances within that system, so that we can then

7 use that data to help give them the information at

8 their fingertips anytime they want it without a heavy

9 lift, so that they can make good operational decisions

10 to help manage their business.

11 Q. And your background is set forth in some more

12 detail with some more specifics in LLA Exhibit 13a that

13 I have up in front of us?

14 A. Yes.

15 MS. FICKBOHM: Your Honor, I would move

16 for admission of 13a.


18 ALJ SHEDDEN: 13a is admitted.

19 BY MS. FICKBOHM:

20 Q. As part of your background and training, are

21 you familiar with emergency medical services being

22 provided in small rural areas that might, in great

23 part, be serviced by a fire service or department?

24 A. Sure. Yes.

25 Q. And since you're working for AMR, is there


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 941

1 any type of community, as far as size, rural, urban,

2 super-rural, frontier, that you don't work with?

3 A. No. I think we have examples of pretty much

4 every possible area and combination, probably, out

5 there.

6 Q. If you wanted to evaluate an ambulance

7 transport provider's ability to respond within a

8 particular area from a particular location, what the

9 timing of its responses might be expected to be, how

10 would you go about doing that?

11 A. So what we're talking about is kind of system

12 design, right, so -- and we do that all over the place

13 on a regular basis. We bid on a number of RFPs in

14 areas that we aren't even familiar with and have to

15 come through and do that same kind of effort.

16 But, basically, you start off with the -- the

17 two base components of any system design is, what is

18 the standards, response time standards, that we're

19 going to be held to, and what is the geography that

20 we're dealing with, what is our physical locations

21 going to be. And we build up that piece of it, that

22 is, that part, that footprint of what's necessary from

23 a resource standpoint to be able to respond and meet

24 our response time compliance as stated or desired, even

25 if it's not a contract.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 942

1 So we build that component and then we build

2 in what I call the capacity planning, which is the

3 demand analysis, looking at the patterning of all the

4 calls that have occurred through whatever period of

5 time we're evaluating.

6 And we focus an extreme amount of attention

7 on the task time that it takes to complete the call,

8 and we marry that information up together in order to

9 come up with that this is our deployment plan.

10 Q. And is efficiency within the system design,

11 so that it can be sustainable, one of the factors that

12 you build in, or do you take the utopian approach?

13 A. I generally take the utopian approach as a

14 starting point. You have to design a system in a way

15 that ensures your success from an on time compliance.

16 We use -- the response time compliance drives a lot --

17 a lot of what we do. It's a major component. I don't

18 want to minimize patient care or any of the other

19 things that we do, but in this category our on time

20 performance is what we're trying to balance everything

21 around.

22 Q. Is there a visual representation that you're

23 able to create regarding expected response time

24 abilities?

25 A. Yeah. So we have -- the geospatial aspect of


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 943

1 when we're doing our evaluation, you have to take the

2 existing road network in the service area that we're

3 looking at, and every roadway has a speed that you can

4 generally travel on that roadway. We use that

5 information to create a drive time polygon, basically.

6 It's a -- it's -- if our -- let's say if our

7 response time standard was 10 minutes, we normally are

8 going to subtract some time off of that to account for

9 our out of chute, how long it takes us to get in the

10 ambulance and physically go. But we take that

11 parameter of -- say if it's a 10-minute standard and we

12 adjust it down for, let's say, a minute to allow for

13 proper out of chute time, that means we have a 9-minute

14 response time polygon. And they look all different,

15 but it's based on the actual roadways and the speeds

16 you can travel on those roadways.

17 And so then we lay that across the calls and

18 where the calls have occurred, to be able to measure

19 what percentage of those calls we can capture within

20 each polygon. And we add up more posting locations and

21 coverage until we adequately cover that within the

22 response time standards and the geography to be able to

23 come up with that plan.

24 Q. And are those -- does the diagram that ends

25 up getting generated as a result of that have fairly


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 944

1 irregular boundaries?

2 A. Yeah, there are globs of misshapen spokes,

3 and they're not easy to describe except they are

4 realistic to what the conditions are based on the

5 geography and roadways that we're dealing with.

6 Q. If you didn't have the technological

7 resources or the -- to do what you just described --

8 well, let me back up and say drive time polygons, is

9 that state-of-the-art, or is there something that's

10 better than that to predict response parameters?

11 A. I think that's current state-of-the-art.

12 That's generally the approach that would be taken.

13 Q. If you didn't have the technological

14 resources in order to do a drive time polygon --

15 A. Yep.

16 Q. -- what other sort of rudimentary, less

17 perfect, less satisfactory measures could somebody

18 take?

19 A. So I'll just flash back into my own past on

20 some of the things that we used to do. Originally, we

21 came up with you just did the circles, right. Now, how

22 big is the circle is another trick, right. You can't

23 just create a circle from a common point and say

24 8 minutes is 8 miles or whatever and make a circle,

25 because your average response time speeds are generally


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 945

1 very unimpressive.

2 You know, in the system I came from, just as

3 an example, our emergency response time average speed

4 was somewhere in the ballpark of around 35 miles an

5 hour.

6 Q. And what community was that?

7 A. That was in Pueblo, Colorado.

8 Q. And that was a mixed population center,

9 rural --

10 A. Yeah. We had a strong urban center. It's

11 about 100,000 people in the city itself; suburban,

12 we've got suburban communities around. We've got the

13 rural and even the super-rural stuff in that community

14 as well.

15 Q. So you would make your circles much smaller

16 than, for example, 60 miles per hour?

17 A. Yeah.

18 MR. MEYERSON: I would object to she's

19 either testifying in her questions or leading the

20 witness.

21 MS. FICKBOHM: I was just --

22 MR. MEYERSON: In this one leading the

23 witness.

24 MS. FICKBOHM: I was just circling back

25 to what he said, so I can ask the question.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 946

1 ALJ SHEDDEN: Well, I think that, you

2 know, there's, I guess, a question between clarifying

3 questions, one. But the objection is noted and

4 overruled.

5 BY MS. FICKBOHM:

6 Q. What was the next step in the progression of

7 what you used to do in the old days after circles?

8 A. So once we started to understand the

9 roadways, actually drive everything, then it was

10 becoming -- the tools that would be coming available in

11 that category that would allow us to use mapping

12 software to be able to look at the roadway speeds,

13 adjust the roadway speeds based on the area that we're

14 in, and start getting more accurate development of what

15 the coverage footprint would be from a geography and

16 response time standpoint.

17 Q. Are you aware of how CON 58 is currently, you

18 know, as -- let's just look at the last 30 days or so,

19 resourcing its service area?

20 A. From AMR's perspective, yes.

21 Q. And do you -- so have you analyzed resources,

22 response time compliance with its CON, call load,

23 et cetera?

24 A. My team has, and I've looked at it here as of

25 late, based on the reason we're all here; but, yes, my


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 947

1 team has actively worked in this area to be able to

2 evaluate.

3 Q. Do you think, with regard to personnel and

4 ambulances, CON 58 is underresourced?

5 A. No. Now, so I'm an efficiency geek, right.

6 I try to find what is that best balance of resources,

7 without overdoing it at the same time. My personal

8 opinion is, on our current staffing model in Payson,

9 from a data standpoint it is overstaffed some.

10 Now, you have to understand what my position

11 is and what my team's position is. We are not the

12 deciders of what goes on in a market. We are -- we

13 consider ourselves a strong customer service group, and

14 we make recommendations to the business leaders, so to

15 John and Glenn and other people within the company that

16 are truly managing the business units. We make our

17 recommendations based on the data.

18 And just like with just about anything, you

19 can't sit in a room in another state running numbers

20 and expect that you're going to come up with the

21 perfect plan for a local operation.

22 We deliver that information, present it, and

23 then there's an interaction that takes place, which is

24 the talking through any concerns, ideas on why this

25 should be different than what we've presented. And


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 948

1 then so they do the tweaking and adjusting, which I

2 think has happened in this example as well, and why the

3 staffing plan is exactly what it is.

4 It's a rural community. It's tough. You

5 can't run it like an urban area where you've got depth,

6 you know, major depth and easy backup very close,

7 right. So because of that, John's decision, and I

8 think it was appropriate, is, you know, to staff that

9 up a little bit stronger than would normally be

10 recommended based on data.

11 Q. If someone told you that looking back at the

12 last year's time, on average CON 58 had looked to

13 either another AMR-owned company or one of its local

14 EMS system partners X times per day to resource the

15 system, and let's assume X is 1 -- use that as the

16 number. -- would that indicate to you that the system

17 has not been appropriately resourced?

18 A. Not necessarily. It depends on what the

19 scenario, is a little bit, right. So sometimes using

20 mutual aid -- actually, I would say more than not the

21 use of mutual aid is a positive thing.

22 If you're going to staff to make sure that

23 you are covering a hundred percent of everything all

24 the time, there's a cost that goes with that, so -- and

25 most systems can't afford to do that, and that's why


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 949

1 mutual aid exists. That's why we share resources with

2 our neighboring operations, partnerships with Fire

3 Departments, whatever that is, because everybody

4 understands that sometimes things just don't work out

5 quite the way you plan, and you need to have good

6 backup plans and cooperating resources to be able to

7 help you out. And it works both ways, right. So that

8 everybody benefits and we cover some of those unusual

9 peaks when they do, those unusual occurrences.

10 Q. So is one thing that you would want to know

11 if somebody asked you that question, whether it was

12 really once a day or on one day there were like six

13 times because there was a multi-accident that piled up

14 and -- I mean is that information that would be

15 important to you?

16 A. Absolutely. So when we look at -- we would

17 categorize this from a data standpoint as a lost call,

18 a call that we wanted to run, but didn't. We handed it

19 off to somebody for some reason.

20 We would pattern all that by hour of day, by

21 day of week, you know, throughout what periods of the

22 year. We do the same kind of patterning with our --

23 anytime we have delayed calls. We look for the

24 patterns. We look for anything that is reasonable that

25 we should be covering that, or was it just an


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 950

1 exceptional situation, you know, like your example.

2 You might have six in one day because of an event, and

3 that's not something that necessarily changes how you

4 staff. That is an exceptional situation.

5 Q. You've been informed by the local operation

6 that the majority of calls in CON 58 come out of the

7 city of Payson, correct?

8 A. Correct.

9 Q. Okay. And you also understand that Payson is

10 where the only hospital in the area is, correct?

11 A. Correct.

12 Q. Okay. So knowing that -- and you also are

13 aware of the size of CON 58 and how much of it is

14 wilderness and rural land. In fact, I think I'll, in

15 connection with this question, pull up a map for you.

16 Here's the -- the pink is CON 58, and then

17 you've got within it the Tonto Basin Fire District.

18 You've got overlap with Rural/Metro (Maricopa). You've

19 got the Pine-Strawberry Department up here, et cetera.

20 But here's the map, and right there is Payson. Let me

21 show you another one here. Hold on.

22 The Hellsgate area is, generally speaking,

23 around here, and then here's the Greater Phoenix Area

24 down there. And I'm looking at, for purposes of the

25 record, LLA-21a.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 951

1 Is the map familiar to you?

2 A. Yes.

3 Q. Okay. Knowing what you do about the source

4 of most of the calls and location of the hospital,

5 wilderness, urban -- or wilderness rural area, do you

6 believe that it is a bad model to staff a single

7 station in Payson, and by a "bad model" I mean a bad

8 model for an ambulance transport provider?

9 A. You mean just to have a single station?

10 Q. Correct.

11 A. So it's an interesting question, because the

12 environment in which that exists depends -- will have a

13 different potential outcome, right. So if I might, I'm

14 going to hit it from an urban angle first.

15 Q. Okay.

16 A. And then I'll answer that part of the

17 question.

18 So in an urban system, we do a fair amount of

19 what we call double-posting, right, so we actually have

20 two ambulances sitting in the same location ready to

21 respond on calls. The reason we do that is because

22 when you identify what your base geography footprint is

23 that you need, so I know if I have, whatever, these six

24 posts locations covered all the time, I know that I

25 will be successful on my on time performance standards,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 952

1 right.

2 I can put ambulances further out and try to

3 catch the onesie, twosies, outskirts types of calls,

4 right, but that's -- you know, why would I move out to

5 try to capture those when I know when there's -- you

6 know, 98 percent of the time the volume is coming out

7 of this area.

8 Q. And "this area" meaning the --

9 A. In that core volume area where the calls are

10 happening, right.

11 So in Payson, this is a rural example of

12 this. And we see this every once in a while in other

13 areas as well. If that is where the calls are

14 happening, then it doesn't make a whole lot of sense to

15 start spreading these resources out. Because what

16 happens is, is you get the call clusters. They come in

17 pairs. You get one call comes in and two minutes later

18 another call comes in, also.

19 So the more spread out that you are,

20 depending on what the volume that you're trying to

21 cover is and where that's occurring, it can

22 actually take a longer response time to get back into

23 the system, and you can cause more harm to the more

24 calls by spreading out to cover small amounts of

25 volume.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 953

1 So it's very situation-dependent, but I don't

2 have an issue with it in Payson. Once we get to three

3 ambulances in one location, I start to scratch my head,

4 and I've brought that up to John. But, you know, until

5 we get some of these issues settled out, I don't -- you

6 know, we want to make sure that we're heading in the

7 right direction before we make more investments in

8 doing things like that.

9 Q. By "these issues settled out," you mean the

10 issue of whether or not Life Line Ambulance will be

11 able to continue being --

12 A. Yeah, if our business is potentially at risk,

13 the timing is not great right now to try to make moves

14 like that.

15 Q. When you were looking at Life Line's

16 performance in this area, did you want to look at out

17 of chute time?

18 A. I always want to look at out of chute time.

19 Q. Okay. And were you interested in what

20 Hellsgate's out of chute time is?

21 A. Yeah. I'm interested in everybody's out of

22 chute times when I'm analyzing the area. It's a major

23 factor. I think it's undervalued by a lot of people.

24 But, so we're talking about from the time

25 that that unit gets dispatched until the time that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 954

1 they're in their unit and responding, right. So it's a

2 category of our overall response time that oftentimes

3 is missed when you're looking at the assessment.

4 Now, we're very aware of out of chute time.

5 So to me, it is a category of wasted seconds, right.

6 It's -- there's -- some of it is out of necessity.

7 This is why we generally, like in an urban area, don't

8 have 24-hour units, right. We're in quarters and the

9 crews are sitting in recliners watching TVs or

10 something.

11 That extra time it takes from the time the

12 call comes in to get up, get your shoes on, put your

13 coat on, whatever that is, walk out to the vehicle,

14 physically leave the station, that is time that's

15 taking away from my response time window, right.

16 So it makes a big impact. If you're sitting

17 in your ambulance ready to go, that's the most optimal

18 situation. And if you're actually moving a little bit,

19 that helps even more. If I could just trim 5 seconds

20 off of out of chute times, that's a big deal, right.

21 That's that much more time I have to get on scene.

22 And if you look at this from the customers'

23 perspective, who is our patients, and we have lots of

24 customers, but from our patients' perspective, they

25 could care less of what it is that's taking us so long


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 955

1 to get there, right. We want to shave that off as much

2 as we can. They just want to know from the time they

3 call to the time somebody shows up.

4 Q. So were you able to find a resource to see

5 Hellsgate Fire District's average out of chute time?

6 A. The one thing I did see is just reviewing

7 from their website and pulled up the most recent fiscal

8 year report. I think it was '14-'15 was the date on

9 the report. But the time frame that I understood to be

10 their, what I call out of chute time, is their turnout

11 time, and for that fiscal year period, their average

12 turnout time was a minute and 40 seconds.

13 Q. And what about CON 58?

14 A. Well, that was the Hellsgate time frame. So

15 I don't know if that covers the whole CON. My

16 assumption is that is just for that Fire Department

17 specifically.

18 Q. Right. And did you look at the out of chute

19 time for CON 58?

20 A. Oh, yes. From the AMR perspective?

21 Q. Yes.

22 A. Yeah. We look at that stuff all the time.

23 They've run, over the period of the last year, right in

24 that 40-second range. And the numbers I pulled up this

25 morning, just to double check and see where we were at,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 956

1 and a four-week trending on that was running at a

2 43-second average.

3 Can I say one more thing about out of chute

4 times?

5 Q. Since you obviously like it so much, yeah.

6 A. Well, and I'm -- yeah, I do, I love this

7 stuff.

8 Averages are -- averages are averages. They

9 really don't tell the whole story, right. So if we've

10 got an average out of chute time of 43 seconds, I know

11 that in the daytime when they're moving, the chances of

12 having a much quicker out of chute time average during

13 the day is probably very likely; and at night, if

14 they're down and napping or whatever they're doing, I

15 know that it's going to be more than that.

16 So a simple way of looking at that is, if

17 I've got a 40-second average, at night I bet you

18 that's, you know, as much as twice that sometimes,

19 right; and in the day maybe it's half that. And

20 there's a balancing and a weighting on that that goes

21 on.

22 So on the same respect from a minute and 40

23 on the turnout time, you can make the same assumptions.

24 And that's eating up a lot of important minutes.

25 Q. So I want to ask you another question and


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 957

1 just establish your awareness of a couple of facts

2 first.

3 You're aware that the historic call volume in

4 this area is significantly under 4,000 calls a year,

5 correct?

6 A. Correct.

7 Q. And you're also aware of the fact that the

8 majority of the area is wilderness and rural, twisty

9 roads; as Hellsgate's GIS person put it, you can't get

10 there from here?

11 Yes?

12 A. Yes.

13 Q. So based upon your training and experience,

14 do you believe that two providers could cover

15 essentially an identical -- the identical service area

16 with that volume of calls and both be sustainable?

17 A. The last part of what you said is the

18 problem, right, sustainable. The financial viability

19 of our rural systems is tough. That's why the

20 reimbursement in rural areas is higher than it is in

21 urban areas. It is hard to be able to sustain things

22 from a cost and efficiency basis.

23 Ambulance service, in my personal opinion, I

24 don't have a problem with competition, right; but I

25 have a problem with competition directly in the market,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 958

1 especially in the 911 category, because it makes it

2 very difficult. You're duplicating resources to be

3 able to try to take care of the same thing, and it

4 costs the system a lot more money to do that. And the

5 likelihood of individual providers being able to

6 survive in that scenario is much less.

7 MS. FICKBOHM: Thank you, Mr. Jones. I

8 don't have any other questions.

9 ALJ SHEDDEN: Mr. Ray, any questions?

10 MR. RAY: Yeah, just a few.

11


13 BY MR. RAY:

14 Q. Good morning Mr. Jones.

15 A. Good morning.

16 Q. I am the Bureau of EMS's attorney.

17 So I want to get into how you arrived -- or

18 how you reached the conclusion that the current CON 58

19 staffing is, from a data standpoint, overstaffed. So

20 that's where I want to go.

21 A. Okay.

22 Q. Let's start with a definition. When you are

23 looking at staffing, what does that mean? Does that

24 mean equipment, personnel, both, something in addition?

25 What are we talking about?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 959

1 A. So, generally, the combination of equipment

2 and personnel, as well as facilities, if appropriate.

3 So when I talk about staffing, I'm generally talking in

4 terms of unit hours.

5 Q. Okay.

6 A. Right? So a unit hour would be comprised of

7 a crew, qualified, certified to the levels that they

8 need to be, in a transport-capable vehicle that meets,

9 you know, whatever the requirements are there, with all

10 the equipment they need to be able to meet the

11 standards there. If they're in service for one hour,

12 that would be one unit hour. So there's two people,

13 maybe, involved in that, but it creates one unit hour.

14 So usually we evaluate that as a resource

15 that is needed to take care of a call, and however long

16 it takes them to take care of that call would then

17 comprise their task time.

18 So that task time piece plays a major role,

19 right. So, for instance, I'm aware that the hospital

20 is right there in Payson. So in a lot of emergency

21 calls, our task time is much shorter than it would be

22 if we were picking up an interfacility patient out of

23 that hospital and heading down into Phoenix, and the

24 time -- because you can't just count the time that they

25 get to Phoenix and drop off their patient, because


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 960

1 until they're back in their primary service area,

2 they're really not available. Even though they aren't

3 tied up directly on the call, they're on the

4 aftereffects of the call.

5 Q. So it sounds like you use unit hour

6 utilization as your -- as one of the formulas driving

7 your analysis for staffing?

8 A. It actually is a -- it's a result of the

9 analysis. Transport utilization or UHU, unit hour

10 utilization, is not a driver of anything that we do,

11 from my department's perspective.

12 As a matter of fact, I have refused to

13 include that metric in any of our design pieces within

14 our OPAP platform. In the demand analysis section,

15 where you can run these demands, which I'll go into a

16 little bit more to answer your question, it's not

17 there.

18 Transport UHU is what I would consider to

19 be a financial indicator, right. So we generate

20 revenue off of a transport. Therefore, however many

21 transports we have in a certain period of time, a

22 number of unit hours would -- that's how you would

23 derive your transport UHU. That doesn't mean that your

24 system's covered. That's, again, a financial

25 indicator.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 961

1 I'm not minimizing the importance of it, but

2 not from my team's approach, right, from a system

3 design approach. Whether or not it's going to make

4 money, that's somebody else's issue. We're going to do

5 it on the design piece to make sure that we've got the

6 right amount of resources there to be able to service

7 the customer, because it's not just a transport. It's

8 also, like I just mentioned, what we call that dead

9 leg. When you're out of your service area, but you're

10 cleared off your call, we actually capture that time

11 element until they get back into their primary service

12 area.

13 You have dry runs or refusals, where the --

14 part of providing good care to your community is you

15 need to respond on those calls. They don't all, you

16 know, eventually land as a transport.

17 Q. So if you don't use unit hour utilization to

18 arrive at the decision as to whether a particular

19 location is understaffed, overstaffed or staffed just

20 right, what do you use?

21 A. It's task time, task time and the combination

22 of the call history and how those calls combine against

23 the number of resources that are potentially available

24 to service those calls.

25 Q. Okay.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 962

1 A. So it is a --

2 Q. So task time would be different in a pure 911

3 system than a mixed 911 and interfacility system?

4 A. Task time is different in every system. You

5 know, it's the old adage of if you've seen one

6 ambulance service, you've seen one ambulance service.

7 Because all of them are different, and so

8 it's very hard to come across and say this is -- this

9 is the right answer for all of our services. Now, in

10 general, we try to be efficient, right. But we have to

11 design the system around being able to meet the

12 requirements or the standards set forth that we need to

13 meet, generally in terms of response time performance

14 is one of the primary drivers of that.

15 Q. Okay. So if you were making a decision based

16 on your data only, what would be the appropriate

17 staffing for CON 58, in your opinion?

18 A. So it's based on the combination of the

19 geographical footprint, the roadway speeds, the calls

20 and the patterning of the calls and where they're

21 falling, combined with that capacity of, well, these

22 are all the calls that we ran during this period that

23 we're going to evaluate. And when we marry that all up

24 together, I would have to reference my materials to be

25 able to give you the exact number, but it's ballpark


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 963

1 around probably 60 unit hours less than what's being

2 done currently in that market.

3 Q. Okay.

4 A. And that's per week. Sorry.

5 Q. Okay. So let's assume 10 calls a week -- and

6 this is a hypothetical number. -- are being transferred

7 to other providers to do those calls.

8 How do those 10 calls a week factor into

9 your --

10 A. Great question.

11 Q. -- analysis?

12 A. Yeah, great question.

13 So this is that lost call category. We look

14 at those as if they were calls that we actually ran

15 when we are doing our demand analysis work. So we have

16 visibility to the fact that we had a call that we

17 wanted to run, but didn't. We passed it off on a

18 mutual aid situation.

19 We take that call, and although we don't have

20 visibility to all the times after we handed that off,

21 we'll take the average task time in that market, we add

22 it to the start time when we know the start of the call

23 occurred, and when we do our demand analysis, we

24 evaluate that call and any lost call as part of the

25 overall calls that we ran, pretending, right, so that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 964

1 we design the system off of that.

2 We also design it, from an interfacility

3 transport standpoint, that if we were late on an

4 interfacility call, we actually shift the time in the

5 demand so that we build the demand off of being on time

6 instead of being late, right.

7 Q. Okay.

8 A. So we do a number of adjustments to the data

9 to try to make sure that we're recognizing everything

10 we possibly can that would realistically contribute to

11 the way that system should be designed --

12 Q. Okay.

13 A. -- and covered.

14 Q. Okay. So I think the takeaway from your

15 answer was that even if you roll calls to other

16 providers, you utilize that data in determining whether

17 your current staffing model is appropriate or not; is

18 that fair?

19 A. That is fair, yes. It's kind of like that

20 dead leg portion, right.

21 Q. Say -- I'm sorry?

22 A. That dead leg portion. If we're measuring an

23 IFT call that came out of Payson and went into the City

24 somewhere, that time portion of going back up into

25 Payson, that's a significant piece of time.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 965

1 Q. Yes.

2 A. If I build a system off of not recognizing

3 that, then I'm going to underestimate what resources it

4 would take to get it.

5 So we spend a lot of time and effort trying

6 to make sure that we're gathering all the information

7 that we possibly can, to give the most accurate

8 recommendations that we can.

9 And they're still subjective, because the

10 business leader can make adjustments to that above and

11 beyond what we've recommended. We've given them this

12 is what the perfect plan would be, and they usually

13 will, you know, push that up just a little bit so that

14 they are covering things from their perspective as

15 well, you know.

16 Q. Sure.

17 A. It's on top of the data.

18 Q. So focusing on what the perfect plan for

19 CON 58 currently is, does that perfect plan build in an

20 assumed number of transfer calls?

21 A. No, because, again, I don't care if it's a

22 transport or what kind of call it is. It's segments of

23 task time, and we actually break it down into 5-minute

24 intervals. So most demand analysis stuff is done on an

25 hourly basis. The problem with taking that approach


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 966

1 is, is that you have to make the underlying assumption

2 that your task time is about 60 minutes, on average.

3 That's a huge assumption to make, right. So I might

4 have a call that we get canceled en route. It only

5 took five minutes task time. That was it. I wouldn't

6 want to show that as it took an hour. Or the other

7 side of it is, I send somebody to the hospital in town

8 and coming back. Well, that's a lot more than an hour.

9 And the patterning of when the timing of all

10 these things happened contributes greatly to that

11 system design plan. So the 5-minute increments

12 allows us to measure how many units are active every

13 5-minute interval, to make sure that we can see exactly

14 what is needed and how we can be successful in this

15 system.

16 Q. So how often do you run these analyses?

17 So --

18 A. All the time. It's a --

19 Q. So how often would you pick up the phone and

20 call Mr. Valentine or --

21 A. Monthly.

22 Q. Okay.

23 A. Monthly for my team's interaction with the

24 operation. But the great thing about OPAP is, is that

25 we put it in a web platform where, literally, if John


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 967

1 wants to run or Glenn, anybody wants to run, from our

2 organization, the demand analysis for Payson, they

3 literally have to select Payson from the pull-down. We

4 have all the settings by default already set up for

5 them, and they hit run. There's not any kind of formal

6 knowledge on the front end on how to do it.

7 That's part of the beauty of that

8 application, is we do all that for them all the time by

9 helping them manage that data to make sure the data is

10 in good shape so that they can push a button anytime

11 they want to. And we recommend it actually is looked

12 at daily. Because not that the demand changes daily,

13 but you can also see what your active call volume was

14 on the previous day.

15 We spend tons of money and effort and time on

16 hiring the right people, trying to meet Dr. Racht's

17 standards on clinical excellence, ambulances,

18 equipment, all these things, so that we can try to be

19 in the right place at the right time, right.

20 If we don't evaluate how we are actually

21 doing on that plan every day, then it's -- I consider

22 that to be a disservice to all the effort and time

23 we've spent on all the other pieces, right. You have

24 to evaluate we had a plan, we staffed it, we had the

25 right equipment and everything; how did it work. And


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 968

1 you can evaluate that very easily on a daily basis with

2 a push of the button.

3 And that's in all of our operations that we

4 have their CAD data flowing into, into OPAP, and we

5 have for Payson here for the last -- for this last

6 year, ballpark, since we merged.

7 Q. Okay. So at your shop, is it fair to say you

8 monthly communicate reports and data on this, the

9 appropriate staffing level, to your managers, whether

10 it's in Payson or someplace in Colorado, and --

11 A. Right.

12 Q. But that those separate managers also have

13 the ability to pull that information whenever they need

14 it?

15 A. Yeah.

16 So our cadence is monthly meetings and

17 interactions. Sometimes that switches around. I would

18 have to investigate to find out for sure it happened

19 every single month with -- you know, with CON 58; but

20 that's our cadence, right.

21 And the purpose of those is not to show them

22 everything. It's just to kind of give them our

23 experienced eyes on what we're seeing, right. So we

24 shouldn't be telling them anything they don't already

25 know, but we are advisors.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 969

1 So my OPAP manager for the south region is

2 the one that would be having that conversation with the

3 operations folks and just pointing out anything that he

4 sees as like, "You guys notice a little trending up on

5 your drop times at the hospital, right?"

6 "It's only 3 minutes. What are you talking

7 about?"

8 "Well, 3 minutes, that's kind of a big deal.

9 What's going on? What's the driver of that?"

10 Those are the types of conversations that we

11 have. So we challenge, is kind of the whole point, is

12 to challenge them to make sure that they're doing

13 everything that they're supposed to; and we counsel

14 them the best we can on things they can do to help make

15 better decisions.

16 Q. All right. And when was the last time you

17 did your review for purposes of determining their, from

18 a data perspective, overstaff?

19 A. A couple nights ago I ran it. Ran it myself

20 and just evaluated it just to take a quick look at how

21 the demand was laying out across everything.

22 MR. RAY: All righty. Thank you --

23 THE WITNESS: Yep.

24 MR. RAY: -- Mr. Jones.

25 ALJ SHEDDEN: All right. Let me just


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 970

1 verify, Mr. Meyerson. You have questions, I assume?

2 MR. MEYERSON: I do.

3 ALJ SHEDDEN: And does it make sense to

4 take our lunch break first, from your perspective?

5 MR. MEYERSON: Yeah, I think it would be

6 a good idea.

7 ALJ SHEDDEN: All right. We're right

8 about 20 to 12:00, so why don't we meet up in an hour

9 and a half at 1:10.

10 (A lunch recess was taken from

11 11:39 a.m. to 1:11 p.m.)


13 the record. The recording is going again. Mr. Jones

14 is back in the witness chair. I'll just let you know

15 again, like yesterday, although we had a little hitch

16 in our plans yesterday, we'll go ahead and take two

17 shorter breaks this afternoon, rather than one longer

18 one. So we'll go about an hour and 10 minutes, take a

19 break of about 10 minutes, and then do it again.

20 But with that, whenever you're ready.

21 MR. MEYERSON: Okay.

22


24 BY MR. MEYERSON:

25 Q. You provided some testimony earlier about the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 971

1 mapping and -- that Hellsgate had done in preparation

2 in its application and submitted with its exhibits.

3 Did you do a detailed analysis of the response time

4 tolerances that were proposed by Hellsgate in its

5 application?

6 A. I didn't have anything to do it on from

7 Hellsgate's perspective, but I did from AMR's. I did a

8 couple quick, not in depth, just for illustration of

9 the differences. And we did some original work on it,

10 you know, six months ago or whenever it was that we got

11 started.

12 Q. So you're not testifying today that Hellsgate

13 can't make the response times that it proposed in its

14 ARCR, right?

15 A. So we're talking about the response circles?

16 Q. No, I'm saying the response times in its

17 ARCR.

18 A. Oh, no, no, no, no. I'm not implying that at

19 all. Correct.

20 Q. You testified also that you believe that

21 CON 58 is overstaffed?

22 A. Okay. Yes.

23 Q. Yeah?

24 A. Yes.

25 Q. Can you provide us an analysis to show us


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 972

1 that?

2 A. I certainly could, yes. So -- and we've got

3 the tools to do that.

4 Q. Okay.

5 A. That's what my Department does --

6 Q. Okay. I --

7 A. -- is evaluate that, right. So -- and,

8 again, we propose from just a data perspective what our

9 recommendations would be, and I base my opinion on what

10 that is, and then it's tailored by the operation to

11 suit -- you know, to suit the needs of the business as

12 appropriate. But yeah.

13 Q. Did you provide us the analysis to show us

14 that CON 58 is actually overstaffed?

15 A. I did not.

16 Q. Can you explain to us why the Maricopa-based

17 ambulance is being used in Payson, on average, one and

18 a half times per day if, in fact, CON 58 is

19 overstaffed?

20 MS. FICKBOHM: I'm going to just make an

21 objection. And the objection is, I believe that

22 assumes facts not it evidence, because counsel is

23 including a body of data that wasn't established

24 actually resulted in CON 58 not responding to the

25 scene. And I'm referencing the Payson and Strawberry


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 973

1 data.

2 ALJ SHEDDEN: All right. And do you

3 want to respond to the objection, Mr. Meyerson?

4 MR. MEYERSON: Yeah. I mean, her

5 objection is irrelevant. The 368 Maricopa-based

6 ambulances is in evidence, and it's actual transports

7 done by those ambulances. It's through 244 days of

8 2016, and if you divide 368 by 244, it's a fraction

9 over one and a half. So I'm not quite sure what the

10 objection is.

11 MS. FICKBOHM: So I --

12 ALJ SHEDDEN: Yeah, go ahead.

13 MS. FICKBOHM: I guess I understood that

14 you were talk -- so you're just talking about the

15 actual Maricopa entity provider reported information to

16 DHS?

17 MR. MEYERSON: The actual Maricopa

18 County ambulance transports done in CON 58.

19 MS. FICKBOHM: Okay.

20 MR. MEYERSON: Actual numbers.

21 MS. FICKBOHM: And I hadn't averaged

22 that out. I'll withdraw my objection. It is what it

23 is.

24 ALJ SHEDDEN: All right. You can answer

25 the question.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 974

1 THE WITNESS: So I can speak in general

2 on some of this, right. So if -- my perception is, is

3 that we have had Maricopa ambulances going up and

4 taking some of the interfacility transport calls to try

5 to make sure that we have availability in the 911

6 system and not drain that system.

7 So when you're talking about whether or

8 not the staffing currently today is the same as when

9 those situations occurred, that's the part that I can't

10 specifically speak to and say, yes, staffing was too

11 much back then and then have an explanation for you,

12 because I don't know that that's the case.

13 BY MR. MEYERSON:

14 Q. Okay. The -- I guess what is the peak load

15 for CON 58?

16 A. I don't have that information in front of me.

17 I don't know.

18 Q. Do you know what hour of the day is the

19 highest demand of CON 58?

20 A. For medical calls, I assume we're talking?

21 Q. For calls on -- for calls for services on

22 CON 58, yes.

23 A. But, again, are we talking about

24 medical-related calls, of which AMR would be responding

25 to?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 975

1 Because I can't necessarily speak to calls

2 that we don't get. But in general, that trending, we

3 see a little higher trending on Tuesday through Friday.

4 Q. And that's specific for CON 58?

5 A. That is specific for CON 58.

6 I know looking at the annual report stuff

7 from the Fire District, it's Saturday tended to peak

8 more; but I have to assume that there's more calls that

9 we wouldn't respond to helping to affect some of these

10 numbers.

11 Q. And what is CON 58's average time on task, I

12 think is the term that you used?

13 A. It is, and I'll have to be a little bit

14 ballparky here. I apologize. But on your 911 calls

15 within the system itself, ballpark, around 45 minutes.

16 And it's much higher than that when we're doing our IFT

17 calls going into town. I want to say it's up in the

18 120-minute range, but I probably shouldn't even guess,

19 because I would have to verify that information for

20 you.

21 Q. And do you know how many times CON 58 has run

22 out of units in 2016 or doesn't have a CON 58 unit

23 available?

24 A. I don't, specifically, no.

25 Q. You've reviewed the call load in preparation


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 976

1 for this hearing. You said in the last 30 days you've

2 looked at it a few times. But we don't have any detail

3 on the reasons for any of the 368 interfacility

4 transports; is that correct?

5 A. We don't -- you're saying you don't

6 understand why we've got 368 interfacility transports

7 done by Maricopa, is that your point?

8 Q. My question is, we don't have any breakdown

9 of any of that information. There's been testimony

10 earlier or suggestion earlier that those are

11 prescheduled calls or a Maricopa County ambulance is

12 already up in the Payson area and, therefore, that's

13 why it did that call.

14 But we really don't know any of that, because

15 there's no information being provided by Life Line in

16 that regard, correct?

17 MS. FICKBOHM: I'm going to object to

18 the form of the question as misstating what's happened

19 thus far.

20 ALJ SHEDDEN: All right. How so?

21 MS. FICKBOHM: What was established

22 during the applicant's case-in-chief was that some of

23 them would involve situations like counsel's talking

24 about, and we didn't really know how many. It wasn't

25 that all of them were that. That -- nobody elicited


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 977

1 that testimony.

2 ALJ SHEDDEN: All right. Mr. Meyerson,

3 do you want to respond?

4 MR. MEYERSON: I think the testimony

5 that was provided in our case-in-chief was more a

6 could, to create some level of doubt regarding -- you

7 know, suggesting that these interfacility transports

8 were based on, you know, legitimate reasons, not lack

9 of resources.

10 And so I'm just asking the witness that

11 would seem to have access to that information the

12 question about that information.

13 ALJ SHEDDEN: Well, I guess the thing

14 that jumped out about me was, I don't know that Life

15 Line had to present any evidence on this. So that was

16 the -- so when you said Life Line didn't present any

17 evidence on it, you know, I'm not sure they were

18 obligated to.

19 I'll overrule the objection, and you can

20 answer.

21 THE WITNESS: So it's being portrayed as

22 that's a negative thing. I don't have all the details

23 on each of those calls, but the way that I look at

24 things, that's not a negative thing. That's tapping

25 into the resources that we have in order to best serve


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 978

1 a community.

2 That's one of the good things about

3 servicing a rural community when you also support the

4 larger urban centers, the ability to share resources to

5 help augment things, for whatever reason. Whether it

6 was, you know, practically, this was absolutely needed

7 or it was scheduled or they were there anyway, that's

8 almost inconsequential. It's taking advantage of the

9 opportunity that we have to be able to do something

10 like that. I don't think -- my opinion is, that's not

11 a bad thing.

12 BY MR. MEYERSON:

13 Q. So it was described earlier as the Maricopa

14 County ambulances coming up as a form of mutual aid; is

15 that correct?

16 A. You could call it that. I don't call it

17 mutual aid when it's amongst our own operations,

18 but fair enough. That's a close enough example, I

19 guess.

20 Q. And by "our own operations," you're talking

21 about AMR generally?

22 A. Correct. We have sister neighboring

23 operations, and it is an advantage when they're close

24 enough to be able to help, to be able to run those

25 calls in, whether they're there or these guys are short


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 979

1 and you're able to kind of shuffle some of those

2 resources and tap into the power of having that

3 networking piece together.

4 Q. Do you know where Pine-Strawberry is?

5 A. I'm familiar with the name. I know it's in

6 the general vicinity, and it's another Fire District

7 right in the area; but not specifically. I've

8 never and don't purport to know all the specifics about

9 Payson enough to be able to tell you exactly where

10 that's at.

11 Q. Is it your understanding, though, that

12 Pine-Strawberry is closer to the Payson area than

13 Maricopa County?

14 A. Yes, I believe that to be true.

15 Q. And earlier we heard testimony about a verbal

16 mutual aid agreement between Pine-Strawberry and CON 58

17 and that they would respond in if CON 58 were short on

18 ambulances.

19 Does it make sense to you that that auto-aid

20 doesn't apply to any interfacility transports that

21 might go out of the area?

22 A. Sure. So timing of the need is a big factor

23 there, right. So if we're talking a 911 call that's

24 holding, then, yeah, that would make sense; go for the

25 closest resource to bring them in to help you.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 980

1 In an interfacility transport scenario, the

2 timing is generally such that you can schedule and plan

3 your resources around the demand as needed. And I

4 would -- I certainly wouldn't want to have to put

5 another District out of -- out of sorts because of

6 something that wasn't, from a timing standpoint, an

7 urgent need.

8 So timing would be the biggest definer for me

9 on whether or not it would be more appropriate to do

10 mutual aid with them versus our own resources coming up

11 from a different location.

12 Q. But you are pulling a resource from another

13 area, just not Pine-Strawberry; but you are having to

14 pull a resource from Maricopa County to come do that

15 anyway. So we are pulling -- whether it's an AMR

16 company or a non-AMR company, it seems to me that

17 keeping it within the family is maybe more important

18 than getting it -- getting a closer mutual aid partner

19 to the area to provide the transport; is that --

20 MS. FICKBOHM: Your Honor, I'm going

21 to object to the form of the question because,

22 basically, he's not giving the witness all the facts,

23 which include Pine-Strawberry not being certificated

24 by the State of Arizona to do interfacility

25 transports.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 981

1 ALJ SHEDDEN: All right. And let me

2 ask, Mr. Meyerson, you would agree that the Chief, I

3 think it was Chief Morris from --


5 ALJ SHEDDEN: -- Pine, said that they

6 weren't certificated for IFTs?

7 MR. MEYERSON: Yeah. Yeah, that's

8 correct, except that it's my understanding that if a

9 CON holder is unable, under their own certificate, to

10 provide an interfacility transport, that if they were

11 asked by a CON that does have that, that they would

12 have the ability to do that interfacility transport, I

13 guess if they're asked. They're not allowed to do it

14 on their own, but they could fulfill that duty if

15 necessary.

16 ALJ SHEDDEN: All right. With that

17 additional information, you can phrase your question to

18 the witness however you would like.

19 BY MR. MEYERSON:

20 Q. Okay. So Pine-Strawberry, which is much --

21 or I won't say much; which is closer than Maricopa

22 County -- and, you know, I think I'll pull up an

23 exhibit to help us out here. So I'm going to go to

24 Hellsgate Exhibit 16, and this is the total number

25 of -- and I'll rotate this. This is the total number


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 982

1 of mutual aid calls that it received in 2016 through

2 November. It's already been admitted as evidence, but

3 we'll go through November.

4 Can you read for us how many calls total that

5 says?

6 A. It looks like there's 8 total.

7 Q. No, it's actually written in there. I

8 apologize. It's the handwritten number at the top of

9 that page. The 26?

10 A. So 26 calls, but I don't see 26 calls here.

11 Q. Yeah, it's a multipage document.

12 A. Oh, I see what you're saying. Okay.

13 Q. Yeah. So it provided 26 calls. It's closer.

14 And Maricopa County ambulances provided 368 calls. And

15 my question was, why wasn't a closer partner that could

16 provide those interfacility transports used; what,

17 8 percent of the amount that the Maricopa County

18 ambulances were used?

19 MS. FICKBOHM: And I'm going to object

20 again. Payson doesn't even have a CON. This is -- is

21 this -- no, this is Payson. This is -- is this

22 Pine-Strawberry or is this Payson?

23 MR. MEYERSON: This is Pine-Strawberry.

24 MS. FICKBOHM: Oh, I'm sorry. I

25 misunderstood.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 983

1 And I guess my only objection is that I

2 thought we established through Captain -- or Chief

3 Morris that he doesn't know that all of these resulted

4 in a transport being done, and, in fact, some of these

5 could have been canceled within minutes of the call

6 coming in and CON 58 could have performed the

7 transport. Didn't he say that?

8 MR. MEYERSON: Yeah, but that would make

9 my point even worse.

10 ALJ SHEDDEN: Well, I'm going to tell

11 you, I don't -- here's the problem I have with this

12 line of questioning, just to be clear: It would seem

13 to me to be silly for the -- Life Line to call

14 Pine-Strawberry if they needed an interfacility

15 transport to go from Payson to Maricopa County. I

16 don't understand why that would make any sense. I

17 heard the Chief say they've got two ambulances. So

18 under the scenario that's being laid out here, you'd be

19 calling Pine-Strawberry to take an ambulance out of

20 service for a couple of hours at least.

21 So my assumption would be that these

22 questions would have been asked on some sort of

23 follow-up of this witness.

24 But with that, one, we don't know where

25 the transports went, to my knowledge. The exhibits


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 984

1 don't show that. But it doesn't seem to me to make a

2 lot of sense to call on Pine-Strawberry to do an

3 interfacility transport to Phoenix.

4 Let me just ask the witness a question.

5 Do you know how many ambulances the AMR folks have in

6 the Phoenix Metro area?

7 THE WITNESS: Tons.

8 ALJ SHEDDEN: So a hundred?

9 THE WITNESS: Well, we're talking

10 physical ambulances or what we're peaking at? It's

11 not -- I don't think it's as high as a hundred, but I'm

12 ballpark guessing. It's up in the, probably, 60, 70

13 range peaking.

14 ALJ SHEDDEN: And you're aware that

15 there are other CON holders in the Phoenix Metro area

16 now, correct?

17 THE WITNESS: Yes. Yes.

18 ALJ SHEDDEN: So -- but I'll let you ask

19 your questions, but, you know, as we embarked down this

20 road, that's what hit me. Why would you call on a

21 provider with only two ambulances to take them out of

22 service, go a hundred miles from Pine-Strawberry, I

23 guess probably a little further than Payson to get to

24 Phoenix. But that's what I'm having trouble

25 understanding.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 985

1 But let me go back to Ms. Fickbohm. So

2 understanding then that certainly Chief Morris didn't

3 know whether all of these calls resulted in transports,

4 that's your only objection at this point?

5 MS. FICKBOHM: That's my only concern,

6 because he seemed to be implying to the contrary to the

7 witness.


9 ask whatever question you would like, Mr. Meyerson.

10 BY MR. MEYERSON:

11 Q. Okay. So let me clarify a little bit; is

12 that the mutual aid requested by CON 58 resulted, we'll

13 concede in this context, less than 26 calls to

14 Pine-Strawberry. The mutual aid requested from its own

15 family of companies from Maricopa County resulted in

16 368 interfacility transports. We don't even know if

17 there are non-CON 58 ambulances from the family that

18 provided emergency/911 transports in the area.

19 My question is that disparate treatment of

20 these two. I understand the judge's point, and I want

21 to be careful not to testify to you. So I'll let you

22 answer that. I assume your answer is the same or

23 similar to his?

24 A. Yeah, so the -- again, the how close they are

25 is not necessarily a determining factor, depending on


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 986

1 the timing requirement or priority of the mission. And

2 you can't abuse your mutual aid neighbors with things

3 that can be handled a different way internally, and

4 shouldn't, shouldn't abuse those relationships, unless

5 absolutely necessary.

6 So from an urgency standpoint, I would say

7 that we would activate them in emergency situations

8 that had a timing-critical nature to them. If it

9 wasn't timing-critical, then we would access our own

10 resources to take care of that.

11 Q. So couldn't Pine-Strawberry then provide

12 coverage for 911/emergency call in CON 58 and have a

13 CON 58 ambulance go do the interfacility transport,

14 rather than have a Maricopa County ambulance do a

15 200-mile roundtrip trip --

16 A. Right.

17 Q. -- to pick up a patient in Payson and drive

18 it back?

19 A. Our preference is to try to run our business

20 the right way as much as possible, right. And that

21 would mean not counting on somebody who's got -- we've

22 got an agreement. And I would have to see the nature

23 of that agreement also, right, to understand what the

24 nature is.

25 But why would we bother them with stuff that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 987

1 we can handle ourselves? That doesn't make any sense

2 to me. I wouldn't engage a mutual aid partner when I

3 can handle that with my own service resources.

4 Q. But as far as CON 58 goes, you're technically

5 not handling it by yourself.

6 A. So if we're going to draw a CON line, it's

7 still part of our operation, our business, and it's not

8 our -- we don't have lines that say we don't cross here

9 because that's AMR Payson or that's CON 58, this is

10 Maricopa. That's not how we do things.

11 Now, primarily that's how we run our

12 business; but when we have an opportunity to do

13 something to help each other out and benefit each

14 other, absolutely. I would expect that we would do

15 that.

16 Q. So CON 58 really is just an extension of the

17 Maricopa County CONs that are to the south?

18 A. Well, I can't say in terms of CON. I don't

19 think that's an appropriate statement. But as far as

20 being able to help cover, we have resources and

21 neighboring CONs in areas that we absolutely will use

22 to our advantage to help make sure that our customers

23 are well-taken care of.

24 Q. So operationally, though, not for regulatory

25 purposes, but operationally, you look at CON 58 as an


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 988

1 extension of the CONs in Maricopa County, from an

2 operational standpoint?

3 A. Not quite the way I would phrase it, I guess;

4 but in general, we try to work together as much as

5 possible, if we can, to help each other. It's not our

6 primary mission to be helping out each area a whole

7 bunch, right; but when those opportunities come up, I

8 think it would be a poor decision not to do that.

9 Q. So we talked earlier, and I think this is

10 correct. I don't think there was any misunderstanding

11 on this point. But when a non-CON 58 ambulance comes

12 in to provide one of those 368 interfacility

13 transports, first off, they're interfacility, but

14 even --

15 MS. FICKBOHM: And I am going to object,

16 because I don't think anybody testified that all of

17 those were interfacility. Some of those could have

18 been resources pulled up into Payson to back up the 911

19 system under a system status management plan. I don't

20 think anybody testified yet that those are all

21 interfacility transports.


23 is it your understanding that there has been that

24 testimony?

25 MR. MEYERSON: This is interfacility


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 989

1 only, from my understanding, and we've been testifying

2 that this is interfacility only. I don't believe that

3 the reporting -- I don't believe that the reporting

4 requirement -- I would -- if they're pulling Maricopa

5 County ambulances up to do 911 calls, I guess I would

6 like to have some data on that. All we had available

7 to us was total interfacility.

8 ALJ SHEDDEN: All right. And the point

9 being that at this point the assumption is that you've

10 got -- what is it? -- Exhibit Hellsgate 15 on the

11 screen, and that's the little table that has, really,

12 just call numbers on there. It doesn't necessarily

13 give any more information than that. But the

14 assumption in your mind is these are all interfacility

15 transports, correct?

16 MR. MEYERSON: And not -- not calls.

17 They're actual interfacility transports.

18 ALJ SHEDDEN: All right. And

19 understanding that the exhibit itself doesn't

20 explicitly show that, correct?

21 MR. MEYERSON: That's correct.

22 ALJ SHEDDEN: All right. With that

23 clarifying information on the record -- well, let me

24 ask, Ms. Fickbohm, do you want to weigh in?

25 MS. FICKBOHM: No. I -- you know, I


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 990

1 might have misunderstood the witness that had this in

2 front of them, but I didn't recall hearing anyone say

3 that this was exclusively IFT. If I'm wrong, I'm

4 wrong. And it doesn't say that, so it's confusing.

5 ALJ SHEDDEN: All right. So go ahead

6 and ask your question.

7 BY MR. MEYERSON:

8 Q. So the question was that these times are not

9 included in any sort of response time analysis; is that

10 your understanding?

11 A. I honestly don't know.

12 Q. So -- but you did say that when you determine

13 what resources are necessary for a system, that you do

14 track how long it takes for an ambulance to respond as

15 part of your analysis --

16 A. Sure.

17 Q. -- of whether or not more resources are

18 necessary in the area.

19 So did you run that analysis for these 368

20 calls in determining whether there were sufficient

21 resources?

22 A. I would assume that if these calls, in fact,

23 were run in the Payson area, that I would then have

24 that data included in that assessment, yes.

25 Q. And when you -- but you don't -- you didn't


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 991

1 provide anything that shows us a breakdown or what

2 the -- what was it again, the -- let me find that.

3 I've got to use that term of art that you use, so I

4 want to make sure that I've got that right. It was the

5 load -- it was an acronym you used. I'm trying to find

6 it here. I made a note.

7 I think it's fairly important that I get that

8 correct, so give me one second while I find exactly

9 what that term was.

10 MS. FICKBOHM: Are you looking for OPAP?

11 MR. MEYERSON: I think it was the

12 average load hour or something to that effect.

13 THE WITNESS: I apologize. That's not

14 ringing.

15 BY MR. MEYERSON:

16 Q. Yeah, I'm sorry. Let me take a quick look.

17 A. Are we talking about workload? I could start

18 guessing, but --

19 Q. No, no, don't guess. I've got it here. I

20 just need to find it. I got off here.

21 Oh, average -- that's it. I apologize. It

22 was in one of my earlier questions. So the average

23 time on task.

24 Did you run an average time on task for these

25 368 interfacility transports?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 992

1 A. I don't know specifically on these calls.

2 But, again, assuming that these were all within the

3 body of run in Payson, so they would be part of our

4 Payson data set, they would be included in our

5 calculations for task time that we routinely do. It's

6 part of our daily efforts to keep an eye on task times.

7 Q. Okay. And so what I would like, because you

8 mentioned this as well, is that analysis that supports

9 your opinion that two providers can't coexist in

10 CON 58. Can you provide that?

11 A. I don't think that I testified to that. I

12 said sustainable, right. So you can have -- you can

13 have six providers in there. I don't think financially

14 that any of them will survive. The more you split it

15 out, the higher likelihood for all to fail.

16 Q. Well, I think that's saying another way what

17 I'm saying.

18 A. Okay.

19 Q. But you don't have any analysis? You just

20 think that based on what you've seen?

21 A. Okay.

22 Q. And, really, in the course of your testimony,

23 we don't have any reports or analysis that we can

24 review to support, really, anything that you said about

25 overstaffing, about average -- you know, average hour


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 993

1 on task; none of that is supported by anything that is

2 reviewable. We just have to take your word for all of

3 your testimony here?

4 A. I suppose so. I'm under oath. I wouldn't --

5 wouldn't give you incorrect information.

6 Q. Okay. Thank you.

7 A. Not intentionally.

8 MR. MEYERSON: That's all I have.



11 MS. FICKBOHM: Just a couple.

12


14 BY MS. FICKBOHM:

15 Q. Mr. Jones, when you run the OPAP data

16 platform, would it be easy for you to come in here and

17 show us all the information that's input to that, or

18 would that be a mountain?

19 A. That would be a mountain.

20 Q. And so, basically, I think I understand what

21 you're saying is that you take the CAD, all the CAD

22 data, the computer-aided dispatch data, and you put it

23 into this platform that you've already built, and then

24 you get the results out of it?

25 A. Correct.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 994

1 Q. When you -- you mentioned -- well, during the

2 lunch break, did you go back to get a precise answer to

3 a question that Mr. Ray asked you about how long CON 58

4 had been at a point where they could use the OPAP

5 platform?

6 A. Yeah. I think I earlier stated I thought it

7 had been about a year, and it hasn't been that long.

8 It was third week in June when we were on site doing

9 the training to deliver that OPAP tool. So closer to

10 six months.

11 Q. And you wanted to make that precise --

12 A. I did.

13 Q. -- information part of the record?

14 A. Because of that whole I took the oath thing,

15 and I certainly wouldn't intentionally provide wrong

16 information.

17 MS. FICKBOHM: Thank you.


19 MR. RAY: Nothing further.

20 ALJ SHEDDEN: Let me just ask a question

21 or two.

22

23 EXAMINATION

24 BY ALJ SHEDDEN:

25 Q. You used, maybe, two different terms


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 995

1 regarding response time or -- one, you talked about out

2 of chute time.

3 A. Right.

4 Q. And then for the Hellsgate, though, you

5 talked about turnout time.

6 How do those differ?

7 A. My assumption is that we're talking about the

8 same thing, and they would have to validate that from

9 their perspective, since that was their report. But it

10 generally indicates the time -- I functioned in a

11 firehouse environment on the ambulance for many years.

12 And as I understood it, from their perspective, they

13 use turnout time the same way we use out of chute.

14 Q. Okay.

15 A. The time you get dispatched to the time you

16 actually physically get moving.

17 Q. All right. And then if I heard right when

18 you were answering some of Mr. Ray's questions, your

19 thought was that on the data only, the overstaffing, if

20 you will, was 60 unit hours per week; is that right?

21 A. That's a ballpark number, yes.

22 Q. Okay. How many unit hours per week total are

23 there now?

24 A. It's about 540.

25 Q. 540? Okay.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 996

1 ALJ SHEDDEN: And let me -- I probably

2 should have asked my questions before going back, but

3 we'll just go all the way around again. Any additional

4 questions, Mr. Meyerson?

5 MR. MEYERSON: Yeah, just a couple.

6

7 RECROSS-EXAMINATION

8 BY MR. MEYERSON:

9 Q. Would you agree with me that assuming that

10 out of chute data and turnout time, despite your

11 experience, could be different, based on dispatch

12 systems --

13 A. Certainly.

14 Q. -- how they measure it, how AMR measures it?

15 A. Yeah. I have no firsthand information on how

16 they measure that time.

17 Q. And then Ms. Fickbohm asked you a question

18 about what would the data look like if you were to

19 bring it all in here; but then she said something

20 that I think is my point, is you put it all into

21 the computer and it spits -- I mean I know that this

22 is --

23 A. I'm with you so far.

24 Q. -- a colloquialism. It spits out some

25 information that you could have summarized and


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 997

1 submitted as an exhibit and then used for your

2 testimony; isn't that right?

3 A. I suppose we could have, yeah.

4 Q. Okay.

5 A. Yeah.

6 MR. MEYERSON: Thank you.


8 Ms. Fickbohm?

9 MS. FICKBOHM: No.

10 ALJ SHEDDEN: No, all right. Thank you,

11 sir.


13 ALJ SHEDDEN: All right. Who's

14 next?

15 MS. FICKBOHM: Alan Maguire.

16 ALJ SHEDDEN: Come on up.

17 Go ahead and have a seat. And I

18 don't think you got here before this afternoon.

19 I'm Administrative Law Judge Thomas Shedden. What

20 I'll do is get you sworn in, and then we'll follow

21 the same procedure we did with Mr. Jones there, all

22 right.

23 THE WITNESS: Okay.

24 ALJ SHEDDEN: If you would raise your

25 right hand.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 998

1 ALAN MAGUIRE,





6

7 ALJ SHEDDEN: All right. Please state

8 and spell your name for our record.

9 THE WITNESS: My name is Alan Maguire,

10 A-L-A-N, M-A-G-U-I-R-E.

11 ALJ SHEDDEN: All right. And what you

12 may have missed coming in at the -- kind of the

13 midpoint with Mr. Jones is that we'll have

14 Ms. Fickbohm, who is, of course, the Life Line lawyer,

15 go first. So whenever you're ready, Ms. Fickbohm.


17


19 BY MS. FICKBOHM:

20 Q. Good afternoon, Mr. Maguire.

21 A. Good afternoon.

22 Q. Can you tell us what your current occupation

23 is?

24 A. Yes. I'm an economist and I run a public

25 policy consulting firm.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 999

1 Q. And as part of that public policy consulting

2 firm, do your regular duties include engaging in

3 economic forecasting?

4 A. Yes, they do.

5 Q. And tell me how long you've been -- well, let

6 me back up first.

7 Do you have any college degrees?

8 A. Yes. I have a degree in economics.

9 Q. And how long have you been involved in

10 economic forecasting?

11 A. Since the late 1970s.

12 Q. I see you're an original founding member of

13 the Arizona Western States and Metro-Phoenix Blue Chip

14 Economic Forecast Panel. What's that?

15 A. Well, the Blue Chip Forecast is -- actually,

16 the original one is a national survey that was

17 originally set up by an economist named Bob Eggert, who

18 was the retired economist for -- Mr. Eggert had been

19 the economist for many years at Ford Motor Company and

20 set up a national consensus forecasting process because

21 he had learned that many economists thinking together

22 come up with better results than a single economist

23 working alone.

24 Mr. Eggert, after he left Ford, retired to

25 Sedona, Arizona. Mr. Eggert and I became friends. We


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1000

1 worked together on several projects. And there was an

2 interest in creating a forecast in Arizona similar to

3 the National Blue Chip Forecast.

4 So he and I set up the original Arizona Blue

5 Chip Forecast, recruited about a half a dozen,

6 initially, people to join us over time, and now it's

7 been going on ever since. I think that was 1982 or

8 thereabouts. That's been going on ever since, and it

9 has spread now. The Arizona State University took it

10 over after a period of time, and they now do it for the

11 Western States. So the methodology has been copied in

12 California, Washington, Nevada, et cetera.

13 Q. Sort of going sequentially or talking about

14 what you've done, your resumé says you've served as an

15 economic, fiscal and policy advisor to several Arizona

16 Governors?

17 A. Yes.

18 Q. And other State Representatives.

19 Approximately when did that begin?

20 A. So beginning in the late 1970s, I was the

21 senior economist for the Arizona State Senate. I

22 worked for both the Democrat Majority and the

23 Republican Majority during that period of time.

24 I left that position and became the Chief

25 Deputy Treasurer in the State of Arizona. Throughout


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1001

1 that period of time, I conducted detailed analyses of

2 fiscal systems within the State of Arizona, including

3 the formation of local government agencies and

4 operations.

5 After I left that, I went on and was an

6 investment banker, doing public finance, municipal

7 finance in the state of Arizona. And that included,

8 also, forecasts for local governments, both economic

9 forecasts as to their local conditions, as well as

10 revenue forecasts for them for their upcoming budgets.

11 And since initially 1986, but ultimately

12 1991, I've been doing the same thing as a consultant,

13 during which period of time I have had the good fortune

14 to work with multiple State agencies, including all the

15 large agencies that do forecasting, Counties across the

16 state of Arizona, Cities across the state of Arizona,

17 and a number of various Special Districts over time.

18 Q. And is that background of yours further

19 detailed in your biographical sketch that we have up in

20 front of you as Exhibit 13k?

21 A. It is in brief, yes.

22 MS. FICKBOHM: I move for admission of

23 13k.


25 ALJ SHEDDEN: All right. 13k is


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1002

1 admitted.

2 BY MS. FICKBOHM:

3 Q. Mr. Maguire, were you asked by Life Line

4 Ambulance to review facts relating to your making an

5 economic forecast for Fire Districts in the state of

6 Arizona, in particular those holding certificate of

7 necessities and including the Hellsgate Fire District?

8 A. We did an analysis of the reported data to

9 the Department concerning the operations of ambulance

10 services across the state of Arizona operating under a

11 CON that provided significant information; and on the

12 basis of that data, we were able to draw some

13 conclusions.

14 Q. Okay. We'll break that down in just a

15 second.

16 So you were asked to perform that task?

17 A. Yes.

18 Q. Okay. And can you tell me how you've been

19 compensated for your time on this project?

20 A. Yes. I'm being paid a fee of $5,000 for this

21 expert witness work.

22 Q. Okay. In the information that you considered

23 for this project, did it include the compilation of the

24 tax rates for 2014 and 2015, with emphasis or

25 demarcation of Districts providing ambulance service,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1003

1 as represented in LLA Exhibit 9?

2 A. Yes, we looked generally at tax rates for

3 Fire Districts over the last several years, and this is

4 an evidence of that.

5 Q. And this was part of what you considered?

6 A. Yes.

7 Q. And that was provided to you by Mr. Kasprzyk?

8 A. Yes.

9 Q. Tell us what else, besides LLA-9, you looked

10 at as facts in order to perform the tasks that you

11 performed?

12 A. As I mentioned, we looked at the reports

13 routinely submitted to the Department.

14 Q. I'm sorry, you're going to have to slow down

15 for me too.

16 A. Okay. I apologize to both of you.

17 We looked at the reports that are routinely

18 submitted to the Department. In some cases the reports

19 had gaps in them, and so we couldn't consider them; but

20 by and large, the vast majority of them were complete

21 and allowed us to do some analysis and draw some trends

22 from those reports.

23 Q. And, now, what reports are you referring to?

24 A. The ARCRs.

25 Q. Okay. ARCRs submitted by Fire Districts?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1004

1 A. Right.

2 Q. Did you review the pro forma ARCR submitted

3 by Hellsgate Fire District?

4 A. Yes, we did.

5 Q. Did you review their annual financial

6 information submitted as part of this process?

7 A. Yes, we did.

8 Q. Did you review the findings that the Bureau

9 of Emergency Medical Services made as part of their

10 analysis of Hellsgate's application for a CON?

11 A. Yes, we did.

12 Q. Anything else that you dug in to look at?

13 A. We looked at other material that was out

14 there. For example, we looked at tax rates as

15 published by the Arizona Tax Research Association,

16 which align with the data that's in the exhibit before

17 you.

18 Q. And did you then apply your experience and

19 knowledge gained since the late '70s in the area of

20 economic forecasting to perform your work on this

21 project?

22 A. Yes, we did.

23 Q. So can you tell us what you see, as an

24 economist, as historic trends for Fire Districts that

25 hold CONs in Arizona, just in general?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1005

1 A. So generally speaking, what we learned was

2 that most of the ambulance services operated by Fire

3 Districts tend to operate at an annual loss, based upon

4 the data in the reports that they file.

5 We also learned that it appears that based

6 on, again, the reports, that they have a higher average

7 share of their expenses derived from personnel-related

8 expenses. That's not surprising. They are able to

9 maintain themselves by virtue of the fact that they can

10 use their general revenues to cross-subsidize their

11 operations.

12 And they also tend to have a lower number of

13 trips per employee. And they are able to maintain that

14 operation over time because of that cross-subsidy that

15 comes from their general fund, which is largely

16 supported from their property taxes, one of the major

17 sources that allows Fire Districts to operate.

18 And many of them, including Hellsgate, as a

19 matter of fact, are at their statutory cap of $3.25,

20 and that's been an issue for Fire Districts generally

21 in Arizona for a number of years.

22 Q. And looking at the historical data, how do

23 you believe what you see as those trends impacts the

24 future outlook for Arizona Fire Districts holding CONs?

25 What's the economic forecast for that class of


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1006

1 entities?

2 A. Right. I think that the challenges that Fire

3 Districts operating ambulance services face is the fact

4 that they tend to operate at a loss, and they use the

5 cross-subsidy through their general funds to maintain

6 that service.

7 And there's no reason to believe, because of

8 the categorical commonalities of Fire Districts in

9 Arizona, that they -- that Hellsgate would be any

10 different than the other ones.

11 Q. So, in your opinion, is certificate of

12 necessity acquisition a financial plus or a

13 negative?

14 A. Well, based on the fact that the majority of

15 Fire Districts that operate ambulance services have to

16 cross-subsidize because they have a loss in their

17 ambulance services, it is very likely -- no one can be

18 positive, but it's very likely that Hellsgate could, in

19 fact, adversely affect their financial condition.

20 Q. And plugging that into what you saw as their

21 current financial condition vis-à-vis how much they

22 tend to maintain for cash reserves, what would your

23 economic forecast for them be?

24 A. Hellsgate appears to be a very well-run Fire

25 District. They have cash balances that range in the,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1007

1 you know, about three-quarters of a million dollars

2 from year to year. That's better than a lot of Fire

3 Districts, frankly. But that's because of the

4 operations that they're running right now.

5 If they were to take on an operation that

6 costs them -- that caused them to have a loss, that

7 cash surplus, that available liquid reserve would be

8 endangered. And depending how big the annual loss is,

9 that would be a greater or lesser danger to them.

10 Q. Are you aware of the recent Arizona Supreme

11 Court decision relating to Public Safety Pension

12 payments?

13 A. Yes, I am.

14 Q. And can you speak to how that decision could

15 impact the economic forecast for any Fire District in

16 Arizona?

17 A. Well, what the Court did in, actually, a

18 series of decisions, the most recent one being just

19 very recently, was constrain the ability of employers

20 to modify the contribution rates made by employees to

21 support the defined benefit contribution system through

22 the Public Safety Retirement System.

23 The fundamental challenge that the Public

24 Safety Retirement System faces is that it has a very,

25 very large unfunded liability that has accrued over


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1008

1 many years from past service, where insufficient funds

2 were set aside to offset that liability, and the

3 expected rate of return on the available assets was

4 less than expected.

5 The consequence of those is that their

6 unfunded liability has grown. The contribution rates

7 have grown. And so, essentially, the cost per employee

8 has risen for operators.

9 Q. And if I already asked you this, I apologize.

10 But as you looked at the data, including Hellsgate's

11 application and its finances, did you see any reason to

12 believe that the Hellsgate Fire District's experience

13 with the financial implications of holding a

14 certificate of necessity are going to be any different

15 than other Fire Districts that have certificates of

16 necessity?

17 A. We saw no evidence of that fact.

18 Q. Thank you, Mr. Maguire.

19 MS. FICKBOHM: That's all I have, Your

20 Honor.

21 ALJ SHEDDEN: All right. Mr. Ray,

22 anything?

23 MR. RAY: I have no questions,

24 Judge.

25 ALJ SHEDDEN: All right. Mr. Meyerson.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1009

1 CROSS-EXAMINATION

2 BY MR. MEYERSON:

3 Q. You mentioned a few items that you reviewed,

4 which it sounds -- were those provided by Ms. Fickbohm?

5 A. Other than the exhibit here, no.

6 Q. And the information that you reviewed didn't

7 consider management or different staffing models; is

8 that right?

9 A. It did not.

10 Q. And the findings letter that was provided to

11 you, was that an assumption that you made that the

12 findings letter was the correct information for

13 purposes of your analysis?

14 A. I'm sorry. Which letter?

15 Q. The findings letter. She said that -- sorry.

16 Ms. Fickbohm said that one of the items you reviewed

17 was the findings letter. You can go to it, if you

18 would like.

19 It looks like Ms. Fickbohm is getting --

20 pulling it up now.

21 Does this look familiar to you?

22 A. Yes. So you mean the findings letter

23 submitted by the Department to the applicant.

24 Q. Yes. And so was the information you reviewed

25 and determined was accurate the applicant's proposal or


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1010

1 the Department's proposal for purposes of determining

2 if the applicant could sustain operations of an

3 ambulance service?

4 A. Right. The letter from the Department to the

5 applicant indicates that they believe that their

6 charges are insufficient, and that even with the

7 adjusted charges, they would have a loss.

8 Q. So you used the Department's proposed rates

9 for purposes of your analysis?

10 A. Well, it certainly appears that the findings

11 of the Department are consistent with the experience

12 evidenced in the reports from other Fire Districts

13 across the state.

14 Q. So you did use the proposed rates by the

15 Department?

16 A. In part.

17 Q. And then you said another thing and then

18 contradicted yourself a second after that. You said

19 "due to the categorical commonalities." And maybe

20 that's a technical term, but in my mind, when I hear

21 "categorical commonalities," it means every Fire

22 District is the same.

23 Is it common for Fire Districts to have

24 available capital of approximately a million dollars?

25 A. It depends on the size of the District and


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1011

1 their financial standing.

2 Q. And then the losses from ambulance operations

3 that you referred to a second ago, I think the

4 testimony was, based on an analysis of most of the Fire

5 Districts in Arizona that operate their ambulance

6 services at a loss, you would have to assume that

7 Hellsgate would also operate at a loss.

8 That's a fairly broad statement, don't you

9 think, without looking and drilling down closer and

10 asking specific questions to Hellsgate?

11 A. So we know that Fire Districts have the same

12 structure across the state. They have the same

13 principal revenue sources. They have the same

14 principal employment agreements. They have the same

15 general common characteristics. There's very little

16 that differentiates them, except for their particular

17 location and the particular tax base that they happen

18 to have.

19 And so it's a fair assumption, I believe,

20 that if you look at a wide range of Districts that have

21 general commonalities in common, that they will act

22 similarly. That's based upon working with local

23 governments for 40 years.

24 Q. Yet they, in some way, by having available

25 capital of a million dollars, are you aware of any


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1012

1 other Fire Districts in the state of Arizona that have

2 available capital of that amount?

3 A. So those are two different questions. With

4 regard to the operation of Hellsgate as a Fire

5 District, that capital balance has been -- has been

6 developed and has been relatively stable at least over

7 the least three financial statements that I looked at;

8 and as a consequence, any change -- material change to

9 their operations could either increase that balance or

10 decrease that balance.

11 Q. Correct. But that was based on the

12 assumption that the ambulance services are operating at

13 a loss?


15 MR. MEYERSON: That's all I have, Your

16 Honor.

17 ALJ SHEDDEN: Ms. Fickbohm, anything

18 else?

19 MS. FICKBOHM: No.

20 ALJ SHEDDEN: Mr. Ray?

21 MR. RAY: Nothing, thank you.

22 ALJ SHEDDEN: All right. Thank you,

23 sir.

24 All right. Who will be next?

25 MS. FICKBOHM: Mr. Bartus.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1013

1 ALJ SHEDDEN: All right. Let me give

2 you a minute to get ready.

3 Ready?


5 ALJ SHEDDEN: Let me get you sworn in.

6

7 RICHARD BARTUS,





12



15 THE WITNESS: Richard Bartus, last name

16 B, as in boy, A-R-T-U-S.


18 you're ready.

19 MS. FICKBOHM: Thank you, Your Honor.

20


22 BY MS. FICKBOHM:

23 Q. You stated your name for the record. Can you

24 tell me what your current occupation is?

25 A. I'm currently the regional operations and


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1014

1 finance officer for the South Region of American

2 Medical Response, which encompasses the state of

3 Arizona.

4 Q. On a parallel with performing that job, have

5 you recently received another job title?

6 A. Yes. I am in the process of transitioning to

7 an executive vice president role with the organization.

8 Q. Congratulations.

9 A. Thank you.

10 Q. I think.

11 Let's talk about how you came to emergency

12 medical services and the path that your career has

13 taken.

14 First of all, do you have a college degree?

15 A. Yes. I have a Bachelor's degree, emphasizing

16 in accounting, from Temple University.

17 Q. And when did you first start working in the

18 emergency medical services field?

19 A. September of 1992.

20 Q. And how did that come about?

21 A. Like most people that have been in the

22 business for well over 20 years, a lot of people just

23 happen to fall into it.

24 I fell into some of the front-line work

25 through a mutual friend. Got started in the ambulance


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1015

1 business working in fleet maintenance, of all places.

2 Eventually migrated over to the operations side and

3 working in the communications center, both as a

4 dispatcher and call-taker, eventually receiving my EMT

5 certificate from the Commonwealth of Pennsylvania

6 shortly thereafter.

7 And after a few years of working both field

8 and communications-related jobs, worked my way into the

9 financial and accounting division --

10 Q. And approximately --

11 A. -- for the AMR locations.

12 Q. And approximately when was that?

13 A. In October of 1994, I transitioned to the

14 business side of the ambulance business.

15 From 1994 all the way up through present,

16 I've worked in various regional and corporate level

17 roles, rising up through the ranks as between

18 accounting supervisor, corporate accounting manager,

19 regional director, and then ultimately into various

20 executive roles as regional corporate vice president

21 roles.

22 Q. And you've also -- you're not just a finance

23 guy; you also have run operations?

24 A. Yes, for a period of time I did perform

25 day-to-day oversight with various operations as a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1016

1 divisional and regional chief operating officer.

2 Q. And for the last -- now I'm going to show. --

3 seven years or so, have you been gaining experience in

4 the Arizona ambulance transport market?

5 A. Yes. It was about eight years.

6 Q. Eight years.

7 A. From the AMR acquisitions with River Medical

8 back in 2008, acquisitions of Life Line Ambulance just

9 a few years ago, maybe three.

10 Q. And when you say "Life Line" -- excuse me,

11 for interrupting. -- then what was Life Line? It was

12 located in --

13 A. Located in Prescott --

14 Q. Okay.

15 A. -- Arizona.

16 And that was just a few years ago. So

17 starting in 2008 I began to get exposure to the Arizona

18 regulatory environment, which included the regulatory

19 requirements for the annual revenue and cost report.

20 Q. Which is we continually refer to as the

21 ARCRs?

22 A. The ARCRs, correct.

23 Q. So are you the person who's been preparing

24 the ARCRs for River Medical, now known also as one of

25 the Life Line members, since its acquisition by


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1017

1 American Medical Response in 2008?

2 A. Yes, I have personally prepared those ARCRs

3 myself over the last eight years.

4 Q. And subsequent to American Medical Response's

5 acquisition of Life Line in Prescott a few years ago,

6 have you been preparing -- or have you been putting

7 together the ARCR reporting for that organization?

8 A. Yes, I have personally prepared and signed

9 the ARCRs for the Life Line organization out of

10 Prescott.

11 Q. And subsequent to AMR getting a certificate

12 of necessity in Maricopa County, have you filed at

13 least one ARCR for that entity?

14 A. Yes, I did personally prepare the ARCR for

15 CON 136 for AMR of Maricopa.

16 Q. And that -- they've just filed one, correct?

17 A. Correct, we filed our first ARCR for calendar

18 year 2015. Yes, 2015.

19 Q. And in addition to filing ARCRs, do you also

20 have managerial oversight of billing and collections?

21 A. In addition to filing the ARCRs, I've also

22 prepared pro forma ARCRs. So I would like to make sure

23 the record reflects that I've prepared numerous

24 pro forma ARCRs as well.

25 Q. So in connection -- thank you for that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1018

1 clarification.

2 In connection with the acquisition of River

3 Medical, Life Line Prescott, and the CON in Maricopa

4 County, you're the person who prepared the pro forma

5 ARCRs for each of those?

6 A. Yes, I did prepare those.

7 Q. Do you also look at the data coming out of

8 Arizona regarding billing and collections?

9 A. Yes. While I don't have direct oversight of

10 the billing and collections personnel, it is part of my

11 duties to routinely review in depth billing detail in

12 the production of the ARCR.

13 Q. And as part of your duties, are you required

14 to keep up to date on change in Medicaid/Medicare

15 compensation?

16 A. Yes. Not only is it part of our day-to-day

17 in the performance of the job, but it is part of our

18 annual strategic planning when it comes to budget

19 forecasting and understanding upcoming changes in

20 reimbursement.

21 Q. And as part of your annual budget

22 forecasting, do you also look at trends in collection

23 and billing rates?

24 A. We look at trends in billing rates. We look

25 at trends in payor mix. We look at levels of service,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1019

1 whether there's changes in the mix, whether it's

2 advanced life support or basic life support, whether

3 they are emergent or nonemergent in nature, various. A

4 lot of those indicators could impact your trends, which

5 ultimately will impact your future collections.

6 Q. And when you use the term "payor mix," what

7 does that mean?

8 A. It's understanding of the amount of

9 transports you have, what percentage is routinely

10 billed to Medicare, what percentage would routinely be

11 billed to Medicaid, third-party insurance, and even a

12 percentage of transports where patients have no

13 insurance.


15 for admission of LLA-13b.


17 ALJ SHEDDEN: All right. 13b is

18 admitted.

19 MS. FICKBOHM: This is where

20 LLA Exhibit 27 isn't showing up.

21 ALJ SHEDDEN: Right. This has not yet

22 been copied over. Hang on.

23 MS. FICKBOHM: There it is.

24 ALJ SHEDDEN: This one on the screen I

25 copied over. And I will let folks know, if there's a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1020

1 preference, it is on the internet version. It's been

2 updated to our docket, but I'll leave it to you folks

3 if you're content with the one that I made the

4 electronic copy and copied to this computer. This

5 is -- and it looks like this one's still showing the

6 labeling error, because it's showing it as

7 Hellsgate 27. So let me get the --

8 MS. FICKBOHM: But the document itself

9 is marked as -- okay. You're right, it is. Yeah.

10 ALJ SHEDDEN: Hang on and I'll get

11 the -- so now I've got the internet open and we're on

12 the electronic docket for this hearing. You'll note,

13 perhaps, that that version has been updated to show the

14 exhibits that had been admitted as of yesterday, and

15 then Life Line 27 is appropriately marked on there and

16 is on the screen.

17 MS. FICKBOHM: Thank you for that

18 assistance, Your Honor.

19 BY MS. FICKBOHM:

20 Q. Mr. Bartus, we have before us LLA Exhibit 27.

21 Is this something that you prepared?

22 A. Yes, I did prepare this document.

23 Q. And I'm not going to pull up the earlier

24 version, but you did an earlier version of this that

25 you corrected?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1021

1 A. Yes, I did. I believe that was AMR or Life

2 Line 16.

3 Q. And can you -- does this exhibit show where

4 the corrections were? And feel free to move around

5 there.

6 A. Yes. One of the advantages of using color,

7 like I like to do, is to be able to point out things

8 like that. I did color-code and add a legend for the

9 Court's benefit of understanding things that I may have

10 changed.

11 The items I labeled in purple were some

12 things that I had, upon second review, felt that I had

13 a formula error in one cell that drove a handful of

14 calculations. So I thought it was important to change

15 those numbers and accurately reflect my analysis.

16 The one number I did change is reflected here

17 on Page 4 relating to the increase in accounts

18 receivable in the cash flow statement, which did impact

19 a couple line items on the balance sheet.

20 Q. And so you changed the individual line item,

21 but there may be -- the totals underneath those will

22 also change?

23 A. Yes. I did not go through and highlight each

24 one of those, but, yes, it is with that notion.

25 Q. Oops, I'm making it -- that would be cruel.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1022

1 Okay. So can you tell us how you went about

2 putting this document together and what your intended

3 purpose of it was?

4 A. Sure.

5 This document represents a comparison of the

6 applicant's proposed ARCR, the Bureau's proposed

7 findings, which were --

8 Q. The second column?

9 A. -- would be the second column that is colored

10 and labeled BEMSTS Proposal. Those findings were

11 ultimately accepted by the applicant.

12 The next section is labeled the 2015 ARCR for

13 CON 58. And my purpose was generally to do a

14 comparison of the three sets of figures in order to

15 understand whether the pro forma proposed by the

16 applicant was achievable and reasonable.

17 Q. So you -- your intent was to compare the

18 first three columns of the first page of Exhibit 27?


20 Q. And where did you obtain the information that

21 you used to do this?

22 A. Through the publicly available documents with

23 this hearing.

24 Q. So tell us what the first comparison was that

25 you did.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1023

1 A. First comparison I've labeled sort of with an

2 A up at the top.

3 Q. We're still on Page 1?

4 A. We're still on Page 1, correct.

5 It says CON 58 Actual 2015 Revenue With

6 Applicant/Bureau Proposed Expenses.

7 Q. So what does "Applicant/Bureau Proposed

8 Expenses" mean?

9 A. The Bureau, in their analysis, in their

10 findings, with the exception of bad debt, concurred

11 with the expense proposal with the applicant. So I am

12 not intimately involved with Hellsgate's fire expenses,

13 so I have to presume at this point that those expenses

14 are true and accurate and is what is expected for them

15 to incur in the performance of services.

16 Q. And why did you want to compare their

17 expenses with CON 58 actual 2015 revenue?

18 A. Well, being that we have the experience of

19 the approximately 3,000 transports in the CON area, I'm

20 very confident that, you know, we, you know, have

21 maximized the revenue opportunity in that CON area.

22 And given that the applicant has proposed to displace

23 CON 58, my presumption is that despite their

24 projections and our experience in collecting in that

25 area, that based on our 2015 report, there is only


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1024

1 $2,986,000 worth of revenue to obtain.

2 Q. And so what was your ultimate conclusion in

3 doing that comparison?

4 A. My conclusion, that if you utilize our

5 revenue experience, coupled with the proposed operating

6 expense structure from the applicant, that the proposed

7 applicant will lose a little more than $575,000 in its

8 first year of operation.

9 Q. And that's what's showing down at the very

10 bottom of your fourth column on Page 1?


12 Q. Labeled A.

13 What comparison did you do in Column B?

14 A. Column B I just wanted to test the revenue

15 and bad debt based on the Bureau's proposed rates and

16 charges that have the higher base rate of $1,727 and

17 the smaller mileage rate of $10.97.

18 Q. So you compared the -- you compared Hellsgate

19 pro forma that's the amount -- that's the rate that the

20 Bureau was allowing them with the -- with what?

21 A. In the -- the last column does that

22 comparison, essentially, Section B.

23 Q. Oh, so I'm sorry. So in Column B, is that a

24 comparison or you're just restating it?

25 A. I'm restating the revenue based on the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1025

1 Bureau's proposed rates and charges structure.

2 Q. So Column B is not a comparison; it's just

3 restating?

4 A. It's restating, and, really, it was an

5 analysis to show that the revenue -- gross revenue

6 proposed by the Bureau would have no material impact on

7 the net revenue achieved by the applicant.

8 Q. Okay. So this isn't a restatement of the

9 Bureau's findings. This is applying -- as opposed to

10 using CON 58's allowed rate, you used the rate allowed

11 by the Bureau?

12 A. Correct, again, to show that there is no

13 material impact in what the rates the Bureau has

14 proposed.

15 Q. And your final column there, A compared to B,

16 is doing exactly that, correct?

17 A. Correct. It just shows that despite the

18 different rates and charges, in the end there's no

19 material change in the operating revenue, whether it's

20 the rates proposed by the Bureau or the rates proposed

21 by the applicant.

22 Q. There's basically a $3,049 difference between

23 the two?

24 MR. MEYERSON: I'm going to object to

25 the line of questioning. All the questions she's


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1026

1 asking are leading the witness.

2 ALJ SHEDDEN: Well she's asking -- you

3 know, and I've got to admit, I was struggling before to

4 the exception to allow background. We're looking at

5 the exhibit.

6 So the objection's overruled. And,

7 again, to the extent any leading question is asked,

8 there's really little that can be done other than

9 determine what weight can be given to the answer.

10 BY MS. FICKBOHM:

11 Q. And, Mr. Bartus, can you tell us why there

12 isn't a significant difference if you change the rate?

13 A. Yes. Because at the end of the day, the

14 payor mix is still the payor mix. There are so many

15 Medicare calls. Regardless of what you charge, you're

16 going to get paid the same Medicare rate, as various

17 witnesses have testified already. You're going to get

18 paid the same rate from AHCCCS, regardless of the rates

19 and charges, although AHCCCS does move with the rates

20 and charges.

21 Since the Bureau has adjusted the $1,727 rate

22 as a means of offsetting the lower mileage rate, in

23 total there is really no major change in revenue, and

24 it will not change AHCCCS reimbursement as well.

25 Q. Can you go to Page 2 and tell us what you did


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1027

1 there.

2 A. Page 2, I did not perform any detailed

3 analysis other than, for my benefit, have a means of

4 doing a side-by-side comparison in understanding the

5 different line item expenses.

6 Q. So can you just start at the top and tell us

7 what the three different columns are?

8 A. Sure. The three columns, again, were

9 comparing the applicant's proposed operating costs

10 compared to the Bureau's proposed operating costs, and

11 then the third column lists the operating costs of the

12 certificate holder CON 58.

13 Each of the, if you will, row structures

14 correspond to the ARCR categories for wages, payroll

15 taxes and benefits, general and administrative

16 expenses, cost of goods sold, as well as other

17 operating expenses.

18 Q. And the first column is based on what? When

19 you say "applicant's proposed," where did you get those

20 figures from?

21 A. That came from their pro forma ARCR in their

22 application. I'm sorry, the revised pro forma; not the

23 original one that was in the application that had a

24 higher income number. The second column, the Bureau's

25 Proposed, was from their findings. And the third


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1028

1 column, CON 58, was our actual ARCR filed for 2015.

2 Q. And what does the comparison demonstrate to

3 you?

4 A. Primarily, the major difference between the

5 three revolves around wages, taxes, and benefits. And

6 it is not uncommon to see that large of a gap between a

7 private provider and a Fire District provider, and I

8 believe Mr. Maguire had offered testimony on that

9 already.

10 Q. Take us to Page 3, and let us know what we're

11 looking at here.

12 A. Page 3 is a comparison of the balance sheet.

13 Column 1 is the applicant's proposed balance sheet.

14 Column 2 is a balance sheet that I had calculated based

15 on the Bureau's findings letter.

16 Q. DHS Exhibit 9?


18 Q. And when you say "Balance Sheet, Page 15,"

19 this is a -- can you tell us what that is?

20 A. Page 15 is the page number in the required

21 ARCR documents, where Page 15 you have to supply the

22 projected balance sheet for the pro forma period.

23 Q. Okay. So tell us what we have here.

24 A. So Column 1, when I analyzed the applicant's

25 proposed balance sheet, I noted a couple items in


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1029

1 yellow that I was not sure on what they represented.

2 The first one is the accounts receivable

3 number of $588,574. Normally, in the first year of

4 operation for a start-up, that number usually will flip

5 back to a line item in your cash flow statement. And

6 that number did not tie to a number in the cash flow

7 statement in terms of the working capital impact for

8 accounts receivable.

9 And I believe Mr. Taylor testified yesterday

10 that there was additional Fire District AR that he

11 included in this to explain why those would not match.

12 Q. And when you're doing an ARCR reporting to

13 the Bureau, do you include income from operations other

14 than the ambulance transport operation?

15 A. It's my understanding that it is solely the

16 ambulance operation that's included in the ARCR.

17 Q. So if you were doing an ARCR for a Fire

18 District, a pro forma ARCR, would you include trailing

19 accounts receivable that the Fire District has for its

20 other services, non-ambulance services?

21 A. No, I probably would have treated this ARCR

22 as sort of like a start-up that shows, you know, zero

23 cash and really show the cash infusion coming from the

24 District versus existing cash on hand, just to sort of

25 be transparent that it's a new venture and that it


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1030

1 should be treated as a new venture; and, thus, it would

2 be more applicable to, you know, like a brand-new

3 company.

4 Q. Anything else you noticed in looking at the

5 ARCR Page 15 balance sheet that's reflected in the

6 first column on Page 3 of Exhibit 27?

7 A. Just two other things. One, I noticed there

8 was no inventory amount in the ARCR. Income statement

9 reflected that there would be an end-of-year inventory

10 of $40,000, so I did not see that noted on the balance

11 sheet.

12 And then the last item was, I believe,

13 referenced yesterday during Mr. Taylor's testimony,

14 $59,115 on Row 18. It was an item that he did not

15 identify in his pro forma ARCR.

16 Q. What do you mean, he did not identify?

17 A. There was no description under Current

18 Liabilities of what that liability represented.

19 Q. And did he tell us what that is?

20 A. I believe he did. I can't exactly quite

21 recall his exact words.

22 Q. What's Column No. 2?

23 A. Column No. 2 is a pro forma balance sheet

24 that I prepared using the findings information that the

25 Bureau had prepared. The Bureau did not prepare a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1031

1 balance sheet, but a balance sheet can easily be

2 prepared through -- from applying their findings

3 information. So Column 2 represents that if a balance

4 sheet was to have been prepared as a result of the

5 Bureau's findings, Column 2 represents what I believe

6 the balance sheet would have looked like.

7 Q. And the bottom line for 1 as compared to 2,

8 is that a calculation that you made?

9 A. Yes. Essentially, the major difference

10 between the two was a result of my projected net income

11 of a loss of $575,000, and using the -- I'm sorry, it

12 was the Bureau's findings of $251,000. That using the

13 Bureau's findings of a loss of $251,000, which the

14 applicant did concur with, the largest impact would

15 have been in the fund balance and cash line items,

16 showing that the loss would have a drain of cash in

17 their remaining fund balance.

18 Q. And is there anywhere in this that you can

19 show us the difference between those two?

20 A. Could you say that --

21 Q. I'm sorry. What's the third column show us?

22 A. Sure. The third column is based on my

23 pro forma calculation of using our actual revenue

24 experience with their proposed operating costs that

25 showed a loss of $575,000. I had prepared a pro forma


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1032

1 balance sheet here to show the sections that would be

2 impacted if the District incurred such a loss, and,

3 again, it's primarily cash and fund balance. And those

4 differences are represented in the far right column,

5 where it says "3 minus 1," Column 3 minus Column 1, as

6 the "Pro Forma v Applicant."

7 Based on my, again, pro forma review, I

8 believe that the cash and fund balance would have a

9 material impact, to the tune of approximately $575,000,

10 after its first year of operation.

11 Q. That's the bottom line number in the green

12 column?

13 A. Correct.

14 Q. And we didn't -- I'm not sure if we discussed

15 the blue column or not. Tell me what that shows.

16 A. The blue column was, just a few minutes ago

17 we talked about how the primary change was because the

18 Bureau had concluded that the applicant will lose

19 $251,000. So if we had applied the Bureau's findings

20 to a balance sheet, Column 2 would be the projected

21 view of that balance sheet.

22 Q. And does -- is 2 to 1 a comparison or -- the

23 blue column.

24 A. Yes, the blue column, 2 to 1, that is,

25 "2 minus 1," is basically showing the difference


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1033

1 between the applicant's proposed balance sheet and what

2 a balance sheet would have looked like using the

3 Bureau's findings.

4 And, again, the difference being that the

5 Bureau is projecting a $250,000 loss versus a $30,000

6 income figure the applicant has proposed.

7 Q. So tell me again the difference between the

8 column that you've numbered 1, Applicant Proposed.

9 That's off of their ARCR?


11 Q. And then Column 3, Hellsgate Pro Forma, how

12 is 3 different from 1?

13 A. Column 3 is what I had prepared, again, using

14 the actual revenue experience of CON 58 against the

15 proposed expenses by the District.

16 If the application had reflected a $575,000

17 loss, it is my estimation that Column 3 would have been

18 the balance sheet that would have been proposed in the

19 ARCR by the applicant.

20 Q. And turning to Page 4, what calculations did

21 you do here?

22 A. Page 4 is a comparative analysis of the cash

23 flow statement that is supplied as Page 16 of the ARCR.

24 Q. And does a cash flow statement show us?

25 A. Well, a cash flow statement will show, you


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1034

1 know, the primary categories that account for your cash

2 balance change during the year. So in any given year

3 you will see your accounts receivable grow or decline,

4 and that will indicate what your movement in cash was

5 as a result of the accounts receivable. It will also

6 show positive or negative movements in your liabilities

7 that show you how well you managed your cash outflow.

8 In addition to that, it will show other

9 long-term financing activities, as well as capital

10 investments into your operation.

11 It is merely intended to, you know, give any

12 reviewer of the document an opportunity to understand

13 how you spend your money and how well you manage your

14 accounts receivable and accounts payables.

15 Q. So you have a bright yellow shading that your

16 legend says "Appears to be incorrect or missing." So

17 explain what that is here.

18 A. Sure.

19 Column 1, again, in a similar format as the

20 balance sheet that was on the previous Page 3, I listed

21 the applicant's proposed cash flow statement, as well

22 as various other calculations that I performed.

23 I noted in the applicant's proposed cash flow

24 statement that, again, the income statement indicated a

25 $40,000 inventory balance at the end of the year, so I


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1035

1 would have expected to see a negative $40,000 inventory

2 number in the cash flow statement.

3 Q. At Line 6?

4 A. On Line 6. Because the District would have

5 paid that 40,000 in cash to establish a supply

6 inventory for the ambulances.

7 Q. So that's missing?

8 A. So that appears to be missing.

9 Q. Okay. And then the next yellow block where

10 there is no information, what would you have expected

11 to see there in Column 1?

12 A. In Column 1, with respect to accounts payable

13 and accrued expenses, again, being that the

14 ambulance -- the proposed ambulance operating structure

15 for the District would have resulted in increased

16 operating costs, I would have expected to see a

17 positive impact to cash as a result of the normal delay

18 in paying your expenses.

19 You know, as an example, accounts payable

20 normally has 45-day payment terms. So while you may be

21 incurring a liability, the cash isn't leaving the door

22 for 45 days. So that would have been a positive effect

23 to the applicant's cash flow statement.

24 Q. And Column 1, where did you get those numbers

25 from?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1036

1 A. Column 1 is as presented by the applicant in

2 their ARCR.

3 Q. And then Column 2 --

4 Well, tell us what the bottom line of

5 Column 1 is.

6 A. So the third missing item, accrued expenses,

7 again, you know, given that there's a payroll lag of

8 14 days, there is some positive impact to accrued

9 payroll at the end of the year, so that would have been

10 a benefit.

11 But the bottom line that the applicant has

12 proposed net of a $250,000 borrowing against their line

13 of credit, they would have seen a decrease in cash of

14 $347,000 at the end of the first year as they have

15 proposed. And, again, that is as the applicant has

16 proposed.

17 Q. Okay. And take us through Column No. 2, and

18 tell us where you got your figures from.

19 A. Basically, with Column No. 2, I started with

20 the Bureau's findings. They had proposed an operating

21 loss of $251,000 in their findings letter, which was

22 agreed to by the applicant. I had recalculated

23 accounts receivable, inventories, as well as accounts

24 payable and accrued expenses.

25 Q. And let me stop you right there. When you


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1037

1 say you had to recalculate those, what do you mean?

2 A. Yes. The accounts receivable number based on

3 the higher bad debt ratio that the Bureau proposed, the

4 total net operating revenue minus bad debt was lower

5 than what the applicant proposed. So, thus, it would

6 have lowered the net accounts receivable on their books

7 at the end of 12 months.

8 So based on that, I recalculated the true

9 cash flow impact to the expected accounts receivable at

10 the end of the year.

11 Q. So let me just stop you, Mr. Bartus. The

12 accounting stuff I've got to go a little slow on.

13 So the columns that are, I'll call it, peach

14 in Column 2, your legend says "Calculated by AMR."

15 Where did you get the numbers that you used to

16 calculate these?

17 A. So from the accounts receivable perspective,

18 using the Bureau's proposed revenue and bad debt,

19 you're able to calculate accounts receivable on a

20 60 days outstanding, which the applicant also proposed

21 a 60 days outstanding. So using that average daily

22 revenue times 60 days, you can calculate that at the

23 end of the year they would have a $432,000 accounts

24 receivable balance.

25 Q. And where did you get the numbers used to


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1038

1 calculate 40,000 in inventories?

2 A. The inventory, again, I just previously

3 discussed that it appeared to be missing from the

4 applicant's cash flow statement, because they had

5 indicated a $40,000 inventory balance.

6 Assuming that that is the same level of

7 inventory needed, and the Bureau did not change any

8 projections with respect to inventories or operating

9 expenses, I assumed that $40,000 would have -- should

10 have been the correct number reported as cash outflow

11 for inventory.

12 Q. And where did you get the accounts payable

13 number?

14 A. Accounts payable number and accrued expenses,

15 I had used the applicant's proposed operating expenses,

16 which the Bureau did not change in their findings, and

17 applied 45 days account receivable lag on general

18 operating expenses, as well as a 14-day lag on payroll

19 costs, to show that those lag times in paying that debt

20 actually produces a positive impact to the cash flow

21 statement for the applicant.

22 Q. And where did you obtain the 45-day lag and

23 the other you said, 14-day lag?

24 A. Those are the normal payment terms that AMR

25 operates under and is a consistent payment term that


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1039

1 most organizations, whether they're Fire Districts or

2 Microsoft, operate under in the normal course of

3 business. So it is not unusual to see 45-day payment

4 terms, nor a 14-day payroll float.

5 Q. Okay. And using those normal time periods,

6 the applicant's information where accepted by the

7 Bureau, the Bureau's numbers, what's your bottom line

8 on the cash flow analysis using the Bureau's

9 calculations?

10 A. Using the Bureau's calculations, I prepared

11 the middle column highlighted in light blue.

12 Ultimately, I concluded that as a result of the

13 Bureau's projected loss, it would further erode cash to

14 the tune of $131,000 and leave them a balance of

15 approximately 327,000 at the end of the first year.

16 Q. So your blue column in the middle is not

17 meant to imply they will have a negative 131,000-plus

18 cash at the end of the year. That's just the

19 difference between Columns 1 and 2?

20 A. That's correct. The cash balance that would

21 be indicated by using the Bureau's findings would be

22 $327,523, which is on Row 23, Column 2.

23 Q. Okay. What's Column 3?

24 A. Column 3, as we discussed with my income

25 statement projection, as well as the balance sheet, is


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1040

1 the resulting cash flow by using my pro forma

2 calculation of $578,919 loss.

3 Q. And that was the one that you prepared using

4 their expenses, but AMR's experience with regard to

5 revenue?

6 A. Correct. Yes. And since that revenue has

7 been relatively consistent over the years, that is more

8 than likely their revenue that is available to any CON

9 holder covering the same exact geography and performing

10 the same exact transports, that I believe was

11 2.9 million, was the rough figure, prior -- before bad

12 debt.

13 So applying CON 58's revenue against the

14 applicant's proposed expenses yielded a $578,000 loss.

15 And as a result of that loss, I recalculated the cash

16 flow statement. And, really, the only change at that

17 point was to reflect that the accounts receivable value

18 would be lower with lower revenue, and it would be a --

19 less of an impact to their cash flow.

20 Q. And using the existing provider's revenue

21 experience in the area and the applicant's pro forma

22 expenses, what's the impact to the cash flow statement?

23 A. So the impact to the cash flow statement on

24 Row 21 indicates that with the loss that the District

25 would incur in the first year, coupled with the working


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1041

1 capital that would be used during the start-up,

2 including a $250,000 line of credit borrowing on

3 Line 20, that the District would still incur a $751,979

4 decrease in cash, as shown on Row 21, leaving a cash

5 balance of $53,728 after the first year of operation.

6 Q. And tell me what you have represented in the

7 very last column of AMR-27.

8 A. The last column is just, again, some formulas

9 that show the difference between what I believe to be

10 the correct pro forma for what the applicant has

11 proposed compared against what the applicant did

12 propose.

13 And the primary difference between the two is

14 the difference in net income. That would be the

15 primary driver of the cash impact for the District.


17 Exhibit LLA-27.


19 27?


21 ALJ SHEDDEN: All right. 27 is

22 admitted.

23 All right. Why don't we take about

24 10 minutes and reconvene at, it looks like it will be,

25 2:54, 2:55.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1042

1 (A recess was taken from 2:44 p.m. to

2 2:56 p.m.)


4 the record, ready whenever you are, Ms. Fickbohm, to

5 have you pick up your questioning.


7 BY MS. FICKBOHM:

8 Q. Mr. Bartus, in preparing LLA Exhibit 27, were

9 you mindful of the fact that the applicant proposes to

10 do 78 more transports than CON 58 reported on its 2015

11 ARCR?

12 A. Yes, I was mindful of that. And being that

13 it was not a material difference, I do not believe it

14 has a material impact on my analysis. I still firmly

15 believe that Hellsgate's model as they have proposed is

16 at risk for a half a million dollar loss.

17 Q. And tell us about the trend in obtaining

18 Medicare payments when you're a start-up operation.

19 A. Well, as I think we discussed at great length

20 yesterday, that there's an enrollment process that you

21 must go through to get an NPI number and to be able to

22 bill Medicare.

23 The first step in obtaining a provider number

24 is to go through an exhaustive enrollment application

25 with Medicare. You cannot begin that application


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1043

1 process until you are a licensed provider, because one

2 of the conditions for the application is to provide

3 your authority to operate.

4 So as a new start-up, we couldn't even begin

5 to -- or any provider could not begin to pursue an NPI

6 number until they receive full authority to operate.

7 Q. So let me stop you just for a second there.

8 So if AMR Maricopa is already operational and

9 AMR is starting a second operation, can't it just use

10 the AMR Maricopa number?

11 A. Yes and no. The operation can use the same

12 NPI number, provided they are the same legal entity

13 providing the service. However, there is a process

14 with Medicare that you still have to submit an update

15 to your enrollment package, because you're now

16 operating in a different service area.

17 So you still need to go through a review

18 process with Medicare in terms of an expanded service

19 area to operate. So regardless of existing provider or

20 not, you still have to amend your Medicare enrollment

21 to account for changes in your business.

22 Q. And how long is that review process going to

23 take?

24 A. You know, it's a wide range, but over the

25 last year it seems to be that Medicare is really


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1044

1 focusing real hard on the enrollment. They're very

2 particular about their information now. And we've seen

3 180-day waiting periods until we receive the complete

4 approval from Medicare with an NPI number.

5 Q. So that you've seen. What's the lowest range

6 that you've seen?

7 A. Anywhere from 120 to 150 days. I have not

8 heard of anything recent in our company experience

9 where we're receiving 30 or 60-day turnarounds for

10 Medicare. You know, we may turn around applications

11 quickly, but there are numerous times where we wait.

12 Q. And to get a Medicaid authorization, you have

13 to have your Medicare number first?

14 A. Yes, the first step is Medicare. And

15 Medicare will retroactively approve your NPI number so

16 that you have the opportunity to bill and collect. But

17 after that typical 180 days, you get your Medicare

18 number. You apply to Medicaid. That generally can

19 take 60, 90, 120 days as well. They will also backdate

20 the effective date so you can, you know, retro-bill for

21 claims.

22 At the same time that you're applying for

23 your Medicaid NPI number, you're also applying for any

24 agreements with third-party payors or now you're

25 getting enrolled with the third-party payor to show


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1045

1 that you have a Medicare number now.

2 So even after getting your Medicare number,

3 there's not only Medicaid, but being an enrolled

4 provider for third-party insurance.

5 Q. And how does that impact a company that's

6 starting an ambulance transport business, that delay in

7 getting numbers?

8 A. Well, again, between all of the agencies

9 involved, if you're looking at 180 days for Medicare;

10 once you receive that from Medicare, your Medicaid

11 clock starts at zero, so now you're looking at another

12 60, 90, even 120 days for Medicaid, so your Medicaid

13 sales outstanding is reaching 200, 300 days; but, you

14 know, generally, you are starting your operations

15 incurring expenses from day one. Your employees are

16 getting paid in two weeks. You're still paying your

17 vendors. You can't make them wait six months. So you

18 are writing checks out the door to continue operation,

19 all the while not receiving any material cash inflow

20 from the result of your transports. So it's a

21 significant cash strain for any start-up.

22 Q. And how do you predict that would impact

23 Hellsgate if it received a CON?

24 A. I believe we did discuss this yesterday; but,

25 you know, in the event that Hellsgate is awarded a CON


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1046

1 and they start up operations, it is reasonable to

2 expect that 180-day time period before you get your

3 Medicare and other associated provider numbers. You

4 have to be prepared to fund roughly half of your

5 operating expenses before you start receiving any

6 material cash deposits.

7 And I believe we walked through the math

8 yesterday, but, you know, Hellsgate would need to be

9 prepared to fund anywhere from 1.1 to $1.3 million of

10 operating expenses before they would receive any

11 material cash inflow to offset those expenses.

12 Q. And is that consistent with your experience

13 in the ambulance transport business from the financial

14 end?

15 A. Yes, it is, and it is consistent with the

16 experience we saw with AMR of Maricopa a little more

17 than a year ago with going through that process, where

18 we've incurred operating expenses during our enrollment

19 period and it took approximately 180 days and a little

20 bit longer for AHCCCS.

21 Q. Mr. Thomas, when he testified yesterday, told

22 us that he used the period of 2009 through 2012 to

23 predict bad debt for the Hellsgate operation. Do you

24 think that's reasonable?

25 A. I believe it was Mr. Taylor, right?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1047

1 Q. Mr. Taylor. Thank you.

2 A. No, I -- you know, 2009 through 2012 is a

3 roughly five to seven-year, you know, historical view.

4 I mean it's pretty far back in time. Medicare has

5 changed quite dramatically over the last five to seven

6 years, and we already know that AHCCCS changed their

7 reimbursement recently compared to 2009. I believe

8 AHCCCS in 2009 was paying 80 percent of your base rate

9 as an allowed number, and effective November 1st of

10 2015, they now pay 68.59.

11 So that would be a significant reduction in

12 expected revenues from AHCCCS, just, you know, 11 basis

13 points alone.

14 Q. Since -- subsequent to 2009-2012, have you

15 also noticed any trends with private payors?

16 A. Yeah. There's been -- you know, ObamaCare

17 has been the big topic over the last few years.

18 Another trend that we've seen over the last couple

19 years is a growth in high-deductible plans. Those

20 traditional plans of $500 deductibles and $10 office

21 visits are a thing of the past.

22 And flex accounts, healthcare spending

23 accounts, and high-deductible plans is, you know,

24 pretty much the world we live in now. And when you

25 provide services and the patient is still within their


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1048

1 $2,000 or $4,000 high-deductible plan now, then you're

2 not billing the Blue Crosses of the world. You're

3 billing the patient. And when the patient gets a

4 $1,000, 1,500 or even $2,000 ambulance bill, those

5 become harder to collect than five, seven years ago.

6 So, you know, that impacts bad debt.

7 Q. What about Medicare sequestration that

8 Mr. Taylor said he didn't include in his calculations;

9 what's the impact if you don't consider that?

10 A. I believe -- I'm not sure of the exact year,

11 whether it was 2013, 2014; but as part of the Balanced

12 Budget Act, Medicare did implement a 2 percent

13 sequestration on the fee schedule. So although

14 Medicare publishes a fee schedule, they will only apply

15 98 percent of that fee schedule to your explanation of

16 benefits. And there's no opportunity to recoup that

17 from the member. You can only pursue 20 percent of the

18 allowable from the member, and the 2 percent is eaten

19 by the provider.

20 Q. So that would negatively impact Mr. Taylor's

21 computations also?

22 A. Yeah, I suspect it would be material,

23 considering Medicare is the primary payor in most

24 healthcare systems. It would be a material number to

25 lose 2 percent of your Medicare revenue.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1049

1 Q. Let's talk about financial benefits CON 58

2 has due to being part of the American Medical Response

3 organization.

4 What financial synergies are available to

5 CON 58?

6 A. Oh, there's numerous. For one, purchasing

7 power is probably the number one benefit to all of our

8 operations. Given the size, the scale, and, you know,

9 the broad geography that we cover in purchasing power,

10 I mean we're able to purchase ambulances at

11 significantly lower cost than a small company or even a

12 small Fire District would be able to obtain.

13 We're able to negotiate very cost-effective

14 supply costs with our vendor. Some of those costs are

15 better than some of the biggest hospitals in the U.S.

16 Fuel, as an example, is always a volatile

17 expense line item; but given our size and scope, we

18 have folks in our corporate finance department that are

19 always analyzing hedging opportunities, where we can

20 hedge fuel costs. If there's a speculation that fuel

21 prices will rise, which they typically do in the

22 summer, we have the opportunity to hedge and prepay

23 fuel at certain rates and offer those rebates through

24 our fuel vendor, fuel purchasing vendor, Wright

25 Express, to all of our operations throughout the U.S.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1050

1 And then, in addition, we, you know,

2 have great relationships with Physio-Control and

3 Medtronic. We're able to purchase all of our

4 equipment, whether they're stretchers or Life-Paks or

5 AEDs, at better rates than, you know, most other

6 organizations can.

7 Q. Tell me what you believe the financial impact

8 would be to CON 58 if Hellsgate's application is

9 granted?

10 A. Well, based on the number of transports they

11 have proposed and the service area that they have

12 included in their application, they are basically

13 looking to displace us. And it's going to be very hard

14 to financially justify sustaining operations when you

15 don't have a dollar of revenue coming in and we still

16 have to put expenses on the road. So when a business

17 is looking to displace us, that basically makes us, you

18 know, not viable for the go forward.

19 Q. We have an exhibit that's been admitted into

20 evidence showing a small number of calls, I think it's

21 23, in the -- transports in -- calls, calls in the very

22 northeast corner of Maricopa County that Hellsgate's

23 CON will not cover, because they only go as far as the

24 Maricopa County line, but that CON 58 is required to

25 cover.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1051

1 Is there any way that CON 58 could create a

2 financially viable plan to do those 23 or so calls a

3 year in that very rural area?

4 A. One call every 15 days, I don't believe

5 there's any financial plan that could be prepared to

6 sustain operations for 20-some-odd calls a year.

7 MS. FICKBOHM: I believe that's all my

8 questions, Mr. Bartus. Thank you.

9 ALJ SHEDDEN: All right. Mr. Ray, any

10 questions?

11


13 BY MR. RAY:

14 Q. Just a couple related to Exhibit 27,

15 Mr. Bartus.

16 Whoop. Let's see.

17 MS. FICKBOHM: You can change the page

18 at the bottom if you want to change the page.

19 BY MR. RAY:

20 Q. All right. All right, old man eyes.

21 A. There is a zoom feature. There is a

22 plus-minus in that, if you wanted to do that.

23 MS. FICKBOHM: That's why I gave you

24 that paper.

25 MR. RAY: Yeah, thank you.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1052

1 BY MR. RAY:

2 Q. So if you take a look at, under your Revenue

3 column, if we focus on Less AHCCCS Settlements.

4 A. Yes, okay.

5 Q. Okay. Let's roll over to the third, your

6 ARCR. There is a significant difference between the

7 five-year average used by the Bureau in its

8 calculations of 722,000-and-change as a deduction from

9 revenue and Life Line's increase. Can you explain

10 what -- for 2015. -- what would justify that much of an

11 increase? A change in payor mix?

12 A. Yes, a change in payor mix is the primary

13 reason for that. You know, with the ObamaCare coming

14 into play a couple years ago, we did see, not only in

15 Arizona, in CON 58, but in many other parts of the

16 country, you know, we now have a population of people

17 that had no insurance are now Medicaid-eligible.

18 So we did see, over the course of the last

19 few years, that growth in Medicaid-eligible patients,

20 where in years past, pre-ObamaCare, they were private

21 pay, and we were receiving little to no funds for those

22 patients.

23 Q. Okay. Do you know what -- how much of a

24 percentage increase have you seen in your AHCCCS payor

25 mix? Do you know?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1053

1 A. Off the top of my head, I don't know.

2 Q. So you have a higher deduction from revenue,

3 but you have a lower bad debt, if you drop down in the

4 green column to the bad debt.

5 Can you -- let me see if I can pull it over

6 here so we can follow. Right here under -- the first

7 line under Expenses?

8 A. Correct, yeah.

9 Q. So rationalize that for me.

10 A. Well, we have less people in the private pay,

11 no insurance, that we're writing off as bad debt. So

12 now we have more people on AHCCCS. So, you know, you

13 would see less of an impact with your bad debt, now

14 that you have folks that are covered by AHCCCS. So

15 those deductions transfer up to AHCCCS settlements, as

16 well as other changes in payor mix in the market that

17 may be driving that.

18 Q. Let's -- I would like you to focus on

19 Column B now.

20 A. Sure.

21 Q. And it's titled Hellsgate Pro Forma with the

22 Applicant/BEMSTS Expenses. And as I go through -- so

23 as I go through this column, I'm having a hard time

24 figuring out when -- why you chose to use the Bureau's

25 calculations on one column and the applicant's in


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1054

1 another. And let me just give you some examples here.

2 So we start with bad debt, which is down

3 here, and that number, what is that number? That's

4 different than your historical 2015 number, the

5 applicant's number, and the Bureau's number.

6 A. Yes. I wanted to give the benefit of the

7 doubt that with projected lower revenue, the applicant

8 would not incur as high as a bad debt as 760,000 that

9 the Bureau projected with 3,394,000 of net operating

10 revenue.

11 Q. Okay. So what you've done above that in the

12 revenue line is you've reduced the gross revenue by a

13 little over 200,000, and because of that you've reduced

14 their bad debt?

15 A. Correct. I recalculated --

16 Q. Okay.

17 A. -- with our experience of settlements, as

18 well as bad debt, as it would not have been appropriate

19 to carry forward the higher bad debt number since I had

20 adjusted gross revenue.

21 Q. Okay. All right. And then you're

22 utilizing -- you're not utilizing your payroll expense

23 line. You're utilizing the applicant's and the

24 Bureau's right below that, the million 720.



2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1055

1 Q. And why?

2 A. I don't know the applicant's payroll. They

3 know it better than I do. And as Mr. Maguire

4 testified, Fire Districts tend to have higher payroll

5 and benefit cost, particularly with the pension

6 liability. So given that that is what the applicant

7 believes it will incur in operating costs, I have no

8 reason to doubt that that's what they will incur.

9 Q. Okay. And the next two columns you've

10 utilized the applicant's numbers, or, I'm sorry, the

11 next two numbers in order, the 312,000 and the 106,000?

12 A. Correct. Again, I don't have any -- based on

13 my review, did not have any reason to expect anything

14 more than what the applicant and the Bureau have

15 proposed.

16 Q. Okay. And then we get to the Other Operating

17 Expense line, which is represented by a $745,000

18 figure. And that is not the applicant's number. That

19 is the Bureau's number?

20 A. That's correct. I believe in this case the

21 Bureau did calculate a slightly lower vehicle cost, and

22 I felt that that was reasonable to bring forward.

23 Q. All right. Thank you, Mr. Bartus.

24 MR. RAY: I don't have any other

25 questions.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1056

1 THE WITNESS: You're welcome.

2 ALJ SHEDDEN: All right. Mr. Meyerson.


4

5 CROSS-EXAMINATION

6 BY MR. MEYERSON:

7 Q. I'm sorry. Looking at your resumé, I just

8 wanted to clear one thing up. It says "Regional CFO"

9 or something. What region is that?

10 A. It is the South Region of AMR. AMR is

11 broken up into three regions, just because of our size

12 and scope. We have an East Region that generally

13 covers the eastern half of the United States, South

14 Region that covers the whole southern half, maybe from

15 Mississippi through Arizona and Nevada; and then a West

16 Region that sort of covers the West/Northwest of AMR.

17 Q. Okay. Thank you for clarifying that.

18 A. You're welcome.

19 Q. I want to clarify one thing before we

20 continue on these tables. These tables are based on

21 2015 ARCR, correct, as far as the Life Line/AMR number

22 or --

23 A. Yes.

24 Q. -- Life Line number?

25 A. Yes, the 2015 ARCR number from Life Line, as


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1057

1 well as what the applicant --

2 Q. Was AMR in charge of operations of CON 58 in

3 2015?

4 A. We were -- I believe we were operating under

5 temporary authority as owners sometime in October, but

6 for the large part of 2015 we were not.

7 Q. So when you say "we" and "AMR" and refer to

8 the 2015 numbers, it's a little bit misleading, right,

9 because almost three-fourths of the year you weren't

10 operating the CON at all?

11 A. Define "you." Me personally, I wasn't, or --

12 Q. Well, AMR.

13 A. Okay, AMR. That's why I was looking for

14 clarification.

15 No, AMR, for a large majority of 2015, was

16 not the owners of CON 58.

17 Q. So you don't really know if the Medicare

18 settlements, AHCCCS settlements, bad debt, you don't

19 really know if those were minimized, and you don't know

20 if revenue was maximized based on the 2015 numbers,

21 correct?

22 A. I can't speak to their billing and collection

23 process prior to that.

24 Q. But your financial analysis assumes all of

25 this is correct and that everything is maximized for


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1058

1 purposes of applying it to the Hellsgate numbers?

2 A. The CON was prepared in accordance with

3 generally accepted accounting principles, and they were

4 approved by our auditors in terms of the entire

5 financials. So I have to assume at that point that the

6 auditors did do due diligence and signed off on the

7 financials.

8 MS. FICKBOHM: And just I'm going to

9 make a record of clarification. I think you just said

10 the CON. And Jody is nodding. So did you mean the

11 ARCR?

12 THE WITNESS: Yes. Sorry.

13 BY MR. MEYERSON:

14 Q. No problem.

15 But I'm not questioning whether they're

16 correct. I'm questioning whether or not the results of

17 operation reflect the best numbers that should be used

18 here, because you, being AMR, weren't in charge of the

19 operations for three-fourths of the year.

20 A. So what's your question?

21 Q. I guess with Rural/Metro in control, in the

22 middle of a bankruptcy, trying to transition a CON, and

23 no additional input into the operations, can these

24 numbers be relied on as the right numbers to use for

25 this analysis?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1059

1 A. I find them very reliable if the external

2 auditing firm signed off on them that they were in

3 accordance with generally accepted accounting

4 principles.

5 Q. Well, again, I agree that the numbers are

6 correct. I'm not saying they're not correct. But an

7 auditor doesn't come in and say, "Did you maximize

8 revenue and minimize expenses?" They come in and say,

9 "Yes, your revenue was X. We agree. Your expenses

10 were Y. We agree. Everything's good to go."

11 It doesn't have anything to do with

12 efficiency or collections or anything like that,

13 correct?

14 A. I can't attest to whether they were efficient

15 or inefficient at all.

16 Q. You also mentioned synergies. You talked

17 about AMR synergies and buying power.

18 Does any of that impact Hellsgate's ARCR as a

19 result of operations if it were awarded a CON?

20 A. Our purchasing power would not apply to

21 Hellsgate.

22 Q. Okay. And I did want to walk through this,

23 and pardon me. It's like the lighter green column on

24 the first page, the green column farther to the right

25 than the other ones.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1060

1 A. Sure.

2 Q. Other than lowering the bad debt by 80-some

3 thousand dollars, I mean using the numbers here really

4 is a worst-case scenario for Hellsgate. You're using

5 the rates that produce the least amount of revenue, and

6 then you're increasing their settlements for both

7 AHCCCS and Medicare. And the only other number,

8 really, that you're adjusting is bad debt, and you're

9 giving them a little bit of credit for that.

10 So other than that bad debt number, this

11 column is like worst-case scenario for Hellsgate; would

12 you agree with that?

13 A. Worst-case scenario, I would not agree. It

14 is my opinion that this is what to expect based on our

15 operating experience and the expenses proposed that it

16 will cost Hellsgate to run the same service area. I --

17 Q. In 2015, when you operated the CON for three

18 of the 12 months, correct?

19 A. What's -- I'm basing it off of our revenue

20 experience and the costs proposed by Hellsgate. So I

21 don't deem that to be a worst-case scenario. I believe

22 that to be my opinion as to the realistic expectation.

23 Q. But only three months of the 2015 ARCR that

24 you're using to impose on Hellsgate was actually months

25 in which AMR was in charge of the operations?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1061

1 A. That's correct. I have no reason to doubt

2 those numbers, though.

3 Q. You've heard testimony surrounding the

4 368 interfacility transports, correct?

5 A. Yes.

6 Q. And as one of the lead financial officers or

7 regional officers over the South, with assuming CON 58

8 under your purview, would you agree that the

9 performance of CON 58 is important to you?

10 A. I would agree.

11 Q. That maximizing profit, maximizing revenue is

12 an important part of that process?

13 A. I would agree.

14 Q. And I hate to do this, because I need you to

15 do some math for me, because I was thinking about this

16 368 trend. So do you happen to have a phone that we

17 can do some simple math on?

18 A. I do not have a phone.

19 Wait, I do. I didn't think I did. I do. I

20 thought I left it over there, because this big thing

21 slows me down.

22 Q. Do you know how many interfacility transports

23 were done -- we only have data on interfacility

24 transports from January 1st through the end of August.

25 Do you know offhand how many have been done since


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1062

1 then --

2 A. I don't.

3 Q. -- September, October, November, prior to

4 December?

5 A. I do not know.

6 Q. Okay. For our purposes, I would like to just

7 use an annualized number, if that's okay with you. And

8 to get that, would you agree with me that if you took

9 the 368 through eight months, so if you take 368 and

10 divide by 8, that will give you your per month number;

11 and then multiply it by 12 to get the annualized

12 number?

13 A. Sure.

14 Q. And did you do that on there?

15 A. Yes.

16 Q. And what did it come to?

17 A. 552.

18 Q. And do you happen to know the Maricopa County

19 unified rate for the Southwest Ambulance and PMT?

20 A. Not the exact number, without looking at the

21 charge schedule from DHS; but it's probably somewhere

22 just south of $900.

23 Q. Yeah, that's -- that's all right. That's

24 really good.

25 A. 898 and change, if I --


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1063

1 Q. Yeah, that's pretty good, yeah, 898 --

2 A. 56 cents?

3 Q. -- 56.

4 A. Thank you.

5 Q. Yeah, very nicely done.

6 A. Give or take.

7 ALJ SHEDDEN: I'm going to caution you,

8 you're talking at the same time.

9 MR. MEYERSON: I was impressed. I'm

10 sorry.

11 BY MR. MEYERSON:

12 Q. So can you multiply the 898.56 by the 552,

13 and tell us what that comes out to?

14 A. 496,005 gross dollars.

15 Q. And then if I told you the mileage rate for

16 the Maricopa County ambulances were $18.63, would that

17 sound about right?

18 A. That number I do not know, but I will trust

19 that you are representing that as the correct number.

20 Q. Okay. Well, assuming for our purposes that

21 your CON 58 ambulances aren't driving a hundred miles

22 to do a ten-mile interfacility transport across Payson,

23 let's assume a hundred miles for each of these

24 transports as an average.

25 Can you multiply 552 times 100 times $18.63?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1064

1 A. 1,028,376.

2 Q. Yeah. And, I'm sorry, I think I misspoke the

3 mileage rate for CON 58.

4 And then if you would add the previous number

5 to that, the 496,005?

6 A. Okay. Can I ask for a clarification? You

7 just stated that you misstated the mileage number

8 for --

9 Q. No, no, no. Just the -- I think the CON

10 number.

11 A. Oh, okay. Yeah.

12 I got rid of those two numbers, so it's

13 probably a million 520 and change.

14 Q. Rather than have you do the math, the

15 difference between that, having a Maricopa County

16 ambulance provide those interfacility transports and

17 having a CON 58 ambulance do those transports, is

18 approximately $535,000, because of the lower rate for

19 the Maricopa County ambulances.

20 Are interfacility transports generally more

21 profitable than 911/emergency calls?

22 A. Just for clarification, you said the

23 difference would be 500-and-what-thousand?

24 Q. 36,000, $535,000?

25 A. In gross charges, correct?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1065

1 Q. In gross charges, yes.

2 A. Okay. I'm sorry. What was your --

3 Q. Yeah. My question was, would you agree that,

4 generally speaking, interfacility transports are more

5 profitable than 911/emergency calls?

6 A. Well, generally speaking, I think that

7 depends on the market. I don't think you can make that

8 characterization. I think as Mr. Jones even testified,

9 you see one ambulance operation, you see one ambulance

10 operation. But I don't know if that's a

11 characterization that can be applied nationally.

12 Some systems from the 911 side do receive

13 government subsidies to fund the operations, so in some

14 of those instances there's no difference in

15 profitability between 911 and interfacility; but I

16 guess it would depend on the specific area.

17 Q. Would it be more profitable for interfacility

18 transports versus 911/emergency calls for the payor mix

19 in CON 58?

20 A. Can you repeat that question, maybe, if Jody

21 wants to read it or --

22 MR. MEYERSON: Yeah, she can read it.

23 (The record was read by the court

24 reporter as follows:

25 QUESTION: Would it be more profitable


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1066

1 for interfacility transports versus

2 911/emergency calls for the payor mix in

3 CON 58?)

4 THE WITNESS: I'm not sure I can answer

5 that without, you know, kind of doing a detailed

6 analysis of that. Again, every ambulance operation is

7 different.

8 BY MR. MEYERSON:

9 Q. Would you agree that if Life Line leaves the

10 area, that the AMR entities from Maricopa County will

11 most likely stop providing interfacility transports

12 from CON 58 to Maricopa County?

13 A. I would have to defer that to our operations

14 group. I mean I would -- we would review the data and

15 do a financial assessment, but ultimately, if Life Line

16 has an abil -- not ability; a requirement to fulfill

17 those CON obligations, then the operations would make

18 the necessary adjustments to adhere to their CON

19 requirements.

20 But whether they would do them, I would have

21 to defer to operations in terms of, you know, they

22 would develop a more detailed SSM and operations plan

23 to determine if that's even something they could do.

24 Q. The amount of revenue that would be generated

25 in CON 58 if CON 58 provided 552 interfacility


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1067

1 transports is, with the mileage reimbursement, is over

2 $2 million.

3 MS. FICKBOHM: And I -- Your Honor, I'm

4 sorry to jump in here. I didn't object before because

5 I thought we were done with it, but now we're going to

6 spend more time.

7 I don't understand the relevancy of this

8 part of the discussion, because when you're comparing

9 the operations side by side, the applicant didn't apply

10 to do 3,552 transports as part of its operations.

11 There's only a 78-transport difference between CON 58's

12 2015 ARCR transport numbers and what the applicant

13 proposes its operation is going to look like and what

14 it supposedly is going to staff in order to cover.

15 So counsel is now saying, oh, there

16 should be 552 additional transports added into the

17 money. And I don't think that that's a reasonable

18 discussion, because CON 58 didn't do it in 2015, and

19 Hellsgate isn't saying that they're going to do it if

20 they get a CON.

21 So this whole discussion seems

22 irrelevant to me and wasting time.


24 do you want to respond on the relevance objection?

25 MR. MEYERSON: Yeah. I mean it goes


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1068

1 directly to all of the various numbers that are being

2 altered and given to us on Mr. Bartus' spreadsheet here

3 and changing numbers and showing different

4 possibilities of operations. And I'm just merely

5 suggesting, one, that, first off, there may be

6 additional, but at the very least, it accounts for the

7 additional transports that we've included in the ARCR

8 that they have questioned since the beginning of this

9 hearing.

10 ALJ SHEDDEN: Well, I'm going to

11 overrule the objection; but, you know, I don't -- if he

12 took the figures from your pro forma ARCR, it's a

13 little hard for me to see how you can contend that

14 those are wrong. But I'll overrule the objection, and

15 you can go ahead and ask your questions.

16 BY MR. MEYERSON:

17 Q. So I started to say that the interfacility

18 transports, the 552 annualized, represent about

19 $2 million in additional gross revenue. Would you

20 agree that adding that revenue would significantly

21 change your financial analysis as set forth in your

22 exhibit?

23 A. Well, by nature of adding 552 more transports

24 to any operation, including CON 58, yes, it would

25 increase revenue.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1069

1 Q. You also heard testimony from Chief Bathke.

2 I think you were here for the Chief's testimony? Yes?

3 A. Yes.

4 Q. About a personnel model that he said could be

5 employed by the applicant at the 3,000-transport model.

6 Would you agree that that would decrease

7 personnel costs? If you want me to remind you of what

8 he said, and then I can restate the question.

9 A. Yeah.

10 Q. It was the model where there was a single EMT

11 on an ambulance and then the engine would respond, and

12 if a transport was necessary, the medic from the engine

13 could ride in with the EMT to staff the ambulance.

14 Would that decrease personnel costs?

15 A. Yes, it would decrease costs. But that is

16 not what the applicant had proposed, and I had no

17 ability to analyze that.

18 Q. You also heard the Chief testify about a

19 capital lease arrangement where there would be a

20 12-month abatement of the lease payment.

21 Would that provide additional cash flow that

22 would be available to Hellsgate in the first year?

23 A. I believe their ARCR did represent capital --

24 I'm sorry, operating lease payments of -- it was

25 roughly 39,500 times 5. I believe that's what they


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1070

1 represented in the ARCR.

2 So your question is on a capital lease?

3 Q. Yeah, cash flow, with a rent abatement of

4 12 months, would that impact?

5 A. Yeah, if they had proposed a capital lease,

6 then it would have changed all of the ARCR documents,

7 from the balance sheet to the cash flow to the income

8 statement.

9 Q. As well as the analysis that you did here?

10 A. Yes. My analysis is dependent upon the

11 applicant's application.

12 Q. Okay. Thank you, Mr. Bartus. Appreciate it.



15 MS. FICKBOHM: Briefly.

16


18 BY MS. FICKBOHM:

19 Q. Mr. Bartus, is it important, for purposes of

20 your calculations, who was running the ambulance

21 transport operation during calendar year 2015?

22 A. In terms of whether it was Rural/Metro versus

23 AMR? No, not really. I mean these were -- these

24 financials were certified by a third-party auditor, so

25 I have no reason to doubt that those are the operating


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1071

1 results as reported under generally accepted accounting

2 principles.

3 Q. And I think what counsel was trying to

4 suggest to you was that you can't say that when AMR

5 wasn't there, that appropriate billing and collection

6 efforts were made. I think that's what he's trying to

7 suggest.

8 So let me just ask.

9 MS. FICKBOHM: I hate to leave this

10 document if it's going to be hard to get back to it,

11 Judge, but I wanted to go to another exhibit.

12 BY MS. FICKBOHM:

13 Q. Or maybe you know this. Maybe we don't have

14 to.

15 Do you know what the net income shown on the

16 ARCR for 2015 for CON 58 was?

17 A. You can pull it up.

18 Q. Okay.

19 A. I believe it was roughly 203,000.

20 Q. Okay. Let me go to that so I'm not making

21 you guess. This isn't a memorization.

22 A. And I'm not going for the last three numbers,

23 although I'll take a guess and say 497.

24 Q. Let's see. I'm going to HG-24a, to Page 2 of

25 the -- No. 2 of the document and Page 4 of the PDF.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1072

1 Does this refresh your recollection as to

2 what the net income figure was?

3 A. Yes. $244,793 after tax.

4 Q. Given your Arizona experience, the size of

5 this entity, the geography, et cetera, and the number

6 of transports done, does that figure speak of a lack of

7 good attention to collection and billing practices?

8 A. No. If there was a lack of attention to

9 billing and collections, that number would be in the

10 red, negative.

11 MS. FICKBOHM: I don't have any other

12 questions, Mr. Bartus.

13 ALJ SHEDDEN: Mr. Ray, nothing?

14 MR. RAY: Nothing.

15 ALJ SHEDDEN: Anything else,

16 Mr. Meyerson?

17 MR. MEYERSON: No, thank you.


19 sir.


21 ALJ SHEDDEN: All right. Who's the next

22 witness?

23 MS. FICKBOHM: Jim Roeder.

24 ALJ SHEDDEN: All right. Come on up.

25 All right. Let me get you sworn in, if


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1073

1 you would raise your right hand.

2

3 JIM ROEDER,





8

9 ALJ SHEDDEN: All right. Please state

10 and spell your name for our record.

11 THE WITNESS: Jim, J-I-M, Roeder,

12 R-O-E-D-E-R.



15


17 BY MS. FICKBOHM:

18 Q. Good afternoon, Mr. Roeder.

19 A. Hi.

20 Q. I have up on the screen what's been marked

21 for purposes of identification as LLA-13g. Can you

22 tell us what this is?

23 A. Pardon?

24 Q. Do you recognize this document?

25 A. Yes.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1074

1 Q. And what is that?

2 And what is it?

3 A. It's my bio.

4 Q. Okay. I'm not going to have you read it to

5 us, but could you provide the Judge and the Director a

6 summary of your career in the emergency medical

7 services field?

8 A. Sure. I became a basic EMT in 1976 in a town

9 of 800 in Missouri. From there I went to nursing

10 school, managed the Emergency Department in a local

11 hospital. Moved from there to a new hospital in

12 another town; managed the Emergency Department there

13 and developed an ambulance service out of that

14 Emergency Department.

15 Then I moved to the Level I Trauma Center at

16 University of Missouri in Columbia. I worked there in

17 a thoracic intensive care unit for eight very long

18 months, and moved from that to working on their

19 helicopter service as a flight nurse. I did that for

20 two and a half years.

21 Moved to Tucson, where I was the chief flight

22 nurse of UMC AirCare for five years. From there I

23 moved to Southwest Ambulance in 1994; developed and

24 managed their training and education department. As

25 time went along, became responsible for managing the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1075

1 scheduling department, OSHA compliance, other

2 government compliance.

3 Rural/Metro bought the company. I became

4 national director of OSHA compliance for Rural/Metro

5 Corporation. In 2001 I left Rural/Metro to go to work

6 for Bob Ramsey's companies, and for a little over a

7 year traveled to Las Vegas every week to work at Medic

8 West.

9 And subsequently from there, managed American

10 ComTrans here in the valley and then American

11 Ambulance. LifeStar then purchased -- I'm sorry, not

12 LifeStar. Bob's company purchased PMT. StarWest

13 purchased PMT, and I was clinical director for that

14 company and also did compliance for them.

15 We were subsequently bought by Rural/Metro,

16 where I did regulatory compliance for them.

17 AMR purchased the company, and I'm currently

18 the regulatory manager there.


20 for admission of Exhibit 13g.


22 ALJ SHEDDEN: All right. 13g is

23 admitted.

24 BY MS. FICKBOHM:

25 Q. And, Jim, you additionally have some


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1076

1 professional activity that relates to regulatory

2 compliance, correct?


4 Q. As stated on your resumé.

5 In Arizona, is a big part of regulatory

6 compliance reporting to the Department of Health

7 Services with regard to ambulance response times,

8 numbers of transports, et cetera?

9 A. Correct.

10 Q. And does that continue to be part of your

11 obligations for the American Medical Response family?

12 A. It does.

13 Q. I would like to show you what has been marked

14 as 14. Is this a document that you created?

15 A. It is.

16 Q. And can you tell us how you went about

17 creating it?

18 A. Sure.

19 I get a report every month showing the number

20 of emergency calls and the response time for each of

21 those, and developed that report into the response time

22 tolerances that are on CON 58's CON and record that.

23 Under Statute the State tracks your

24 compliance tolerance on a 12-month basis, so I keep it

25 in a rolling 12-month basis, and this is the rolling


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1077

1 12 months at the end of August of 2016. Below that is

2 the same calculations for the calls that are just in

3 the city of Payson.

4 Q. And so tell us what this document

5 demonstrates.

6 A. It tells us that CON 58 is in compliance with

7 the required response time tolerances of the State and

8 our CON.

9 Q. And you drilled down to just the city of

10 Payson itself. The top one is the entire service area?

11 A. The top one is the entire service area, the

12 bottom one the city of Payson itself.

13 Q. And when the Department of Health Service

14 looks at CON response fractile compliance, does it

15 focus on individual areas or look at the CON area as a

16 whole?

17 A. It only looks at the whole CON.

18 Q. So this gives us a better look at response

19 time compliance within the city limits of Payson?



22 admission of LLA-14.


24 14?



2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1078


2 admitted.

3 BY MS. FICKBOHM:

4 Q. I'm going to show you HG-20g.

5 I'm tracking over here whether or not these

6 have been admitted, so I'm not sure if that one, 20 --

7 which has already been admitted into evidence.

8 And looking at Page 1 of it, that's your

9 signature?

10 A. It is.

11 Q. And it attaches a response time compliance

12 letter from you to the Department at the very end, that

13 we will get to momentarily. Probably a quicker way to

14 do this.

15 We're on Page 16 of the -- the last page of

16 the PDF. It's a second letter also from you, correct?


18 Q. There was some suggestion during the

19 applicant's case-in-chief that these calculations may

20 have been intended by you or understood by DHS to

21 include interfacility transport calls.

22 Does this include interfacility transport

23 calls?

24 A. It does not.

25 Q. And do you believe any person would


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1079

1 reasonably understand it that way?

2 A. Yes. It's commonly known that response time

3 tolerances reported to DHS do not include interfacility

4 calls.

5 Q. Unless you have an interfacility transport

6 requirement?

7 A. Correct.

8 Q. Now we're going to go to a document that's

9 already been admitted as LLA-22, a map of the

10 applicant's proposed service area and the Hellsgate

11 Fire District boundaries.

12 Are you the person who prepared this?

13 A. I am.

14 Q. And can you tell us how it is you went about

15 preparing this document?

16 A. The proposed service area for the Hellsgate

17 CON was prepared from their amended service area from

18 their application, and the Hellsgate Fire District area

19 in the middle of that --

20 Q. Represented by the dark blue?

21 A. Correct.

22 -- was prepared using the maps on the

23 Hellsgate Fire District website.

24 Q. So you heard some suggestion from the Chief

25 that that's not an accurate depiction; but according to


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1080

1 their website, is it an accurate description?

2 A. It's exactly what's represented on their

3 website.

4 Q. And did you try to roughly guesstimate the

5 difference in size between their proposed service area

6 as compared to the Fire District area itself?

7 A. It's approximately 40 times greater than the

8 Fire District.

9 Q. I'm going to LLA-17, which I believe has

10 already been admitted with a foundation objection.

11 Yes, 17a and 17b have already been admitted.

12 Can you tell me if this is a document that

13 you prepared, Jim?

14 A. It is.

15 Q. And tell us, first, how it is you went about

16 preparing this document.

17 A. I took the map of the proposed service area

18 overlaid over the CON 58 service area. I then took the

19 CAD report of all the emergency transports where a unit

20 arrived -- I'm sorry, not transports; calls where a

21 unit arrived on scene for the 12 months ending August

22 the 31st of this year, and I populated those into those

23 maps. Then --

24 Q. You have software that will allow you to do

25 that?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1081

1 A. I do. It's made by DeLorme, which is the

2 largest CD map producer in the United States.

3 Our CAD tracks latitude and longitude for

4 each call, and I used that to locate the calls into the

5 map. I then counted the number of calls between the

6 Hellsgate proposed CON service area and the southwest

7 edge of CON 58 service area, which is the area in

8 Maricopa County that Hellsgate originally requested and

9 subsequently withdrew from.

10 I also was able to click on each of those

11 calls on the map and obtain the run number associated

12 with that call and the location. And that's what is

13 shown on this particular exhibit.

14 Q. And did that same data look allow you to

15 determine what the issue was reported by dispatch

16 requiring an ambulance transport response?

17 A. By taking the run number and going back to

18 the CAD report, it would tell me -- it told me what the

19 problem was that we were responding to.

20 Q. And so you personally prepared this?

21 A. I did.

22 Q. And so I just want to clarify. This is the

23 very southwest corner of CON 58, the little tiny part

24 that's included -- or the small part that's included in

25 Maricopa County, but has been excluded by the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1082

1 applicant?


3 Q. And did you check your research results? Did

4 you check each one of these to make sure it was true

5 and accurate?

6 A. I did. And, furthermore, I had Edward Armijo

7 verify them.

8 Q. So you double-checked. Thank you.


10 for -- oh, we already have this admitted? It's -- you

11 just -- there was a foundation objection.

12 BY MS. FICKBOHM:

13 Q. Okay. We will go next to 17b. And did you

14 also prepare this, Jim?

15 A. I did.

16 Q. And tell us how you did that and what this

17 shows.

18 A. This chart comes from the same exercise that

19 I just performed for the previous one. In fact, I

20 populated all of them at the same time and just created

21 two separate reports from the same effort. And these

22 calls were the ones that I found east of CON 58.

23 Q. Outside of the service area?

24 A. It's outside of CON 58, outside of the

25 proposed Hellsgate CON, and, in fact, is in an area


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1083

1 that is not included in any CON.

2 Q. And you were looking at the same period of

3 time?

4 A. Yes.

5 Q. And did you double-check the accuracy of this

6 determination?

7 A. These I also double-checked and also had

8 Edward Armijo double-check them.

9 Q. Specifically going back to 17a, the

10 Maricopa -- the calls from that section of Maricopa

11 County excluded by the applicant, you heard Chief

12 Bathke testify that there have not been any calls

13 generated from that area for a long time?

14 A. I did hear that.

15 Q. And based upon your research, is that an

16 accurate statement?

17 A. It is not.

18 Q. And what is Highway 87?

19 A. Highway 87 is the highway that runs from

20 Maricopa County up through Payson and on north.

21 Q. Thank you, Mr. Roeder.

22 MS. FICKBOHM: No further questions.

23 ALJ SHEDDEN: All right. Mr. Ray, any

24 questions?

25 MR. RAY: No questions.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1084

1 ALJ SHEDDEN: And, Mr. Meyerson.

2 MR. MEYERSON: I have just a few.

3

4 CROSS-EXAMINATION

5 BY MR. MEYERSON:

6 Q. Do you, being AMR, keep track of waiting

7 times on interfacility transports? Not for reporting

8 purposes, but just keep track of them generally?

9 A. Do I personally?

10 Q. No, AMR.

11 A. AMR? They track them for CON 136.

12 Q. They do not track interfacility transports

13 waiting -- response times for CON 58?

14 A. Not at this time.

15 Q. And 17a, really quick, I think it's up right

16 now.

17 No?

18 Yes.

19 MS. FICKBOHM: Yes.

20 BY MR. MEYERSON:

21 Q. Yes, 17a is up.

22 Is there, to your knowledge, another CON

23 holder that is in that area?

24 A. Yes.

25 Q. Which CON holder is that?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1085

1 A. CON 136 covers that.

2 Q. And then in 17b, these were the calls here --

3 it's your understanding that these calls are outside of

4 CON 58?


6 Q. And as Ms. Fickbohm mentioned, you were here

7 when Chief Bathke said that if called, Hellsgate, if

8 awarded a CON, would respond to both areas depicted in

9 17a and 17b, correct?

10 A. Correct.

11 MR. MEYERSON: That's all I have, Your

12 Honor. Thank you.

13 ALJ SHEDDEN: Any follow-up questions?

14 MS. FICKBOHM: Nope.


16 sir.

17 Why don't we take about 10 minutes

18 until -- we'll call it nine minutes, till 5 after 4:00.

19 Who is going to be the next witness?

20 MS. FICKBOHM: Mr. Valentine.

21 ALJ SHEDDEN: All right. Thank you.

22 (A recess was taken.)

23 ALJ SHEDDEN: All right. We're back.

24 Mr. Valentine is in the witness chair, so we're going

25 to get you sworn in.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1086

1 JOHN VALENTINE,





6



9 THE WITNESS: My name is John, J-O-H-N,

10 Valentine, V-A-L-E-N-T-I-N-E.


12 you're ready, go ahead.

13


15 BY MS. FICKBOHM:

16 Q. Good afternoon, Mr. Valentine.

17 A. Good afternoon.

18 Q. Please tell us how you're currently employed.

19 A. I am currently the regional director of

20 the -- part of the Arizona market with American Medical

21 Response.

22 Q. And what part of the Arizona -- part of the

23 state of Arizona do you cover?

24 A. So I currently cover the River Medical

25 operation, which is located along the Colorado River,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1087

1 which includes from Quartzsite, Arizona all the way to

2 Kingman, Arizona and a lot of dirt in between there. I

3 oversee the Prescott Life Line operation, which is

4 about 9,000 square miles as well. I oversee the Payson

5 operation. I oversee four --

6 Q. And that would be CON 58?

7 A. CON 58, yes, ma'am. Sorry.

8 Q. Okay.

9 A. I oversee four large 911 systems here in the

10 valley; Scottsdale, Chandler, Tempe and Peoria. I work

11 alongside with our other regional director here, John

12 Karolzak. I also cover Safford, Arizona and Tri-City.

13 A lot of these are legacy PMT operations that are now

14 rebranded or will be rebranded into the Life Line name.

15 Q. So tell us how it is that you came to become

16 involved in the emergency medical services profession.

17 A. Well, way back when there used to be a

18 television show called Emergency. Some of the folks

19 are old enough to remember that show. It was a very

20 appealing show when I was a young child. I always

21 wanted to be a firefighter/paramedic from that point

22 on.

23 Right out of high school I went to school to

24 become an emergency medical technician. I was torn

25 between police officer and emergency medical


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1088

1 technician, going on to be a firefighter. I got into

2 the EMS world at a very young age and have been with it

3 ever since.

4 I spent a little time in California from

5 about 1980 to about 1983. I went through paramedic

6 program at the Daniel Freeman Institute in Inglewood,

7 California. At that time paramedic programs were

8 basically county to county. I had an opportunity to

9 come to Arizona. I came to Arizona, challenged the

10 program here, and went to work as an emergency medical

11 technician here in Arizona.

12 From there I worked for a private ambulance

13 service, River Medical, Incorporated, for about four

14 years. And from that point I moved on and went to work

15 for a small Fire District called Quartzsite Fire

16 Department. I worked there from 1984 until about

17 ninety -- I'm sorry, from 1988, excuse me, until later

18 on, about 1999. I left there as a division chief. My

19 responsibilities were coordinating EMS and overseeing

20 the EMS division. I worked as an operations chief and

21 ran the day-to-day operations of the Fire Department.

22 I left there and went to the Colorado River

23 just up from Quartzsite. I was looking for a

24 Department where I could spent a little bit more time

25 with my family, and I was looking for more shift work.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1089

1 As a Chief, you're pretty much on call 365 days a year,

2 7 days a week.

3 I lateraled, basically, over there as a

4 Captain. Spent a couple years there and had an

5 opportunity to go back to private sector shortly

6 thereafter and ended up going back to River Medical.

7 And River Medical was acquired by AMR in 2008. I

8 spent -- and I've been there ever since.

9 Q. And you were the operations manager at River

10 Medical?

11 A. I was the operations manager. I oversaw

12 day-to-day operations of the southern quadrant of our

13 9,000 square miles of operation area, very rural

14 section of our -- La Paz County.

15 Q. And subsequent to AMR's purchase of River

16 Medical, did your position there change?

17 A. It did. I was the general manager over River

18 Medical. There was a change in leadership in New

19 Mexico. I was asked to go run several operations in

20 New Mexico, two high-speed 911 systems; one in

21 Las Cruces, New Mexico and a much more rural, smaller

22 operation in Alamogordo, New Mexico, both run by AMR.

23 And then I was instrumental in working a new market in

24 Albuquerque, New Mexico, which was both an IFT and a

25 911 operation in Valencia California; or, I'm sorry,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1090

1 Valencia, New Mexico.

2 Q. So would it be fair to say that until very

3 recent times, when American Medical Response developed

4 a presence in the Greater Phoenix/Maricopa County area,

5 most of your experience has been in the rural

6 environment?

7 A. That would be accurate, yes.

8 Q. And as the regional director -- well, first

9 of all, let me clarify.

10 You're currently a paramedic, correct?

11 A. I still am, yes, a State-certified paramedic.

12 Q. And in your current position, what do your

13 duties include?

14 A. So from a very high level, I oversee the

15 business units that I spoke of earlier. I work with

16 the operational managers, who run and oversee those

17 operations.

18 I work directly in line with the COO, Glenn

19 Kasprzyk, and several of our leadership team to oversee

20 some of the financial pieces of the operation, look at

21 deployment, staffing needs and requirements, call

22 volumes, all the way down to small day-to-day needs

23 from our operational staff, fleet needs, any host of

24 operational pieces in between there.



2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1091

1 for admission at this time of LLA-13h.


3 ALJ SHEDDEN: All right. 13h is

4 admitted.

5 BY MS. FICKBOHM:

6 Q. As part of your current job duties, is it

7 important for you to be aware of and involved in

8 CON 58's operations?

9 A. Yes, it is.

10 Q. There has been some discussion about American

11 Medical Response, and I'm going to use air quotations

12 to say operating CON 58 starting in October of 2015.

13 Can you clarify what that did involve and

14 what that didn't involve?

15 A. When the initial transfer took place, we were

16 kind of in a status quo environment.

17 Q. When you say "transfer," let talk -- let's

18 distinguish, first, between American Medical Response's

19 purchase of the Rural/Metro stock, as opposed to the

20 transfer of the CONs that Rural/Metro held in Arizona.

21 Did those occur at two different times?

22 A. Yes.

23 Q. And did the purchase occur first?

24 A. Yes.

25 Q. And when was that?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1092

1 A. In January. I don't know the exact date.

2 Q. I'm talking about not the transfer of the

3 CONs. The purchase by AMR of Rural/Metro stock.

4 A. Okay, reask your question. I'm sorry.

5 Q. Sure.

6 So we have the transfer of the CONs that

7 proceeded via a hearing after the purchase, correct?

8 A. Correct.

9 Q. So the purchase of the Rural/Metro stock

10 was -- the commitment was finalized on or about when in

11 2015?

12 A. I would have to look at the dates. October,

13 I believe.

14 Q. Okay. And -- but then pursuant to Arizona

15 law, there had to be permission by the Department of

16 Health Service to actually get the transfer of the

17 CONs, correct?

18 A. Correct.

19 Q. And that occurred when in 2016?

20 A. Late February, I believe.

21 Q. And I think that we actually have --

22 A. You may have the document.

23 Q. -- some documents that can give you that.

24 It's not a memorization test. We'll give you the

25 precise time frame.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1093

1 I'm pulling up the Director's final decision

2 in the transfer. Do you recognize that document?

3 A. Can you scroll down?

4 Q. Sorry. Yeah.

5 A. Yeah, I recognize it.

6 Q. Oops. Sorry.

7 A. January 26, 2016.


9 for admission of AMR-5c.


11 ALJ SHEDDEN: And I'm sorry, that was

12 5c?

13 MS. FICKBOHM: I'm sorry. LLA-5c.

14 ALJ SHEDDEN: All right. Life Line 5c

15 is admitted.

16 BY MS. FICKBOHM:

17 Q. So between the Director authorizing the

18 transfer of all of the Rural/Metro entity-held CONs --

19 which would include CON 58, correct?

20 A. Yes.

21 Q. -- and the AMR purchase of Rural/Metro's

22 stock with certain contingencies, by your recollection,

23 sometime in October, to what extent was AMR able to

24 operate CON 58 or any other CON that was

25 Rural/Metro-held in Arizona?


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1094

1 A. It was my understanding that we were in a

2 status quo type operation, which meant we didn't change

3 staffing, leadership, or make any changes to the

4 operation at that point.

5 Q. And what was the visibility for you of the

6 finances, et cetera?

7 A. I had no visibility of the finances. That

8 was much, much farther above my pay grade.

9 Q. So it was your job to just maintain the

10 status quo?

11 A. It was our job to maintain status quo and

12 make sure that anything didn't go awry.

13 Q. We'll get back to CON 58. I wanted to cover

14 a couple other topics first.

15 As part of your professional history and your

16 ongoing duties, do you like to keep up on what's going

17 on with the Arizona Fire Districts, especially those

18 that hold CONs?

19 A. We have several fire partners around the

20 state of Arizona, so I'm always trying to stay up on

21 current affairs. I work with a lot of them side by

22 side. So it makes sense to do that.

23 Q. And in particular, do you have some pretty

24 in-depth experience with the Fire Districts that are

25 out in the west -- the more rural, but western part of


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1095

1 the state?

2 A. I would say that's where most of my time has

3 been spent, that would be correct.

4 Q. Okay. So tell us about how some of those

5 Fire Districts are doing with regard to CONs they hold.

6 How is Lake Mohave Ranchos doing?

7 A. Lake Mohave Ranchos is a small District that

8 came out of a bankruptcy. They ran an operation of

9 three rescues or ambulances with transport

10 capabilities. They operated for a long time.

11 They actually at one point approached us

12 about taking their service over because of their

13 struggles. This was very apparent in 2010, '11, kind

14 of as the recession -- kind of towards the middle of

15 the recession. They lost their Fire Chief. We were

16 pretty clear about what they could do fiscally. We

17 actually sat down with them on a financial analysis

18 with them and reviewed what they could successfully run

19 there, and they didn't feel that they wanted to do

20 that.

21 So sometime after our conversations, they

22 ended up going into bankruptcy. They lost the Chief.

23 They ended up going to the County to basically bail

24 them out to make wages. They did a dramatic reduction

25 of staffing and took their transport capabilities from


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1096

1 three down to one.

2 Q. And you're referring to ambulances?

3 A. Ambulances, yes.

4 We have a backup agreement with them. We

5 provide a lot of service for them. They were actually,

6 during their bankruptcy phase, being run by the

7 Northern Consolidated Fire Department, which the Chief

8 is Pat Moore, and I believe Pat Moore was either the

9 president or directly involved with the Arizona Fire

10 Districts. He was helping run that through the help of

11 John Flynn, who is their lobbyist, and oversaw that for

12 the County.

13 Q. When you say "we backed them up," what CON

14 holder has been providing backup services to them since

15 the 2010-2011 period?

16 A. CON 94, River Medical, Incorporated, also dba

17 Life Line.

18 Q. And are there times that Lake Mohave Ranchos,

19 you know, doesn't have any availability to provide

20 ambulance transports?

21 A. That's the case.

22 Q. What about Bullhead City?

23 A. Bullhead City is a good fire partner of ours.

24 We have been doing several, for several years, backup

25 interfacility transports out of their market. They


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1097

1 recently submitted a letter to their hospital saying

2 they weren't going to take interfacility transports

3 after a certain time at night unless they were

4 absolutely emergent, which puts the hospital in kind of

5 a lurch.

6 So through cooperation with that certificated

7 holder, we will respond in at a request from the

8 Bullhead City Fire Department and take transports out

9 of Bullhead City to other places. Most of those go

10 into Las Vegas. Some of them come back into Phoenix.

11 Q. And is that, again, the River Medical

12 organization?

13 A. That's the River Medical organization.

14 Q. What about the Fort Mojave Mesa Fire

15 District?

16 A. So Fort Mojave Mesa and Fort Mohave are three

17 agencies that are really tied in with Bullhead along

18 the river stretch there. There's another hospital

19 there called Valley View Hospital. It's a little bit

20 smaller facility, but they do -- they have the same

21 challenges there that the main hospital in Bullhead

22 has, is there's a lack of resources at night to take

23 interfacility transports, and they're commonly not

24 taken by the Fire-based providers, for a number of

25 reasons.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1098

1 So we end up taking those transports. Some

2 of them, unfortunately, we turn down because we're not

3 available. We don't build our deployment models around

4 their volume. So, unfortunately, some of those

5 patients are taken by helicopter that probably don't

6 need to go by helicopter.

7 Q. And these are all outside of River Medical

8 CON 94's certificated area?


10 Q. So it sounds like River Medical does quite a

11 bit of mutual aid?

12 A. That's fair to say.

13 Q. Can you quantify, like, the percentage of

14 work that it does, how much of that's mutual aid?

15 A. It would be hard to put a number on it. I

16 would say probably at least one call to sometimes three

17 calls a day. We work with other providers to do, you

18 know, mostly interfacility work, because we have the

19 CON for almost all of Mohave County and all of La Paz

20 County, so we're the primary provider there.

21 Q. Changing topics, there was quite a bit of

22 discussion by Chief Bathke about Christopher-Kohl's

23 Fire District being part of the consortium and I think

24 maybe even placement of a station there. I'm not sure

25 about the last part.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1099

1 But has Christopher-Kohl -- has the

2 Christopher-Kohl's Fire District's interest or lack of

3 interest in the Hellsgate application been a matter of

4 interest to you?

5 A. So since we first got into Payson or I myself

6 and some of my leadership got into Payson, I could

7 sense there was a little frost in the area of something

8 going on, so I've been hypersensitive to interactions

9 between Fire Departments, trying to meet with the Fire

10 Chiefs, find out what's going on.

11 I'm new to that area. Try to be, you know,

12 the new guy there. But it became very apparent that

13 the CON process was going on, so we became

14 hypersensitive to what things were going on with all

15 the Districts that were there and trying to manage and

16 look at -- either through myself or our employees

17 concerned have been looking at minutes or going to

18 board meetings and City Council meetings.

19 Q. So did you come to learn that the

20 Christopher-Kohl's Fire District's governing board was

21 going to consider at an official board meeting whether

22 or not to support Hellsgate's application for a CON?

23 A. Yes, one of my -- my operations manager was

24 made aware by an employee that he had gone to a board

25 meeting, at which time there was a discussion regarding


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1100

1 a letter, a letter of support for the Hellsgate Fire

2 District.

3 Q. Was that in late November?

4 A. It was. I actually have that document in

5 front of me.

6 Q. And so you received an oral report of what

7 happened at that meeting?

8 A. I did. I received an oral report from

9 Mr. Baker, my operations manager, and asked him -- you

10 know, it's -- unfortunately, a lot of these

11 communities, both rural and suburban, I want to

12 validate what was said. So I asked Mr. Baker to obtain

13 some written documentation of that. I didn't want to

14 just go on hearsay.

15 Mr. Baker provided me with a copy of some

16 board minutes. They don't appear to be signed, but

17 they are board minutes on decisions made on that date,

18 November 21st of 2016.

19 Q. And what did the Christopher-Kohl governing

20 board decide on that date about the Hellsgate

21 certificate of necessity application?

22 A. It says here, "Payson rejected the

23 Certificate of Necessity. Basically, Hellsgate is

24 interested in starting an ambulance service. After

25 much discussion the Board determined that the


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1101

1 current -- there is no current --" I'm sorry -- "that

2 currently there is little interest in this proposal.

3 Mark Haynes [sic] spoke to the issue. Karen Thornton

4 made a motion that at this time Christopher-Kohl --"

5 it's in initials, "CKFD Board does not see a need for

6 an additional certificated ambulance [sic]. Jeff

7 Daniels seconded the motion."

8 Q. And was the motion -- was the vote split?

9 A. No, it was a unanimous vote.

10 Q. Against?

11 A. Against it, right.

12 Q. Okay. Changing topics, I would like to ask

13 you to look at what's been marked as LLA-20, and ask

14 you if you recognize this document?

15 A. I do.

16 Q. And can you tell us what this is and how you

17 came to get a copy of it?

18 A. So shortly after the merger, as we started to

19 go through the merger --

20 Q. "The merger," what do you mean by that?

21 A. When AMR acquired, I'm sorry, the

22 acquisition, AMR acquired Rural/Metro, shortly

23 thereafter, within several months, the employees of the

24 Payson operation decided to form or actually become

25 part of the -- what is known as the legacy PMT,


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1102

1 Professional Medical Transport, union or labor group,

2 the International Association of EMTs and Paramedics.

3 This letter is a letter addressed to the

4 Arizona Department of Health Services, and basically

5 talks through the fact that they're, you know -- they

6 want us, AMR, to keep it, and they are not in favor of

7 the current provider -- or I'm sorry, that Hellsgate

8 getting a CON.

9 Q. And let me ask you. These are people who

10 work for Southwest Ambulance?

11 A. These are people that work for the Payson

12 ambulance under the Life Line.

13 Q. Oh, the Payson.


15 Q. Okay. And it's a labor union, correct?

16 A. It is a labor union, that's correct.

17 Q. And does American Medical Response or the

18 Life Line Payson operation have the ability to control

19 what these union employees do, don't do, say, don't

20 say?

21 A. Within the Federal guidelines.

22 Q. In fact, at some times, do you find yourself

23 on the other side of the negotiating table with them?

24 A. I'm currently on the other side of the

25 negotiating table, that's correct.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1103

1 Q. And just for purposes of the record --

2 MS. FICKBOHM: Your Honor, would it be

3 helpful to have this read into the record, or no?

4 ALJ SHEDDEN: It's not been admitted

5 yet. I don't know that we need any document read into

6 the record.


8 admission of Exhibit LLA-20.


10 20?



13 admitted.

14 MS. FICKBOHM: I just didn't know if

15 anybody wanted to take some time to read it.

16 Anybody want more time to read?

17 Okay, hearing no request...

18 BY MS. FICKBOHM:

19 Q. So, Mr. Valentine, when did you become able

20 to really start to take a good look at CON 58's

21 operations deeper than what you were permitted to look

22 at during the temporary operating phase at the end of

23 2015?

24 A. Pretty much the latter part of March of this

25 year.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1104

1 Q. Okay. And so tell us how you went about

2 doing that, what you saw, and what your impressions

3 were.

4 A. First of all, you know, I was the new guy in

5 the area. We -- I relied heavily on some of the local

6 knowledge and several of the employees that have worked

7 there for a long time.

8 I engaged our deployment team, through Doug

9 Jones and his group, to look at some demand analysis of

10 what is going on in the local area, trends that are

11 going on.

12 I asked Mr. Baker to look at some local

13 requirements and see how we were doing at the hospital,

14 tried to start some interactions with the hospital.

15 I engaged our local operations supervisor,

16 Mr. Brumbaugh, about, you know, things that were going

17 on in the area. He was pretty clear there were some

18 pretty interesting dynamics going on between the

19 Chiefs, and we -- you know, at which time we found out

20 that there was a CON application being revolved.

21 I did make -- myself, Mr. Kasprzyk, and

22 Mr. Karolzak, John Karolzak, met with the Payson Fire

23 Chief, I believe once in person, and I had a couple of

24 conversations with him on the phone.

25 From that point, you know, I found a couple


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1105

1 of glaring items.

2 Q. Which remember?

3 A. One, there was a staffing shortage. It

4 appeared that they were having some challenges with

5 staffing, not unlike many both rural and urban

6 Departments looking for paramedics. There's a national

7 shortage of paramedics. We see it around the country.

8 The more rural those areas, it becomes a little harder

9 to staff.

10 The other challenges, I saw that a large

11 number of interfacility transports were being handled

12 by units coming out of the valley. Some of the other

13 challenges --

14 Q. "The valley" meaning the Maricopa area?

15 A. I'm sorry. Out of the Maricopa area.

16 Q. I know that people in Phoenix think that "the

17 valley" means Phoenix.

18 A. The great state of Maricopa.

19 Q. But there's other valleys in the state,

20 right?

21 A. Correct.

22 Q. Okay. So...

23 A. I noticed that they were having some

24 challenges with some of their equipment that needed

25 some refresh. I mean those are just some of the many


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1106

1 things that we look at. There was also some scheduling

2 issues on current scheduling that they were doing that

3 didn't meet the current needs.

4 Q. And were you able to see all of this

5 immediately as of late March, or did this take time to

6 develop?

7 A. It takes time. I mean, one, you want to make

8 sure -- look, everybody's on edge when the new guy's in

9 town, the new sheriff's in town. So we baby-stepped

10 into it. But there was a lot of things going on in the

11 background that people just didn't see were going on,

12 such as, you know, uniforms and branding and a lot of

13 the things that take time to put together.

14 We started to put together the process of

15 what that was going to look like and put together a

16 project plan.

17 Q. So can you tell the Judge and the Department,

18 insofar as hard, physical equipment, capital

19 expenditures, what you directed be put into the system

20 after you got a look at what was going on there at

21 CON 58?

22 A. So part of the overall CON or the overall AMR

23 acquisition of Rural/Metro was to put, obviously,

24 vehicles into the market. And two of those vehicles

25 have been placed in the Payson market. I believe they


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1107

1 went in service last month or maybe -- yeah, I believe

2 last month.

3 Q. And are these new ambulances?

4 A. They're brand-new ambulances.

5 Q. And, John, why not until last month?

6 A. It took time. They were only one of the

7 needs of Arizona, and we looked at things as a very

8 stairstep graduation. They were one of them that

9 needed them, and they got them as soon as we possibly

10 could get them there. We have two more additional

11 units coming that direction and a refresh on a

12 four-wheel drive vehicle that is much, much needed in

13 that market.

14 Q. And tell -- what do you mean by "a refresh on

15 a four-wheel drive vehicle"?

16 A. Off the top of my head, I'm not sure if it's

17 a brand-new four-wheel drive or it is a newer

18 four-wheel drive. I don't know if it's a 2013 or '14.

19 I don't know exactly. I don't have the capital list up

20 in front of me.

21 Q. And that's a four-wheel drive ambulance?

22 A. Correct.

23 Q. So how many ambulances does CON 58 have right

24 now?

25 A. There should -- there's usually between five


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1108

1 and seven there, but we rotate some of those out for

2 PMs.

3 Q. What's a PM?

4 A. I'm sorry. That's just routine maintenance

5 on the vehicle, oil changes, tire changes. We utilize

6 a local shop for some small stuff; but if it's anything

7 large or a longer maintenance cycle, they'll come down

8 to the valley and have our own mechanics go through

9 those.

10 Q. So at any point in time there's five to seven

11 ambulances present?

12 A. Yes.

13 Q. And two of them are -- I think I understand

14 your testimony to be two are brand-new, and you have

15 two more new coming?


17 Q. And the two that are coming, are you going to

18 add those to what you have, or are you going to pull

19 old ones out?

20 A. No, those will replace old fleet.

21 Q. What about medical equipment; did you add any

22 medical equipment to the operation?

23 A. They were operating on a Zoll, which is the

24 brand name of a cardiac monitor, which was an older

25 platform, pretty much antiquated platform. We did a


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1109

1 refresh on some Lifepak 12s, which are not a brand-new

2 monitor, but we felt it was a great stopgap to get them

3 onto the Lifepak platform that is commonly used in AMR

4 around the country. It gave them more state-of-the-art

5 equipment available to them.

6 Q. Did you update any software?

7 A. So there was a couple of different things

8 that were updated, and this is a lot of the pieces that

9 go on in the background that the employees don't see.

10 They've been moved over to our MEDS platform as of

11 about two months ago. The MEDS platform is our ePCR

12 platform. That's a proprietary electronic patient

13 record, which allows Payson to be included in the

14 Arizona SHARES data, report --

15 Q. SHARES or CARES?

16 A. I'm sorry, Arizona CARES data; and it

17 automatically dumps the data into that, as well as into

18 the Bureau for their EMS data collection as well.

19 Q. So -- and that was as of a couple months ago?

20 A. Couple months ago. We actually did the whole

21 Arizona market. As you can imagine, 1,800 employees,

22 it was quite an undertaking, both from a capital and

23 training piece.

24 Q. So will CON 58 be able to report annual

25 information into the CARES program that Dr. Racht


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1110

1 talked about earlier this morning in calendar year --

2 for calendar year 2017?

3 A. It's happening as we speak. It will allow,

4 after we gather some data -- they run 220, 230 calls a

5 month. That's not a whole lot of data to gather.

6 After several months we'll be able to gather a lot more

7 and start to see where things are benchmarking, as

8 Dr. Racht spoke of earlier.

9 Q. Any other equipment or additions that you can

10 think of off the top of your head that you want to

11 bring up?

12 A. We've redone the scheduling. They have now

13 moved over to a TeleStaff scheduling platform, which is

14 our standard platform to do scheduling. It just gives

15 us a higher level of accountability for the employees,

16 and that's all done -- instead of being done locally in

17 Payson, that's being handled now out of our operation

18 in Mesa at the 22 West Main operation. So that gives

19 us a little bit more global. We've added -- we added

20 staff when --

21 Q. What staff did you add?

22 A. So we added staff. So we fully staffed three

23 24-hour ambulances in Payson with paramedic level and

24 then we added a fourth peak time truck. After

25 Mr. Jones and his team, Doug Jones and his team, put


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1111

1 together some demand analysis and, really, after

2 reviewing a lot of these so-called 368 interfacility

3 transports that were coming from Payson and being

4 utilized by Maricopa units, we saw a need for a peak

5 demand truck that operates a 10-hour-a-day Tuesday,

6 Wednesday, Thursday and Friday. We also --

7 Q. And let me just stop you for a second.

8 We heard some testimony about CON 58 having

9 some of its ambulance staffed without having a

10 paramedic on board. Is that occurring now?

11 A. I'm not going to say it could never occur.

12 Payson's interesting to the fact that they do keep a

13 certification that is not kept around the state very

14 much, and that's an intermediate or an EMT-I.

15 They can be used in an ALS capacity, which

16 means they can start IVs and do advanced airways. They

17 don't carry all of the same drugs as a paramedic, and

18 they don't do all of the same interventions, but they

19 can be used in an ALS capacity. And in the past,

20 Payson has used intermediates with an EMT to run calls

21 if they had a staffing issue, a call-off, a sick call,

22 or maybe there was even a callback.

23 Q. What's a callback?

24 A. Commonly in a lot of these small rural areas,

25 they have a system where they'll call back employees if


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1112

1 all the units go out or they had an extraordinary bad

2 event, such as --

3 Q. So you're referring to calling off-duty

4 employees back?

5 A. Calling, yeah, off-duty employees back in.

6 And, you know, if that -- if they came back and staffed

7 an ambulance with an EMT and an I, they would still be

8 an ALS unit. They just wouldn't have a paramedic on

9 board.

10 Q. And how often, to the best of your knowledge,

11 is CON 58 having to look to use of an EMT-I as opposed

12 to a paramedic these days?

13 A. I don't think we're using them very often.

14 Right now those intermediates are being used in

15 conjunction with a paramedic on a car. That's the way

16 they're staffed and scheduled currently. So all four

17 units are staffed paramedic level with EMTs or I-EMT

18 drivers.

19 Q. Okay. So I think -- I guess I was thinking

20 paramedic and an EMT. You're saying that all of them

21 have two paramedics or one paramedic with an EMT-I?

22 A. No.

23 Q. Okay.

24 A. They're all staffed with either an EMT and a

25 paramedic or an EMT-I and a paramedic.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1113

1 Q. Okay. Thank you.

2 A. Yeah.

3 ALJ SHEDDEN: Let me ask. We're right

4 about a quarter of. If you want to wrap up an area of

5 questioning, that would be probably a good idea. If

6 this is a good place to stop, that works for me as

7 well.

8 MS. FICKBOHM: Yeah. Let me just ask

9 Mr. Valentine to tell us when the staffing of vehicles

10 was upped, and I can -- that would be -- so I don't

11 pick up with a trailing question tomorrow morning.

12 BY MS. FICKBOHM:

13 Q. So when was this staffing upped on the

14 vehicles?

15 A. So as of October 29th, after negotiations

16 with our labor group, we went into service with the

17 fourth unit with that peak time deployment.

18 Q. And when did you move to making sure that

19 every ambulance transport unit had a paramedic on it?

20 A. That was a process over a few months of

21 hiring.

22 Q. And you already told us why hiring isn't

23 something that can happen overnight?

24 A. Yeah, it just doesn't happen overnight, so...

25 Q. Is it easier to recruit paramedics to urban


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1114

1 areas?

2 A. It is. Sometimes you get more skilled older

3 paramedics that like to go to these slower -- slower

4 911 services, but like the medicine that happens in

5 these very rural areas. The call volume is not as

6 much, but the medicine that they get to provide is much

7 more needed sometimes.

8 MS. FICKBOHM: Your Honor, this would be

9 a good place for us to break.

10 ALJ SHEDDEN: All right. Let me just

11 let you know that what my records are showing is one

12 exhibit, Life Line 9, which was the tax rate

13 information that Mr. Maguire was testifying about, I

14 don't show that as having been admitted. So either I

15 missed that or it was not offered.

16 Was it your intention to offer that?

17 MS. FICKBOHM: No. I'll offer that

18 during Mr. Kasprzyk's testimony, since he put it

19 together. But thank you, Your Honor.

20 ALJ SHEDDEN: All right.

21 MS. FICKBOHM: I got all my resumés

22 requested today, didn't I?

23 ALJ SHEDDEN: That, I think so, the

24 ones -- I try and only write down the ones I didn't

25 see.


2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1115

1 MS. FICKBOHM: Okay.

2 ALJ SHEDDEN: So is there anything we

3 need to address, or we'll just reconvene tomorrow

4 morning?

5 MR. RAY: Judge, just so everyone is

6 aware, this afternoon our staff delivered the missing

7 ADHS exhibit. So hopefully it will be uploaded tonight

8 and available tomorrow.

9 ALJ SHEDDEN: All right. Thank you.

10 All right. We'll see everyone tomorrow.

11 (The hearing adjourned at 4:46 p.m.)

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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 1116

1 STATE OF ARIZONA ) COUNTY OF MARICOPA )

2

3 BE IT KNOWN that the foregoing proceedings were taken before me; that the foregoing pages are

4 a full, true, and accurate record of the proceedings, all done to the best of my skill and ability; that

5 the proceedings were taken down by me in shorthand and thereafter reduced to print under my direction.

6 I CERTIFY that I am in no way related to

7 any of the parties hereto, nor am I in any way interested in the outcome hereof.

8 I CERTIFY that I have complied with the

9 ethical obligations set forth in ACJA 7-206(F)(3) and ACJA 7-206 (J)(1)(g)(1) and (2). Dated at

10 Phoenix, Arizona, this 31st day of December, 2017.

11

12 _______________________________________

13 JODY L. LENSCHOW, RMR, CRR Certified Reporter

14 Arizona CR No. 50192

15 I CERTIFY that Coash & Coash, Inc., has

16 complied with the ethical obligations set forth in ACJA 7-206 (J)(1)(g)(1) through (6).

17

18

19

20

21

22

23 _______________________________________

24 COASH & COASH, INC. Registered Reporting Firm

25 Arizona RRF No. R1036


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