Concerned about their future and tired of what they say are inadequate resources, paramedics at Denver Health and Hospitals have been trying for months to switch city agencies and join the Denver Fire Department, where they would stand to enjoy greater clout and earn more money.

Unfortunately for them, DHH doesn't want to see them go. A task force appointed this past spring by the mayor's office to study the move voted overwhelmingly against it, saying it was too expensive. At the same time, the task force did acknowledge that more resources were needed and recommended the addition of two ambulances to the city's fleet of nine. But a member of the task force says the group was "biased" against the paramedics' request to move.

Last spring about 70 percent of the city's approximately 100-member Paramedic Division joined the International Association of Fire Fighters Local 858 as an independent EMS local. (The paramedics' group has not been recognized by the city as a bargaining unit, however.) "The thing that drove us to unionize is that we wanted to be able to present a strong, unified voice to the hospital and be able to have a little muscle behind it," says Jim Manson, the union's president. "Anybody who isn't a fool knows [the firefighters] have more clout."

The paramedics insist that the move would mean better service--including shorter response times--for Denver residents, but DHH administrators suggest that the paramedics' desire to move is largely motivated by money. "They never brought up pay," says Denver General Hospital administrator Stephanie Thomas, "but I think that was a concern. You know how people won't sometimes get to the real issue."

Until last March, when the paramedics received a 10 percent raise, their salaries had remained stagnant for years. Now DHH paramedics make $38,000 a year, while senior paramedics make $50,000. Their average pay is comparable with that of their counterparts in the suburbs, according to figures obtained from metro-area departments.

The paramedics probably do stand to make more money if they join the fire department, but they would also enjoy collective-bargaining rights and more opportunities for advancement.

"Our primary objective was not money," says senior paramedic Bob Petre, a task force member. "When you look at problems the task force looked at, nowhere in there was a demand for more money by the paramedics."

The paramedics have argued all along that their prime concern is quality of service. They point to the generally accepted benchmark that, in 90 percent of calls, the average response time for paramedic care should be under eight minutes (the point at which cardiac-arrest patients almost always begin to suffer brain damage). Seventy-four percent of DHH paramedic calls in the first eleven months of 1995 were responded to in less than eight minutes; the average response time was 7.2 minutes. Proponents of the merger with the fire department point out that the firefighters' average response time, as calculated last spring, was 2.54 minutes. (The response times in the Aurora, Littleton, Englewood and West Metro fire systems, which all have paramedics, are under 4.5 minutes.)

But response time isn't the only measure of the quality of emergency care. Denver's overall survival rate--the percentage of people who call 911 for transport and leave the hospital alive--is well above 90 percent.

Other issues between the paramedics and their bosses revolve around working conditions. For years, paramedics say, they have had to contend with inadequate decontamination facilities, a shortage of staff and ambulances and unresponsive management. "They've gotten such a bargain out of us over the years," Manson says. "To get paramedic coverage for $5 million a year is unheard of. It's dirt cheap."

But the eleven-member task force, which was dominated by city administrators, didn't agree. Among its members were DHH chief Patty Gabow, DHH boardmember Roger Steinbecker, and Butch Montoya, Mayor Wellington Webb's manager of public safety (which oversees the fire department); also on the panel were city councilwomen Happy Haynes and Joyce Foster. They were joined by two physicians--William Duke from Grand Junction and Alden Harken from the University of Colorado; two paramedics; and two private citizens, Robert Harkin and Mary Sylvester.

"I did not think it was a fair and open process," says Sylvester, noting that Gabow set the tone. "In spite of our best efforts to say what we wanted, it always kept coming out in Patty's words." A fire official who asked not to be identified agrees, and yet another fire department employee says the process was slanted against the paramedics.

"The unfortunate thing about politics," says senior paramedic John Putt, "is that the hospital officials feel like they are losing control of something that is theirs. They don't want us to do it."

Defenders of the task force's decision point to the fact that, according to the city's Office of Budget and Management, the switch would cost $3.4 million just to get off the ground, plus $3.4 million per year in additional appropriations.

But at the task force's final meeting, supporters of the move tried unsuccessfully to present a new cost analysis concluding that having the paramedics merge with the fire department would have cost, at most, only $200,000 per year more than keeping them as a DHH division.

"You can figure the numbers any way you want," Sylvester says. "What we were doing was all hypothetical. I'm not sure all factors were considered." She adds that if those later figures had been in everyone's hands ahead of time, the task force might have decided differently.

And in a memo dated August 2, Councilwoman Foster wrote, "At this time, we don't have a picture of the economic impact of the EMS service on DGH to make an informed judgment on the raw dollars of which proposal costs more."

Despite the request by some task force members to hire a consultant to analyze the cost estimates, the panel approved its final recommendations the same day as Foster wrote her memo.

"Why did they uniformly say they didn't understand cost and then vote on it?" Petre asks. (Foster defends the decision, saying the task force "fixed what was broken this year.")

The paramedics' battle reveals just one more instance of how the health-care industry is changing. Emergency medical service is an attractive business not only for private health-care providers but also for fire departments. Although fire administrators only cautiously allow that such a merger between their crew and the paramedics could have been worked out, the fire union clearly wanted it. Fire departments nationwide (and in metro Denver) are answering far more medical calls than fire calls, and both administrators and rank-and-file firefighters say they're nervous about the prospect of competition from increasingly powerful health-maintenance organizations or other private companies.

Consequently, more than 51 percent of fire departments across the country have paramedics as a part of their EMS service, according to 1994 figures. George Burke, spokesman for the International Association of Fire Fighters, says that percentage is expected to rise.

"The fire union's real issue is that over the past several years, firefighting as a job function has decreased," says Greg Stahmer, a senior paramedic at DHH and a member of the task force. "Their entire job is EMS. If they can't get into and stay in the EMS business, their entire existence is a question mark."

But no more than that of DHH, as it tries to keep itself afloat in a radically changing health-care environment. This summer the city is expected to turn DHH into a quasi-independent health authority, hoping it will be able to compete better with private industry. Its officials don't like the prospect of losing an important link in their health-care-delivery system. "Our mission is health, their mission is fire," says Denver General's Stephanie Thomas, arguing in favor of keeping the paramedic division where it is. "You're much better off for the future, when the dust settles, having an integrated health system."

Were a merger to take place, DHH would not only lose its paramedic division and the money it generates ($12,809,021 in gross revenue in 1994), but it would essentially turn over all EMS care (the first line of service in DGH's nationally admired trauma service) to the Denver Fire Department.

"The survival of the [new, independent health] authority is tied to our survival," says Stahmer. Some paramedics view DHH as poorly run and the yet-to-be-launched health authority as an already sinking ship. For them, the fire department is an island. "The hospital is great at practicing medicine," says Lieutenant Pat Hynes, executive boardmember of the firefighters' union, "but as far as taking care of people who provide the service, they're not as good."

"We're all fighting for a pile of crumbs, while the fire department presumably has more clout, a big union," Stahmer adds. "But would EMS have that same clout in the fire department? If they have a budget crunch five years from now, what do they cut first--ambulances or fire trucks?"

Although they've been stymied, the paramedics will continue to solicit city council support and, starting next month, will take their case to the people through community slide shows.

Though sympathetic, Mary Sylvester is skeptical about that tack, saying, "Frankly, I don't think people care. Who thinks about whether they need an ambulance?

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