When the Edina City Council gets a handwritten thank you note, it’s likely to be from a grateful senior citizen about a speedy city ambulance and the kindness of firefighter paramedics who responded to a 911 call.

Edina is among the metro cities, including St. Paul and Burnsville, that run their own ambulance service through their fire departments.

For residents, it’s a city amenity that ranks right up there with parks and prompt snowplowing.

But in an ever-more-complicated medical environment, city ambulance services face challenges. Equipment is expensive. Trained personnel must be available in an instant. And though ambulances are busier than ever responding to calls from senior citizens in aging suburbs, each year cities collect a smaller percentage of what they bill for ambulance runs.

Some cities, such as partners Apple Valley, Lakeville and Farmington, have decided it’s easier to guarantee quality service by hiring an outside provider.

Cities such as Edina, Burnsville and St. Paul, meanwhile, say that they are committed to their ambulance services and that they are proud of their speedy response times.

“This is something that our residents have grown to appreciate and expect,” said Edina City Manager Scott Neal. “They like it when the city shows up to help at what is sometimes their lowest moment.”

Burnsville Fire Chief B.J. Jungmann echoed that.

“This is one of those public service things where residents get excellent care and excellent response,” Jungmann said. “We get people who stop by our stations, send notes and call. They are very thankful for the service.”

In St. Paul, where city officials say the survival rate for cardiac arrest patients is two to three times higher than average, the ambulance service also is efficient, said Steve Zaccard, the city’s fire marshal.

“Firefighters are being used for ambulance service, as well; it’s dual staffing,” Zaccard said.

Since 1980, Minnesota has been divided into ambulance service areas, with one license holder per area.

Among 321 ambulance services, 47 are linked to city fire departments and another 110 are public services that likely are connected to cities, according to the Minnesota Emergency Medical Services Regulatory Board.

Covering costs tricky

Anyone who runs an ambulance service knows they are likely to collect only part of what they charge for an emergency trip, said Buck McAlpin, who works with North Memorial Health Care and is lead lobbyist for the ambulance industry in Minnesota. Ambulance services that charge $1,400 for an emergency trip usually are reimbursed $425 or $450 by Medicare or Medicaid, he said.

“If you’re a community-based system, city councils have to look at this as a service they want to offer,” he said. “I would say the majority of large fire [department]-based systems do not cover their costs, so they offset with tax dollars.”

Some smaller cities have dropped their ambulance service and hired larger organizations such as hospitals or health companies to provide the service, McAlpin said.

“Most all of these shifted from city-based [emergency medical service] to large hospital-based [services] because of economy of scale,” he said. “We can buy materials cheaper when we buy in bulk. Buying 12 ambulances is cheaper than buying one.”

In the case of partner cities Apple Valley, Lakeville and Farmington, the three agreed to drop their ambulance service in 2008 to contract with Allina Health and to improve service, said Steve Mielke, Lakeville city administrator.

“We were concerned about quality of care,” Mielke said. “For smaller agencies, it can be difficult just to maintain the latest and most up-to-date capabilities and training. … We’re very pleased. They’ve brought a level of expertise we didn’t have.”

Hiring Allina eased the burden on city employees who were responsible for running the ambulance service. The city consortium still holds the ambulance license, which Mielke said allows it to change providers if service isn’t good enough.

In 2008, the cities estimated that hiring Allina collectively would save them $61,000 each year.

Firefighters as paramedics

In cities where ambulance service is part of fire department duties, the cost of emergency services is embedded in the overall fire department budget.

As fire prevention has improved and fire calls have declined for many departments, the primary job of firefighters is now responding to medical calls.

New firefighters in Burnsville and Edina must also be certified paramedics. In Burnsville and St. Paul, 70 to 75 percent of emergency calls are medical. In Edina, it’s more than 80 percent.

“Some people would say we are an ambulance service that provides fire service,” said Darrell Todd, Edina’s interim fire chief. “I see us as an all-hazard service.”

While the number of medical calls in Edina has grown by 35 percent since 2000, the collection rate on ambulance bills has dropped from 84 percent in 2002 to 42 percent in 2012. Burnsville’s collection rate dropped from 67 percent in 2003 to 49 percent in 2012. Most of the gap in payment is due to changes in Medicare reimbursement.

The cities have coped by raising charges for ambulance runs. So far, that and the increasing number of emergency trips have combined to raise revenue from ambulance operations: Edina’s ambulance revenue increased from $1.3 million in 2002 to more than $1.8 million in 2012, while Burnsville collected $1.1 million in 2003 and $1.9 million in 2012. Both cities put that money in their general funds, as does St. Paul.

Edina’s Todd said it’s the service, not the money, that matters.

“While it’s great that we can offset our costs, this is the level of service that the City Council has decided it wants to provide,” Todd said. “The city’s function isn’t necessarily to make money. We’re here to provide services to people and business owners.”

St. Paul has 12 ambulances that run out of 15 fire stations, Burnsville four ambulances at two stations and Edina three ambulances at two stations.

In Edina, most police are trained as emergency medical technicians, and they carry oxygen and external defibrillators in their cars. Because they are already out in the community, they often are the first responders to a medical call.

John Wallin, Edina’s finance director, said he thinks it would be hard for an outside provider to improve on the service the city already offers.

“They probably would not keep two ambulance sites in Edina, so response times would be different,” Wallin said. “And minutes can make a difference.”

Navigating health changes

Neal, the Edina city manager, said the city is watching ambulance reimbursement trends and wondering about how the Affordable Care Act might affect ambulance use.

He said the city is in discussions with Fairview Southdale Hospital in Edina about possibly expanding paramedics’ duties by having some act as “community paramedics.” In this role, they would check on people after they’ve been discharged from the hospital and help them manage their health at home.

“I’d say there’s a strong possibility the city might be involved in that kind of activity,” Neal said.

He said it’s all part of navigating a changing health landscape.

“We are concerned because our costs don’t drop,” Neal said. “We are not going to refuse assistance. You help first, and get paid second.”