The cab looks like a four-door semi, complete with running boards and a chrome guard for the grill.

In back, the new ambulance at Children’s Minnesota is the XL version of the familiar metal box, with room for a patient gurney and seating for four people plus all the latest technology.

There’s a generator for backup power, advanced machinery to keep patients breathing and interior cameras that allow for constant “telemedicine” communication with faraway specialists.

“This is a microcosm of the hospital,” said Dr. David Hirschman, medical director of the critical-care transport program at Children’s. “This is a replication of an ICU.”

Yet Children’s plan for using this supersized ambulance has sparked an outcry among emergency medical service (EMS) professionals across Minnesota. It’s not the ambulance itself they object to, but a request by Children’s for a statewide license.

Currently in Minnesota, the license for ground ambulance services specifies the care it can provide within a geographic area called the “primary service area.” The license effectively reserves for the ambulance service 911 call response plus patient transfers from hospitals in the service area unless that service or a physician wants an outside ambulance provider due to special patient needs.

Children’s doesn’t want to answer 911 calls, but it is seeking a license that wouldn’t limit its operations to a primary service area. Some ambulance companies are worried that by granting a statewide license to Children’s, the state would open the door to multiple statewide licenses for ground ambulances. That, in turn, could eventually doom the primary service-area rules credited with preserving critical revenue for ambulance companies, they fear, particularly those operating in smaller communities.

It’s not just small outfits, however, that object to Children’s plan. Once the hospital’s application was opened for public comment earlier this year, 18 groups across the state including the Mayo Clinic, Hennepin Healthcare and North Memorial Health voiced opposition.

“Children’s has not demonstrated that any population of patients in Minnesota is not being adequately served,” an official with Robbinsdale-based North Memorial wrote to state regulators in April. “Children’s does not cite a single example of a Minnesota child who has fallen through the cracks in a manner that could have been prevented by use of a pediatric- or neonatal-specific transportation service.”

In its licensure application, Children’s argues that Minnesota is “one of only a few states in the country that lacks a neonatal/pediatric specialized, dedicated transport with critical care capacity.” The hospital added: “Children’s believes that Minnesota kids should have the same health care access as kids in the rest of the nation.”

A spokeswoman for Children’s told the Star Tribune last week that one of the 18 critics recently dropped its opposition to the plan. At the same time, one of the supporters listed in the Children’s application — St. Paul-based HealthEast — is now owned by Fairview Health Services, which is against the plan.

“Fairview strongly opposes the application, and will be issuing our rationale to the state in the coming days,” a spokesman for the Minneapolis-based health system said in a statement to the Star Tribune.

The controversy comes as the ambulance business is being pulled in both directions when it comes to vehicles, with services simultaneously launching smaller “sprinter” trucks while also investing in bigger rigs for special patient groups.

The new ambulance at Children’s is the sort of large vehicle that apparently hasn’t been used before in Minnesota, but is increasingly commonplace at pediatric specialty centers across the country. Some children’s hospitals have been using “quad cab” ambulances for more than a decade, said Dr. James Augustine, a professor of emergency medicine at Wright State University.

“For these mobile units, they require a lot more in terms of the support for the clinical environment than [for] an adult trauma patient,” Augustine said. “With the kids, a lot of times it’s much more complicated.”

In 2016, Children’s purchased two quad-cab ambulances at an overall cost of $1.3 million, including the expense for embedded equipment and technology. The hospital said the rigs were paid for through philanthropy.

For many years, Children’s has operated a team of specialized personnel who help transport neonatal intensive care (NICU) babies and pediatric cases in conjunction with the emergency medical service at Allina Health System, which operates in part of the Twin Cities metro. With its application completed in March, Children’s wants approval for a statewide service that would not respond to 911 calls, but handle transfers between hospitals.

If granted a statewide license, Children’s said it would transport about 805 patients per year at an overall annual service cost of nearly $2.4 million. The hospital said it expects less than $1.6 million in revenue per year.

“This is not a financial windfall for Children’s,” said Hirschman, the hospital’s medical director for critical-care transport. “It’s one of the things that is mission driven. We believe that the outcomes for the kids — the outcomes are optimized if we start Children’s care for pediatric patients sooner. This is one of the ways that we do that.”

Opponents fear the statewide license would be the beginning of the end of the primary service area (PSA) rules that have been around for decades in Minnesota. The regulations help make sure that local ambulance services maintain the hospital transfer business, which provides good compensation that offsets low payment rates for emergency calls, said Aarron Reinert, executive director of Lakes Region EMS, which is based in North Branch.

Opponents also argue that the Children’s proposal doesn’t solve any current problem. Outlying ambulance services say they are happy to call in Children’s, for example, when transporting tiny babies who are destined for the NICU and require extremely specialized care. But some of those services argue they have plenty of expertise and experience for handling many pediatric cases.

At least one transport program — the service run by the Rochester-based Mayo Clinic — said it has a strong track record with NICU patients, as well.

“Granting a statewide license as being considered, would provide an unjust opportunity for Children’s Minnesota to market their ambulance service across the entire state,” a Mayo Clinic official wrote to state regulators in April. “Such license would erroneously imply to referring facilities … that Children’s Minnesota would be the closest most-appropriate facility, thereby bypassing closer, equally capable providers.”

The volume of opposition to the Children’s plan is unusual, said Mark Ebeling of the Minnesota Ambulance Association, a trade group that opposes the statewide license request. In comments with regulators, Ebeling wrote: “The loss in revenue for the current advanced life-support providers may cause financial harm to an already fragile system.”

Hirschman, however, said Children’s plans on transporting such a small number of patients that he questioned the degree of impact on other ambulance services. He also challenged the idea that a statewide license for the pediatric medical center would set a dangerous precedent.

Without the statewide license, there would be an administrative burden for Children’s to field requests to utilize the new service on a case-by-case basis, Hirschman said. Plus, there could be cases where Children’s believes it could provide transport care that’s superior, the hospital says, but other EMS services might disagree.

“We’re the leaders in pediatric care,” Hirschman said. “We know what the community standard is.”
The decision on whether to grant the statewide license rests with a state agency called the Emergency Medical Services Regulatory Board. Officials said it has been more than a decade since the agency has had to deal with a contested case like the Children’s application. In such cases, the matter is referred to an administrative law judge.

With the Children’s request, the judge has scheduled a public hearing for Sept. 24-28 in St. Paul. Ultimately, the judge will prepare findings, conclusions and a recommendation, all of which goes back to the board for a final decision.