Policy context Ambulance service is a marketplace failure Potential solutions to market failures –Regulatory approach Price controls/supply limits –Competitive approach Create a structured marketplace RFPs are a tool to select and integrate organizations into the system
Methodology Started with EMSAs Ambulance Zones Ground document (July 2012) Eliminated –Non-exclusive zones –Military –Sovereign nations –RFPs by non-LEMSAs –Non-competitively granted exclusives –Multiple competitions in the same county –Those over 10 years old Didnt receive 2 Performed item analysis on 18 RFPs
Three types of criteria Legal standards Objective (absolute) standards Subjective (competitive) standards
Criterion: Legal standards Criterion: Comply with the LEMSAs insurance requirements. Response desired: Accept the standard Cue: Initial each area of agreement or disagreement with minimum requirements and sign the final page. Evaluation: Pass/fail
Criterion: Objective standards Criterion: At least 51% of the personnel who staff ambulances shall be full-time employees. Response desired: Accept the standard AND describe compliance Cue: Provide the number of full-term and part time field personnel. Evaluation: Pass/fail
Criterion: Subjective standards Criterion: Deployment plans shall ensure that the proposed locations and numbers of ambulances to be deployed during each hour of the day and day of the week and shall be sufficient to meet response time standards... (etc.). Response desired: Accept the standard AND describe compliance
Criterion: Subjective standards Cue: Present a proposed deployment plan that complies with all minimum requirements of this Request for Proposal. Evaluation: Compared to other proposals
How are LEMSAs reviewing RFPs? Areas of reviews: Proposal format and content Credentials of the organization Minimum standards Competitive standards
How are LEMSAs reviewing RFPs? Proposal format and content review Review –Is everything included? –Is it in the proper format? –Are all the required signatures present? 7/18 included a pass/fail evaluation of responsiveness to the RFP requirements 2/18 included in scored criteria
How are LEMSAs reviewing RFPs? Credentials of the organization May be staff/consultant or evaluation committee Review –Prior experience –Financial capabilities Should not be looking at how the proposer would meet current RFPs specifics
How are LEMSAs reviewing RFPs? Credentials of the organization Pre-review –One mentioned a staff review –Two mentioned use of a separate evaluation 12/18 evaluated credentials as pass/fail 5/18 competitively scored credentialing criteria 1/18 wasnt specified
How are LEMSAs reviewing RFPs? Minimum standards We agree to... We agree to... and heres how well do it... Review: –Is everything addressed? –Does it meet minimum standards –Are any variations proposed (if allowed by the RFP)?
How are LEMSAs reviewing RFPs? Minimum standards 4/18 had a specific manner of accepting minimum requirements Many had minimum standards mixed in with competitive standards
How are LEMSAs reviewing RFPs? Competitive standards (rated) System design/SSM Quality process Pricing/subsidy Review: –Which one is better?
How are competitive criteria being scored? Relative scoring Global scoring Grading Global ranking Committee developed process
How are competitive criteria being scored? Relative scoring (7 RFPs; one for financial only) Each evaluator gives maximum points for the category to the best proposal and fewer points to others –Identify the strongest submission and assign maximum points and –Award relative points to other submissions consistent with the reviewer's assessment of the relative strength of the competing submissions.
How are competitive criteria being scored? Global scoring for each criterion (1 RFP) Each evaluator awards points from maximum for the category –Scored 0-100 for poor-excellent
How are competitive criteria being scored? Grading (2 RFPs) Points awarded in categories –100% = Excellent (The proposal successfully addresses all relevant aspects of the element being evaluated. Any shortcomings are minor and the element contributes appropriately to the meeting the requirements of the criterion) –75% = Good –50% = Fair –25% = Poor –0% = Fail
How are competitive criteria being scored? Global Ranking (3 RFPs) Non-points based system Each evaluator ranks total proposals from best to worst
How are competitive criteria being scored? Committee developed (3 RFPs) Process not specified
How are competitive criteria being scored? Process not specified (3 RFPs) Too confusing to classify (1 RFP) (Two RFPs used different processes for financial and non-financial areas)
Questions Do proposers know what the LEMSA is looking for? Does the LEMSA get information to make good decisions? Is the LEMSA able to do good reviews?
Do proposers know what the LEMSA is looking for? Ambiguity This RFP requires a well-defined charge system which assures no overcharging." Proposer shall provide evidence that the organization has sufficient capital to provide for implementation and start-up of the contract.
Do proposers know what the LEMSA is looking for? Is what the RFP asks for what the LEMSA really thinks it wants? The EMS Agency expects Proposers to establish, in their responses to the RFP, that Proposers have a firm commitment to maintain sufficient financial capacity to commence all services listed in the RFP on July 1, 2009; and, sufficient financial resources to maintain all services for at least the primary franchise period of five years.
Does the LEMSA get information to make good decisions? Credentialing: Pass/fail or competitive? Ambulance operator business licenses (Graded 0.7%) Proposal format (2 RFPs; mean 1.5%)
Does the LEMSA get information to make good decisions? Point distribution: Is the LEMSA emphasizing what it really values? Does the RFP show what the LEMSA thinks makes one proposal better than another?
Does the LEMSA get information to make good decisions? Point distribution : Is treatment of the incumbent workforce (7.8%) really more important than: –Key personnel (4.18%)? –Equipment (5.2%)? –Equipment maintenance (1%)?
Does the LEMSA get information to make good decisions? Point distribution: Are the collection process and cost effectiveness (12.53%) really more important than SSM and System Design (11%)?
Does the LEMSA get information to make good decisions? Charges as a major criterion: The combined weight of the evaluation criteria is of greater importance than cost in determining the greatest value to the County. 11 RFPs used charges as a competitive criterion Value ranged from 5% to 30% –Median was 16.2%
Does the LEMSA get information to make good decisions? Charges as a major criterion Payer mix AAA Hobbs, Ong Butte RFP Calaveras RFP Medicare44.00%34.00%53.10%45.50% Medicaid14.00%21.00%26.70%18.70% Private Pay14.00%17.90%8.80% Commercial Insurance21.00%17.70%11.30%33.40% Other7.00%8.50% 2.50% Subject to price changes28.00%26.20%11.30%35.90%
Does the LEMSA get information to make good decisions? Charges as a major criterion Assuming that the maximum charges are regulated, does the amount charged say anything about the efficiency, effectiveness, or equity of the proposed service?
Is the LEMSA able to do good reviews? Do the evaluators have the correct expertise? Current ratio greater than or equal to 1.32.
Is the LEMSA able to do good reviews? How objectives is the process really? Are the scores really objective? The mathematization of subjectivity will founder upon the resplendent fact that we are ambiguous beings. Leon Wieseltier, 2013 Does the process really just mathematize subjectivity?
Is the LEMSA able to do good reviews? Inter-rater reliability Top scores Bottom scores Reviewer #123 Reviewer #2103 Reviewer #377 Reviewer #4415 Reviewer #544
Is the LEMSA able to do good reviews? NIHs grant review process: –Specific rubrics showing what is required for each level of points –Training for evaluators
Recommendations for improving RFP evaluation Criteria Develop criteria first –Determine whether it is a legal, absolute, or competitive standard Be sure that the cue matches –the information that is wanted –the type of review that will be used
Recommendations for improving RFP evaluation Criteria Make relative importance of criteria more rational Unfortunately, most leaders don't differentiate between the critical few measures that will have the greatest impact and the...the trivial many. Dean Spitzer Rethinking the Measurement of Innovation (2007)
Recommendations for improving RFP evaluation Criteria Make relative importance of criteria more rational Make sure you are measuring the right things! Peter Drucker (probably paraphrased from the original)
Recommendations for improving RFP evaluation Criteria Make relative importance of criteria more rational Primary: System design/SSM Clinical level/performance Cost Key personnel Quality programs Other???: Community programs First responders Employees Incumbent workers
Recommendations for improving RFP evaluation Criteria Cost v. charges –Charges dont tell us much –Better to look at the costs Total system cost Dollars per unit-hour ($/UH) measures comparative efficiency –Can still have them commit to maximum charges
Recommendations for improving RFP evaluation Evaluation process: First qualify the organization Second, ensure that the proposal meets minimum standards Third, compare a limited number of competitive criteria
Recommendations for improving RFP evaluation Evaluation process: Change credentialing to pass/fail –The question asked is whether the proposing organization has the ability to comply –Whether one is better than another should be linked to a specific competitive criterion
Recommendations for improving RFP evaluation Evaluation process: Change credentialing to pass/fail –Could C.A.A.S. accreditation replace the credentialing process?
Recommendations for improving RFP evaluation Evaluation process: List legal minimums and have them sign off directly Identify objective (absolute) standards clearly as minimums and evaluate them as pass-fail –Example: Cost guarantee (Graded 5%)
Recommendations for improving RFP evaluation Evaluation process: Limit the number of competitive choices –Pick the important criteria and focus on comparing those –Seek an effective way of rating these criteria
Recommendations for improving RFP evaluation Evaluation process: The RFP process should allow the LEMSA to make good decisions among proposals and to defend against legal challenges Lets accept the subjectivity of the process
Mathematization of subjectivity County grand jury recommendation (2005): A scoring system be clearly defined in advance to assist in properly and thoroughly evaluating applications and in adhering to the selection process. Said scoring system/sheet be retained as part of the evidentiary chain in the event of challenges or appeals in awards. The review committees (sic) receive clear and precise training/information as to their role and responsibilities in reviewing and rating applications.
Mathematization of subjectivity An initial scoring of the requests for proposals resulted in a tie in November. At the time, Health Services Director _________ recommended the county negotiate with __________. But _______ protested, and ultimately, both companies were asked to make additional presentations to the board. (2005)
Mathematization of subjectivity First, was there any rational basis for a reviewer to give a poor grade to _______s response? Yes, there was and the grade was neither irrational nor arbitrary or capricious. Second, is there any pattern in the reviewers grading to cast doubt on the overall reliability of his ratings or the ratings of the panel as a while? No. (2011)
Mathematization of subjectivity _______,s contract was in jeopardy after [it] initially lost its bid to renew the contract last year. Instead, it was slated to go to _______, which won the bidding by four points -- receiving a cumulative score of 364.8, compared with _______s score of 360.6. (2012)
Conclusion RFPs are an important part of EMS system implementation The process can and should be made better.
Richard A. Narad, DPA, JD, FACHE Dept. of Health & Community Services California State University, Chico Chico, CA 95929-0505 (530)898-5309 Rnarad@csuchico.edu