October 5, 1998
To:Toronto Emergency and Protective Services Committee
From:Acting General Manager, Toronto Ambulance
Subject:Recovery of Costs for Ambulance Service Delivery into Regional Municipalities
Purpose:
To advise Council of its options for the recovery of the cost of cross-border ambulance service to the Regions of Peel,
York, Durham and Halton. In the absence of inter-regional agreements, new Ontario Regulations provide for the ability of
individual municipalities to bill regions directly for such costs, using a specific billing formula.
Funding Sources, Financial Implications and Impact Statement:
The process of billing of regions for cross-border ambulance service will result in the creation of revenues for Toronto
Ambulance and/or the City of Toronto. Based on the pricing formula established under Ontario Regulation 354/98, net
revenues of approximately $590 thousand are potentially available, based on the assumption that cross-border demand for
service in 1998 is similar to actual demand in 1997.
Recommendations:
"It is recommended that:
(1)The Chief Administrative Officer and/or the Commissioner of Works and Emergency Services be requested to
formally advise the CAOs and/or Councils of the Regional Municipalities of Peel, York, Durham and Halton of
Toronto's desire to negotiate with the appropriate authorities a process for the recovery of the cost of cross-border
ambulance services delivered by and into the City of Toronto; and
(2)Failing the conclusion of such agreements in a reasonable period of time, the CAO and/or the Commissioner of
Works and Emergency Services be directed to submit bills and/or make payments to appropriate regional municipalities,
using the formula established in Ontario Regulation 492/97 as amended by O. Reg. 354/98; and
(3)Concurrent with such negotiations, the Chief Financial Officer and Toronto Legal Services be directed to determine
whether outstanding amounts under this Regulation should be shown as an accrual within the Toronto Ambulance
budget; and
(4)Toronto Ambulance set up a process to monitor specific cross border response activity, and to report back to the
Emeregncy & Protective Services Committee if extraneous demand in any way compromises ambulance coverage within
the City of Toronto; and
(5)The appropriate City Officials be authorized and directed to take the necessary action to give effect thereto."
Council Reference/Background/History:
Toronto Ambulance remains a substantial provider of service to the surrounding regional municipalities. Under the
Ambulance Act of Ontario, no request for service into an adjoining region can be refused or redirected by Toronto
Ambulance. Consequently, the City bears the cost of maintaining the staff and equipment required to meet these requests.
Similarly, though, there are occasions when ambulance service providers from the surrounding regions will deliver service
within Toronto's borders. On a net basis, however, Toronto Ambulance provides approximately twice as much
cross-border service than it receives (in 1997 it responded to over 5650 calls in the combined GTA regions, while GTA
services responded to just under 2900 calls in Toronto).
On January 1, 1998, the full funding and operation of ambulance services was downloaded from the Ministry of Health to
upper tier municipalities, including the City of Toronto. Through Bill 152, the Province provides for the creation of
inter-local agreements for compensation for the cost of ambulance services provided by adjacent municipalities to each
other. Subsequently, Ontario Regulation 492/87 was amended as O. Regulation 354/98 to provide an explicit pricing
formula for such services where such inter-local agreements are absent, or cannot be mutually developed.
Comments and/or Discussion and/or Justification:
Staff from Toronto Ambulance have, earlier this year, held meetings with representatives of the surrounding regional
municipalities for the purposes of discussing cross-border service and billing matters (as well, Toronto Ambulance has
offered consultations on the development and operation of emergency medical services systems to the regions, and to
other various representatives of the Association of Municipalities of Ontario). Up to that point no formal billing
agreements had been attempted or struck. While the Ambulance Act allowed for adjacent municipalities to establish
billing agreements, it did not offer any direct dispute resolution process for situations where municipalities could not
come to a satisfactory billing arrangement.
At the same time, the four regions did not then and do not yet have in place a formalized mechanism to deal with matters
related to cross-border billing, since the regions are themselves still exploring the issues related to delivery of ambulance
services within their communities. As a consequence there have been delays in being able to create official jurisdictional
agreements.
Recently, the Ministry of Health amended the Regulations to allow for municipalities to directly bill the municipalities
adjacent to them, where no formal billing agreements exist.
In Toronto Ambulance's 1998 budget submissions, revenues of $350,000 were anticipated for cross-border service
delivery. However, the current Regulatory formula now provides for the return of significantly higher revenues for the
City of Toronto, in the range of $590,000. Amended estimates based on the provincial pricing formula follow.
If these revenue targets are to be met, Toronto Ambulance and/or the City itself requires agreements with the regions of
Peel, York, Durham and Halton in order to establish a mechanism for the reconciliation of these costs, and recovery or
payment of any net amounts billable. In the absence of
such agreements, Toronto Ambulance and/or the City requires authorization to submit bills to the four GTA regional
governments under the provisions of O. Regulation 354/98.
Other Billing Opportunities:
There also exists an opportunity for the City of Toronto to explore other revenue return opportunities with the four GTA
municipal regions, in such areas as disaster resource and contingency preparation.
For example, the City of Toronto has historically provided emergency disaster and large incident responses to areas
outside Toronto. It may now find itself able to 'bill' for the availability or actual use of these resources, based on a fee
schedule separate from routine cross-border billing agreements.
Revenue Estimates:
Based on complete figures for 1997, the following table demonstrates estimates of the revenues and payables likely to
arise from operations during 1998. Actuals for 1998 will be determined at year-end.
For the purpose of these calculations, the formula provided in Regulation 354/98 is used, which yields an average cost of
an ambulance call for Toronto Ambulance of $214. The same figure is used for the adjacent regional services, in the
absence of more precise cost-per-call information from them. This assumption produces a conservative estimate of net
revenues available to the City of Toronto, as ambulance wage rates (and therefore the costs-per-call) are lower in the
adjacent regions.
Revenue Estimate Table:
The present Ambulance Act of Ontario has made legislative provisions for the downloading of ambulance services from
the Province to municipalities. Some of these allow for a transition period, whereby municipalities have the option of not
having to assume immediate responsibility for the operation of their own ambulance services. Municipalities can wait
until the latter part of 1999 before they have to declare how their service will be provided, and by whom. Full
responsibility for service provision takes place effective January 1, 2000. In the meantime, though, municipalities are
responsible for the full funding of their ambulance services.
In the meantime, for those municipalities who are electing not to declare their model of service provision, the Ministry of
Health is continuing to provide direct ambulance service delivery, but is billing back the costs to the municipalities being
served. To this date, each of the four regional municipalities surrounding Toronto have not committed to assuming
immediate responsibility for service delivery. As Toronto Ambulance (through the CAO and the Commissioner)
commences discussions regarding cross-border billing agreements, it may well enter into financial negotiations through
the Ministry, as the provider of service to the regions. These agreements, if established, will expire January 1, 2000, and
any agreements thereafter will be directly with the regions.
Significant net revenues are owed to the City of Toronto for the provision of ambulance service to the surrounding
municipalities. In turn, and by extension, the City owes each of the municipalities monies for ambulance services rendered
within Toronto. Reconciliation of the cost of these services is now provided for under the Ambulance and its Regulations.
The City is in a position of now being able to formally approach each of the four GTA regions to initiate the process of
establishing cross-border billing agreements. In the absence of such agreements, the City is in a position of being able to
bill for services anyway, based on billing formulas introduced by the Ministry. The potential net revenue to Toronto is in
the range of $590,000. In addition, the City can explore other potential service billing and/or fee-for-service arrangements
in such areas as disaster response.
