California Ambulance RFPs: Evaluation and Scoring Richard A. Narad, DPA, JD, FACHE California State University, Chico May 30, 2013

California Ambulance RFPs: Evaluation and Scoring

Richard A. Narad, DPA, JD, FACHECalifornia State University, ChicoMay 30, 2013

Introduction

• Purpose of RFPs• Models

– Types of criteria– Types of cues given to proposers– Types of review

• Findings from review of RFPs• Questions raised• Recommendations for improving the process

Conflict of interest statement

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 EMSA’s 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

• Didn’t 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 LEMSA’s 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


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


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 RFP’s specifics


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 wasn’t specified


Minimum standards• “We agree to . . .”• “We agree to . . . and here’s how we’ll

do it . . .”• Review:

– Is everything addressed?– Does it meet minimum standards– Are any variations proposed (if allowed by the

RFP)?


Minimum standards• 4/18 had a specific manner of accepting

minimum requirements• Many had minimum standards mixed in

with competitive standards


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


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.”


Global scoring for each criterion (1 RFP)• Each evaluator awards points from

maximum for the category– “Scored 0-100 for poor-excellent”


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


Global Ranking (3 RFPs) • Non-points based system• Each evaluator ranks total proposals from

best to worst


Committee developed (3 RFPs)• Process not specified


• 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%)


Point distribution:• Is the LEMSA emphasizing what it

really values?• Does the RFP show what the LEMSA

thinks makes one proposal better than another?


Point distribution:• Is treatment of the incumbent workforce

(7.8%) really more important than:– Key personnel (4.18%)?– Equipment (5.2%)?– Equipment maintenance (1%)?


Point distribution:• Are the collection process and cost

effectiveness (12.53%) really more important than SSM and System Design (11%)?


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%


Charges as a major criterion• Payer mix

AAA

Hobbs, Ong

Butte RFP

Calaveras RFP

Medicare 44.00% 34.00% 53.10% 45.50%Medicaid 14.00% 21.00% 26.70% 18.70%Private Pay 14.00% 17.90% 8.80% Commercial Insurance 21.00% 17.70% 11.30% 33.40%Other 7.00% 8.50% 2.50% Subject to price changes 28.00% 26.20% 11.30% 35.90%


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.”


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?


• Inter-rater reliability

Top scores

Bottom scores

Reviewer #1 2 3Reviewer #2 10 3Reviewer #3 7 7Reviewer #4 4 15Reviewer #5 4 4


• NIH’s 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


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)



rational

“Make sure you are measuring the right things!”

Peter Drucker (probably paraphrased from the original)



rational

Primary:•System design/SSM•Clinical level/performance•Cost•Key personnel•Quality programs

Other???:•Community programs•First responders•Employees•Incumbent workers


Criteria• Cost v. charges

– Charges don’t 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


Evaluation process:• First qualify the organization• Second, ensure that the proposal meets

minimum standards• Third, compare a limited number of

competitive criteria


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


Evaluation process:• Change credentialing

to pass/fail– Could C.A.A.S.

accreditation replace the credentialing process?


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%)


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


Evaluation process:• The RFP process should allow the LEMSA

to make good decisions among proposals and to defend against legal challenges

• Let’s 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.


“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)


“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 reviewer’s grading to cast doubt on the overall reliability of his ratings or the ratings of the panel as a while? No.” (2011)


_______,’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, FACHEDept. of Health & Community ServicesCalifornia State University, ChicoChico, CA 95929-0505

(530)898-5309

[email protected]

Documents

California Ambulance RFPs: Evaluation and Scoring Richard A. Narad, DPA, JD, FACHE California State University, Chico May 30, 2013