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Frequently Asked Questions





1. What is an emergency services district?

Emergency services districts are political subdivisions formed under the Texas Constitution and governed by Chapter 775, Texas Health and Safety Code. These districts have the constitutional and statutory authority to provide emergency medical services to residents of their area. Emergency services districts use tax revenue to provide emergency services to residents directly or through a third-party emergency services provider, like a private ambulance company. Providing services directly has become increasingly popular with emergency services districts, since it cuts out the middleman, which reduces costs, streamlines communications, and allows for greater transparency concerning the use of tax revenue.

2. How often does ESD 11’s Board of Commissioners meet?

ESD 11 regular board meetings are held on the third Thursday of each month at 9 a.m. unless otherwise noted. Meetings are held at ESD 11’s new campus at 18334 Stuebner Airline Road in Spring, Texas, and agendas for such meetings can be accessed here.

3.What is the purpose of executive session?

Texas law requires that all ESD 11 Board meetings are open to the public. When the Commissioners go into executive session, however, the public is asked to leave the Board meetings so that Commissioners can speak with ESD 11’s attorneys about confidential topics or confer with ESD 11 staff on other confidential matters. Just like other governmental entities, Texas law allows the ESD 11 Board to speak confidentially with its attorneys about certain issues, such as any attorney/client privileged matters or pending or threatened litigation. The Board can also review personnel issues, real estate transactions, and security matters in executive session.

4.Why is executive session so long?

By law, the ESD 11 Board can only discuss ESD 11 business at public meetings that have been properly noticed via a posted agenda. Because executive sessions can only be held at Board meetings, the Commissioners have limited opportunities (sometimes only once a month) for these discussions. Over the lastyear, concerns related to Cypress Creek Emergency Medical Services’ (CCEMS)use of taxpayer dollars and its performance have required Commissioners to spend more time in executive session speaking with attorneys. In September 2020, CCEMS filed a legal challenge to ESD 11’s decision to terminate its contract. Due to the lawsuit with CCEMS, Commissioners need additional executive session time to receive updates about the lawsuit and legal guidance from counsel.

5. How can I learn more about decisions made by ESD 11?

ESD 11 Board meetings are open to the public, and the agenda is posted online at least 72 hours prior to all scheduled meetings. Additionally, A live stream of the meeting is available on the ESD 11 website here. A video recording of each meeting can be found here. Minutes of each meeting are also posted on the website once approved by the Board and can be found here.

About ESD 11’s New Ambulance Service

1. What will ESD 11’s new ambulance service be called?

The official name of ESD 11’s new ambulance service is Harris County ESD 11 Mobile Healthcare.

2. What are the benefits of starting a new ambulance service?

When Harris County ESD 11 Mobile Healthcare launches Sept. 4, 2021, residents should expect the quality of service to increase significantly because ESD 11 is hiring an incredible team and plans to provide nine additional ambulances at less cost to taxpayers.

3. Will it cost ESD 11 more to run Harris County ESD 11 Mobile Healthcare?

No, ESD 11 expects to pay less for more. Harris County ESD 11 Mobile Healthcare’s Chief Executive Officer Doug Hooten estimates taxpayer funding of approximately $10 million will be required to put 28 ambulances on the street in 2022. For comparison, ESD 11 has historically provided CCEMS with taxpayer funding of approximately $16 million per year for only 19 ambulances. By providing its own emergency medical services, ESD 11 will save about $6 million per year for nine additional ambulances in service.

4. What does the creation of Harris County ESD 11 Mobile Healthcare mean for the standard of care for residents?

The standard of emergency medical care will improve. By centralizing operations, increasing efficiency, and implementing new, cutting-edge technology and services, ESD 11 residents will enjoy the benefits of a higher quality emergency medicine/mobile health service.

5. Will the creation of ESD 11’s ambulance service leave local EMS employees out of jobs?

CCEMS has told its staff they are free to seek work with ESD 11, and ESD 11 Mobile Healthcare welcomes all qualified candidates. ESD 11 expects that residents will see a lot of the same faces on the streets come September. ESD 11 Mobile Healthcare is excited to offer industry-competitive compensation and an incredible suite of health and retirement benefits.

6. Who is the new Executive Director of Harris County ESD 11 Mobile Healthcare?

In December 2020, ESD 11 hired Doug Hooten as its first Chief Executive Officer. With more than 35 years in the EMS field, Mr. Hooten directly oversees and manages the emergency medical services operations. He reports to the ESD 11 Board of Commissioners and provides expert guidance as ESD 11 starts a new chapter in providing emergency medical services. To learn more about Mr. Hooten click here.

7. Who are the other leaders in charge of running ESD 11 Mobile Healthcare?

The ESD 11 Mobile Healthcare executive team includes:

8. What infrastructure does ESD 11 have to support ESD 11 Mobile Healthcare?

ESD 11 purchased 43 acres at 18334 Stuebner Airline Road in Spring, Texas. Here, ESD 11 is building its state-of-the-art headquarters where ESD 11 Mobile Healthcare and its employees can train, work, and grow. The campus will contain six buildings, including the ESD 11 main administration building, its ambulance deployment center, a fleet maintenance facility, and an ambulance car wash. ESD 11 will also build a 164-foot tower for its new communications system.

About ESD 11’s decision to terminate CCEMS

1.What is CCEMS’s relationship to ESD 11?

ESD 11 contracted with CCEMS to provide emergency medical services some time ago. The ESD 11 Board of Commissioners voted on Sept. 3, 2020, to terminate the agreement, effective Sept. 4, 2021.

2. Why did ESD 11 terminate the Service Agreement with CCEMS?

The Service Agreement has always allowed either party to terminate the agreement for any or no reason at all. ESD 11 exercised its right to terminate the Service Agreement for convenience for a variety of reasons, including CCEMS’s failure to meet performance goals, like response times; CCEMS’s long-standing resistance to ESD 11’s requests for information and transparency; and the CCEMS administration’s hostile and uncooperative attitude toward ESD 11. For these and many other reasons, ESD 11 could not in good faith continue to use taxpayer dollars to prop up a failing partnership.

3. What are ESD 11’s concerns with CCEMS’s use of taxpayer dollars?

ESD 11 has historically had a great relationship with the rank-and-file first responders of CCEMS and has immense respect for the work they do. Unfortunately, ESD 11’s relationship with CCEMS management became very strained as ESD 11 questioned CCEMS’s fiscal responsibility and leadership. In response to ESD 11’s questions, CCEMS management has historically been aggressive, threatening, and evasive.

For some time now, ESD 11 has heard from CCEMS first responders that equipment is outdated and beyond its useful life. ESD 11 Commissioners have also heard that CCEMS first responders are overworked, and that their health insurance claims often go unpaid. ESD 11 does not understand how it has provided so much funding to CCEMS, and yet CCEMS has run-down facilities and equipment, and inadequate insurance. It is even more puzzling considering that CCEMS generates approximately $12 million a year in revenue from Medicare, Medicaid, and private insurance billing for calls inside ESD 11 and from other emergency service providers through the CCEMS 9-1-1 Communications Center (Comm Center). ESD 11’s projections indicate that revenue could be doubled by following established best practices in the industry. That should be enough to pay for regular maintenance to ESD 11-owned facilities or to purchase new vehicles and equipment.

When ESD 11 finally started receiving information about these and other issues, its discoveries were troubling. For example:

• ESD 11 learned that CCEMS spent almost $4 million on an employee self-insurance plan in 2019/2020, amounting to approximately $20,000 per worker. For comparison, the average statewide group health insurance premium in 2019 was $14,563 to cover a family and $6,967 to cover an individual. Despite CCEMS spending an outrageous amount on employee insurance, some first responders have approached ESD 11 Commissioners to complain that they cannot get insurance claims paid (before ESD 11 began withholding funds). ESD 11 also learned that CCEMS quietly added additional personnel, families of personnel, and services to the insurance plan without first getting ESD 11 approval, which is required by the service agreement. ESD 11 estimates that it has overpaid CCEMS for insurance by hundreds of thousands of dollars per year.

• ESD 11 also learned that it has been overpaying for dispatch services. CCEMS runs the Communications Center (Comm Center) that services ESD 11 and at least 15 other fire departments and first responder organizations. For a long while, CCEMS refused to tell ESD 11 what percentage of 9-1-1 calls were generated inside ESD 11, and what percentage were related to CCEMS’s other customers. Under pressure from the ESD 11 Board of Commissioners, CCEMS finally admitted that only about 47 percent of all calls received by the Comm Center are related to ESD 11, even though CCEMS has been improperly billing ESD 11 for about 95 percent of the Comm Center’s employee salaries and health insurance. ESD 11 estimates it has overpaid CCEMS for Comm Center services by hundreds of thousands of dollars.

• CCEMS chronically under-collects from insurance companies, Medicare, and Medicaid, leaving residents to fund more than their fair share of CCEMS’s operations through ESD 11 taxes. The company that CCEMS uses for billing – which is owned and operated by the wife of CCEMS CEO Wren Nealy – collects at a much lower rate than most others in this industry. In fact, many emergency medical service providers charge the governments that hire them nothing because the collections alone are substantial. Instead of changing internal billing procedures or hiring a different independent billing and collections company, CCEMS has looked to ESD 11 taxpayers to supplement shortfalls each year.

These alarming discoveries demanded action, and in turn ESD 11 demanded answers from CCEMS. CCEMS has been uncooperative in providing answers and information. However, ESD 11 has managed to learn that, on top of the problems already noted, CCEMS executives signed contracts in ESD 11’s name without the permission to do so; claimed ESD 11 assets (like ambulances and medical equipment) as its own; pledged ESD 11 assets to CCEMS’ lenders as CCEMS collateral; and purchased medical supplies using taxpayer dollars, then sold those supplies to other first responder organizations without crediting ESD 11 with the sale proceeds.

4. Why is ESD 11 reviewing CCEMS’s books and records?

ESD 11 has the right under the Service Agreement to review CCEMS’s books and records. ESD 11 has repeatedly asked CCEMS to explain how it uses the public funding provided by ESD 11. In every instance, CCEMS has refused to fully cooperate. In fact, in 2018 ESD 11 tried to investigate CCEMS’s use of ESD 11 taxpayer dollars. However, CCEMS would not provide requested documents and refused to fully cooperate.

In June 2020, ESD 11 initiated a second investigation to tackle these unanswered questions along with a growing list of new ones. This investigation is ongoing.

5. Where are the results of the investigation into CCEMS’s use of taxpayer dollars?

The investigation is ongoing. The investigator’s preliminary results were announced at ESD 11’s Dec. 17, 2020 Board meeting. A copy and video recording of this presentation can be found here.

6. On Sept. 30, 2020, CCEMS filed a lawsuit against ESD 11. What is the lawsuit about?

Essentially, CCEMS has asked the court to force ESD 11 and its Board of Commissioners to pay CCEMS despite its poor performance and lack of transparency. While CCEMS’s claims are pending, the court has rightfully refused to directly involve itself in ESD 11’s right to withhold payments from CCEMS at this time.

ESD 11 has filed a counterclaim alleging a number of issues, among them that CCEMS cannot account for a $11 million budget discrepancy.

Additional claims in ESD 11’s filing(s) include:

CCEMS management acknowledged it has been using its maintenance facility to service private vehicles owned by employees and friends while on the clock and ESD 11’s dime. One of the cars serviced was that of CCEMS CEO Wren Nealy.

CCEMS overbilled ESD 11 for 9-1-1 Comm Center services. Initial estimates show that CCEMS has overcharged ESD 11 $3.3 million since 2016.

CCEMS wrongly used taxpayer dollars to pay administrative and other employees, contrary to agreements that ESD 11 funding would pay for EMS and Comm Center staff only.

CCEMS secured a loan using ambulances owned by ESD 11 as collateral without ESD 11’s knowledge or consent.

7. Does ESD 11 owe CCEMS millions in back pay?

No. ESD 11 withheld money from CCEMS when it discovered that CCEMS owed ESD 11 million because of overbillings and outright fraud.

8. Is there any way that CCEMS can convince ESD 11 to reverse its decision to terminate the Service Agreement?

CCEMS consistently failed to meet performance goals, allowed under-the-table repair schemes to run out of its maintenance facility, and withheld information that could be used by ESD 11 to hold CCEMS accountable. CCEMS has lied to employees and the community about ESD 11’s motives for terminating the Service Agreement. This is not conduct that elicits confidence. It is definitely not conduct that ESD 11 wishes to bankroll. ESD 11 attempted twice (in 2017 and in 2019-2020) to amend the Service Agreement in an effort to preserve the working relationship. Both efforts failed because CCEMS was either non-responsive, declined 99 percent of the amendments or stalled negotiations in other ways. The amendments would have allowed for all capital costs to be the responsibility of ESD 11 while paying CCEMS a flat cost per call response and allowing for cost of applicable employee living increases every year. It would have been a win-win situation for both parties, but despite ESD 11’s best efforts, CCEMS was unwilling to budge. With this backdrop, it became impossible to see a path forward that involved CCEMS.

9. What is the timeline for unwinding the relationship between ESD 11 and CCEMS?

The relationship with CCEMS has been terminated with the required notice of at least 360 days. ESD 11 expects CCEMS to fulfill the terms of the contract through September 3, 2021. In the meantime, ESD 11 will continue investigating CCEMS’s financial irregularities and pushing for performance and equipment improvements. ESD 11 has the authority to terminate the contract at any time for cause during this period if it finds that CCEMS has breached its agreement with and duties to ESD 11 and its residents.

10. What sort of back-up does ESD 11 have in place if CCEMS fails to maintain emergency services?

ESD 11 has back-up plans in place in the event that CCEMS fails to fulfill its obligation to serve the community during the 360-day termination notice period. For example, on Sept. 3, 2020, ESD 11 entered into an agreement with Harris County Emergency Corps (HCEC) to provide emergency medical services in the event of a sudden stoppage by CCEMS. HCEC and its partners are top-performing EMS providers that have the capacity to serve ESD 11 residents on a moment’s notice.

11. When the service agreement with CCEMS ends in September 2021, how will residents receive emergency medical services?

Beginning in September 2021, ESD 11 will be directly providing emergency medical services to the approximately 600,000 people who live in ESD 11. To that end, ESD 11 is actively purchasing ambulances, hiring personnel, and working diligently to implement its long-term plan to provide the best possible self-operated emergency medical services.

12. Will ESD 11’s tax rate increase after CCEMS is no longer in the picture?

While ESD 11 cannot predict the future and therefore does not know what will happen with real property values, it is the goal of the Board of Commissioners to continue to reduce the tax rate – just as it has done the past few years and just as it did when setting the 2020 tax rate. The intention with this transition is to, over time, increase revenue from the provision of emergency medical services while simultaneously decreasing dependence on tax revenue. Once all necessary capital components are in place, taxpayers will likely see a reduction in their ESD 11 tax bills. For reference, the average homeowner pays $74.37 ANNUALLY ($6.24 per month) in taxes to ESD 11.

13. Will the standard of care be better or worse when ESD 11 takes over?

The standard of emergency medical care will improve. ESD 11 is putting systems in place to provide for improved response times and allow for a less grueling work schedule for the field staff. Further, in order to make sure ESD 11 emergency medical services meet or exceed the national standards, ESD 11’s new ambulance service will pursue national accreditation, something CCEMS has refused to do.