Watauga County: at a Crossroads of Life and Death?

By David Rogers. BLOWING ROCK, N.C. — Watauga Medics serves as the contracted, for-profit franchisee for providing ambulance service in Watauga County and has done so since 1999. At the May 6 meeting of the Watauga County Board of Commissioners, Watauga Medics CEO Craig Sullivan asked the commissioners to bless the prospective sale of his company to a Knoxville, Tenn.-based, for-profit EMS provider.

Obviously, Sullivan now wants to move on, to cash out. That, of course, is his right as a business owner and for whatever reason: retirement, change of business direction… any number of explanations are potential motivating factors.

And yet, is moving from one for-profit concessionaire to another for-profit corporate entity the best thing for Watauga County?

For an outside observer, the proposition of a new ambulance service entering the Watauga County market begs some pressing questions:

• Is the current franchisee model working? Is EVERYONE in Watauga County receiving the EMS services they are paying for with their tax dollars?
• If that model is not working, are we not at a historic “crossroads” when it comes to providing adequate Emergency Medical Services to ALL of Watauga County?
• Is there another operating model to improve the services being delivered to ALL constituent interests, including residents, businesses and the many visitors to the county?

Blowing Rock constituents — the second largest population center in the county — have complained since 1974 that the for-profit franchise model (the Boone-centric ambulance service conceived and contracted by the county government decades ago) is inadequate in serving not just Blowing Rock but all parts of Watauga County that are not within the Boone town limits — and the numbers reflect that reality.

What is “good”?

Before we dive into those numbers, though, we have to ask: what should the goal be in providing fair and equitable EMS service in Watauga County?

There are plenty of studies out there, as well as common sense, suggesting that when it comes to medical intervention and transport for cardiac arrest, car crashes, workplace injuries and the like, getting to the patient sooner and to the hospital is better than later. The National Fire Protection Association sets a fractal standard for ambulance response times — at least for urban centers — that 90 percent of all calls within a jurisdiction should be responded to within nine minutes (colloquially known as the “90 in 9” model). For a rural county, that 90-in-9 standard may be less attainable, but it is still something to work toward.

Is Watauga County “urban” or “rural”?

In 2023, Stacker.com reported that of the 100 counties in North Carolina, Watauga is right in the middle, considered No. 50 as the “most urban” or “most rural” county within the state.

…as if to say a Boone life is more valuable than one in Blowing Rock, Todd, Valle Crucis or Bethel?

Diving deeper, Stacker.com ranked Watauga County as No. 28 in terms of the most densely populated county in the state, with 200 residents per square mile. That number (200/square mile) is calculated grossly as the total population divided by the total number of square miles in the county.

And yet, when you consider that a large percentage of Watauga County is undevelopable because of the mountainous terrain or comprised of government-protected lands (National Park Service, U.S. Forest Service, Grandfather Mountain), the density number gets pushed up considerably towards “urban” because the population gets pushed into smaller territory.

Look around and, yes, there are chunks of dense population in the four incorporated towns (Boone, Blowing Rock, Seven Devils and Beech Mountain), but there are also large populations in the many residential subdivisions outside of the town limits, even gated communities like the fast-growing Blue Ridge Mountain Club. You would be hard-pressed to tell the residents of Sorrento Skies, Heritage Ridge, Two Rivers, Misty Mountain, Sweetgrass, Grace Mountain, Valle Crucis, Powderhorn and the like that they are rural when they have paved streets, manicured lawns and gardens, and many of the other trappings of affluent neighborhoods. Even less likely to agree with a “rural” description are the full-time or seasonal residents of Blowing Rock, Seven Devils or Beech Mountain, the other three incorporated towns not named Boone.

The point is, even with its large agricultural sector, Watauga County increasingly approaches every definition of “urban” with each passing year and the demand for the appropriate government services is increasing, too, whether in law enforcement, fire protection or ambulance services.

Watauga County’s contract with Watauga Medics sets a goal of 10 minutes response time, on average. Defenders of the current EMS services provided by the county point to an “average” response time of a little more than 10 minutes (10:10, according to the 2024 Watauga Medics Annual Report) for all calls responded to by the current provider.
To the uneducated or unenlightened, that might seem reasonable — but the national standard that most jurisdictions aspire to meet is NOT an average. It is a fractal standard.

That is 1,355 human lives put at greater risk.

Most Boone-based emergency calls (roughly 52 percent of all calls, according to the Watauga Medics 2024 report) are responded to within five to seven minutes (great service), so they drag down any calculations of an average for the county as a whole. A fractal standard suggests that 90 percent of ALL calls, including the many calls outside of the Boone town limits, should have a response time of no more than nine minutes, too.

But OK, since parts of Watauga County are clearly rural, let’s relax the standard to 90-in-10, meaning 90 percent of all emergency calls should be responded to within 10 minutes.

Statistically speaking, 90-in-9 (or even 90-in-10) is a higher standard than “average.” Why is that important? NONE of the 12 Watauga County fire districts other than Boone meet a 90 in 9 standard — and while Boone-based calls represent a higher percentage of emergency calls, the number of emergency calls in the rest of the county represent almost half of all emergency calls in the county (48 percent, according to the Watauga Medics 2024 report). And every single one of them outside of Boone — that is 1,355 emergency calls in 2024 — are far outside nine minutes, or even a 10-minute fractal standard.

Put in perspective, that is 1,355 human lives that were put at greater risk in 2024 simply because the ambulance services contracted and paid for by Watauga County are lacking. When it comes to cardiac arrest, a car crash or someone getting injured on the job, both the EMT response time and the transport of a patient to a hospital could mean the difference between life and death.

A closer look

Blowing Rock response times have historically ranged from 10 minutes on the low end to 20 minutes or even more. According to the 2024 Watauga Medics report, response times to other parts of the county have been even slower: Beaver Dam Fire District in the west (more than 22 minutes); Stewart Simmons Fire District in the east (almost 26 minutes); and Todd Fire District in the north (more than 24 minutes) are prime examples. In fact, of the 12 fire districts in Watauga County, the only one that comes close to meeting a 9-minute or less standard is the Boone Fire District (7:12), according to the latest published report by Watauga Medics.

Given that Watauga County is still not fully urban, if the county’s agreement with the concessionaire was “90 percent of all emergency calls should be responded to within 10 minutes,” it would be more palatable. At 10:32 (10 minutes, 32 seconds “average”), Cove Creek Fire District, for which an ambulance base was added near the outskirts of Boone a few years ago, comes closer to what might be a more acceptable 10-minute standard, but it is still not there. Same with Beech Mountain (10:30), which made arrangements for a new base a couple of years ago. All the other fire districts were well outside of professional expectations.

Let’s get off our duffs and get this done.

It is hard to fault Watauga Medics. They operate under the contract agreed to by the county’s board of commissioners. Watauga Medics delivers what they are being paid to deliver — which simply isn’t enough.

Critics of the Boone-centric model, though, including Blowing Rock News on several occasions in recent years, pose the question: why are so many non-Boone residents (65 percent of the county population), who pay the same county property taxes as Boone residents, subsidizing great ambulance service to Boone but receiving substandard service themselves?

And the inequity goes beyond where people live. There is the money angle, too. According to other research we examined regarding this issue in 2023, approximately 65 percent of Watauga County’s property taxes are received from taxpayers outside of the four incorporated towns (Boone, Blowing Rock, Seven Devils and Beech Mountain).

Is there an answer?

Is there an answer to the question of why 65 percent of the Watauga County population is paying for superior ambulance service in Boone but receiving substandard service themselves?

That’s easy: “They shouldn’t be. They should be getting as close as possible to equal service.” Supporters of the current system may say there aren’t as many emergency calls in those other fire districts — as if to say that a Boone life is more valuable than a life in Blowing Rock, Todd, Valle Crucis or Bethel?

The answer is NOT contracting with another for-profit ambulance provider.

With an increasing number of subdivisions proliferating throughout the county (and not so much in the Boone Fire District), the inequity of the problem only stands to get worse. Sorrento Skies, Blue Ridge Mountain Club, Misty Mountain, Heritage Ridge, Sweetgrass, Riverwalk, Grace Mountain, Powderhorn, Bloomingdale, Ski Mountain… the number of new and existing “urban-like” subdivisions is growing. And every single new home represents just that much more money added to the county coffers in property taxes paid from outside Boone.

And consider this: from late spring, through summer and to autumn, the population of Watauga County — especially outside of the Boone town limits — swells considerably in communities like Blowing Rock, Valle Crucis, Beech Mountain and Seven Devils, to name a few. The number of seasonal residents far outnumber the permanent residents and that is also the case in many residential subdivisions, too. Then, when you add the many High Country tourists escaping the heat and visiting for fun and frolic, the challenges for EMS coverage outside of Boone increase commensurately.

The remedy is pretty simple, even if the devil is in the details. We need more ambulance bases, more ambulance trucks, and more staffing to deliver those services. Each fire district should have its own 24/7/365 ambulance base because no one knows when or where the next car crash, heart attack, farm accident, or any number of other medical emergencies are going to occur. Everyone, including the taxpayers in all 12 fire districts, need assurance that emergency medical personnel will respond within mere minutes and transport them to the local hospital when need arises.

Given any semblance of a reasonable budget, the answer is NOT in hiring another for-profit provider but in creating a county-owned and operated system.

The peer group models for county-owned EMS services surrounding us are plentiful: nearby Caldwell County, Cleveland County, Wilkes County and Burke County are all county-owned and providing a more uniform level of EMS services to their respective constituents, wherever those constituents live, work and play within their respective county boundaries.

While some county-owned EMS services are in more urban areas like Raleigh or Greensboro, many others are in rural or quasi-rural counties just like Watauga. Again, given the influx of seasonal residents during the late spring, summer and autumn months, Watauga is already more urban than many other North Carolina counties.

In short, those counties with county-owned services are delivering a better EMS “product” for their constituents than Watauga County residents, business owners and visitors are receiving.

This is not criticism of Watauga Medics because they perform a pretty good service — as far as they go. They just don’t go far enough and, if the county chose to expand its contract to better serve all 12 fire districts, the cost would be unmanageable with a for-profit concessionaire because as taxpayers we would be paying not just for the basic costs of providing ambulance service but contributing to the built-in profits of a larger for-profit operator, too.

The answer is transitioning to a county-owned ambulance service. The county would own and operate the trucks, the base stations and all the equipment. The county would pay the personnel (wages and benefits), pay for the maintenance of the property and equipment… everything — just like it already does with other government services like the sheriff’s department, public works, parks and recreation, landscaping, health services and so on.

That may sound expensive, and it is — but the county is already paying Watauga Medics more than $2.2 million per year AND, unlike many of the government services provided to taxpayers, with EMS the county can also receive the patient billings, estimated to be as much as half of the outlays. In 2023, according to the most recent ambulance company’s financial report, in addition to the county-paid subsidy ($2.2 million), Watauga Medics collected more than $1.7 million in patient billings). Those could be county receivables. What’s more, there are important advantages for a county government to control the billing and collection of the EMS transport user fees, whether paid by Medicare, insurance companies or the private individuals.

We can’t stall

The key consideration, though, is that we cannot transition to a county-owned EMS service overnight. It requires planning and, arguably, up to three years to implement. So the county commissioners need to make a decision NOW to transition to a county-owned service. Pay Watauga Medics a bonus for keeping things going during the transition period, rather than sell out to another concessionaire.

Watauga County needs startup and operating cost analysis by independent consultants, not conjecture by so-called professionals with a vested interest in maintaining the status quo. Talk to the other counties that have already taken that step, away from for-profit concessionaires to county-owned services delivering a better and more equitable EMS product.

As the plans are readied for implementation, we need to start the capital planning process. We need to start locating or building stations. We need to start ordering the necessary ambulances (there is reportedly a backlog of 12-24 months) and explore staffing opportunities.

If the vast majority of the counties in North Carolina have already transitioned to a county-owned service to provide the best quality EMS product possible, why can’t Watauga County? Why do we have to keep hearing that it cannot be done, that it is too expensive?
Those naysayers are either uninformed, misinformed, unmotivated, or unresourceful.

For ALL of Watauga County, this is important stuff. Let’s get off our duffs and get it done.