Navigating Through the Turbulent Skies

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Helicopter Air Ambulance (HAA) Fees Present Policy Challenges

When making the decision to transport a critically ill patient by helicopter air ambulance (HAA), the emergency medicine physician must now face the perverse prospect of saving the patient’s life only to devastate that patient’s financial well-being.


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Helicopter air ambulance services have proliferated over the past decade, and with them reports of patients and families ruined by exorbitant HAA bills not covered by insurance.[1,2]  With federal law currently preventing state- and local-level action against these predatory HAA billing practices, EM physicians must engage in policy reform and other efforts to protect our patients within the helicopter aeromedical transport system.

HAA LANDSCAPE AND COSTS

The sky is abuzz with helicopters. More than 1,000 HAA aircraft currently operate across the US.[1,2]  Historically, non-profit outfits run by governmental agencies such as state police or by hospitals themselves accounted for most HAA services.

Now, just three corporate for-profit groups — Air Methods, Air Medical Group Holdings and PHI — account for nearly 50% of the HAA market by revenue and by number of operating aircraft.[1-3]  This growing privatization of HAA operations is not necessarily a negative development, were it not for the significant financial implications for patients.


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As the number of HAA aircraft has increased, so too have HAA fees. Kathryn Green’s story in the September 2017 edition of Consumer Reports is illustrative. Green’s husband was flown by HAA after a head injury at their home in Mississippi. He died in hospital, but the HAA company charged Green $58,142 for the flight. Only $7,192 was covered by her insurance. The HAA company’s subsequent collection efforts destroyed Green’s finances even as she mourned her husband’s death.[1] Green’s story is not unique. The average HAA bill across all companies is roughly $30,000 per flight,[2] but this pricing differs dramatically for non-profit vs. for-profit carriers.

The average bill of the country’s largest for-profit company, Air Methods, exceeds $50,000 per flight.[2,4]  In contrast, some hospital-affiliated non-profit operators charge as little as $15,000 to $20,000, often less than half or even a third of the price of for-profit carriers for the same flight.

These enormous charges to patients exist despite independent research showing that actual operating costs for HAA transport average around $10,000 per flight,[2,4] with Medicare reimbursing approximately $6,000 per flight.[1,2]  Thus, HAA companies, especially the for-profits, charge far in excess of their actual operating costs and standard Medicare reimbursement. Unfortunately, commercial healthcare insurance turns out to provide little safeguard against these charges.

BALANCE BILLING

The ability of HAA groups to balance bill accounts for the prohibitive sums patients often face for HAA transport. Many for-profit HAA agencies refuse to contract with commercial insurers in their flight areas, thereby remaining “out of network.”[1]  As a result, when these HAA companies bill a patient whom they’ve carried, the patient’s insurance will only pay a small “allowable” out-of-network rate, and the HAA company can then directly charge the patient for the remainder.


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Federal law shields Medicare and Medicaid patients from excessive balance billing, but commercially insured patients enjoy no protections. The problem of balance billing in other areas of medicine (e.g., out-of-network anesthesiologists providing care during a surgery performed by an in-network surgeon) is being addressed through a combination of state- and federal-level efforts.[5]  No such remedies exist for HAA billing, owing to a piece of federal legislation from the 1970s.

HAA-pic-2

AIRLINE DEREGULATION ACT

HAA companies enjoy vast immunity from efforts to restrict balance billing or any other aspects of their operations. This protection stems from a seemingly unrelated federal law. The 1978 Airline Deregulation Act (hereafter, the Deregulation Act) was originally passed with the intent of deregulating the US commercial airline industry[6] and reads in part as follows:

Except as provided in this subsection, a State, political subdivision of a State, or political authority of at least 2 States may not enact or enforce a law, regulation, or other provision having the force and effect of law related to a price, route, or service of an air carrier that may provide air transportation under this subpart.[7]

The Deregulation Act preempts any state or local level action against the “price, route or service” of commercial air carriers.[6] The word ‘preemption’ carries specific legal implications. As a result of the Supremacy Clause of the U.S. Constitution, federal law preempts conflicting state or local laws. Preemption can be expressed (as in the Deregulation Act), implied or achieved by default if federal law occupies the entire field of authority over a policy area.[6]

Preemption, unless ruled by the courts as unconstitutional or as otherwise not applicable to the related state policies, can only be overcome by passage of new or amended federal laws.[6]  Three cases have outlined just how broadly the Deregulation Act’s expressed preemption reaches. In Morales v. Trans World Airlines, 504 U.S. 374 (1992), state laws against misleading advertisements by airlines were ruled as preempted by the Deregulation Act.[6]

In American Airlines, Inc. v. Wolens, 513 U.S. 219 (1995), state consumer protection laws were ruled as preempted when applied to airline frequent flier programs.6  Similarly, in Northwest, Inc. v. Ginsberg, 572 U.S. __ (2014), state common law on good faith and fair dealing was preempted when applied to an airline loyalty program.[6]

In a case on preemption of state trucking laws, the US Supreme Court quotes Morales in explaining that a state statute will be federally preempted when it “produces the very effect that the federal law sought to avoid, namely, a state’s direct substitution of its own governmental commands for ‘competitive market forces’ in determining…the services that…carriers will provide.”[8] Federal regulations classify HAA companies as commercial air carriers [9,10] and as such, they fall under the protections of the 1978 Airline Deregulation Act.[11]  Thus, the Deregulation Act offers sweeping protection to HAA companies.

FAILED SOLUTIONS

Several states have felt the sting of the Deregulation Act’s preemption clause in their attempts to rein in the HAA industry. The following are state legislative and regulatory strategies that have failed due to preemption by the Deregulation Act.

Multiple courts have determined that states cannot require HAA companies to obtain certificates of need or other proof of public necessity before operating within a market.[3,12-14]  In 2015, a Florida man sought relief against HAA bills through the state’s Personal Injury Protection Statute, Deceptive and Unfair Trade Practices Act, and Consumer Collection and Practices Act. The court ruled that all of these laws were preempted by the Deregulation Act.[15]

In 2016, a North Dakota law that required HAA operators to form in-network contracts with the state’s commercial insurers before being listed on primary call lists and that required publication of HAA transport fees was struck down on the basis of preemption.[14] In that same case, a separate law that required HAA operators to accept state worker’s compensation fees and precluded balance billing to injured workers was struck down, again on the basis of federal preemption.[14]

Against this long track record of failures, what policy options do exist to combat excessive HAA bills?

PROPOSED SOLUTIONS

Rising HAA costs to patients and increased recognition of the Deregulation Act’s preemptive power have fueled recent efforts to address HAA issues. On a federal level, three separate bills in the current Congress focus on the HAA industry.

S.B. 471, the Isla Rose Life Flight Act, has been proposed by Senator Tester (MT) to amend the language of the 1978 Deregulation Act to explicitly exclude HAA operations from federal preemption protections.[16]

In a move supported by non-profit HAA carriers, Rep. Richard Hudson (NC) has proposed H.R. 3780, the Air Ambulance Quality and Accountability Act, which would establish minimum standards for HAA operators; would require HAA quality and price reporting; and would mandate the Medicare Payment Advisory Commission to use those quality and price data to inform adjustments in Medicare reimbursements for HAA transport.[17]

H.R. 3378, the Ensuring Access to Air Ambulance Services Act of 2017, proposed by Rep. Jackie Walorski (IN) and endorsed by for-profit HAA companies, would immediately increase Medicare reimbursement rates for HAA transport while mandating that companies report cost and limited quality metrics to create performance scores that would affect their reimbursement rates.[18]  EM physicians should familiarize themselves with these policy efforts and should contact their congressional officials to express their stances on the measures.

The fight against predatory HAA billing need not take place solely in the halls of Congress, however. EM physicians can take an active role on their next shift. They can call their local HAA companies to ask for pricing information; the HAA company should be willing to disclose an approximate range of fees.

They can scrupulously consider whether a patient truly warrants helicopter transport or could safely travel by ground. Whenever the need does arise to transport a patient by HAA, the physician can choose to preferentially call non-profit HAA groups over for-profit carriers, thereby potentially saving the patient tens of thousands of dollars. This choice may not always be an option if, for example, the local non-profit is already out on a call or is not flying due to weather. However, thousands of EM physicians across the country consistently calling non-profit companies will certainly capture the attention and perhaps influence the pricing models and corporate behavior of for-profit groups.

CONCLUSION

As emergency medicine physicians, we frequently must decide whether to fly patients: a multiply injured trauma victim, an unstable septic patient or a newborn requiring specialized care. In these moments of life-or-death decisions, we now must also consider whether by calling a helicopter air ambulance we will financially ruin our patients and their families. As a crucial link in the helicopter aeromedical transport system, our specialty has a duty to engage in policy discussions and efforts to ensure equitable and affordable air transport for medicine’s most critical patients.

REFERENCES
  1. Perry AE. Up in the air: inadequate regulation for emergency air ambulance transportation. Consumers Union, Health Policy Report, March 2017. PDF available at <<consumersunion.org>>.
  2. Government Accountability Office. Air Ambulance: data collection and transparency needed to enhance DOT oversight. GAO-17-637. July 2017.
  3. Government Accountability Office. Air Ambulance: effects of industry changes on services are unclear. GAO-10-907, September 2010.
  4. Rosato D. Air ambulances: taking patients for a ride. Consumer Reports, 06 April 2017. Accessed 22 Jun 2018 at <<consumerreports.org>>.
  5. Pollitz K. Surprise medical bills. Kaiser Family Foundation, 17 Mar 2016. Accessed 22 Jun 2018 at <<kff.org>>.
  6. Dempsey P. Federal preemption of state regulation of airline pricing, routes, and services: The Airline Deregulation Act. 10 FIU L. Rev., 435 (2015).
  7. USC Title 49, Subtitle VII, Part A, Subpart ii, Chapter 417, Subchapter I, Section 41713(b)(1). Accessed 22 Jun 2018 from <<uscode.house.gov>>.
  8. Rowe v. New Hampshire Motor Transp. Assn., 552 US 364 (2008).
  9. 14 CFR 119 Subpart B. Accessed 22 Jun 2018 from <<gpo.gov>>.
  10. 14 CFR 135 Subpart L. Accessed 22 Jun 2018 from <<gpo.gov>>.
  11. Med-Trans Corp. v. Benton, 581 F. Supp. 2d 721 (2008).
  12. Baptist Hosp., Inc. v. CJ Critical Care Transp. Sys. Of Fla., Inc., CV-07-900193 (Cir.Ct. Montgomery Cty., Ala., July 31, 2007).
  13. Rocky Mountain Holdings, LLC, v. Cates, 97-4165-CV-C-9 (W.D.Mo. Sept. 3, 1997).
  14. Valley Med Flight, Inc., v. Dwelle and Klipfel, US District Court ND, No. 1:15-CV-070, 2016.
  15. Bailey v. Rocky Mountain Holdings, LLC, 136 F.Supp.3d 1376 (2015).
  16. Tester J. S. 471: Isla Rose Life Flight Act. Available at <<congress.gov>>.
  17. Hudson R. H.R. 3780: Air Ambulance Quality and Accountability Act. Available at <<congress.gov>>.
  18. Walorski J. H.R. 3378: Ensuring Access to Air Ambulance Services Act of 2017. Available at <<congress.gov>>.

ABOUT THE AUTHORS

Dr. Schwartz is academic chief resident of emergency medicine at Dartmouth-Hitchcock Medical Center. With a background in health policy, he has previously worked on projects in firearm violence, sex education in schools, LGBT rights and workplace discrimination.

Dr. Trimarco is an emergency and EMS physician at Dartmouth-Hitchcock Medical Center and an assistant professor of medicine at the Geisel School of Medicine at Dartmouth. He is the associate medical director of the Dartmouth-Hitchcock Advanced Response Team (DHART) and is a regional EMS medical director for Vermont and New Hampshire.

5 Comments

  1. David P. Thomson, MS, MD, MPA on

    As an emergency physician who has been involved in helicopter air ambulance operations for about 30 years, I have some concerns about the policy for which you advocate.
    First, as an emergency physician, the issue of prohibiting out-of-network patients from receiving balance bills has implications for all physicians as well as for air ambulances. A prohibition such as this could create a situation where an insurance company can set an artificially low price for a service and the physician or other health care service provider would have no recourse but to accept whatever the insurance company decided to pay. Or the service provider could sign up to be in-network, but the insurance company has a massive advantage in that marketplace.
    Regarding calling the air ambulance service for pricing: Air ambulance service pricing is just like any other form of healthcare finance. There are too many twists and turns between the listed price and the charged price to allow for a discussion in real time. This is no different than a patient asking the emergency physician how much the head CT is going to cost. The answer is, “It depends.” That is why HR 3378 is good policy. Reporting cost and quality in a standardized, national setting will provide the information to answer the question of how much should this cost.
    Some of us can remember a time when the Airline Deregulation Act did not apply to air ambulances. There were situations where air ambulances were not allowed to cross state lines to pick up patients. The program in Sayre, PA, only a couple of miles south of the New York line, was prohibited from entering New York. Vermont physicians had concerns about allowing DHART from entering their state to care for patients. The case that applied the ADA to air ambulances was brought because a Kansas City, KS based program was not allowed into Missouri. Although some people have said that such prohibitions would never happen, the reality is that any policy that demands licensure is, on some level, a protectionist policy. If a state is given a choice between licensing the program in their state versus the program from an adjacent state, which will be successful?
    Representative Hudson’s bill would require the development of minimum standards The industry developed better than minimum standards over a quarter century ago in the form of CAMTS. If emergency physicians are concerned about their patients, they should insist on using accredited services.
    The tax status of an organization has little to do with their pricing structure. Whether it is called profit or operating margin, an organization has to produce revenue in excess of expenses in order to survive. Many of the not-for-profit air ambulance programs are hospital based. Like many other hospital-based services, hospitals cross-subsidize programs. Community based programs do not have that ability. While I do understand some of the bills from these organizations have appeared excessive, without the cost reporting it is impossible to understand the market and to know what an appropriate bill should be.
    One last consideration about for-profit and not-for-profit organizations. While many people portray not-for-profits as wearing a white hat, and for-profits as the dark side, there are very few physicians who are not profit takers.

  2. This is great. Totally agree HAA fees are beyond the pale. However with the nation’s largest EM physicians group, Envision Healthcare, going out of network with United Healthcare, and with ER’s increasingly using the “trauma” code in an effort to increase fees, there are a whole host of problem areas EM physicians should be addressing if they really cared about helping lower costs for ER patients.
    The for profit hospitals, provider groups and payer corporations are going to keep syphoning up profits as much as they can, until even the plutocratic, paid off politicians in DC wont be able to save them from the avalanche of the public’s ire and anger and the who system comes crashing down.

  3. Kevin Hutton, MD FACEP on

    Dr’s Trimarco and Schwartz,

    I have been at this EMS/ HEMS thing for 30+ years and am speaking based on billions of dollars in customer billing through my company. I rarely respond to such one sided and poorly informed publications, but I can’t let what you wrote stand without a reality test.

    What you wrote if you even were the sole authors is blatantly one-sided and frankly dangerous to patients and in the end hurts the US coverage of HEMS. Your not providing expertise in your article your repeating rhetoric from one side and its deceiving and may prove to be hurtful to the US coverage of HEMS.

    If you allowed someone to use you as a pulpit you need to refocus back on patients and not get pulled into politics. Very interesting the timing related to the legislation that recently rejected removing the ADA from FAA reauthorization something your article could not have known. If I had to guess you are unwittingly part of a grand communications plan funded by the insurance industry. Your article contains words and ways of saying things that are word for word the same as many recent press releases.

    Do you believe creating and fostering economic distrust with patients is in our industry’s best interest? Do you think calling your colleagues predatory is going to benefit the hospital-based market? Telling a physician to make a decision like this based on money is not the answer gentleman.

    Pricing transparency is already present publicly but is not typically part of informed consent and it should never be discussed when the patient can’t be informed and you are acting under implied consent. Do you let every patients you care for know the costs of every procedure you recommend in the ED? Do you tell them you will be billing them a level 5 plus critical care time, if you preform this test that they demand or do this procedure? Do you give them a cost vs. risk analysis (Including financial risk) before you throw that central line in using ultrasound guidance because it’s safer but costs more? Is pricing posted anywhere in the ED? Were you taught about pricing, charges, collections, allowable limits, coordination of insurance benefits in Medical School? Do you know what it costs a patient to “Open the Trauma Room”. This is not done in ED practice and it’s for good reasons which BTW also financially benefit a hospital. It’s inappropriate in an emergency situation most of the time to talk about money, so you believe in an emergency transfer its appropriate to tell a patient they don’t need an expensive air ambulance? Or worse here is a few to chose from based on price? Patient’s rarely have a choice, time pressure, ED flow, and health plan destination policy are all factors that argue against giving a patient a choice based on price and by the way advertising that you are undercharging to get Medicare business could be viewed as an inducement (Anti-kickback Violation) if the patient is choosing based on price.

    Why is finance not part of our medical education? There is a reason. Ethics aside making decisions for overt financial reasons is an invitation to get sued. Not saying there isn’t a place for shared decision making including financial risks when there is an informed choice which there often isn’t.

    Also the exorbitant (lobbyist word “exorbitant”, doctors use “large”) bills you speak of are not exclusive to For Profits. Medicare Charge data 2012 showed that a not for profit air medical provider was charging $65,000, 6 years ago! Hospital are also not immune to charging “exorbitant” amounts either, in fact its Standard Operating Procedure. Our customer studies shows average inpatient charges for an air medically received patient is 10- 12 times the charges of the transport. So do the math ~ $500,000 inpatient charges (collect $100, still devastating to a patient). The point is that ALL of healthcare charges more to collect a fraction, and it’s not only the air medical bill that is “exorbitant” or causing patients to declare Bankruptcy. It’s the “system” and its broken so don’t point fingers at others cuz 3 fingers point back at you. You are part of the system, and so am I.

    Before you call somebodies billing process “predatory” (which is clearly offending to me), you better understand billing, For example you don’t know what is and what is not a balance bill. For example, is it balance billing when you try and collect from a patient who was paid directly by an insurance company who uses “pay to patient” as a tactic to not pay the provider? Or to bill a patient who chose a catastrophic insurance plan with a $10,000 deductible so that they could even afford health insurance. Balance billing is the only tool a provider often has to get the patient to authorize provider insurance negotiation in a denial. Balance billing is part of the process, in some case to just find out if the patient has insurance. Insurance companies want to remove the lever that makes them pay usual an customary charges.

    What you are really talking about is hard vs soft collections. Hospitals, based on indirect revenue, can afford to give away services as charity and use soft collection techniques. They also receive reimbursement based on their charity care from the Government. This is not the case for private providers so do you blame them for having harder collection techniques and more rigid charity care polices.

    You also don’t understand how insurance company’s negotiate. It’s the insurance company that prevents contracting by demanding low contractual limits which do not allow cost shifting to cover the 70% of underpaying or non-paying. You are just repeating rhetoric unless you have done billing, and negotiated as a small provider. The insurance Industry is tired of paying too much for claims across the board. That why lobbyist and the news media is involved. I am not saying it doesn;’t need to change, but there is two types change, evolution and revolution, I am advocating a thoughtful evolution to maintain coverage and that means don’t allow insurance companies an ability to underpay.

    There is no insurance negotiation when all you have to offer an insurance company is air medical services, providers who thought they had negotiated a good deal soon find out they can’t survive. Hospitals wheel and deal and often “deal out” their air medical providers in insurance contracts because they receive 10-12 times this in inpatient revenue (indirect revenue). Translation insurance companies haven’t had to pay Hospital-based providers much in the past and they didn’t like it when we got smarter and went non-par. Sole providers have no power and depend on transport revenue only. Hospital CFO’s keep your program alive on indirect revenue. You bringing patients to their high paying service lines so they can afford to take less than cost, in fact it’s a great investment, but your labelled a loss leader! Sorry nobody does this for free, you are a conduit to bring patients to the hospital and as a conduit you are replaceable. Believe me I know took 6 weeks to close my program.

    You also don’t understand the ADA. Today Golden Hour complies with nearly a 70 versions of NEMSIS . It’s a state, county and territory managed SNAFU that has polluted the NEMSIS data making it barely useful, its also been very expensive for companies like Golden Hour to keep up with this unfounded mandate. Similarly the ADA prevents this untenable level of complexity, operational variability, uncertainty, and expense for air ambulances. We can’t afford more complexity. The data shows 25% of transports are interstate, we need the ADA to create one standard not many. The challenge to ADA is about insurance company control on pricing at the state level. Removing the ADA will not fix the problem it will make it worse. It will shrink coverage and cause program closure.

    Lastly you understand issues in your response area, you don’t have the big picture of national coverage in places tertiary care medical centers don’t place helicopters (outside their sphere of influence), but private providers will. We have the best coverage ever in the US, built on private equity investment, investments that individual hospitals would never have made. This coverage is what saves the most lives, not one program. Call private equity a deal with the financial devil if you want, but the deal was they grow it, invest in it, figure out how to make it efficient and profitable, and they make a profit. Not complicated and it’s the American way, capitalism.

    Our research in HEMS stroke coverage proves we have adequate US coverage. In over 25,000 patients we demonstrated that 98% reach tertiary care in 4 hours and they have a 2.5 hour symptom onset to transfer decision time window. Do you believe that hospital-based programs can ever match this national coverage in low volume but critical need places? This is the for-profit providers creating this coverage not the hospital-based programs. So unless you are thinking national coverage you are not helping the conversation that ultimately saves lives and reduces healthcare costs. In fact, if the profitability suddenly goes away the coverage goes away in many areas that are subsidized today and your program will not be immune.

    I got into this industry just like you and had the altruism challenged when my financially mismanaged program, UCSD Life Flight San Diego (3 AC, 16 years, 1500 pts a year) closed abruptly. All California hospital-based programs closed except for one soon thereafter, the hospital-based market is far from secure. The altruism lesson and what we as physicians should advocate for is NATIONAL COVERAGE not beat a competitive drum or allow our voice to be used against a sector of the industry that is willing to take the risk to increase the coverage when the sector you represent would not.

    The lobbyist playbook is simple and it’s the same playbook as a divorce attorney, get the parties divided, create a controversy, and bill as many hours until the run out of money.

    Doctors advocating for something they only partially understand is very dangerous gentleman.

    Kevin

    Kevin Hutton, MD FACEP
    CEO, Chairman Golden Hour/ EMS Charts
    Past Chairman MedEvac Foundation International
    Associate Clinical Professor, UCI
    Attending Physician, Catalina Island Medical Center (Critical Access Hospital)

  4. David Stuhlmiller, MD FACEP FAEMS CMTE on

    As an emergency, EMS, and air medical physician for nearly 20 years, I am disappointed to read this article that implies that air ambulances are the only healthcare entity with (the inflammatory), “predatory billing” as the article should acknowledge that each and every healthcare entity in our American healthcare system charges a much higher price than the cost of delivering care and ultimately collects a much lower amount from insurance payors than charged. For example, look at any itemized hospital bill for the charge for one acetaminophen pill. Every business must generate enough revenue to cover costs and stay in business and healthcare entities are no exception, regardless of whether their tax status is not-for-profit or for-profit.

    The article correctly notes that an air ambulance transport costs about $10,000 yet Medicare reimburses about $6,000. Medicaid is even lower. How then does the HAA service recoup the $4,000 shortfall for each and every Medicare patient transported and stay in business? If your local HAA service is affiliated with government then your taxes pay for the shortfall (perhaps even the entire operation) and if your HAA service is a hospital/hospital consortium/healthcare system-based HAA, the cardiothoracic surgery program, neurosurgery program, or other profitable service lines make up the loss. If you are an independent HAA service, often termed a community based program, then the shortfall must be covered by transporting patients with private insurance. Government monies and hospital monies are not available to community based HAA services. The problem then, is not that private HAA services charge too much; rather, the problem is that the reimbursement for 70% of HAA transports do not cover costs (lose money) so that the reimbursement for the other 30% must sustain the entire operation. The article notes that hospital-based HAA used to be the model but now, the majority of HAA in the United States are operated by three for-profit companies. Why? Many hospitals that used to own their own HAA service have turned the service over to the for-profit HAA services because these hospitals then still get the patients (that generate a lot of revenue for the hospital) without having to figure out how to cost shift to pay for the loss of operating their own HAA service.

    The problem that needs solving then is how to reimburse HAA services to retain this life-saving service in our country. Unlike physicians that practice inside a hospital within a state and do not cross state lines to treat their patients, HAA often crosses state lines to bring patients to the closest appropriate hospital. Critically ill or injured patients that live in rural areas often rely on HAA to bring them to the hospital and provide them the critical care they need and deserve during transport. And predominantly, only private HAA services have helicopter bases in rural America where no hospital is, or a critical access hospital is, so no hospital-based HAA would be willing to place a helicopter in such a rural area as it is outside of the catchment area for that hospital. These rural HAA services are truly part of the safety net of healthcare in our country and without them, millions of Americans would not have access to tertiary care centers or trauma centers when faced with a critical illness or injury and some would die trying to reach the hospital, “in time”. Removing HAA from the Airline Deregulation Act is not the answer. Carve HAA out of the ADA and these rural helicopter bases would be the first to close as the 50+ different reimbursement rules would provide insurance companies numerous different opportunities to deny reimbursement. The rural, low volume, small profit/operate-at-a-loss helicopter bases would be the first to close and rural Americans would suffer.

    The answer is also not to expect the emergency physician, or any other provider that requests HAA transport for that matter (critical care physician, surgeon in the OR, EMT, paramedic, etc.) to have the knowledge and time to have an informed discussion with the patient regarding the cost of different transport options, in the middle of that patient’s medical emergency. We (physicians) must make patient-centric decisions regarding what scope of care our patient needs during transport and which transport service provides that scope of care. Imagine that you are a patient with an abdominal aortic aneurysm at imminent risk of rupture. Are you truly able and willing to ask whether or not the vascular surgeon on call that is ready to care for you is in network or out-of-network? And know or be able to look up your insurance plan to learn how much more that would cost you out-of-pocket? Or perhaps even call the insurance company to get pre-approval for an out-of-network emergency operation (if the insurance company office is open to answer such a call)? Or instead, find out which vascular surgeon at the hospital is in network and find out if that doctor is available now to take care of you and if not available now, then how long until that doctor would be available? Then understand the risk-benefit of waiting to have the operation by an in-network surgeon, perhaps even discussing being transferred to another hospital because there is a surgeon at that other hospital that is in-network and then, having to find out if that surgeon is available and willing to take care of you, then checking with your insurance again to see if the ambulance transfer to the other hospital would be covered, and … your aneurysm just burst.

    The answer is H.R. 3378/S. 2121 which requires cost-reporting by all HAA providers, whether you denote them community based/hospital based, not-for-profit/for-profit, government/private, etc. and then requires Medicare to reset its fee structure based on the cost reporting. H.R. 3378/S. 2121 also requires submission of clinical quality measures and uses the concept of value based purchasing to provide a higher reimbursement to those HAA services that provide higher clinical quality. H.R. 3780 also requires cost reporting and clinical quality measure reporting but does not mandate a change in the Medicare fee structure; rather, it recommends a MEDPAC study of the issue which prohibits a timely response to bridge the gap between cost and Medicare reimbursement and further threatens the existence of the HAA safety-net.

    As an emergency physician, I think about the fact that my next critical, trying-to-die patient may very well survive because of the critical care provided during HAA transport to the hospital that can care for the patient.

  5. As a retrievalist for 17 years, a board certified emergency and EMS doc, and a HEMS medical director for 12 years (working for a not-for-profit hospital-based rotor wing and ground critical care transport medicine program), I personally know and respect Dr. Trimarco, as well as the three commenters above: Drs. Thompson, Hutton, and Stuhlmiller. (I do not personally know Dr. Schwartz.) There are just a couple of things I’d like to point out.

    Clearly, the issues at hand are quite complex. However, to suggest, as Dr. Hutton did in his comments above, that Dr. Trimarco lacks the expertise to qualify him to render an opinion on the current state of the financial side of American HEMS is quite unfair to Dr. Trimarco. He has extensive experience as a flight physician. He has completed an EMS Fellowship and is board certified in EMS. He has many years of experience as DHART’s associate medical director. He is a fellow member of AMPA, the Air Medical Physician Association, and has completed AMPA’s Core Curriculum, where he learned a great deal about the business of American HEMS from none other than Dr. Hutton himself, who knows more about HEMS / CCT billing than anybody on the planet. This is the background of a doctor who I’d say is extremely well qualified to render an opinion on the topic at hand. Just because Dr. Trimarco has reached different conclusions than the commenters above certainly does not mean he is unqualified or doesn’t understand the issues.

    Dr. Hutton brings up the idea that “the American Way, capitalism” works for HEMS. I am a proud American and financially I’m personally quite conservative. I fully believe that in almost every sector of the business world, capitalism is indeed a great thing that allows the cream to rise to the top. However, I fervently disagree that capitalism works for HEMS, for one reason: the person who calls the helicopter isn’t the person who gets the bill (and of course, it has to be that way). But capitalism wouldn’t work so well for the pizza industry if I could call Pizza Hut and order a $1000 medium pan supreme (that you probably didn’t want) and tell them to send it to *your* house and stick *you* with the bill. That’s essentially analagous to the situation in American HEMS at present.

    It seems that the commenters above believe that Drs. Trimarco and Schwartz were advocating that ER docs request HEMS pricing information in real time, at the point of the spear, at the moment when they need a helicopter for a critically ill patient. I don’t think that’s what they were saying. My read of the article is that they were advocating that ER docs learn as much as they can about pricing of the HEMS programs in their region ahead of time, so they’ll be armed with that information to better inform their decisions later when they find themselves in the heat of battle, working to save and transfer a crashing patient. I’d also add that ER docs additionally need to learn as much as they can about the clinical capabilities of the HEMS programs in their region ahead of time, because it’s unfair to our patients for us to labor under the misconception that “a helicopter’s a helicopter, a HEMS crew is a HEMS crew, and they’re all the same”. What’s the crew configuration? What diagnostic capabilities do you have? iStat / Epoc? Ultrasound? What procedural capabilities do you have? Do you carry blood products?

    I was surprised and relieved to learn from the comments above of the noble efforts of the for-profit sector of American HEMS to focus their efforts on super rural coverage that would otherwise be uncovered by not-for-profit hospital-based programs. That has not been my experience to date. I’m glad to know they will no longer be operating by the “Surround ’em and ground ’em” mantra, trying to put my program out of business by opening new bases in areas that my program is already serving at a world-class level, which we’ve done since 1984. (See http://www.adamsairmed.org/pubs/AMTC18_poster.pdf .)

    The “industry” of American HEMS is not built around putting the needs of critically ill patients first. Aviation and clinical quality are not properly incentivized, and I don’t believe HR 3378 goes nearly far enough to fix that. We’ve got a lot of work to do, folks.

    Sincerely,

    Bill Hinckley MD FAAEM CMTE
    Associate Professor of Emerg Med, University of Cincinnati
    Retrievalist and Air Medical Director, UC Health Air Care & Mobile Care
    Past President, Air Medical Physician Association
    ABEM Diplomate in EMS Medicine

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