On the night after Christmas 2013, as Whitney Corby was driving to the gym in Corning, N.Y., the University at Albany lacrosse player’s car hit black ice and smashed into a tree. The crew who arrived at the scene knew they couldn’t treat Whitney and that she was running out of time. They called the closest air medical provider, Guthrie Air from Sayre, Pa., and drove Whitney to a nearby school football field where the helicopter could land with the critical care team. They flew her to the closest Level 2 trauma hospital, which was back in Pennsylvania, to treat her fractured skull, traumatic brain injury, broken collarbone, and more.
Corby’s story isn’t unique. Air medical providers fly approximately 375,000 patients each year. Ninety percent of those patients are transported because they have suffered a serious cardiac event, stroke, or other trauma. Many of those flights cross state boundaries to take patients to the closest, most appropriate hospital. In many rural communities across the country, hospital closures have decreased access to emergency care and essential medical services, requiring rapid transport by air over longer distances, and in many cases across state lines, to larger hospitals.
Private insurers are now putting patients helped by air medical transport in the middle of payment issues. Not only are insurers limiting which air medical companies are in their provider networks, and therefore affecting whether the transport is covered, they are also limiting the amount they will pay for the cost of the emergency transportation and the treatment received on board. That means patients needing air transport are often left with unpaid bills in spite of paying monthly premiums for health care coverage.
To make matters worse, Medicare and Medicaid payments for air transport are low — sometimes as low as half of what it costs — in part because the Centers for Medicare and Medicaid Services hasn’t evaluated what it pays for air medical transport in nearly 20 years. Seventy percent of patients’ bills for air medical transport are paid at the Medicare rate or less. In some cases, private insurers base their rates on a percentage of what Medicare pays.
Congress could help fix a big part of the problem by passing the Ensuring Access to Air Ambulance Services Act. This bipartisan legislation would require all air medical transport providers to submit their costs for transport to CMS so it can update its reimbursement schedule based on the actual cost of care today, not 20 years ago. This will go a long way toward preserving access to air medical services that provide not only emergency care but also timely access to our nation’s emergency health care systems for those whose life depends on this care.
A different proposal, this one contained in the Federal Aviation Administration Reauthorization Act of 2018, would have a devastating impact on access to air medical services. Section 412(h) of this act would allow each state to regulate air medical services according to arbitrary state- or even county-level preferences. The net effect would be a crazy quilt of regulations that would essentially create borders in the sky and make it more difficult for emergency air medical providers to get patients to the best, closest medical facility.
If this section passed, an air ambulance based in Maryland that picks up a patient in Virginia and delivers her to a hospital in Washington, D.C., would be subject to different laws and regulations in three different jurisdictions. Those regulations could affect everything from the equipment on these aircraft to how the aircraft are operated, where control centers are located, and the medical staff on board.
When Congress enacted the Airline Deregulation Act in 1978, one of the primary purposes was to encourage expansion of the air transportation industry by exempting air carriers from overly burdensome and disparate regulations by the states. Air medical services were part of the discussion as lawmakers considered the broad impact of this change to federal oversight of the aviation industry.
Among other provisions, the Airline Deregulation Act says that a state “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.” This allows air ambulance companies to provide lifesaving services and make decisions based on what is in the best interest of the patient, rather than on arbitrary state, county, or municipal boundaries.
By their very nature, air ambulances operate on an interstate basis. Every day they transport more than 30 percent of their patients across state lines for definitive care. Exempting air medical services from the deregulation act would drastically change the way the air medical transport system works, and not for the better.
Section 412(h) also requires air medical services to split their charges into two categories: aviation related and non-aviation-related charges. This would allow insurers to further limit coverage for the emergency medical transportation that uses highly specialized medical helicopters, state-of-the-art medical equipment, and very experienced pilots and focus only on the “allowable treatment” provided on board. While that would lower insurance company payments, it would leave patients with a bigger portion of the bill.
Although Section 412(h) is supposed to be aimed at protecting patients from onerous charges, it does absolutely nothing to lower the bills that patients get for air medical transport. In addition to eroding uniform federal oversight of the aviation industry, it is likely to create a more complicated payment structure that will benefit health insurance companies at the expense of patients.
If the intent of Congress is to address the issues of access to emergency care and cost of air medical services, then it must address the root cause of the problem — vast under-reimbursement by Medicare — by passing the Ensuring Access to Air Ambulance Services Act and eliminating Section 412(h) of the FAA Reauthorization Act.
Richard Sherlock is the president and CEO of the Association of Air Medical Services.