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Although so-called surprise medical bills have become commonplace and routinely provoke outrage, even those numb to the staggering charges by hospitals are horrified by the avarice of many air ambulance companies.

Generating bills that can exceed $500,000, air ambulances are the giant squid of surprise bills that suffocate unsuspecting patients. One air ambulance bill sought $54,727 from a Bismarck, N.D., woman for a transport that would have taken less than one hour by ground, even after a ground ambulance had already arrived at the scene and had stabilized her. Her insurance paid for less than $14,000, leaving her with a $41,029 bill.

These staggering charges are caused by a confluence of market failures. First, as with all surprise bills, the price is hidden. When patients can’t shop for less-expensive alternatives, they are stuck with inflated prices. But hiding prices — and then allowing providers to charge outrageous amounts after service is provided — also fuels excessive supply, since many providers are eager to capitalize on the inflated profits.


Economists have long focused on the concept of moral hazard, in which demand increases because insurance pays for a large portion of the bill. The story of air ambulance bills illustrates the impact of moral hazard on suppliers, where both price and quantity of services are artificially inflated.

The investor community is already cashing in on these market distortions. Air ambulances are so wildly lucrative — their charges far exceed their costs — that private equity investors have fueled most acquisitions since 2011. Three for-profit providers now control two-thirds of all medical helicopters. And the effects of supplier moral hazard are bearing out, increasing both price and supply: The influx of investment has caused the U.S. air ambulance fleet to double in size in the past 15 years, and a Government Accountability Office report found that the median price for air ambulance services doubled from 2010 to 2014.


Simultaneous increases in both supply and price might befuddle economics majors, but it doesn’t astonish those familiar with surprise bills.

High and surprise air ambulance bills are the most recent iteration of a familiar problem. They emerge from the same billing strategy employed by hospitals and other providers, in which a provider cares for a patient in a setting in which public or private insurance does not predetermine the price for that service. Under such circumstances, usually arising from out-of-network care or care for the uninsured, providers claim they are entitled to charge whatever they want. They then point to their chargemaster — a master list of prices that providers unilaterally determine and that are routinely far higher than prices agreed to by commercial insurers and Medicare — and aim to collect the extortive amount from insurers or patients.

We and many others have written about the dangers of surprise bills. They are now widely understood to be a problem in need of a regulatory solution. The emergence of the especially egregious charges by air ambulances is a stark indication that policymakers have not yet solved this pervasive problem.

Air ambulances illustrate that the harm from surprise bills is not just high prices secretly charged to vulnerable patients. Prices are important for consumers, but they are also vitally important signals in a market, and economic harm results when charges cannot be readily compared to market prices. When market prices are absent or hidden, providers can charge whatever they want, and private equity follows the lucrative opportunity.

Inflated prices then fuel a feedback loop. High prices encourage providers to generate more output, so they invest in additional capacity — capacity that would not have been economically viable in the presence of market discipline. And they continue to do so until their marginal costs finally meet the elevated price they can charge.

This cycle of overinvestment reveals the dynamic costs of chargemaster strategies. For these reasons, society should worry when private equity invests in specific health care services with the kind of gusto it has invested in air ambulances. Private equity investment might be the flashlight that illuminates the health sector’s costliest distortions.

The cycle of overinvestment also reveals how health markets with overcapacity can dupe regulators. When policymakers eventually question the need for high prices, suppliers point to their costly investments and suggest that the service is not exceedingly profitable. Yet that is a false analysis: The marginal service would never have existed if managers had been forced to make investment decisions based on the establishment of a reasonable market price. Prices and costs after overcapacity reveal nothing about whether the market is working as it should. As a result, the price of services in a market distorted by chargemaster strategies should never be considered the market price.

Air ambulances offer two important lessons. The first is that hiding prices not only imposes enormous harm on consumers, but also inflicts real harm on the rest of the market. Hidden prices induce excessive investment from financiers and elevate costs by suppliers, producing markets that extract immense health care dollars while providing patients with very little value. We should not confuse profit with value, and we should be leery when investors exhibit noticeable enthusiasm for a certain health care service.

Second, effective solutions to the surprise bills problem require forcing price disclosure. Current efforts that merely prohibit the worst excesses, correct outrageous bills through arbitration, or pass these costs onto insurance companies (thus increasing health insurance premiums) will continue to mute the price signals that are necessary to harness the benefits of market forces.

Fortunately, the solution to stop surprise air ambulance bills is the same as the solution for stopping surprise bills throughout the health sector: require the disclosure of prices before services are provided, and if they aren’t disclosed, permit providers to collect no more than average market prices. This simple intervention, rooted in rudimentary contract law, would also correct the regulatory vacuum that air ambulance companies have claimed under the Airline Deregulation Act, which thus far has allowed them to escape regulatory curbs on their excesses.

If health care providers and air ambulance companies can collect only prices they have adequately disclosed — a simple constraint that the law applies fastidiously in all other industries — then normal market mechanisms can create market prices, reward managers for investment decisions that create real value, and protect consumers against naked abuses.

Kevin A. Schulman, M.D., is a professor of medicine at Stanford University. Barak Richman, J.D., is professor of law and business administration at Duke University. Arnold Milstein, M.D., is professor of medicine and director of the Clinical Excellence Research Center at Stanford University.

  • This is NOT a defense of the excessive charges in anyway. The Ambulance Services must pick up anyone who is ill or severely injured. Including Medicaid Recipients, the Average Medicaid Reimburse is only $1800 which has to be taken as full payment and recourse to patient. Deservedly so they are indignant and deserve services as well. Factor that the average Medicare reimbursement is only $6556 per ride for Seniors you can see their issue.
    Price gouging goes on in the entire Healthcare Industry for the exact reason you mentioned pricing is cloaked and negotiate rates with insures are NOT less in a lot cases.
    TRANSPARENCY will help but not fix.

  • This piece incorrectly placed the blame of air ambulance bills on the provider. What the authors failed to acknowledge is a broken system and the key market factors that contribute to balance billing and the legislative solutions being considered in Congress to address these underlying causes. They also failed to acknowledge the role private payors play in putting patients in the middle and inaction from Congress to address issues of inadequate Medicare coverage for emergency air medical services.
    More importantly, not only were the authors wrong in placing blame, they also failed to present a solution. We support the Ensuring Access to Air Ambulance Services Act, which would address cost transparency by accruing from air medical companies all the cost data to provide these life-saving services and subsequently, updating Medicare reimbursement rates to reflect the actual cost.
    The authors also didn’t acknowledge private insurers’ responsibility to cover patients in an emergency. Increasingly, insurers are denying claims for life-saving care – this is an issue that extends beyond air medical services, and includes emergency room visits, hospital stays, drug prices, and more. They essentially second guess physicians and medically-trained first responders by ignoring a medical professional’s decision regarding what is best for his or her patients by deeming certain care – like providing life-saving care during transport to the hospital via air ambulance – as medically unnecessary.
    It is important to understand that in medical emergencies – when time is of the essence – “shopping for less expensive alternatives” is not an option. If you or a loved one suddenly goes into cardiac arrest or is injured in a car accident, there isn’t time to do anything except ensure you receive the care you need as quickly as possible. Emergencies aren’t elective, and neither is an air ambulance deploying to the scene of an accident or a hospital. Air medical providers only go when they are called, dispatching only when a doctor or medically-trained first responder deems it medically necessary. The only priority is what is best for the patient and the patient’s health.
    The reason some patients get a balance bill is the result of a broken reimbursement system. Operating an air medical base ready to deploy 24 hours a day, seven days a week, 365 days a year is expensive. Yet 70 percent of those transported by air ambulance are covered by Medicare, Medicaid or have no insurance –these transports are reimbursed at less than 50% of actual costs. The Medicare reimbursement rates haven’t been updated in 20 years and cover only a fraction of the actual cost of care. This then results in cost shifting to the remaining 30% transports (those patients with private insurance) essentially paying for the entire system. It’s just not sustainable.
    Couple that with private insurers shirking their responsibility to adequately cover emergency health care, and patients are left in the middle. Air medical providers consistently are working to go in-network with private insurers, and with increasing success. But some insurers pursue narrow networks in an attempt to reduce their own costs and maintain their profit margins, leading to more and more patients receiving a surprise bill from out-of-network providers. Sometimes these insurers claim the transport was not medically necessary, despite being ordered by physicians or first responders.
    This is especially frustrating considering that a study done by a Montana legislature found that for only $1.70 more per month in insurance premiums, emergency air medical transportation could be reimbursed in full without burdening patients with large bills. A Kentucky study estimated that the increase in health insurance premiums would be between $0.92 and $3.69 per month.
    We agree that addressing patient costs of emergency health care is critical. The solution lies in addressing reimbursement shortfalls by both government-funded and private insurance. To start, Congress must pass the Ensuring Access to Air Ambulance Services Act, legislation that would update Medicare reimbursement rates, establish a mandatory quality reporting program, and improve transparency costs among providers, patients, and insurers. At the same time, private insurers must come to the table with emergency air medical providers to negotiate fair in network agreements and cover emergency health care when it counts.
    If we ignore this two-fold solution, access to these life-saving air medical services could be reduced altogether. That’s not a risk patients should be forced to take.

    • This rises to the level of inhuman financial Preditory behavior by investors seeking to inflict maximum financial injury to panicking and adrenlin impared family members desperate to save the life of a loved one. Shame on US congress members for not regulating this price setting monster and for accepting from their agents, lobbying perqusits and checks written to the “…campaign to reelect.”
      We need to prevent reelections with adjusted single terms as a ballot initative one state at a time and then bring civil if not criminal charges against all these private equity investors and their hedge fund perpetrators for commiting
      Hidden acts of asset confication against emotionally and adrenalin impared family members.

    • I agree the system as a whole needs an over haul especially when it comes to reimbursements for services. There is also a huge need for Air services but there is abuse in the system that also leads to these articles. I have a rural dedicated ground inter-facility ambulance service and have seen many issues. On scene is very different than an inter-facility transports especially because an actual diagnosis has been determined.

    • Lies!
      It is illegal to charge outrageous costs to people who pay for their insurance just to recoup said losses from people insured by a federal or State insurance program. Since when can a provider make you pay your bill and someone else’s?

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