In its latest response to the helicopter emergency medical services (HEMS) industry’s flight record, the National Transportation Safety Board (NTSB) has added a new arrow to its quiver. The agency has ventured into the public insurance reimbursement arena with the idea of using financial pressure to change industry culture. It has recommended tying operator reimbursement to an as-yet undefined standard of safety. The agency hopes to transmit a list of recommended components regarding proposed operator safety audit standards to the federal Medicare and Medicaid authorities before the end of October.
Although this list has not yet been voted on and released, public NTSB discussions in the past indicate that the board wants safety audit standards to include past and current HEMS safety recommendations, such as those on the agency’s Most Wanted List and new items among the 19 issued on Sept. 1, 2009. If the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) incorporate NTSB’s recommendations into their audit standards, the board’s approach could fast-track industry adoption of NTSB-advocated changes.
"We’re hoping to get a real jump on these issues," Joseph Kolly, the board’s acting director of Research and Engineering, told Rotor & Wing. In particular, he cited four items on the Most Wanted List addressed to the FAA:
Conducting all phases of flight under Part 135 — status, open/unacceptable;
Developing and implementing flight risk evaluation programs — open/unacceptable;
Requiring the installation of terrain awareness warning systems (TAWS) — open/unacceptable; and
Requiring formalized dispatch and flight following procedures — open/acceptable.
While the HEMS industry provides vital services, its safety record is not exemplary. In 2008, its worst year so far, there were eight fatal HEMS accidents and 29 fatalities.
The focus on reimbursement — although just a fraction of the Board’s Sept. 1 output — is a significant departure for the agency. "We typically stay close to home with various transportation agencies" and people directly connected to transportation systems, Kolly said. NTSB typically focuses on aircraft technologies, training, operators, manufacturers and regulators.
In looking at the HEMS industry more closely, however, the board found that "business practices may provide a disincentive to safety," Kolly said. He quoted language from a draft letter to CMS, stating that the NTSB is "concerned that current reimbursement practices may serve as a disincentive for HEMS operators who wish to operate at a high level of safety." Kolly suggested that Medicare/Medicaid currently "may not provide an adequate level of reimbursement" — that it may be too low. He added that "while the board does not ordinarily address the business models and reimbursement mechanisms of transport operators, [the] staff believes that for this [HEMS] aviation community these issues are relevant to safety."
What, if anything, comes of the idea of CMS safety audits will be interesting. NTSB wants to make safety audits in effect a precondition for federal reimbursement. In other words, if you want to be reimbursed, you have to meet a new standard of safety, as other press reports confirm.
There is a precedent for aviation safety audits, Kolly said. The U.S. Department of Defense (DoD) has requirements for commercial air carriers providing services for DoD personnel. These requirements, which exceed the minimum safety requirements specified by FAA "include, but are not limited to, minimum equipment requirements, pilot performance standards, operating procedures, training, maintenance, flight reviews and routine audits." Kolly explained that "the DoD conducts routine audits of approved air carrier providers to ensure they continue to meet these minimum safety standards." FAA has regulations governing both HEMS and civil aviation, Kolly added, "but we’re talking about a higher standard — that’s what this audit does."
The board also addressed the Federal Interagency Committee on Emergency Medical Services (FICEMS), asking this government body to develop national guidelines for the use of HEMS transport during emergency response planning and parallel guidance on how to select the appropriate mode of transport. Overreliance on helicopter transport has been an issue in high-profile crashes. According to a presentation by Robert Dodd, chief of the Safety Studies division of the NTSB’s Office of Research and Engineering, "Patients [are] often transported [by helicopter] who are not ill enough to justify HEMS transport." He identified competition, operators’ focus on increasing billable flights and poor decision-making protocols as factors in "over-triage."
The lion’s share of the NTSB’s recommendations on Sept. 1 went to the FAA. These predictably called for improved training and technology — data recorders, night vision imaging systems, autopilots and use of a publicly owned weather tool — as well as implementation of a safety management system (SMS) program, including risk management practices, and establishment of a structured flight data monitoring program. NTSB also asked FAA to require annual operator flight activity reports and to describe the requirements necessary for a low-altitude airspace infrastructure to improve HEMS operational safety.