Commercial, Public Service


By Douglas W. Nelms | February 1, 2005
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Accidents, Billing Top EMS Priorities

THE FACT THAT THE NUMBER OF EMS helicopter accidents is excessive is indisputable. Since 2000, EMS operations have averaged 13.2 accidents per year, with 2004 actually being the lowest year with only 11 accidents. What is in question is whether the rate of EMS accidents has increased, something that is now being heavily researched by the industry, the FAA and the U.S. National Transportation Safety Board.

Tom Judge, president of the Assn. of Air Medical Services and executive director of LifeFlight of Maine, said that while the number of accidents has gone up over the past seven to eight years, flight hours have gone up even more. "One of the dilemmas, and we are working with the FAA on this, is that it is hard to track the number of flights," he said. "But we do know that there are more helicopters involved in EMS than anyone had any idea. The number of flight hours and the number of persons being transported by aeromedical aircraft are up by a huge, huge number."


Over the past seven to eight years, reductions in specific services offered by hospital systems and the closure of individual hospitals have caused an increase in the number of patients who must be transported. This has led to an increase in the number of helicopter operations required to move those patients, Judge said. Prior to 2000, there were thought to be around 375 helicopters flying EMS missions in the United States. However, figures compiled in 2000 by the Air Medical Journal showed 570 or more helicopters to be involved in general EMS operations nationwide, with another 30 or so flying specific hospital-to-hospital routes, he said. Each helicopter carries 450-500 patients a year.

Judge said that the AAMS used the Advanced Data Management System database to determine the number of EMS operations nationwide, and is now tracking those operations. One problem, however, is that the FAA does not record accidents as specifically EMS. Rather, it lumps them together with all general aviation helicopter accidents.

The association's research is part of the efforts to quantify the cause of EMS accidents and then take the appropriate steps to reduce them. Those efforts include the creation more than four years ago of the Air Medical Safety Advisory Council, which got "the heads of aeromedical companies to sit down to discuss the issue of safety," Judge said. "A few years ago these people would not have sat down together." Aeromedical services is a very competitive market place, which Judge said makes participants reluctant to share information. "We have now gotten a commitment from the operators on safety programs so that we have got to take safety out of the competitive market place. Now they are having very frank discussions." Those discussions include federal partners--the FAA and NTSB. The Air Medical Safety Advisory Council was formed following the 2000 AAMS Safety Summit.

James Bothwell, president of STAT MedEvac, said that in the coming year the FAA is going to have to get more involved in resolving the safety issue.

While many EMS operators are adding new, more advanced technology aircraft to their fleets, "there are more and more people getting into the business that are operating 25-30-year-old, single-engine aircraft with terrible safety records," Bothwell said. "I'm not sure how we will fix that problem. I think it is going to come down to where the FAA is going to have to step in at some point and say that we are going to have to make some hard decision, that if we want to operate, we have to operate to a different standard than what is being done today. Unfortunately, I think it is going to have to be done on the part of the FAA. I don't think the industry will do it themselves."

One of the issues that will be heavily discussed by industry and government officials is a requirement for twin-engine helicopters for EMS operations. That would place a serious financial burden on some operators, possibly putting some out of business. A study conducted by the Air Medical Safety Advisory Council and published in 2002 showed that, in fact, a majority of EMS accidents involved twin-engine helicopters, flown by highly experienced pilots. A more recent report by AAMS showed that from 2000 through 2004, 40 of 66 accidents involved twin-engine helicopters. Only 26 involved single-engine helicopters.

Following the 2000 Safety Summit, the industry also formed the National EMS Operators Executive Forum, a collection of top executives, chaired by Larry Pietropaulo, president and COO of CJ Systems Aviation Group, and formed to address issues such as safety.

Other issues facing the EMS sector in the coming year include the increasing cost of fuel, insurance and equipment, as well as cost reimbursement, Judge said.

One of the biggest issues is cost reimbursement, or getting paid for services rendered, he said. There are actually three sub-issues within this area, with the first being the complexity of health care reimbursement. "We deal with literally hundreds of payer sources, all of whom have different rules," Judge said. "Many people don't look at their insurance policies closely, so you have variable coverage and complexity becomes a major issue."

The second sub-issue is the increasing number of people who either have no insurance or are under-insured, but who must be transported by helicopter either from the scene of an accident or from one hospital to another.

The third is the publicly perceived need to ratchet down health care spending, which leads to pressure to further pare reimbursements. Aeromedical services face a great deal of scrutiny, with questions often raised about whether a patient transport was medically necessary. Judge said the pressure is aggravated by disparities in incentives and disincentives in the health-care system. "There is no health care policy in this country," Judge said, "so in the absence of clear policy, there is a very different view of where the health care should be, then all of us as players within that system have to deal with those differences."

In turn, this is leading to a growing industry of billing experts, he said. "Hospitals are relying on that more, doctors are relying on that more. The rules are so complex and the paying sources are so diverse."

Bill Shipman, senior vice president of Baldwinsville, N.Y.-based MultiMed, said that regulations governing billing for health-related services, such as helicopter transport, are constantly changing. Knowledge of those new regulations is critical for billing either the hospital or patients, depending on how the EMS operation is set up, he said. "This is a rapidly growing business, with companies such as MultiMed hired to know those sort of things. We have to have [know] new regulations, how to deal with insurance companies and what is required for Medicare and Medicaid, such as getting signatures from patients to authorize payment to the helicopter company."

Historically, part of the problem has been that when hospitals have billed for and been responsible for EMS transport, they haven't done a very good job of it, Bothwell said. "Part of that is the size of the hospital billing in general. If you have a complicated trauma or cardiac case, there is a $50,000 hospital bill. Of that, a small portion, such as $5,000 for transport, gets lost in the shuffle. So historically hospitals have not done a good job collecting." Whereas if the EMS operator uses a program where transport costs are all that is being billed for, "there will be much more focus on the collection and they will spend much more time on the collection trying to get the maximum amount of dollars back."

With EMS companies such as STAT MedEvac planning major expansion, to include new equipment, during the coming year, collecting on billings is going to be a key industry issue for 2005, Bothwell said.

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