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EMS–Heal Thyself

By Douglas W. Nelms | March 1, 2005
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The emergency medical services industry is preparing to answer a lot of questions regarding its accident record, with one of the biggest being "Just how bad is it?"

On the night of Jan. 10, a Lifenet EC135 crashed into the Potomac River near Washington, D.C., killing the pilot and paramedic. It was the third crash of an emergency medical services (EMS) helicopter, and the second fatal crash, since the new year began.

If the average for EMS helicopter accidents over the past five years holds up, there will be 10 more accidents by the end of the year, three of which will be fatal, according to records kept by the Assn. of Air Medical Services (AAMS).


While the odds were certainly against three EMS helicopter accidents within a two-week period, the accidents experienced during the opening days of 2005 exemplify the problem the EMS industry is facing in reducing the number of accidents and incidents. It is also somewhat ironic, since this is the supposed to be the year that the EMS industry really starts to get a grasp on an apparently out-of-control safety record.

And while the big question will be how to reduce the accident rate, there is also the question of exactly what the accident rate is--which is another issue facing the industry this year.

Actually, the number of helicopter EMS accidents has remained relatively constant over the past five years, ranging from 13 to 14 between 2000 and 2003, and dropping to 11 last year, according to AAMS. And since the industry is growing rapidly both in the number of hours and flight flown, that means the accident rate per hours or flights flown is dropping. But by how much?

At this point, no one seems to know. Since Denver's St. Anthony Hospital started the first EMS helicopter operation in 1972, the industry has grown to over 250 operators flying over 600 helicopters throughout the United States, with each helicopter carrying 450 to 500 patients per year, according to Tom Judge, executive director of Life Flight of Maine and AAMS president.

During that period, the industry has recorded almost 200 accidents. To find out how much the industry is growing--or, more specifically, to determine the number of flights and flight hours flown by EMS helicopters, the industry is turning to a number of information avenues. Judge said that the industry itself has started cooperating in providing information through formation of the Air Medical Safety Advisory Council. This council was formed in 2000 following an emergency meeting of EMS executives in Dallas to address the question of safety. While its ultimate goal is to increase safety, its method is to get the normally highly competitive industry executives to sit down and discuss the issue of safety on a non-competitive basis. "A few years ago these people would not have sat down together. We have now gotten a commitment from the operators on safety programs so that we have taken safety out of the competitive market place," he said.

The AAMS is also using Advanced Data Management System as a database to determine and track EMS flight operations nationwide.

"The problem with finding the accident rate is that we don't have good data," according to Lawrence Pietropaulo, president and CEO of CJ Systems Aviation Group, and chairman of the National EMS Operators Executive Forum, a collection of top EMS executives formed to address problems in the industry, such as safety. "Part of our industry initiatives is to get good flight hour data so we can determine the rate. We expect to start putting this all together early this year."

The FAA is also getting involved in the process through development of a task force to study the problem and develop possible remedies. On Jan. 14, the FAA held an industry meeting that included members from the NTSB, HAI, AAMS and National EMS Pilots Assn. (NEMSPA), as well as representatives from some of the larger EMS providers. In reporting on the meeting, HAI said that the "FAA is attempting to establish a partnership with industry that will significantly enhance safety without destroying the industry with economic burdens that have limited influence on reducing the accident rate." HAI also called on its smaller members to become involved in the FAA's task force, stating that one of the ingredients missing from the first FAA industry meeting "was the voice of the small operator." It said the small operators should not "make the big operators do all the heavy lifting" in the program.

Ron Fergie, president of NEMSPA and chief pilot for Portneuf Life Flight in Pocatello, Idaho, said that there is not going to be a single "silver bullet" that will resolve the problem of accidents, but rather a combination of things such as night-vision-goggles, terrain avoidance warning systems, new IFR rules and revised minimums. "But night-vision-goggles will be a big help and the FAA has made some moves toward making that an easier process." As for minimums, Fergie said that NEMSPA is looking at more restrictive minimums, "and maybe even regionalizing them. You may be able to take off with 1,000 and one (1,000 ft. and a mile visibility) or 800 and two in Kansas, but if you do it here in the Rockies, it's not too smart. We fly in the mountains, so it is absolutely not smart."

He also emphasized the need for greater training in cockpit resource management, in which all members of the crew have a voice in the operation of the mission. "In our program, any crew member can cancel a mission. We call it the `This is stupid' rule. The plan is to determine while still on the ground whether a mission is stupid or not. But if we're in the air, anybody who is uncomfortable either with the mission or anything going on in the mission, can say `Hey, I'm not comfortable with this mission, let's not go.' And there is no arguing with it. The pilot can say that he feels the mission is safe and can meet the requirements, but it's not an argument, he's just explaining his thoughts. If the crewmember still says `No,' then there is no question. We turn around and go home, or we land the aircraft." Fergie added that "there are a lot of programs like that. It's not just here."

Another question facing the industry is whether or not to mandate twin-engine helicopters for U.S. EMS operations. Virtually all European EMS operators use twin-engine helicopters because they required are by law. However, a study of AAMS statistics shows that in the United States, the greater percentages of accidents involve twin-engine aircraft. According to AAMS figures, over the past five years, to include the three accidents this year, twin-engine helicopters have accounted for 42 accidents while singles have had 25. This is apparently based on the law of averages since there are more twin-engine EMS helicopters than single-engine--although the exact number of each type is still being determined.


While the majority of the accidents have involved "pilot error"--albeit highly experienced pilots being put into hazardous situations--there is a general feeling that new equipment and technology will have a major impact on the reduction of accidents, particularly night-vision-goggles and GPS. Both Bell and American Eurocopter offer NVG courses, more aircraft are being certified for NVG-equipped cockpit and more EMS pilots are being trained in NVG operations, Fergie said.

Most of the large EMS helicopter providers, such as CJ Systems Aviation Group and STAT MedEvac, are ordering new helicopters for the coming year, both as replacements for older equipment and for increased operations.

Pietropaulo said his company has expanded "significantly" over the past 10 years, "and certainly over the past five" at around 20 percent per year. CJ Systems currently has 106 helicopters with an additional 10 on order for 2005. Of the new aircraft, about three will be replacement aircraft and seven will be to grow the fleet. "We are presently trying to modernize our fleet," he said. "I hope to get rid of three to five older helicopters this year. Plus customers are buying some new helicopters to replace their older models."

Not all EMS providers are moving into newer, high technology equipment, however. STAT MedEvac President James Bothwell said that while program such as theirs are "investing in all the new technology in attempting to improve the safety associated with the program, at the same time there are more and more people getting into the business that are operating 25-30 year old single-engine aircraft with terrible safety records." He said that STAT MedEvac currently is planning to add four new aircraft to its fleet of Eurocopter helicopters during 2005, giving it a total of 25 by the end of the year. "I can also see us putting on three to four helicopter basis in the coming year or two.

Honeywell, in its 2004 survey of the helicopter industry, said that the two leading industries for new helicopter purchases are corporate and EMS, although EMS applications fell to 19 percent of total demand from 27 percent in the 2003 survey. "Almost all demand for EMS helicopters is in North America and Europe," the report said.

Both Bell Helicopter and American Eurocopter, the two largest manufacturers of EMS helicopters, have reported increasing sales both as replacement and new aircraft for the EMS industry. Terri Ragsdale, EMS marketing specialist for American Eurocopter, said that 2004 showed "a significant increase in EMS market sales" and that the growth of EMS business "will continue over the course of the next several years, not only as new programs start, but as aging aircraft are replaced."

Sandra Kinkade, Bell's EMS marketing manager, said that fleet replacement is, in fact, one of the big driving factors. "There are a lot of old aircraft out there and EMS companies are starting to look at replacing older models."

Ragsdale said that while the AS350 "has always been and continues to be a constant in the market as a single-engine model," there has been significant growth and interest in the twin-engine EC135 and EC145. Popularity of the EC135 comes from its cost efficiency for a light twin, while the EC145's popularity is based on its similarity "to the ever-popular BK117," she said. "Many of the BK117s are being upgraded to the 135 or 145. Currently the 135 has been the most popular replacement, but because the 145 is a new aircraft, I think we'll start to see its popularity increase as well. The BK117s are not necessarily being displaced, but perhaps they are being replaced by newer aircraft and then either being put in another location or being refurbished and placed into programs that are not at this point desiring to purchase a new aircraft."

Kinkade said that the primary Bell products being replaced are the 412s, 222s and 230s, "plus some of the older 206s." However, the replacements range from "exactly the same aircraft to maybe a smaller aircraft, with some operators downsizing a bit." She added that the 206B and L are still very popular, and that Bell sold out the 206 line for 2004 and is backlogged for 2005. "We had to increase production last year because the LongRanger is still very popular."

With economics and efficiency of operations being another major issue for the industry, many operators are downsizing to light twins or single-engine helicopters. "In the United States, it is really single and light twins that have the predominant growth in purchases that we see, although elsewhere in the world it's really the light twins," Kinkade said. "In Europe, it's all light twins. Asia will probably be very similar in some parts, although some parts of Asia may allow the singles."

One of the impacts on downsizing actually occurred back in 1988 or 89, "when Medicare did their negotiated rule making and determined that there would be one piece of the pie for EMS in general, ground and air," Kinkade said. "They carved out a portion for air, so that for every patient, air transport gets X amount of dollars. So it doesn't matter what size aircraft you are flying, you are going to get paid the same amount. That forced a lot of programs to take a hard look at what they had and how to best utilize their resources."

The growth of the helicopter EMS industry results from a combination of things, not the least of which is the decline in numbers of hospitals in the United States, requiring greater distances for patient transportation. According to the American Hospital Association, there were 6,965 hospitals in the United States in 1980. That number decreased to 6,649 by 1990 and 5,810 by 2000. In 2003 there were only 5,764. This is at a time when hospitals are seeing an increase in patients. According statistics from the AHA, latest figures from 2003 showed an 11.6 percent increase in emergency admissions, normally the type using helicopter transportation.

The rise in single service providers, such as surgical hospitals or cardiology centers, is increasing the number of patients to be transported between hospitals. There has also been a growth in physician-owned surgical hospitals over the past few years. AHA said while these did not have a lower cost per patient, they were highly profitable "because the physician owners quickly shifted their patients to the facilities and focus on well-reimbursed services and patients in good overall health, did not operate an emergency department, avoided certain payers and concentrated on elective surgeries." Unfortunately, according to a South Dakota study, the side-effects of the physician-owned surgical hospitals were that "the region experienced problems accessing emergency and trauma services, and increased cost and use of certain services. Full-service hospitals were less able to subsidize services to meet the broader health needs of the community, including services to outlying areas and low-income populations." A Medicare Payment Advisory Commission study of these physician-owned specialty hospitals said that they "more frequently transfer high-cost and sicker patients to other facilities."

The AHA report, issued last October, also reported that "hospitals' financial health remained fragile, with roughly one-third of America's hospitals operating in the red." This lack of financial health by the nations' hospitals is shifting the emphasis from the traditional, or hospital-based, operations in which the hospital pays the helicopter operator for its services, to independent, or community-based, operations where the helicopter is totally owned and operated by an independent company and located at a centralized point, such as a local airport, in order to serve a geographic region rather than a specific hospital.

Pietropaulo said that while the movement is toward independent operations, his business is still about 75 percent traditional. Of that 75 percent, about 25 percent of the hospitals own their own assets "because they feel they get lower cost in capital, they like the residuals of those helicopters, so we just manage the helicopter (operation)," he said.

However, "the independent, or community-based model, is where the growth is," he said. "Hospitals have been going through a changing economic environment probably for the past 10 years of so. They used to be able to charge what they wanted. Then they got into managed care that keeps their costs under control. So some of them have had to consolidate, hospital systems have sprung up and they need a system of transportation. For instance, in Pittsburgh there is a big hospital system owned by the University of Pittsburgh Medical Center. They have affiliations, so if you have a problem, whether a medical problem or some type of trauma and you're out at a distance, say 50 miles from Pittsburgh, they need to get you into their Center of Excellence, so they transport you in for specific care. That is the systems approach. That has helped the utilization of helicopters. The whole system has done that."

Bothwell said that one of the problems with aeromedical programs is trying to operate with a small margin of profitability. "Years ago, many hospitals were willing to run a helicopter program at a loss, thinking that while they would lose X numbers of dollars on the helicopter programs, they were putting paying customers into the hospital and could make up the difference on the incremental revenue. But now there has been more and more pressure in recent years for helicopter programs to be financially self-sufficient and stand on their own."

Bothwell said that STAT MedEvac runs both traditional and independent operations, with six hospitals in the Pittsburgh region that support his operation, but that operations in Maryland, Ohio and other parts of Pennsylvania are totally independent. "So we have to operate each of those areas with a profit margin. That is the challenge for us." He said STAT MedEvac would have 21 helicopters by the end of 2004 and expected to increase that to 25 by the end of 2005. It will also likely add three to four helicopter bases to its operations within the next year or two, he said.

With the changes going on the American's hospitals today, one of the biggest issues now facing the helicopter EMS industry is the question of where, exactly, the industry is going. A major question being raised, and one that will be a focus of the 2005 Air Medical Transport Conference this coming October in Austin, Texas, will be the role of medical practices outside the confines of hospitals, Judge said. "We are starting to see, even from the legal system, a recognition that care outside the confines of a hospital has become a sub-sector of medicine in itself. So one of the things we will see more of in 2005 is research. It is important for critical care, for cost benefits and for safety, and it is important in the regulatory system. (The need) is having good, reliable scientifically based information. You can't have policy without that. You can't have regulations. There will be a lot of work going on there."

Another major issue facing the industry is how is it going to pay for an increasing demand for investment. Judge noted that "clearly, aeromedicine is playing an increasing role in the delivery of health care and the access to health care, especially in rural America. So on one hand there is a demand from the public and within the health care community that we build a system that can lead to all those things and improve the access to rural areas. We have a huge demand that we keep the system intact. We can't take a heart specialty center and put it in every town, but we want access immediately available, so there is a huge investment (requirement). On the other hand, there is a tremendous amount of uncertainty of what the structure of the health care system is going to look like. So we have a need for investment in equipment and technology, but with a huge amount of uncertainty because of the financial climate and rapidly escalating insurance costs. So we are in the balancing of uncertainty of reimbursement, yet increasing demand and need for new investments. Where that is going to come from is a huge question. Getting paid for what we do is a huge issue."

The simple act of getting paid for services rendered is perhaps nowhere more complex than in the EMS industry. "We deal with literally hundreds of payer sources, all of whom have different rules," Judge said. Add to that the number of people carried who either are under-insured or have no insurance, and the problem of reimbursement becomes acute.

As a result, more helicopter EMS providers are turning to a growing number of companies created for the sole purpose of collecting money owed. William Shipman, senior vice president of MultiMed, said that the rules governing billing for health related services are changing constantly. The Baldwinsville, N.Y.-based company specializes in billing for medical transportation. "We have to have knowledge of the new regulations, know how to deal with insurance companies and know what is required for Medicare and Medicaid," he said. That includes just getting the appropriate signatures on the appropriate forms to get the operators paid.

"With the problems of reimbursement, you are going to see a growing industry of the billing experts," Judge 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.

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