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U.S. Air Ambulance Services May Have Too Many Overlapping Bases

By Frank Wolfe | July 16, 2019
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Air ambulance service is key to delivering quality emergency health care to rural residents in the United States, according to the Association of Air Medical Services, but some emergency room doctors and other medical personnel believe the U.S. has more air medical bases than it needs.

As of last September, there were 960 rotary wing air medical bases with 1,111 helicopters in the U.S., according to the Atlas and Database of Air Medical Services  (ADAMS) by AAMS and the Buffalo, N.Y.-based CUBRC.

Dr. Mike Abernethy, a flight physician with the University of Wisconsin Department of Emergency Medicine, has made the argument on his Twitter feed that the U.S. has 300 to 400 more air ambulance helicopters than needed and that he knows at least 30 examples of competing providers within 10 miles of each other, often at the same airport, “in areas which barely have enough business for one helicopter.”

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Abernethy also argued in a published paper that a proliferation of air ambulance bases began in 2002 when the Centers for Medicare and Medicaid Services (CMS)  established a significant increase in reimbursement to air ambulance providers for helicopter transport through a federal rule (67 FR 9100). He and others believe that regulators should require new air medical bases to obtain a "certificate of need" in order to open.

But AAMS said that there is no overcapacity issue in the air medical field.

"When people talk about a reduction of aircraft benefiting the patient, know that there is a rural healthcare crisis in this country right now that is only getting worse," AAMS said. "Many people can only access emergency healthcare by air ambulance and the number is growing larger every day. Right now, 85 million Americans can only reach a Level I or II Trauma Center by helicopter air ambulance. 90 percent of all helicopter air ambulance transports are trauma, stroke, heart attack, burn, high-risk neonatal/pediatric cases. If you cut bases, it will take significantly longer for those 90 percent high-risk patients to get the care they need to survive."

AAMS said that 32 air medical transport bases have closed this year and that the closure of rural hospitals over the last six years is worrisome.

The association pointed to an Apr. 17 letter from Jacksonville, Alabama, Mayor Johnny Smith to Seth Myers, the president of Missouri-based Air Evac Lifeteam.

Smith wrote Myers that the closure last year of Jacksonville-RMC Hospital "caused, and continues to cause, great concern among our first responders and our citizens," as the remaining area hospitals, Anniston RMC and Gadsden RMC, were only Level 3 trauma centers and were 20 to 30 minutes away from Jacksonville by ambulance.

Smith also cited the closure this spring of a Lifesaver air medical base in nearby Rainbow City and asked Myers to locate an Air Evac base in Jacksonville.

The closure of the Lifesaver base "is another huge hit for us, and we are now tasked with finding another way to air transport critical injuries or serious health related patients to Birmingham, our closest hospitals that are Level I and II Trauma Centers," Myers said.

Medicare and Medicaid and uninsured patients account for about 70 percent of air ambulance flights nationwide, while another 30 percent fall under some commercial insurance arrangement. But Medicare only covers about 60 percent of the $10,200 average air medical transport cost, while Medicaid only covers 34 percent, according to AAMS.

That situation has led to instances of exorbitant, so-called "balance billing," in which privately-insured patients receive a bill from their health care provider for the difference between the amount charged for air ambulance services — an amount that takes into account the significant deficits in Medicare and Medicaid payments to air ambulance providers — and the insurer's coverage for those services. Often the air ambulance provider is "out-of-network" for the given air ambulance patient, and the fees can be in the tens of thousands of dollars.

But air ambulance providers say that such amounts are on the "explanation of benefits" and are not bills and that they have been able to work with insurers and patients to reduce "balance billing" in some states, such as Wyoming where the average "balance bill" is $600, AAMS said.

The FAA Reauthorization Act of 2018, P.L. 115-254, directed the Secretary of Transportation to form an Advisory Committee for Transparency in the Air Ambulance Industry, in part to recommend steps that states should take to protect consumers, and AAMS has said that it "supports the establishment of the advisory committee and looks forward to working with its members to develop solutions that protect patients and preserve access to Emergency Air Medical Services."

Rick Sherlock, the CEO of AAMS, has said the advisory committee should finish its work before Congress passes any legislation on "balance billing."

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