Recent reports of exorbitant healthcare bills for air medical transport services—often levied on individual families—have called into question the role of air transport in select clinical cases, as well as the motives of insurance companies and air ambulance providers.
But while it’s a system often criticized, for some advocates, helicopter EMS (HEMS) fulfills a necessary role that simply cannot be filled by ground transport operations. According to the Association of Air Medical Services (AAMS), due to the continuing closures of rural hospitals, 85 million Americans now live more than an hour from the closest Level I or Level II trauma center, requiring critically ill and injured patients to be transported over much longer distances with ICU levels of care. This makes emergency air medical services the only access to definitive health treatments, AAMS says.
“Sustainability of HEMS is very personal to me,” says Kevin Hutton, MD, a veteran flight physician, past board member of the Air Medical Physician Association (AMPA), past secretary of AAMS, and past chair of the MedEvac Foundation International, a Washington, D.C.-based nonprofit that supports research, education, and outreach programs in the air medical transportation arena. Having practiced in centers as diverse as critical access hospitals and village clinics in the Bahamas, Hutton has a unique perspective on air ambulance utilization.
“There are areas in our own country where a pickup truck and a well-meaning volunteer responder is still considered EMS, and ground capability for critical care transports simply isn’t there,” says Hutton. “You’ll never be able to replicate what an air service can offer in these super-rural locations." His data shows that even urban systems rely on air ambulances due to traffic congestion, hospital overcapacity, specialist preference, and the lack of appropriate ground transport.
Hutton is CEO and founder of Golden Hour Data Systems, a San Diego, Calif.-based information system and revenue cycle management company that supports emergency medical transport operations and financial management.
“I’ve been keenly interested in data sharing since the early 1990s,” says Hutton, adding that Golden Hour has a contractual data-sharing arrangement with customers that allows the company to aggregate data sets. Through the company's affiliated Air Medical Research Institute, Hutton’s team is busy looking at a wide range of diagnoses, patient demographics, locations, and more to capture a picture of air emergency operations in the United States.
Stroke—Air medical services are frequently employed to transport patients rapidly from remote scenes to primary stroke centers (PSCs). But how common is it? The Air Medical Research Institute aggregated deidentified patient data from 67 U.S. air medical service providers from 2004–2011. They found a total of 25,332 patients were transported for the primary condition of stroke, and that air transports are becoming more common. The incidence of stroke-related transport increased from 1.4% to 3.9% during the study, performed during the time that primary stroke centers were being accredited across the United States.
A total of 96% of transports arrived at definitive care within two hours via HEMS. While 72% of transports were interfacility, 58% were from rural or super-rural localities, meaning 42% of transports originated in urban areas. The authors’ conclusion was that HEMS has increased access to stroke care for super-rural, rural, and urban communities, offering timely transport within the treatment window if symptoms are recognized within 2.5 hours of onset. Results of the analysis were published in the Jan.–Feb. 2016 issue of Air Medical Journal.
Spinal cord injury—Spinal cord injury is another time-dependent diagnosis Hutton’s team was interested in examining. The descriptive study examined deidentified data of HEMS providers from 34 states from 2004–2011. Of almost 7,000 SCI patients transported, the average patient was 21 years old, male, and had a 63-minute total transport time. Of all SCI transports, 42% were classified as urban, 36% rural, and 22% were super-rural.
Of all SCI transports in the study, 69% arrived at definitive care within one hour of dispatch request, while over 96% arrived within two hours. “HEMS’ ability to identify this subgroup of patients and move them to regional SCI centers early will be cost-effective in the future, because of patients' age and the ability to reduce the societal cost of SCI,” concluded the authors. "[This] demonstrates the high level of accuracy in the triage of these patients to trauma centers, and the lack of specialty care in many areas makes HEMS a health system necessity."
Cardiac arrest—Hutton's group is nearing completion on a large examination of over 10,000 cardiac arrest calls in rural, super-rural, and urban areas, both scene responses and interfacility transports. Areas of scrutiny will include demographics, transport, logistics, and regionalization of postarrest care.
Hutton acknowledges the current reimbursement structure fueling the industry is in dire need of overhaul. According to AAMS, current Medicare rates are outdated and not connected to actual cost data. For every 10 patients flown, five are on government insurance such as Medicare and Medicaid, neither of which pay close to the cost of an average transport, and two pay nothing at all, according to AAMS. Seven out of 10 air medical transports are un- or underinsured, the association says. "Healthcare charges in the U.S. have escalated for the insured population because the government still pays the same amount they did 30 years ago," Hutton says. “The business is structured wrong financially. The problem is that 80% of the bills are paid by 30% of the patients. So you have 100,000 people paying for the availability of HEMS for 330 million people."
Instead of the current structure, Hutton favors hybrid funding via multiple sources, as practiced in other HEMS models around the world. “True sustainability means balancing the financial mission with the clinical mission,” he says.
Sidebar: Traumatic Injury Leads All Air Medical Transports
ESO, a Texas-based provider of software for fire and EMS agencies, examined transport data from January 1 through July 9, 2018. Of roughly 3.8 million records in its repository for that time period, 2,795 were for transfers through the air—less than 1% of their patient records. Diagnoses included:
59% traumatic injuries
16% stroke/acute neurologic emergency
8% cardiac (heart attack, dysrhythmias)
17% “other” (no specific complaint)
Jonathan Bassett is editorial director of EMS World. Reach him at firstname.lastname@example.org.