Deregulation and the EMS industry

[deadstick]

These articles make the rounds somewhat regularly. This is the first one I've read that included a reference to Deregulation.

http://www.msn.com/en-us/news/us/re...e-but-stunned-at-the-sky-high-bill/ar-BBjepH4

Using numbers in the company’s financial filings, Jonathan Hanlon, founder of Research 360, a firm that analyzes companies, calculated that Air Methods’ average bill in 2014 was $40,766, compared with roughly $17,262 five years earlier. A law that deregulated the airline industry in the 1970s has prevented states from capping the amount air ambulances can charge.

 

[BravoHotel]

 

[Rudabega]

It's a flying hospital, does that sound like it is cheap to operate?

 

[deadstick]

It's a flying hospital, does that sound like it is cheap to operate?

You're right. Each base has a pilot and 2-3 medical personnel in duty at all times with a mechanic a phone call away. It isn't cheap.

The issue really comes down to medical necessity, insurance reimbursement rates, and availability of other resources.

1) Many, many, many transfers are not necessary. My opinion (you all know he value of one of those) is that liability on the part of EMS companies (no longer a municipal service in many places) and rural doctors come into play. He first responders of today do not have the training and experience of John and Roy when they worked LA County. Also, as a private company, and this ties into the point on the MDs as well, there is a liability if they don't do everything possible to help somebody. "Doctor, why did you send this patient by ground when an aircraft was available? It's a 4 hr drive vs a 45 min flight." The scenario for the first responders would go something along the lines of the 'little bump' on the head leading to a dead patient. The ground companies don't want to try and defend that in court. If there's a doubt, get the aircraft. Another point, the medcrews of the air ambulance cannot say "this person does not need to fly" without jeopardizing their jobs.

2) The insurance company and the providers have to work something out, especially is there was a legitimate life/limb need. For the BS transfers, my opinion (see above) is that he referring MD or EMS company should shoulder that. They might do a better job of triaging patients if they have to stop shifting responsibility. FWIW, the last numbers I saw were Medicaid paid 10% and Medicare 30%.

3) In rural areas, there aren't EMS units available to transfer a patient 5+ hours away. An aircraft can get it done quicker, but I still have heartburn saddling a patient for a bill more than that of a ground unit.

I think this has all been said before. I just thought the Deregulation aspect was new and interesting.

 

[MoMatt]

General question for my education: If you looked at the industry as a whole, what percentage of EMS airlift operators:

A) Wholly own the operation (ie have operational control and a 135 certificate), including hiring and training pilots and MX and managing the aircraft, in addition to providing medical staff and equipment, or

B) Manage the medical side of things but contract out the aircraft and flight crew to a separate 135 company?

In my experience I see mostly B, but I live in a big city. I wonder what smaller towns with one hospital do if they have just one rotor or king air.

 

[deadstick]

There are several different versions or wats this can be set up. One thing is the certificate holder always has operational control of the flights.

The big, national operations, such as AirMethods, AMGH, PHI, usually have the aircraft, pilot, and medcrews. These are usually the community-based operations that service rural areas. Sometimes in metropolitan areas, they provide the lift (aircraft, mx, and pilot) for a hospital or some other medical organization. Many of those will have hospital employees as medcrews. Other times, the hospital will own the aircraft, put it on the operator's certificate, and supply the medcrews.

The worst example I've seen are the fixed-wing ops that have aircraft and pilots (24/7 call but that's another subject) who fly clapped-out ancient Lears and have a phone list of part-time medcrews who might fly 3 times a year as a moonlighting
gig.

 

[gotWXdagain]

1) Many, many, many transfers are not necessary. My opinion (you all know he value of one of those) is that liability on the part of EMS companies (no longer a municipal service in many places) and rural doctors come into play. He first responders of today do not have the training and experience of John and Roy when they worked LA County. Also, as a private company, and this ties into the point on the MDs as well, there is a liability if they don't do everything possible to help somebody. "Doctor, why did you send this patient by ground when an aircraft was available? It's a 4 hr drive vs a 45 min flight." The scenario for the first responders would go something along the lines of the 'little bump' on the head leading to a dead patient. The ground companies don't want to try and defend that in court. If there's a doubt, get the aircraft. Another point, the medcrews of the air ambulance cannot say "this person does not need to fly" without jeopardizing their jobs.

The first time a flight medic tells a doctor that they refuse to transport a patient out of lack of medical necessity is the last time that facility uses that transport service. I don't know much about running a business but I do know that having customers is a bit of a necessity.

 

[deadstick]

The first time a flight medic tells a doctor that they refuse to transport a patient out of lack of medical necessity is the last time that facility uses that transport service. I don't know much about running a business but I do know that having customers is a bit of a necessity.

That part was really directed at ground EMS scene calls. I kid you not: there are times that the patient is discharged from the ER before the EMS crew returns to base.

On the point of holding referring docs/services accountable, there are several interfacility transfers that are questionable. I believe the AStar crash in Missouri was one of them. Many of these transfers also seem to happen on a Friday afternoon or evening.

 

[gotWXdagain]

That part was really directed at ground EMS scene calls. I kid you not: there are times that the patient is discharged from the ER before the EMS crew returns to base.

In that case if it is determined the patient was "talked into" the ride, the ambulance service should not only be barred from billing the patient but also foot the ER bill.

 

[Boris Badenov]

deadstick is dead on. I worked on a children's hospital contract. Early on, got a call to go pick up in a smaller city about 2 1/2 hours away by car (or ground ambulance). The "kid" was 18 years old and WALKED ON TO THE AIRPLANE. The cherry on top is that I got the call because the rotor had turned it down.

The whole thing is totally out of control.

 

[deadstick]

In that case if it is determined the patient was "talked into" the ride, the ambulance service should not only be barred from billing the patient but also foot the ER bill.

It is out of control.

Extrapolating this earlier post ("Doctor, why did you send this patient by ground...") the medcrews and medical directors (docs who supervise medcrews and whose licenses medcrews practice under) would shoulder the same liability if they said "This person doesn't need to fly." The other aspect that needs to be addressed is tort reform.

If a healthcare professional makes a reasonable assessment of a patient, one that is in compliance with accepted standards of care, then there should be no liability. I'm not talking the quackery of a tv doc either. That's not reasonable. So IF that ever happens, the BS transfers might stop.

 

[NickH]

deadstick is dead on. I worked on a children's hospital contract. Early on, got a call to go pick up in a smaller city about 2 1/2 hours away by car (or ground ambulance). The "kid" was 18 years old and WALKED ON TO THE AIRPLANE. The cherry on top is that I got the call because the rotor had turned it down.

The whole thing is totally out of control.

A lot of this comes from the availability of resources. Sometimes there simply isn't ground transportation available for a six hour drive to the psych facility. My town has no ortho available, which means we fly every broken finger with compromised circulation.

 

[gotWXdagain]

A lot of this comes from the availability of resources. Sometimes there simply isn't ground transportation available for a six hour drive to the psych facility. My town has no ortho available, which means we fly every broken finger with compromised circulation.

And in rural areas having that higher level of care makes sense. I one time did a transport that from the time of the call to the time the patient entered the receiving facility was probably around 1.5x what it would have been had the patient been grounded to the receiving facility, BUT that patient needed a higher level of care during the transport and the fastest way to get that care was to have our medics up there. Additionally, many of the small towns up here only have one ambulance or even a few towns share an ambulance, and the closest facility may be 100 miles away. You can't put the one ambulance that covers the whole county out of service for four hours if there's an airplane or rotor that can do the job.

 

[deadstick]

I really enjoyed my time at a rural base. We definitely did some good, but some trips were just aggravating. On several occasions, the medcrew was venting that so-n-so (insert county EMS or a doc with a bad rep) just saddled this poor family with a huge bill because insurance was going to deny it or only pay a fraction of it.

The rural population (for the most part) are the ones least likely to be able to handle a $20k ambulance bill.

This article also pointed out s shortcoming of the membership programs. It only works if the patient is in the service area and IF that air ambulance company gets the call in the first place. Otherwise, the patient gets stuck with the balance.

 

[deadstick]

You can't put the one ambulance that covers the whole county out of service for four hours if there's an airplane or rotor that can do the job.

You're right, but should the patient get the bill that's 15-20x greater because of a service limitation? The patient cannot be refused transport based on the inability to pay, but maybe the operator in this instance shoul limited by what insurance pays.

Heck I don't know. I just think there's something wrong with that.

 

[gotWXdagain]

You're right, but should the patient get the bill that's 15-20x greater because of a service limitation? The patient cannot be refused transport based on the inability to pay, but maybe the operator in this instance shoul limited by what insurance pays.

Heck I don't know. I just think there's something wrong with that.

Patients should only be made to pay if they request a transfer that is not medically necessary. Ground, Air, or otherwise. But limiting the operator to what insurance pays without forcing insurance to actually cover the cost of the trip is a little bit of a one way ticket.

 

[deadstick]

Patients should only be made to pay if they request a transfer that is not medically necessary. Ground, Air, or otherwise.

In general I agree. Two things: 1) sometimes the referring doc and the insurance company disagree. 2) the patient might not be able to voice an objection.

But limiting the operator to what insurance pays without forcing insurance to actually cover the cost of the trip is a little bit of a one way ticket.

2) The insurance company and the providers have towork something out, especially is there was a legitimate life/limb need.

When I wrote the above point, I was referring to the insurance companies paying $5k on a $30k bill and denying the balance. Then the EMS provider goes after the patient and, as referenced in the article, possible put a lien on the family home. What's the point of insurance in that case?

 

[ppragman]

A lot of this comes from the availability of resources. Sometimes there simply isn't ground transportation available for a six hour drive to the psych facility. My town has no ortho available, which means we fly every broken finger with compromised circulation.

Yep. There's more to this than meets the eye. The other thing is the overall infrastructure required to maintain the EMS coverage we have across the country. If everyone is entitled to have air ambulance service, then don't be surprised when it's expensive to maintain a system that can put a helicopter within an hour of practically everywhere, and a fixed wing airplane for inter-facility transports. This stuff isn't free, we have an airplane, 3 pilots, two cars, a house that is rented out for transient crews and equipment, four full time med crewmembers, and one part-time med crewmember, and more at just my base. Not to mention the numerous bases we have with maintenance personnel, facilities, and more. This stuff costs a lot because we've taken the two most expensive and infrastructure intensive industries in America that I can think of and combined them.

 

[deadstick]

Back before the ACA went live, I wondered how it would impact the industry. @ppragman was right that it isn't cheap to maintain a base. With ACA, one provider figured things might be better because the number of no-pays would fe reduced. Right now the overall percentage of money collected/billed is relatively low. Of you were to take out the no-pays (everybody is covered now, right?) that percentage would go up....in theory. So that one bill this week that's $30k coveres the expenses for the 2 no-pays and Medicaide patient last week.

So, somebody has to file Ch 11 or get a lien palaced on their house. It is expensive to maintain, but it has to be fair, too. Again, the whole thing is messed up and needs an overhaul. How about we go back to MAST?

 

[gotWXdagain]

How about we just go single payer and be done with it?