The Airline Deregulation Act of 1978 has found mention far too many times recently. Every attempt by insurance commissioners and insurance industry has been successfully countered by the air ambulance transport industry, thanks to this act. At the outset, the act itself seems arbitrary considering it takes away the power to control prices by the democratically elected state governments. Then why was this bill introduced in the first place? This is the question that comes to mind often. It was originally passed so that competition can be encouraged. However, it is questionable whether this intent is still being served in the current industry context as prices are simply shooting up. In an ideal competitive world, the prices must be well controlled.
FAA Reauthorization Act of 2018
It must be noted that only the Federal Government can make changes to the existing ADA of 1978. Considering the growing voices against the act, the government enacted FAA Reauthorization 2018. While some were hopeful that it will make drastic changes to the exiting act, it was not to be. The new act limited itself to making provisions to appoint an advisory committee to take a closer look at the air ambulance transport industry and the financial burden on the patients. It has no powers to implement any changes and is limited to offering advice only.
Balance Billing and Air Ambulance Transport Industry
Balance billing continues to be a problem. The healthcare insurance industry, it looks like, refuses to change its reimbursement model for the air ambulance transport industry. It has remained unchanged for over two decades now. On the other hand, medical flight companies are refusing to conform to the prevailing reimbursement rates and adamant against going under insurance networks. The result: balance bills that are not covered by insurance are being thrust upon the patients and they are being compelled to foot bills that amount to thousands of dollars. A solution does not seem at sight, at least at this juncture.
Of course, it all begins with the aircraft model that a medical flight company purchases. Each aircraft is different in some way or the other. However, once the purchase is made, there are certain aspects that one must consider to ensure that the medical flight is fit and convenient enough to provide the healthcare that is expected of it. Here, we discuss a few of those in some detail.
The Floor of the Medical Flight
The floor is a very critical part of the medical flight. It must be such that the in-flight as well as maintenance crew must be able to clean it efficiently and quickly. The emergencies that come a medical flight’s way can involve a lot of blood and other elements, which need to be cleaned out as quickly as possible to maintain hygiene. This might necessitate floor drains and the design must be such that modifications like these can be easily made. Also, the floor can see a lot of heavy equipment which is often moved with little care for the floor itself, so the floor must be sturdy enough to take such abuse.
Important Considerations that Must be Kept in Mind
Today, it is necessary that an aircraft has modern connection facilities such as USBs. Customization is another factor. Depending on the situation, the crew must be able to quickly put in cabins, add/remove seats and/or stretchers. Proper mounts for medical devices must already be in place. While all such facilities bring in a high level of convenience, safety remains the primary concern. For this reason, all the modifications must be certified by a competent agency.
Care must be taken to make use of the space available to the maximum. For instance, the stretcher must be able to double up as a bed that can be immobilized on the flight. Plus, the space beneath the stretcher could be used for storage by building custom cabinets. It is obvious that a one-size-fits-all approach generally does not work; however, a creative approach to the medical flight interiors can go a long way to make it comfortable and efficient.
Let’s understand the scenario with a hypothetical situation – a patient has suffered a serious injury and is in Carthage, Missouri. It is felt that the most appropriate facility to treat the patient is in Joplin, which is just about 12 miles from where he is. A medical flight is summoned, in spite of the ground ambulance being ready to take the patient. The medical flight takes about an hour to reach the patient and another 15 minutes to reach the treating facility. A week elapses, just when the patient is thanking his stars that he was lucky to receive the treatment on time, he is slapped with a balance bill of $25,000. The insurance company has covered $20,000 of the total $45,000 bill. The once happy patient is now contemplating mortgaging his house to pay off the balance bill.
The Argument Against Medical Flight Company
The insurance company argues that the ground ambulance was readily available and the destination was just 12 miles away, which would have taken the ground ambulance about half an hour to reach. Yet, a medical flight was called in, even though it took an hour for it to simply reach the patient. The insurance company feels there was no need for the medical flight service in the first place and refuses to cover the bill in full. In the outset, the argument seems right but only until what the medical flight company has to say.
Looking at the Situation from the Medical Flight Company’s Angle
Medical flight companies do not and cannot choose to take a call whether they want to fly a patient. They are summoned by the hospital and the medical necessity is decided by the treating physician. Come to think of it, the treating physicians usually have a sound logic behind suggesting an air ambulance service. The ground ambulance might not be best suited, owing to the patient’s condition.
What needs to be done in contradictions like these is following a middle ground and for this, there needs to be a mechanism in place where things are sorted out between medical flight and air ambulance companies. Until that happens, the patient will continue to suffer.
Imagine this – you pay for a smartphone in full and then realize that you are only allowed to use certain features in it but not all. How would you feel about that? Would you have bought it had you know about this fact during the time of purchase? Now, take the case of air ambulance coverage provided by insurance companies. Don’t you deserve to know the kind of coverage that you get? Whether you would be monetarily covered in your neediest hour when your health demands urgent medical care? You need to be sure you will be taken to a well-equipped treating facility and that the expense of carrying you to that destination is covered by the insurance provider. Unfortunately, that is not the case today.
Not All Insurance Providers are the Same
There are several health insurance providers out there who cover the air ambulance charges at a fair rate but there are others who do not. On the other hand, it is not under the control of the air ambulance service providers to choose patients. They ask no questions; they simply respond to emergencies. When this act turns into a haggle for money, it becomes a problem. The result, often, is balance billing – the part of the bill that remains uncovered by the insurance provider. The balance bill, ultimately, becomes the responsibility of the patient to pay, despite having insurance coverage. The amount can be so huge sometimes that it can push a common man towards bankruptcy.
Patient Advocacy by Air Ambulance Service Providers
Most air ambulance service providers have a robust policy when it comes to patient advocacy. Such programs are mainly targeted towards helping patients course through the complexities of insurance. However, the question is, why should such programs be necessary. All that is needed is a fair rate at which insurance companies reimburse the air ambulance service providers. As the insurance companies and air ambulance companies sort this matter out, what ultimately comes out is something that we all need to keep an eye on.
If you are a patient who is in a medical serious condition and fighting for life, would you be okay with an air ambulance professional who is fatigued and has been working a shift of almost 24 hours? Would you perceive this condition to be grave for your life? Although air ambulance personnel these days are not expected to work abnormally long hours, this fact is something you should know about. In this context, one must note that 24-hour shifts were a practice, if not common practice, prior to 1997. We bring you a research conducted in this regard by the US National Library of Medicine National Institutes of Health, which is a part of National Center for Biotechnology Information, a US Government undertaking.
The Findings of the Report were Astounding and Contrary to Popular Belief
The primary objective of the research was to assess the psychomotor agility and skill performance of the air ambulance personnel when they worked 12-hour shifts versus 24-hour shifts. The data gathered pertaining to 24-hour shifts belongs to the pre-1997 era. The data collected was compared with times when the air ambulance industry was mandated to work for limited number of hours as against the time when shifts spanning 24 hours were not alien. Intubation – a critical task that is undertaken routinely – was used as a scale to measure the efficiency of the air ambulance professionals. Surprisingly enough, there was hardly a difference between ‘overworked’ professionals and the ones who worked reasonable hours.
How Do Air Ambulance Professional Manage to Work at Optimal Efficiencies?
The answer may lie in the fact that failure is not an option when lives are at stake. No matter what the level of fatigue, when people who are driven by passion and compassion are put in a situation where the outcome depends on how they perform, the chances are they will try their best and come out winners. The fact is also an ode to the dedication of the professionals belonging to the air ambulance industry.
The Commission on Accreditation of Medical Transport Systems and the European Aero-Medical Institute are perhaps the two most well-known organizations that offer accreditation to air ambulance service providers. While the former is primarily for the United States, the latter caters to the European continent. There are several air ambulance companies that certify their quality services through these accreditations. Then, there are those companies that are equally quality oriented but are not accredited. These medical flight companies are usually smaller in size and cannot afford accreditations. This raises the question: are accreditations really needed or is it just another additional cost?
The Benefits of Air Ambulance Service Accreditations are Several
For one, insurance companies are more willing to take an air ambulance service provider in their network coverage when they are accredited by a well known organization. It is an assurance of high quality standards and safety. Many private players who tie up with air ambulance companies too prefer such certifications before tying up for their services. For medical flight service providers, therefore, it makes sense to spend money on such accreditations. Even hospitals and customers veer towards those organizations that have recognized accreditations.
The Constantly Evolving World of Air Ambulance Accreditations
The rules that govern the air ambulance industry constantly evolve. Bodies like Federal Aviation Administration of the United States up the standards that govern air ambulance companies constantly. When this happens, the organizations that offer accreditation automatically are forced to change their standards. For air ambulance service providers, this means upgrading their certifications on a regular basis to stay current. Moreover, these accreditations must follow not just the norms of their own countries since air ambulance services are increasingly going global. An accreditation organization that only caters to a single country risks being ignored as there is a chance of the service providers preferring other more global options.
It might seem that the aviation and air ambulance companies have little in common. While one deals in the mechanics of aviation machines, the other primarily deals with biology and chemistry of the human body. However, when one looks closely, it is easy to spot several similarities between the two. It is these similarities that the air ambulance companies must be aware of and must work on, to improve the safety of medical flights. The risks involved in both industries are very similar to each other. This is why REVA, which is an international fixed-wing air ambulance company, has published a white paper on ‘Just Culture’
What is ‘Just Culture’ and How Does it Apply to Air Ambulance Companies?
This is a highly relevant question. Although one rarely gets to hear about fatal crashes and safety flaws concerning air ambulance companies, such incidents are not unheard of. Apart from this, there are obviously going to be some near misses. The logic behind the ‘Just Culture’ is to treat mistakes as learning opportunities to avoid them completely in the future. REVA released a white paper on the topic recently.
According to Emma Roberts who is the company’s Safety Director, the white paper meant for air ambulance companies, lays down the steps involved in implementation of just culture and explains how this culture increases the degree of safety.
‘Just Culture’ Fosters Transparency in the Way Air Ambulance Companies Function
‘Just Culture’ makes reporting easier for staff who constantly put their lives on the line to protect and serve the needy patients. The culture ensures that these front-line warriors are not punished for the mishaps but are rather encouraged to report them so that apt solutions can be found. The result is improved safety of medical flights and better compliance with medical as well as aviation norms.
The word, Korea, brings to mind the latest development between the two nations – one a proponent of democracy and the other a dictatorship. What most people do not know is that Korea, as a whole, had a huge part to play in the evolution of medical air services. It all began during the Korean conflict in the 50’s of the last century. Making way in the conflict-ridden zone was no joke, owing to the bad reach and wartime danger. What came handy was a modified chopper that could carry patients to the nearest medical base, just in time to save life or at least salvage a limb.
The Idea of Medical Air Services Took Off
The success of the modified aircraft to serve as an air ambulance was a great success. This inspired the military to dedicate choppers for this very purpose. It is believed that over 20 thousand soldiers were rescued using military medical air services. However, owing to the technology and limited logistics of the time, the concept did not make its way to civilian lives for quite some time. Medical air services got further military acceptance when over 80 thousand soldiers benefited from them during the Vietnam War. All the wars from the time of the Second World War had seen medical air services evolve.
The Foothold into Civilian Lives
The mid 1960’s saw a path-changing societal research paper titled, “Accidental Death and Disability.” It questioned the fundamental logic behind limiting medical air services for military use. It brought to light how air ambulances can be of immense help to save civilian lives during medical emergencies ranging from motor vehicle accidents to cardiac arrests. By this time, aviation logistics had also evolved greatly. The result: first medical air service saw the day of light in the United States in 1972. By the turn of the century, over 203 thousand people were benefiting from medical air services.
Over the past few years, the medical flight services have steadily risen in cost, so much so that the cost has gone up at a whopping 5% per annum since almost the past 7 years. There have been concerted efforts on the part of state governments and the federal government to bring the cost of medical flight services down, at least to a ‘reasonable’ level. However, the definition of what is reasonable has been rather loose. In the midst of all this, it is natural that people in general are concerned about workers’ compensation and how it deals with medical flight services.
Handling of Medical Flight Services by Workers’ Comp
The big concern of most people is naturally whether they have to pay out of pocket in the eventuality that medical flight services are utilized for a work-related injury. Many would simply ask whether there is a possibility of a balance payment being demanded.
Such worries, however, have no basis to them. The amount would be settled by the insurance carrier and if the amount being approved by the carrier is less than what the air ambulance company is claiming, the victim of the accident need not be concerned. It is up to the medical flight services company and the carrier to come to a settlement. In most cases, the air ambulance company gives the insurance carrier a discount.
The Clash of Two Laws and the Way Out
Most states have fee schedules that define the extent of medical flight services cost coverage. However, ADA or Airlines Deregulation Act of 1978 allows air ambulance service providers to charge what they feel is reasonable without any questions being raised. The two laws can be, sometimes, contradictory to each other. However, in spite of all this, it still boils down to the air ambulance company and the insurance provider coming to a common monitory agreement, in case there is a dispute.
More often than not, we hear about skyrocketing medical flight bills that families are forced to pay. While it is natural for such families to feel victimized, having some prior knowledge about insurance coverage can prove helpful. If you are among those people who feel all they need to do is pay health insurance premiums, sit back and relax, here’s some news: your most basic health needs might not be covered. This mostly happens when the medical service provider is out of network.
Out of Network Medical Flights can Be Expensive
Take the case of 8-year-old Ben Millheim who met with an unfortunate accident fracturing his skull. The injury necessitated using a medical flight service to a hospital about 100 miles from the site of injury. While the boy survived and recovered well, his parents are still reeling under the $32,000 medical flight bill. Unfortunately for them, the medical flight service that they had used was out of their insurance network. As a result they are now liable to pay the service provider the ‘balance bill.’ In other words, they have to now shell out of their pockets the amount that their insurance provider has refused to pay the medical flight company for the reason that it does not come in their network.
It’s Almost Always a No-win Situation for Patients
Life-threatening injuries leave little room for checking whether a particular medical flight service provider is covered by the health insurance. While insurance companies flatly refuse to bear such expenses, it has been seen that air ambulance companies usually offer a discount to such patients. Plus, several states in the United States have passed legislation to limit balance billing; however, some states like Missouri have not. It must also be noted that there is no federal regulation that governs balance billing, leaving people vulnerable.