AAMS responds to CNN article on air ambulance pricing

AAMS responds to CNN article on air ambulance pricing 7 Dec, 18, Source: AAMS

As part of our mission to represent the work done by air medical services, we must fight against inaccurate information from the media and those who seek to limit access to air medical services. We believe if we all consistently provide accurate information, in as many formats and as many outlets as possible, more members will become spokespeople for this industry and help secure its place in emergency medicine. On Monday, November 5th, 2018, AAMS spent over an hour interviewing via phone with Jen Christensen, a producer with CNN, discussing the critical role of air medical services – especially in the face of increasing hospital closures particularly in rural areas, the issue of balance-billing, the need for Medicare reform, and the role of insurance providers, among other topics. The article was released yesterday and contained many inaccuracies and misinformation. However, it also contained some positive information on air medical transport that AAMS provided. Below is our response to the article, which was shared with CNN this afternoon.  Please share with people or outlets whenever this article is referenced.

Air Ambulances Save Lives in Emergency Situations

CNN’s “Sky-high prices for air ambulances hurt those they are helping” by author Jen Christensen, posted November 26, 2018 failed to emphasize the enormous benefits of air ambulance transports in emergency situations.  It also failed to show the effects that catastrophic underpayments by Medicare, Medicaid, and private insurance have on the availability of these life-saving emergency medical services.

Despite claims made by several individuals as to the necessity of air ambulances, all helicopter air ambulances respond to emergency medical requests made independently by physicians and medically trained first responders at the scene of an accident. Air medical services never-self dispatch and routinely perform after-action reviews on those requests with the medical personnel who were caring for those patients. A study of more than 27,000 helicopter transports of all patient types, concluded that less than 2% of emergency helicopter transports were not appropriate[1] (a statistic that could have been verified by speaking to an EMS doctor rather than just insurance claims specialists).

No one in our industry wants patients to face balance bills they do not expect or cannot pay, but the vast underpayment by Medicare, Medicaid, and now private insurance will inevitably lead to closing bases and loss of access to critical levels of healthcare access for millions of Americans. Mississippi alone saw more than 5 hospitals close and at least four more declare bankruptcy since 2013; as more hospitals close, the need for, and availability, of both ground and air medical transport services will only continue to increase.

We hope that CNN will do a better job of providing an accurate picture of emergency medical issues in the future and focus on solutions for patients and the medical access they deserve rather than what’s right for insurance companies posting record profits at the expense of the patients they purport to serve.

The CNN article can be found here:  https://www.cnn.com/2018/11/26/health/air-ambulance-high-price/index.html

FACT VS. FICTION: What the CNN Article Didn’t Get Right:

Claim:
The patient, Sonna Anderson, could have been taken to a closer hospital. The language suggested that the air ambulance service chose where to take her.

FACT:
Air ambulance providers don’t choose where to transport a patient; physicians at a hospital or medical trained first responders at the scene of an accident request the transport and determine where the patient is taken. Not all hospitals are the same, they provide  varying degrees of care.  The closest hospital to you may not be able to treat certain cases (e.g., stroke, heart attack, severe trauma, burns, etc.).

Claim:
Air ambulance bills range from 34,000-533,000.

FACT:
Helicopter air ambulance services only respond to emergency medical requests from physicians and first responders;  some Fixed-Wing air ambulances respond to emergency medical requests, but most are prearranged services with patients and include estimates as to their costs. The two services are operated differently and should not be analyzed together.

Claim:
“We carry insurance to avoid the catastrophic situations,” wrote the man, whose name was redacted. “I don’t see where the consumer is getting a fair shake in this deal.”

FACT:
AAMS completely agrees.  Insurance companies should cover emergency medical services that are requested by a physician or first responder at the scene of an accident.

Claim:
“Insurance commissioners’ offices and insurance associations have tried to help: sending letters, pleading with Congress to do something about “unreasonably high and unregulated rates,” as one Mississippi insurance commissioner put it. Yet stand-alone legislation, even with bipartisan backing, has gone nowhere.”

FACT:
Complaints made to state insurance officials are directed to the patient’s insurance company. State Insurance Commissioners and state legislators are charged with regulating adequate insurance coverage and payment, and can solve this problem by requiring insurers to offer fair payment for patient transports and stand in the shoes of patients in dealing with emergency medical providers.

Claim:
Private equity firms, not hospitals, now own the three largest air ambulance providers in the United States.

FACT:
Many hospitals and healthcare services are owned by private equity firms or are publicly traded, for-profit companies. Until 2010, one of the largest hospital owners, Hospital Corporation of America, was owned by private equity; its IPO was the largest in history backed by private equity. Further, the nation’s largest health insurers are for-profit companies- Aetna, Anthem, Cigna, Humana and UnitedHealth Group- and they cumulatively collected $4.5 billion in net earnings in the first three months of 2017.

Claim:
“”They have a cash cow on their hands,” New Mexico state Rep. Liz Thomson said.”

FACT:
Two of the patients in this story had already had their bills fully or partially forgiven at the time of publication. The air medical transport companies are taking a significant loss with many of these cases simply because the patient’s insurance company refuses to pay any or part of the cost of the service – despite an independent medical team deeming the medical transport necessary.

Claim:
“When patients travel on helicopters that are not in-network, insurance will cover little or nothing at all.”

FACT:
Insurers refusing coverage for physician-ordered emergency medical services should be, and often is, illegal.

Claim:
“They [air medical providers] don’t have to participate, so they don’t, and then essentially, they can charge what they want.”

“This practice is costing them [insurance companies] a mint. It’s outrageous.”

FACT:
Air medical services have increased their network participation by an estimated 20% in the past year alone. Air medical services actively seek in-network agreements with insurers when a fair and equitable agreement can be reached.

Claim:
“We know what their fuel costs. We know how many hours they fly and how much it costs for a pilot,” Castleberry said. “Add up all those factors, even if you give them a 20% profit on top of that, that’s still not even half what they are charging me, which is more like 300 to 400 times what it actually costs to fly our customers. When I can go rent a private plane and put medical personnel on board for less than some of these bills, I know it shouldn’t cost this much.”

FACT:
This is a highly-trained medical team, not just a pilot and plane.  AAMS members provide full-time, dedicated helicopter air ambulance services that are prepared to respond, in a matter of minutes, to provide medical care to patients-in-crisis 24 hours-a-day, 7 days-a-week, 365 days-a-year.  Every request for an air medical transport comes from a physician or a medically-trained first-responder and, like a fire-department, air medical services are always on-call.

It is the cost of this constant readiness to emergency situations that makes air medical services more expensive than simply renting an airplane.

Claim:
“He also notes that a lot of patients whose bills the firm sees, who are told to take these flights, aren’t trauma cases.” They are not for a wreck on the side of the road needing Level I trauma care,” Castleberry said. “Only about 15% of the air ambulance charges we see involve those kind of accidents. The vast majority are patient transfers from one facility to the other.””

FACT:
The physician or first responder who requested the flight deemed the injury or illness an emergency, even those from one hospital to another. Some of the most severe emergencies occur when the patient arrives at a hospital unable to care for them. 90% of all air medical transports are trauma, stroke, heart attack, burn, high-risk neonatal/pediatric cases, all of which are emergent in nature.

Claim:
“There are few evidence-based guidelines about what appropriate use for air ambulances.”

FACT:
Patently untrue – the Centers for Disease Control, the Journal of Emergency Medicine, the American College of Emergency Physicians, and others all have guidelines for the appropriate use of air medical services.

Claim:
“It’s often the hospital or the EMTs that decide to fly, but consumers are the ones left paying the bills, and there’s really no way for consumers to protect themselves.””

FACT:
Consumers do have recourse to protect themselves.

  1. Call your air medical transport provider. Air medical transport providers have patient advocates who answer any questions, appeal on your behalf to insurance agencies and help with any special consideration with resolving your bill. Working with you throughout the insurer’s appeals process, the advocate’s goal is to help you negotiate with your insurance company for maximum coverage of services provided to you. Dealing with insurance companies can be challenging, and these patient advocates are skilled at navigating the process, including helping you to file a reconsideration or an appeal with the insurance company.
  2. Make your coverage expectations clear to your insurance provider. Transportation during a health emergency, whether by ground or air, is expected to be covered as part of one’s health coverage. If you or a loved one were transported by an air medical service, some or all of the cost of that transport should be covered by your insurance company.
  3. Some insurance companies intentionally under-reimburse for an air medical transport, leading to a large balance bill being sent to the patient. Insurers may declare that a transport was not medically necessary. Should this happen, call your air medical provider: they can help you navigate the insurance coverage process. With ongoing communication between patients and air medical providers, working together through the appeals process, large balance bills have a much better chance for resolution or settlement.
  4. If you receive reimbursement from your insurance company for the air medical transport, remember that this is a payment from your insurer to air medical services provider for the healthcare services you received. Some insurance companies put responsibility for payment on patients by sending reimbursement to the patient, rather than the health care provider. If this happens to you, be sure to send the reimbursement on to the air medical provider. Some people make the mistake of thinking that no further action is needed.

Claim:
“First, I could have driven to that other hospital faster,” Courier said. “We also had tried to do everything in-network. We did everything right insurance-wise, but we still faced this huge bill.”

FACT:
Again, the transport was requested by a physician or first-responder and the patient is being transported by a highly-trained medical team who begins the emergency treatment of the patient en-route to a hospital or trauma center. It’s not just a ride in an Uber.

Claim:
“Other state insurance offices say usually there’s little they can do, beyond holding insurance companies to the letter of their policies. Most offices encourage patients to call with complaints.”

FACT:
There is much more state insurance officials can and should do to regulate insurance payments for patients in emergency medical situations.

This is a direct quote from the article:

“The Association of Air Medical Services believes that the states can “help patients right now and help address the issue of balance billing and take patients out of the middle,” Eastlee said. ”Some insurance only covers a fraction of the price for those transports. We can work together.””

Claim:
“North Dakota tried another approach. Its 2015 law required providers to disclose prices before the flight, upon request. Hospitals that referred a patient to the air ambulance company had to let the patient know the cost ahead of time unless the hospital determined that doing so would jeopardize their health or safety, in which case they would be exempt. The courts overturned that legislation, ruling that it was a federal matter.”

FACT:
Again, the physician or first responder who requested the flight had already deemed the air ambulance transport medically necessary.  Would you want a law requiring an emergency physician or paramedic to discuss price before treating a stroke or traumatic injury where the outcome is dependent on timely treatment?

Claim:
“For a little more than 45 minutes of service, they were asking for more than what my surgeon charged. It’s not fair,” Anderson said. “I’ve since talked to other people who have been transported with no surprise bills, I think air ambulances can run in a fair manner, but the way it is currently done seems unfair and unreasonable. No one should feel shocked or panicked by a bill like this. No one ever.”

FACT:
AAMS agrees no patient should ever be faced with a balance bill they did not expect or cannot afford.  If insurance won’t pay for an emergency medical service that was specifically requested by a physician or medically-trained first responder at the scene of a severe trauma or illness, then what is insurance for?

What the CNN Article Did Get Right:

“Air ambulances remain lifesavers, especially for patients who need critical care fast. Heart attacks, strokes and burns all benefit from quick care. Trauma patients face much better survival odds if treated in the “golden hour” or as quickly as possible after injury, studies show.”

“About 70% to 80% of the patients whom air ambulances transport fall into these categories that the industry argue significantly underpay, like patients with Medicare. This payment is significantly less than the cost of the transportation, Sherlock said. “Medicare pays about 60% of the cost of the flight; Medicaid pays 35% or less. Self-paid patients pay a few cents on the dollar, and that has led to a crisis of being able to sustain the service,” Eastlee said. That means about 7 out of 10 of the association’s flights are under-reimbursed, he said. If the government reimburses the industry more, Sherlock said, “you eliminate the need to balance bill.””

“The Association of Air Medical Services believes that the states can “help patients right now and help address the issue of balance billing and take patients out of the middle,” Eastlee said. “Some insurance only covers a fraction of the price for those transports. We can work together.””

“The industry association said that it supports the FAA Reauthorization Act because it “enhanced consumer protection” and that the industry does want more transparency and accountability, Eastlee said, “but we also have to work to sustain the service.”

Sherlock added, “the amendment does not address the underlying problem to reduce the patient’s balance bill.””

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