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In December 2009, NBCNews.com reported on high prices in the air medical industry in an article titled “Air ambulances leave some with sky-high bills.” The story opened with the case of Charlie Taylor, a then 49-year-old man from Lyons, N.Y., who was flown to the hospital by helicopter after a four-wheeler overturned on his chest, breaking seven ribs. Like many air ambulance patients, Taylor appreciated the care he received, but was stunned when he saw the bill for the flight.
The provision of helicopter emergency medical services has always been an expensive undertaking — helicopters aren’t cheap, and neither is the advanced critical care that has come to be associated with rotary-wing air ambulances. But dramatic recent increases in billed charges by for-profit air medical providers are changing the public profile of the industry in the United States. With growing frequency, these providers are in the news not for saving their patients’ lives, but for presenting them with bills in the tens of thousands of dollars, then “resorting to hard edged legal tactics to get paid” (as the Times put it).
The bad press has been so significant that Air Methods shareholder Voce Capital referred to it explicitly in September of this year, when it issued a press release and public letter to the board of Air Methods arguing for the sale of the company to private investors. According to this activist hedge fund, the popular press now “depicts Air Methods as a villain that victimizes the very patients whose lives it saves, allegedly gouging them with rapacious pricing and then targeting them with aggressive collection efforts when they fail to pay.” Voce contends that Air Methods’ disclosures as a publicly traded company — including its “candor regarding its pricing strategy, and disclosures about its collections and the aging of its receivables” — have made it a prime target for negative attention and contributed to its falling stock price, which as of the date of the letter was down 37 percent over 12 months.
Whatever the actual motivations behind Voce’s letter (which triggered a sizable but temporary bump in the stock price), it is correct in observing that “the granular availability” of Air Methods’ data is unique in the air medical industry. Thanks to its financial disclosures, we know that Air Methods has increased its billed charges from an average of $13,198 in 2007 to $40,766 in 2014, according to data compiled by Jon Hanlon of the independent research firm Research 360. Likewise, we know that this tripling of its prices has contributed to a tripling of its net income, which has grown from $27.5 million to $99.4 million over the same time period.
But Air Methods is not alone in its pricing strategy. PHI Air Medical, a division of the publicly traded company PHI Inc., saw a 26 percent increase in profits from 2013 to 2014 alone, which was also helped by rate hikes. According to Research 360, PHI’s average charge per transport for privately insured individuals now exceeds $40,000 in some states, up from around $28,000 just three years ago. Lawsuits and consumer complaints across the U.S. reveal similar figures for companies in the privately held Air Medical Group Holdings (AMGH) and Air Medical Resource Group (AMRG), which do not disclose their financial data. According to a list of North Dakota Insurance Department air ambulance complaints, in 2014, the AMGH company Med-Trans charged $35,923.47 for a helicopter transport of less than 100 miles. Meanwhile, in 2013 an AMRG company, Guardian Flight, charged $50,062.17 for a transport of less than 20 miles.
However, the community-based programs that have raised their prices the most have deliberately remained out of network — charging, essentially, whatever they want. Like hospital-based programs, community-based providers will accept very low set reimbursement rates for Medicare and Medicaid patients, and will receive little to no reimbursement for uninsured patients who lack the means to pay. The remaining, privately insured patients are consequently their major source of revenue, and many community-based programs, after accepting an initial payment from a patient’s insurer, will balance bill the patient for the rest
As Air Methods CEO Aaron Todd noted in a recent earnings call, the company actually collects “very little” from individuals. But the individuals in question don’t necessarily know that. When an air ambulance company threatens a patient with a lawsuit and a lien or the specter of bankruptcy, the patient tends to lean on his or her insurer or employer to cover a larger share of the charges — often resulting in several more payments from the insurance company before the account is closed. (Todd explained in the earnings call, “When we get to the point where we know that we are just working with the patient, we will work very quickly to get the account wrapped up.”)
For many years, insurers have gone along with these price increases, supporting continued growth in what Todd described to Vertical in 2010 as an already saturated market. Now, however, the tide appears to be turning. While the size of insurers’ first payments to Air Methods continues to grow, the rate of growth has decelerated significantly. Meanwhile, workers’ compensation insurance carriers in Texas have mounted a successful challenge to PHI’s high charges, with an administrative law judge finding that the Airline Deregulation Act (ADA) of 1978 does not preempt states’ rights to regulate the business of insurance. North Dakota earlier this year passed legislation that would force air ambulance providers to negotiate with insurers to be placed on a priority call list, and several other states are also considering legislation that would limit what air ambulance providers can charge.
To be sure, protracted legal battles lie ahead on all of these fronts, and the ADA has served the air medical industry well in the past. The industry is also pinning its hopes on proposed legislation in Congress that would raise Medicare reimbursement rates by an immediate 20 percent, giving a significant boost to providers’ bottom lines. Nevertheless, the challenges being faced by the industry are real. In pushing prices ever higher, has the for-profit air medical industry finally reached a limit?
Too Many Helicopters?
As of September 2014, there were 1,020 public and private helicopter air ambulances in the U.S., according to the Association of Air Medical Services (AAMS) and its Atlas and Database of Air Medical Services (ADAMS). If you think that sounds like a lot, you’re not alone. In Air Methods’ first quarter 2015 earnings conference call, CEO Aaron Todd remarked, “If you ask me personally, do we need 900 air medical helicopters to serve the country, I’d say probably not, maybe 500, 600 could do as well, but it’s an open market . . . and so, therefore, there’s going to be the inefficiency of competition.” (Air Methods, along with PHI Air Medical and AMGH, did not respond to repeated requests for comment for this article; AMRG failed to respond after initially indicating it would do so.)
The U.S. civilian air ambulance industry has grown steadily since the first programs were established in the 1970s, but the industry underwent significant change in 2002. That’s when the Centers for Medicare and Medicaid Services began phasing in a national fee schedule for air ambulance providers, part of a series of Medicare payment reforms mandated by the Balanced Budget Act of 1997.
As described in a 2010 report by the Government Accountability Office, prior to 2002, Medicare reimbursement differed depending on the air ambulance provider’s business model: hospital-based providers were reimbursed based on reasonable costs (and generally received higher reimbursement), while independent, community-based providers were reimbursed based on reasonable charges (and received less). The new fee schedule established a single rate for helicopter transports regardless of the business model followed; although it provided for higher reimbursement for transports in rural areas, it did not make provisions for the type of aircraft used, or the level of medical or safety equipment on board.
The new fee schedule incentivized the expansion of community-based providers flying smaller, cheaper helicopters, and that is exactly what happened. According to ADAMS, in 2003, there were 545 helicopter air ambulances in the U.S.; today, there’s almost twice that number. Meanwhile, the composition of the fleet has shifted from 41 percent single-engine and 59 percent twin-engine in 2004, to 51 percent single-engine and 49 percent twin-engine in 2014.
When Todd addressed the “inefficiency of competition” in the market, he referenced the statistic that the doubling of the U.S. air medical fleet over the past 10 years has helped an estimated 80 million Americans who can access Level 1 or Level 2 trauma centers within an hour only through the use of air medical helicopters. That’s significant, but the expansion of coverage hasn’t been evenly distributed. As the ADAMS maps show (see Figure 1), new bases have clustered in areas where reimbursement rates and payer mixes are most favorable, leaving large areas of the country with close to the same coverage they had a decade ago.
“A helicopter in a rural area improves access to care, but three helicopters in the same rural area do not actually increase access to care, they only increase costs,” observed Tom Judge, executive director of LifeFlight of Maine and a former president of AAMS. “The 2010 study by the GAO showed a 35 percent increase in the number of patients served between 1999 and 2008, but an 88 percent increase in the number of helicopters.”
When the number of helicopters in an area goes up, the number of patient transports per helicopter goes down — which leads to dramatic increases in the cost per transport. That’s because most of the costs associated with running an air ambulance service are fixed costs, which include, according to AAMS, “aircraft and associated maintenance costs; the costs of maintaining highly trained, properly licensed, and experienced flight and medical teams; and the significant costs of necessary safety equipment to ensure patients are cared for in the safest operational environment possible.”
Various industry sources consulted for this article estimated the fixed costs of an air ambulance base with one single-engine helicopter at around $225,000 per month; for a more medically sophisticated program flying twin-engine aircraft, the fixed costs can easily be twice that. The variable costs are relatively small by comparison: for example, Conklin & de Decker estimates the operating cost of an Airbus Helicopters AS350 B3 at around $750 per flight hour, and that of a Sikorsky S-76C+ at about $1,850 per hour. (The cost of medical supplies used during a transport is often factored into fixed costs.)
Declining volumes have forced all air ambulance providers, even the nonprofit ones, to raise their rates. As Hildenbrand put it, “I’m blown away by our charges, and we’re charging a fraction of what other providers are charging.” Of course, for-profit providers are looking to do more than break even; they’re striving to continually grow their profits, year after year. So for-profit, community-based providers have raised their prices to compensate for declining volumes and ordinary inflation, then raised them again — and again, and again — to satisfy investors and pay fat executive salaries.
The extent to which they have been able to do so has been remarkable. As Voce Capital observed in its September public letter, “Because its prices are unregulated and demand is relatively inelastic, Air Methods has been able to take price routinely.” But Voce also noted that this is a “controversial practice” that is increasingly difficult for Air Methods to sustain as a public company.
Hospitals (and, by extension, hospital-based air ambulance providers) generally avoid aggressive collection practices because of the associated bad publicity; as Cato’s Michael Cannon pointed out, such negative press “is one of the market’s ways of disciplining providers.” Because community-based air medical providers typically have a lower public profile than hospitals, they haven’t taken the same precautions, but the market’s discipline may finally be catching up with them.
For many years, the air medical industry’s alarming safety record was the subject of critical media coverage. Now, such stories have given way to disturbing accounts of ordinary, insured Americans being driven into bankruptcy by air ambulance bills they can’t afford to pay. These horror stories have helped scare many people into buying “memberships” with community-based air medical providers, augmenting what is for some providers a substantial source of revenue. However, since memberships only protect individuals from balance billing, they haven’t won over insurers, who are still charged sky-high rates for members’ transports — and are finally starting to push back.
A Legal Workaround?
States have long been told by the U.S. Department of Transportation (DOT) and various court rulings that they are prohibited from regulating air ambulance companies by the ADA, which explicitly prohibits states from enacting or enforcing any law related to “a price, route, or service of an air carrier.” When the ADA was passed in 1978, it was with the belief that deregulation would promote “efficiency, innovation, and low prices” among commercial airlines, and its intended beneficiaries were American consumers, not air medical stockholders. However, courts have consistently upheld that air ambulance providers qualify as air carriers for purposes of the ADA, and the DOT maintains that “state requirements with a ‘significant impact’ on an air carrier’s prices, routes, or services are preempted.”
But the level to which prices have risen has led many states to look for workarounds, and some believe they have found one in the McCarran-Ferguson Act of 1945. This act of Congress explicitly reserves the regulation of insurance to the states, except in cases where federal law specifically relates to “the business of insurance” — which the ADA does not.
When North Dakota passed its landmark air ambulance legislation in April of this year, it was careful to tie the provisions of that legislation to the business of insurance. The new law created service response zones for helicopter air ambulances “which are based on response times and patient health and safety,” and established primary and secondary call lists of air ambulance providers operating in the state. To qualify for the primary call list, a provider must be in network with health insurance carriers representing at least 75 percent of the health insurance coverage in North Dakota. Now, when a call for a request comes in, the recipient of the request must first reach out to the providers on the primary call list within the response zone. Only if none of them are willing and able to respond to the call may the dispatcher proceed to contact the providers on the zone’s secondary call list.
The North Dakota law also addresses the lack of transparency that has helped sustain air ambulance price increases. The ADA assumes the existence of informed consumers making free choices, which most of us are, when we compare airline ticket prices and book a flight on Southwest. However, most critically ill or injured patients have no control over which air ambulance is called for them, and are not told the price of the transport before the flight (which is why air ambulance providers concentrate their marketing efforts on the EMS organizations and hospitals doing the referring, not the patients themselves). The North Dakota law requires air ambulance companies to disclose their fee information, which is made available to referring agencies in advance. It also requires hospitals to make a reasonable effort to provide patients or their legal guardians with this fee information for the purpose of allowing them “to make an informed decision on choosing an air ambulance service provider,” unless a delay in transport might jeopardize their health or safety.
Air ambulance companies aren’t taking this without a fight. Valley Med Flight has filed suit against North Dakota in U.S. District Court, claiming that the law, H.B. 1255, is preempted by the ADA as well as by the Emergency Medical Treatment and Active Labor Act, which vests the treating physician with decision-making authority for emergency transport services. “By virtue of H.B. 1255, the dominant insurance carriers in the state, such as BCBS [Blue Cross Blue Shield], will effectively be setting the prices for air ambulance services,” Valley Med Flight observes in its complaint. The company states it has already been compelled to sign an agreement with BCBS “at rates that are substantially below the market rates charged by an air ambulance operator,” and that if it is unable to set the rates it needs to sustain its operations, it “will likely be forced to cease its critical life-saving operations in rural communities in North Dakota, with such cessation at the expense of the life and health of citizens in rural communities.”
Meanwhile, on Sept. 8, 2015, Texas Administrative Law Judge Craig R. Bennett issued a significant ruling in a dispute involving PHI Air Medical and insurance carriers in numerous workers’ compensation cases. According to a recent article by attorney James Loughlin, who represented insurance carriers in the dispute, air ambulance providers for many years accepted payment under the Texas Division of Workers’ Compensation’s medical fee guideline, which since 2002 has been set at 125 percent of the Medicare rate. Beginning in 2012, however, air medical companies began arguing that they were entitled to their full billed charges, which led to an explosion in the number of active medical fee disputes at the division, and the number appealed to the State Office of Administrative Hearings (SOAH).
In November 2013, SOAH’s Judge Bennett found that, due to the McCarran-Ferguson Act, the ADA does not preempt Texas guidelines for air ambulance reimbursement. He remanded a number of cases back to the Division of Workers’ Compensation, which, in a departure from previous decisions, began finding that air ambulance providers’ billed charges were “fair and reasonable” and ordered payment accordingly. Insurance carriers appealed, and 33 cases involving PHI were joined for hearing under the lead docket. After considering the evidence, Bennett ruled that neither PHI’s billed charges nor 125 percent of Medicare represented “fair and reasonable” reimbursement. Instead, he found the fair and reasonable amount to be 149 percent of the Medicare rate — which “reflects the per-transport amount of revenue that allows PHI to recover its costs and earn a reasonable profit,” and “neither unfairly subsidizes other patient populations nor requires subsidization by other populations.”
Neither Loughlin nor PHI responded to requests for comment on the case, but at press time, industry observers expected both PHI and the insurance carriers to appeal the ruling. While the ruling directly pertains to only a small number of air ambulance transports, its reference to the McCarran-Ferguson Act sets a precedent that other states and insurance companies will likely seize upon in their attempts to limit reimbursement. When Vertical asked AAMS for its opinion on the case, director of communications Blair Beggan stated, “The recent decision in Texas is under review, but it’s too early in the review process for AAMS to be able to comment.”
Help From Congress?
What is often lost in mainstream media coverage of the U.S. air medical industry is the fact that the industry has more than one operating model. While many for-profit, community-based air medical operators are locked in battle with patients and insurance carriers, other providers simply are not. Boston MedFlight chief financial officer Maura Hughes said the service has a “great” relationship with insurance companies. “They know our patients are sick,” she explained. “We don’t have claims denied based on medical necessity.”
Boston MedFlight is a unique example of an air medical transport service: a nonprofit program funded by a consortium of otherwise competitive medical centers. For 30 years, Boston MedFlight has operated with the mission to “provide the right vehicle to the right patient at the right time, and transport them to the right facility.” Often, the right vehicle is a ground ambulance; the service reserves transports in its S-76 and Airbus Helicopters EC145s for those patients who would benefit from them the most.
“Our acuity is among the highest in the country,” observed CEO and medical director Suzanne Wedel. “We’re not doing transports that other services — for example, ground ALS — could do just to add to our numbers.” By contrast, a 2009 review by the Arizona Department of Health Services found a significant amount of inappropriate utilization among trauma patients transported by air ambulance in that state: 43 percent were discharged to home from the emergency department within 24 hours, and 88 percent had non-life-threatening injuries (as defined by a probability of survival greater than 90 percent).
While Boston MedFlight has adhered to the highest clinical and aviation standards and maintained positive relationships with its payors, it’s also true that the service loses money each year — as do many hospital-based and nonprofit programs around the country. The hospitals in the consortium continue to support Boston MedFlight because they see it not as a profit center, but as a cost center that serves a valuable role in the longitudinal continuum of a patient’s treatment. “Would we like to be paid more? Of course; we’re a high clinical acuity service, with significant investment in our aviation technology and training,” said Wedel. “But if you’re just focusing on the transport piece, you’re missing a lot of the patient experience and the cost of delivering care.”
The narrow focus on transport reimbursement is why many nonprofit and hospital-based air medical providers are skeptical of House Bill H.R. 822 and Senate Bill S. 1149 — twin bills, championed by AAMS, that are now under consideration by Congress. The bills would require air medical providers to report cost data, which would eventually be used to set Medicare reimbursement rates that accurately reflect the cost of providing air medical transports. In the meantime, the bills would increase Medicare reimbursement rates by 20 percent immediately, and by five percent each subsequent year until the new, cost-based guidelines are adopted. The House bill would provide a rate boost beginning in 2016; the Senate version would commence rate hikes in 2017, and would require the increased expenditures to be budget-neutral.
“Today’s reality is for every 10 patients flown, two may pay nothing at all (uninsured) and five are on government insurance like Medicare and Medicaid, neither of which pay close to the cost of an average transport (underinsured),” AAMS’ Blair Beggan wrote in an email to Vertical. “Our efforts on Medicare are solely focused on ensuring the Medicare pays a fair price for the cost of the services provided.”
It’s true that Medicare reimbursement rates, which since 2002 have only been adjusted by inflationary updates averaging 2.2 percent a year, no longer come close to covering the current costs of most air medical transports. Moreover, the increases proposed by H.R. 822 and S. 1149 would benefit all providers, including nonprofit services like Boston MedFlight. However, the biggest beneficiaries would be those for-profit, community-based providers who benefited the most from the original changes to Medicare reimbursement. And the legislation doesn’t consider the relationship between the cost per transport and volume of transports — which could encourage providers to pump even more helicopters into an already crowded market. “If this is such a bad business, then why do we have more and more suppliers?” observed LifeFlight of Maine’s Tom Judge. “The industry has created all of its own cost problems.”
Beggan countered that AAMS does not expect to see significant further growth in the number of helicopter air ambulances, but does anticipate growth in their number of flight hours. “It is readily apparent that the need for air medical transport will only increase over time,” she explained. “Air medical transport continues to fill a growing gap in the healthcare system in the U.S. As trauma centers and rural hospitals continue to close their doors, EMS helicopters are the means to move critically ill and injured patients to the medical facility best suited to treat their condition in a timeframe that can make a significant difference in their clinical outcomes.”
Beggan said that AAMS is optimistic about the prospects for H.R. 822 and S. 1149, citing “a number of productive conversations with the committees and our congressional supporters who serve on those committees.” When he’s speaking on the record to Air Methods investors, Aaron Todd is also optimistic about the proposed legislation (which hasn’t stopped Air Methods from recently diversifying into aerial tourism).
But the legislation faces some fundamental hurdles. As Boston MedFlight’s Maura Hughes observed, “Everyone knows we’re spending too much money on healthcare in this country.” Air Methods had over $1 billion in revenue last year, and AAMS’ supporters in Congress will have to make a plausible case for why the company and its competitors deserve even more.