The Wrong Solution to Air Medical Transport Costs

Emergency air medical is a service you hope you’ll never need in your lifetime. Flying approximately 375,000 patients each year, 90 percent of air medical transports are patients that are experiencing health emergencies — strokes, heart attacks and others. With these time-sensitive emergencies, timely access to health care is a necessity, not an option.

Unfortunately, the under-reimbursement of coverage of these life-saving services by Medicare and Medicaid contributes to the issue of balance bills. Like other health care providers, air medical services must cost-shift to overcome enormous uncompensated care. As a result, some patients have been left by their insurers with large bills after their transport — a burden no one would ever want to place on someone who desperately needed health care.

To remedy patient costs, there has been some discussion in Congress about carving the air medical industry out of the Airline Deregulation Act — language found in section 412(h) of the Federal Aviation Administration Reauthorization Act of 2018 in the House, by Rep. Rob Woodall (R-Ga.), and similarly in stand-alone legislation by Sen. Claire McCaskill (D-Mo.) in the Senate. But proposals like these are misguided and, to be frank, often an output of the insurance industry that would like to lower their own payments.

Exempting air medical services from the ADA would drastically change the way the air medical transport system works, and not for the better. What’s worse, it would have a devastating effect on the health outcomes of patients.

When Congress enacted the ADA in 1978, one of the primary purposes was to encourage expansion of the air transportation industry by exempting air carriers from patchwork regulations by the states. Air medical services were considered during those debates, and it was determined that they were properly placed under federal regulation, as well. In part, the ADA says that a state “may not enact or enforce a law, regulation, or other provision having the force and effect of law related to a price, route, or service of an air carrier.” This allows air ambulance companies to provide life-saving services and make decisions based on what is in the best interest of the patient, rather than on arbitrary or burdensome state or local laws.

By their very nature, air ambulances operate on an interstate basis. Every day, they transport more than 30 percent of patients across state lines to access care at the closest, most appropriate facility. For example, in Missouri, almost 50 percent of transports by Air Methods Corp., an air medical provider, go in and out of the state.

The states already have the unfettered ability to regulate health care within their borders.  Carving the air medical industry out of the ADA would essentially allow each state to have expanded oversight beyond health care and could regulate providers according to state- or even county-level preferences. That means states could regulate service hours, how the aircrafts are operated, and where the control center is located. Air medical providers, unable to comply with a set of inconsistent regulations for a flight that would cross state lines, would be forced to transport patients to in-state medical facilities — which in many cases may not be the closest or most appropriate option.

And there’s more. If air medical were carved out of the ADA, states (or counties or municipalities) could bar entry for out-of-state air medical providers entirely — which has been attempted by the state of North Carolina. States could also regulate where an air medical provider can deliver patients based on in-network agreements with insurers, taking away decisions made by doctors and first responders.

In many rural communities across the country, hospital closures have decreased access to emergency care and essential medical services, requiring rapid transport by air over longer distances, and across state lines, to larger hospitals. And it’s not just rural areas that would be affected: If proposals like those being pushed by McCaskill or Woodall succeed, an air ambulance that picks up a patient in northern Virginia might have to transfer that patient to a medical facility in southern Virginia, a few hours away, even though there are several hospitals only 15 minutes away in Washington, D.C.

We also shouldn’t forget specialized care. Often, the best facility to handle a stroke or health care involving children is not the closest facility and could be across state lines. Wouldn’t you want the most qualified doctor to handle your emergency?

Finally, although proposals to carve the air medical industry out of the ADA may be intended to protect patients from onerous charges, they won’t actually lower the bills that patients get for transport. In fact, they are likely to create a more complicated payment structure that will benefit health insurance companies at the expense of patients.

Medicare and Medicaid payments for air transports are low — often less than half of what they cost — in part because the Centers for Medicare and Medicaid Services hasn’t evaluated what it pays for air medical transport in nearly 20 years. Thus, private insurers are basing their rates on what Medicare pays, resulting in 70 percent of patients’ bills for air medical transport paid at the Medicare rate or less.

If we want to address patient costs of air medical services, there is a congressional solution: the Ensuring Access to Air Ambulance Services Act (H.R. 3378/S. 2121), which would, among other things, update reimbursement rates based on air ambulances’ actual costs. This would not only reduce patient costs, but it would preserve and protect critical access to life-saving emergency care.


Rick Sherlock is president and CEO of the Association of Air Medical Services.

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