Sunday, August 14, 2016

Utah’s new air ambulance companies raise the prices, and maybe danger, for patients • Is the growth of Utah’s air-ambulance industry about saving lives or making profit?

When an Eagle Air Med plane crashed into a Colorado mountain in 2007, killing three people, the nation's premier air-ambulance accreditor put the Utah-based company on notice that it could lose its stamp of approval, which would land Eagle out of business.

Critics of for-profit medical flight operators say the incident should have led state regulators to follow suit and tighten the reins on such companies. But when Eagle Air Med's response to the threat of losing its standing was to sue Colorado for having just one path to certification, Utah and other litigation-leery states instead began opening the door to an alternate — and, critics say, looser — accreditation group: the National Accreditation Alliance of Medical Transport Applications (NAAMTA), based in American Fork.

It's just the latest blow for Utah consumers, critics say, as the state's skies become crowded with airborne medical-transport services more concerned with profit than with patient care.

In the past year, four new medical helicopters have been established at Utah bases, bringing the number of rotary-wing ambulances serving the state to 20. Many are operated by profit-driven companies, which charge more for transport services than established players.

Federal law bars states from regulating aircraft routing, rates or operations, and Utah patients — who have no choice about which air ambulance company they ride with — have been hit with transport bills that top $35,000, far exceeding what even the most generous insurance plan will cover.

To complicate matters, the state can't require companies to share aircraft tracking data, which would allow emergency dispatchers to easily determine which provider can respond best to an emergency, and ensure patients get from accident scenes to hospitals quickly and safely.

"If you are injured on the side of the road, it's our job to make sure they are transported to the hospital safely with people who are properly trained," says Eric Swanson, medical director for the University of Utah's nonprofit AirMed — which makes its tracking data available.

"That has all gone out the window," Swanson says. "It's just the Wild West."

Patients are also losing out on medical care, he says, due to the state's recent decisions to recognize NAAMTA and disband the department of health's Air Ambulance Committee, which Swanson led. The panel of emergency medical transport experts had advised the state and developed rules for regulating the medical side of the air ambulance industry — the sole realm over which the state has a say.

The committee objected to NAAMTA gaining accreditation authority alongside the Commission on Accreditation of Medical Transport Systems, or CAMTS, the longtime leader for accreditation companies. NAAMTA's staff and auditors lacked relevant expertise, according to committee members, and its standards appeared to be tailored to its clients' business models rather than national safety norms.

NAAMTA founder and Executive Director Roylen Griffin says the criticism has less to do with standards and more with unwanted competition.

The U.'s AirMed and Intermountain Healthcare's Life Flight, which act as nonprofit arms of the medical centers, have been "the only game in Utah forever ever and ever," Griffin says. "Now that the new hospital programs are coming ... there are new contracts, there are new things that the good ol' boys on the hill weren't ready for. They didn't know how to deal with it, so they think there's some shenanigans going on. ... They just fell asleep and didn't pay attention to the market."

The air medical transport industry is growing nationally, with the number of helicopters in service tripling in less than 20 years. Today, 1,045 helicopters and 362 planes are in service. According to the Association of Air Medical Services (AAMS), helicopters fly 400,000 medical missions and planes 150,000 a year. Just over half these trips transport patients between hospitals.

Two Utah firms are key figures in the industry's rapid evolution: NAAMTA and Air Medical Resource Group (AMRG).

Headquartered in South Jordan, AMRG is an expanding national chain of 12 providers, including two Utah newcomers, Guardian Flight and AirCare, which are currently seeking accreditation from NAAMTA and are operating in Utah under provisional licensing, according to the Utah Department of Health.

Shanon Pollock, AMRG's vice president for development, declined to comment for this story.

While critics fear this expansion could water down the quality of service, the AAMS says it serves a vital medical need.

"The greater societal good is access to health care. There are over 80 million Americans who don't live within one-hour ground transport of a Level 1 or Level 2 trauma center," AAMS President Rick Sherlock says.

"If you live in any large rural area, southern Utah or West Texas, you may not have access to critical care centers," he says. "Air is the only access to critical care in times of need."

More than 300 trauma centers have closed in the past two decades, a period in which emergency room visits have tripled.

Meanwhile, the portion of the population over age 65 is increasing, from 13 percent in 2010 to 20 percent in 2040. Patients over 65 account for a third of medical flights.

Though flights aren't necessary for every patient, they're vital, Sherlock says, when someone has had a heart attack or stroke. "You have a limited window of time, the golden hour, to get that patient to an appropriate medical center that can directly treat their conditions. That makes a significant difference in the outcome for that patient."

But patients dealing with a life-threatening emergency are hardly in the position to shop around — and allegations of price gouging have increased nationwide and in Utah as the ranks of medical helicopters have grown.

A few years ago, a San Juan County man named Cortney Montella had an acute case of pneumonia when doctors at Blanding's Blue Mountain Hospital decided he should be flown to Salt Lake City for treatment. Eagle Air Med, an AMRG affiliate based in Blanding, flew Montella by plane and billed his insurance company $89,894 for the 268-mile flight.

The insurer paid $8,164, and Eagle's efforts to collect the rest from the patient have triggered multiple lawsuits.

In a suit filed against Eagle, Montella's lawyers contend he never agreed to such an exorbitant price, which should be limited to $7,561 — the amount allowable under Medicare.

Eagle filed a counterclaim against Montella seeking the unpaid difference. The case is ongoing.

AMRG is now also suing Sentinel Air Medical Alliance, which reviewed Montella's bill on behalf of the insurer and recommended the insurer pay only the $8,164, based on Sentinel's calculation of what it cost Eagle to fly the patient.

AMRG alleges Sentinel's "defamatory" reviews have cost the company more than $800,000 in billings that insurers have refused to pay.

Sentinel is aggressively fighting back, according to its chief partner Jeff Frazier, who says AMRG suit's aim is to silence his company and its efforts to bring transparency to this business.

"Your state was well served before these other organizations showed up. U. of U. and Intermountain Health provide a high quality of service at reasonable rates," says Frazier, who is based in Montana.

Those nonprofits use twin-engine choppers and seasoned crews that can pull off most mountain rescues and fly in poor visibility.

Many for-profit companies use cheaper aircraft, such as the single-engine Eurocopter AS350 — a model that has been involved in more than half the 23 fatal air-ambulance crashes since 2009, according to a database maintained by the University of Wisconsin's chief flight physician, Mike Abernethy.

Utah's nonprofits have experienced crashes, but none in the past decade. AirMed lost three crew members and a patient when a chopper took off into a storm and crashed in Little Cottonwood Canyon. In 2003, a Life Flight chopper crashed in dense fog, claiming the lives of three crew members; six months later, two more crew members were lost to a mechanical failure.

The crashes spurred safety changes and investments in more powerful aircraft.

But high-quality equipment and personnel means the firms have high fixed costs, Frazier notes. Such operations can be sustained only if these costs are spread around over many transports.

That's jeopardized by the arrival of for-profit providers, according to Frazier.

"Too many helicopters are chasing too few patients," he says.

And because the 1978 Airline Deregulation Act prohibits states from regulating pricing or routes on air ambulance helicopters, the situation is unlikely to change without action from Congress.

States do oversee the medical side of air ambulance services — but Utah and most others have outsourced this job.

Until recently, the South Carolina-based nonprofit CAMTS — which accredits 182 providers across the country — was the sole accreditation company recognized in many states, including Utah. But when the Utah-based Eagle Air Med sued Colorado over requiring CAMTS certification, the Utah Department of Health asked its Air Ambulance Committee to explore ways to authorize an alternative accrediting service.

The committee spent four years crafting criteria for selecting accrediting agencies and vetting would-be accreditors. A court reporter documented every meeting. In 2014, the state invited accreditors to apply for official recognition. NAAMTA's entry came in months late and failed to measure up in every category, former committee Chairman Swanson wrote in an email to Guy Dansie, the state's program manager for emergency medical services.

Among NAAMTA's deficiencies, according to the committee: a lack of clear conflict-of-interest guidelines; a lack of participation by national organizations in developing standards; a lack of relevant experience on its board; clinical experience not being required of its auditors; and that state health officials were not allowed on site visits.

The state's bureau of emergency medical services, however, overruled the committee and in January approved NAAMTA's participation in Utah's licensing program.

The bureau then dissolved the Air Ambulance Committee.

The committee was not authorized under any statute, Dansie says, but the department plans to reinstate it as a subcommittee without rule-making authority.

The state had little choice but to approve NAAMTA, Dansie says, because offering only one accrediting avenue could be regarded as an illegal constraint on trade.

"We've had outside air ambulance companies wanting to come in and they're threatening that if we don't play ball with them, they're going to cause problems or take us to court," Dansie says. "So we're a little gun-shy because we've seen what's gone on in other states."

Griffin rejects Swanson's criticisms and says state officials fully vetted his organization, which so far has accredited 15 clients.

"They've come in here. They've taken me apart and they can't find anything wrong with what goes on with the process," he says. "How could I sleep at night by having substandard standards or giving someone a free meal ticket to do whatever the hell they wanted to with safety and patient care?"

The real issue with the air ambulance industry, he says, is that the government doesn't give accreditors like him the funding to fully watch over companies.

Unlike CAMTS, which does a comprehensive re-evaluation of companies every three years, Griffin says his organization does one accreditation process and then has clients self-report on a quarterly basis about safety issues, new equipment, personnel, etc.

Ira Blumen, medical director of the University of Chicago Aeromedical Network, is an expert in air medical safety issues and finds it troubling that an accreditation agency would not do comprehensive follow-ups on its clients.

"One accreditation and you're done makes no sense to me," Blumen says.

But these kinds of ongoing reviews are expensive, Griffin says, and local governments should offer financial help if they want more.

"You need to either give the accreditation companies the money, or do it yourself," Griffin says, "or shut up and let us do what we can for the money we're collecting."

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