When and Where Air Ambulances Save Lives: Part 2 of a 2-part series

Air ambulances provide quick transportation for patients in remote locations, as well as for paramedics and other medical professionals whose services can be the difference between life and death in an emergency. In the first part of this series, we looked at why hospitals offer air medical services (AMS) and how insurers and patients navigate the challenges of paying for them. In this part, we will look at some of the tradeoffs between convenience and cost in AMS, along with some concrete examples of their use.

The Tradeoffs of Air Ambulances

The benefits from AMS are somewhat offset by costs, yet they greatly exceed those of ground ambulances:

• An air ambulance is recommended for any patient who needs immediate attention but is beyond the reach of a ground EMS service, or would be at a high risk of death if transported by one. Helicopters are the most common mode of transport in emergencies such as cardiac arrest or profuse bleeding, while airplanes may also be used in these cases and in less urgent ones (e.g., long-distance travel to a facility in a different state or country).
• While traditional ambulance service is generally expensive (Medicare paid $6 billion for it in 2013, triple its 2002 total), on a per-trip basis it pales in comparison to AMS. The Montana Commissioner of Securities and Insurance found that patients routinely face five-figure payment responsibilities for AMS, even after private insurance pays as much as $13,000 in liftoff costs alone. The high price of AMS has spurred many states to attempt to cap what providers can charge, but current federal airline law complicates any such regulation.

To see the tension between the benefits and drawbacks of AMS, let's look at where air ambulances are more heavily utilized today.

Air Ambulance Use #1: Remote health emergencies

A helicopter is virtually the only way to reach someone who needs medical attention on a mountain peak or isolated ranch. It is also the fastest way to transport victims of car crashes, which have much higher fatality rates in rural locations than anywhere else. In other situations, an injured individual or a sick infant may need to go to a specialty hospital that is out of state. Timely transport over state lines, via helicopter or plane, is often the only way to access optimal treatment in these cases. For example, on just one day in 2016, air ambulances from Kalispell Regional Healthcare landed five times at Logan Pass in Glacier National Park in Montana to respond to nearby emergencies. Surging attendance at the park, combined with limited on-site personnel and varied terrain, has made air ambulances a fixture in the area in recent years.

Air Ambulance Use #2: International travel

Patients who are injured abroad, or who seek treatment in a different country for economic or technological reasons, may turn to air ambulances. A plane is the mostly likely mode of transportation here, due to the distance. Like medical helicopters, planes are outfitted with specialized equipment and medical personnel for treatment throughout the journey. Ground ambulance transportation may be needed to and from the aircraft, incurring additional expenses. In a widely covered 2012 incident, a Swiss woman who had been treated for blood vomiting in Mysore, India, was transported by air ambulance back to Switzerland after her condition stabilized. The provider in India coordinated with her insurer to set up the international flight.

Air Ambulance Use #3: Fast surgery

The speed of air ambulances and their ability to avoid traffic also make them ideal vehicles for taking doctors and paramedics directly to the scene of a trauma. One notable example of this use can be seen in the United Kingdom which has employed air ambulances to respond to an increase in knife attacks. More specifically, a group of doctors stationed at Magpas Helimedix in Cambridgeshire, England, have demonstrated the possibilities for such rapid response. They have promptly conducted thoracotomies to treat cardiac arrest, as well amputations, after landing via air ambulance.

Paying for AMS: What can patients and insurers do?

In all these circumstances, AMS are likely to be expensive in the U.S., particularly if the provider is out-of-network (always a possibility during an emergency, when there is less time for decision-making and 911 dispatchers may be deciding). As we noted in part one, bills for air ambulances from some providers average more than $40,000 and insurance reimbursement often does not cover all or even most of the costs. Many state governments, especially in the rural west, offer guidance on how to deal with the financial challenges of AMS. For example, some providers offer memberships that have annual fees but eliminate out-of-pocket. One air ambulance firm with 260 air base locations covering 32 states has an AMS membership plan with a fee that is a fraction of the cost of a typical flight.  Another provides an “air ambulance card” that serves as an additional layer of protection beyond standard travel insurance. Pre-approval from an insurer is not required for emergency flights, but may be mandatory for non-emergency ones. Checking with an insurer is recommended to understand the potential scope of payment responsibilities in either case. At Advanced Medical Reviews (AMR), an independent review organization, air ambulance use is a more nuanced topic when examined through the lens of a medical necessity appeal. As Abigail Mosley, Director of Account Services, explains, “I live in a very rural part of the country, so I understand on a personal level how air ambulances can be lifesaving for rural residents. The medical necessity of the service encompasses more than just the use of an air ambulance; it may take into consideration where the emergency occurred and how far away the ambulance flew, for example. There are big price differences depending on the distance traveled, and insurance companies are invested in making sure patients receive quality care at the most appropriate facility given the nature of the care required and the distance to travel.”

The Future of Air Ambulances

Air ambulances fill a critical gap in the healthcare system. That said, there is work to be done in ensuring their services are available and affordable to everyone who needs them. Currently, there is a drive toward more extensive use of drones and remote-controlled telemedicine, which between them may be able to address these concerns by improving response times and lowering costs (since fewer human personnel would be necessary). In rural Sweden, for instance, autonomous drones carrying automated external defibrillators were faster than ambulances in 18 different trials. If deployed at scale, they could potentially save the lives of thousands of cardiac arrest victims each year, with less overhead than helicopters and planes. Providers and insurers will likely continue exploring this route and others to manage issues of accessibility, safety and cost in the years ahead.