New York Times, May 3, 2005 As Medical Airlifts Proliferate, the Public Price Tag Is Rising By BARRY MEIER One night last May, after two cars collided along a rural highway about 40 miles west of Tulsa - killing one driver and seriously injuring the other - firefighters from the nearby town of Foyil called for a medical helicopter.
But as the aircraft descended, they saw it was a helicopter operated by a rival company and not the one their dispatcher had summoned from Tulsa. Randy Atchley, the chief of the Foyil fire department, said he thought the rival helicopter's crew, listening on an emergency scanner, had "jumped the call" and raced to the scene. The firemen waved it off and the Tulsa-based helicopter soon arrived. Air ambulances were once a rarity. Not today. Across the country, competing helicopter services are locked in air wars over patient-rich areas as medical airlifting grows more profitable and common. As with other health care services that have become routine - sophisticated diagnostic tests like CAT scans, for example - the public price tag is soaring and helicopters are being used when ambulances might do. The price of an airlift ranges from $5,000 to $10,000, 5 to 10 times that of a ground ambulance. "They are buzzing above you like buzzards," said Brad Lancaster, the director of emergency medical services in Murray County, south of Oklahoma City. On a recent windy morning, Cliff Rost, the volunteer fire chief in Morrison, Mo., found himself walking an older man bothered by shoulder pain a quarter of a mile down a road to reach a helicopter run by a company called Air Evac Lifeteam. The man had bought a company "membership" that allowed participants to call for an emergency airlift without any out-of-pocket cost. In recent years, Mr. Rost said, Air Evac has made about a dozen flights into the area, about 75 miles west of St. Louis. He said he felt that only one had involved a serious emergency. "They had people running around saying, 'You don't need to call 911, just call Air Evac,' and that's what's been happening," he said. Executives of Air Evac and its investors declined to be interviewed for this article. But in a written statement, its chief executive, Colin C. Collins, said that Air Evac made only medically necessary flights and that the company had saved "countless lives." He also said Air Evac did not "jump calls." An estimated 700 medical helicopters operate nationally, about twice the number flying a decade ago. And with more of them scrambling for business, specialists say that emergency personnel are feeling more pressure to use them. Last year, the number of flights paid for by Medicare alone was 58 percent higher than in 2001. Spending by Medicare, which increased its rate of reimbursement for airlifts in 2002 and set a higher rate for patient pickups in rural areas, has more than doubled, to $103 million, over the same period. In some cases, helicopters can transport seriously ill or injured patients to a hospital more quickly than by ground. But the industry's rapid expansion has taken place amid scant oversight of both flight safety and medical quality. The medical capabilities of competing helicopter concerns can vary sharply. Meanwhile, deaths in crashes have reached alarming levels and questions remain about the effectiveness of air ambulances. In the past, medical helicopters were largely operated by hospitals. But increasingly, aviation companies run them like independent air taxis that respond to emergency calls or ferry patients between hospitals. The industry is diverse, made up of large and small operators and two publicly traded companies, the Air Methods Corporation and Petroleum Helicopters Inc. But if one company exemplifies the industry's growth, as well as its excesses and problems, it may be Air Evac Lifeteam, one of the nation's biggest operators. The company was founded in 1985 with one helicopter in West Plains, Mo., a small town in the Ozark Mountains, to transport rural patients to hospitals in cities. An annual membership is $50 a household. In an emergency, a member can call Air Evac, rather than a 911 operator, and it will send a helicopter. Under the plan, the company will not seek money from a member beyond what a private or public insurer pays. William R. Chritton, a founder of Air Evac, recently recalled the company's earliest days. "I was flying around as a pilot selling memberships," said Mr. Chritton, whose interest in the company was purchased last year. Some communities have welcomed Air Evac's arrival, and last year two private equity firms bought the company at an undisclosed price. Its formula has proved so successful that it now operates out of 54 locations in nine Central and Southeastern states, acquiring 10 bases in Texas last month. But along the way, the company's critics - who include some competitors, doctors and emergency officials - contend that Air Evac has used a variety of tactics to generate flights for itself, including unneeded ones. Air Evac has also fought efforts to tighten oversight of the air medical industry. "When you talk about Air Evac Lifeteam, they are probably the No. 1 opponent to regulation in the country," said Ron Walter, the president of the National Flight Paramedics Association, a professional group. In his statement, Mr. Collins said his company's safety record was strong. "Our company provides a critically needed service to medically underserved areas of rural America," Mr. Collins stated. These days, Air Evac's membership campaigns seem more like aggressive marketing drives than community barn raisings. Two years ago, the company sent a "blitz team" of paid representatives to Scottsboro, Ala., to sell memberships door to door, as well as outside stores like Wal-Mart and to civic groups like the Veterans of Foreign Wars. A former salesman there, Joseph W. Ashmore, said that a focus of such drives were people deemed at high risk of emergencies, like those in dangerous jobs and the elderly. Among his sales stops were assisted-living facilities. "It's a very emotional buying decision," said Mr. Ashmore, who successfully sued Air Evac last year in an Alabama court over unpaid commissions. Some people who have bought memberships said they were glad they did. "It's just like other kinds of insurance," said Lucy Bevill, who lives outside Shelbyville, Mo. "It's there when you need it." Air Evac's strategy has been to keep costs low by buying old single-engine helicopters and retrofitting them as medical aircraft. The number of flights its helicopters need each month to break even is about 25, or half that of most hospital flight services, which often operate larger aircraft and have full-time crews. "We have a Wal-Mart real estate mentality with a Southwest Airlines business" style, Mr. Collins said in an earlier interview. Air Evac said that membership flights represented only a small fraction of its airlifts. The company also builds ties with another vital constituency: ambulance, police and fire personnel, who call for helicopters and often decide which operator to use. Consider the case of Jefferson County, Mo. In 2002, when Air Evac set up a new base there, it sold memberships to public employees in the town of Hillsboro, the county seat, for $10 each. The company also hired the relatives of officials running ground ambulances as its marketing representatives, said Edward L. Kemp, a county commissioner. Mr. Kemp said he believed that Air Evac made those hires so ambulance crews would call for its helicopter and not a competitor's. "If your daughter's livelihood is at stake," he said, "who are you going to call?" The company's allies also tried to persuade 911 officials in the county, which is about 45 miles south of St. Louis, to call Air Evac first, but that effort was rejected. In late 2003, Air Evac closed the base, citing a lack of flight volume. The company continues to operate two nearby bases. But data collected by the Missouri health department indicate that calls for Air Evac services fell sharply after it closed the Jefferson County base. In the last five months of 2003, Air Evac made 60 flights from Jefferson County. But in the last half of 2004, it made only 28. Mr. Collins said in the statement that the company did not single out any age group for marketing purposes. And he added that any suggestions that Air Evac provided benefits to emergency personnel or made hiring decisions to win business "could not be more wrong." Under federal law, providing a financial benefit to solicit health care referrals may qualify as an illegal kickback. Mr. Collins added that other air programs offer memberships. But not long ago, when Air Evac tried to join a trade association of medical helicopter membership programs, the group rejected its request because it is a for-profit company, said Vern Bartley, the director of Air Life of Oregon, which is based in Bend. The group's members are all nonprofit. "We don't door-to-door sell," said Mr. Bartley. As the industry grows profitable, aerial turf wars are flaring up. For instance, as Air Evac gained footholds in the Nashville area, Vanderbilt Medical Center set up four new bases in a protective ring around the Tennessee city and its suburbs. In some places, the arrival of more helicopters has meant more business for everyone, not less. Elsewhere, competitors have raised prices, not lowered them, to make up for lost volume. Meanwhile, areas with high levels of Medicaid patients or the uninsured are often ignored. "It is horribly inefficient," Mr. Bartley said. Government oversight is spotty. While the Federal Aviation Administration sets some basic flight safety standards, state regulations concerning patient care, crew training and flight safety vary. Some states do not regulate medical helicopters at all. A few states like Michigan, Rhode Island and Washington require that air ambulances be certified by a voluntary industry standard-setting group, the Commission on the Accreditation of Medical Transport Systems. But when some operators in Missouri and Oklahoma pressed for such legislation they ran into a formidable opponent - Air Evac. "They shot us down," said R. Shawn Rodgers, the emergency medical services director of the Oklahoma State Department of Health. To avoid another legislative defeat, Oklahoma officials recently adopted the group's guidelines as regulation. Mr. Collins stated that Air Evac had opposed legislative efforts on accreditation because it did not believe there "should be the single standard for state licensure." He also said that Air Evac had a strong safety record and that a consulting group, Aviation Research Group/US, had given it a "Silver" rating. Joseph J. Moeggenberg, the company's president, said the ranking signified that a review of public records indicated that Air Evac had a reasonably good safety record compared with operators of similar size. The industry's growth is likely to continue. Mr. Chritton, Air Evac's founder, said Mr. Collins had told him that Air Evac hoped to open 12 locations a year. And others are scrambling to keep up. Hearing Air Evac's footsteps, three helicopter operators have recently contacted him to learn how memberships work, said Mr. Bartley of Air Life of Oregon. But memberships may have other costs. Craig Yale, an executive with Air Methods, said that one of its helicopters was recently at an Illinois hospital to transfer a cardiac patient. But the man and his family refused to take it and asked for Air Evac to come because he was a member. Air Evac dispatched a helicopter to the facility. But before it arrived, Mr. Yale said, the patient suffered a heart attack and died. Mr. Collins did not respond when asked to comment on the episode. --- URG-L Les archives de la liste d'echange sont disponibles pour consultation a l'adresse : <http://www.mail-archive.com/[email protected]>
