How Air Ambulances (Don't) Work

This video was made possible thanks to CuriosityStream. Sign up for any subscription at CuriosityStream.com/Wendover and get free access to Nebula, where you can watch my new trivia show or our upcoming Wendover original. During World War II, a young doctor named R Adams Cowley spent his deployment on the battlefields of Europe, treating patients on the precipice between life and death. He observed, through this experience, that those who suffered the medical state of “shock” after a traumatic injury were on an often certain, but not immediate, path to death. This exposure to these patients developed his life's goal: he sought to take them down that safe path to death and nurse them back to life.

He wanted to be able to treat severe traumatic injuries that were then untreatable. A few years later, in 1960, he moved closer to his goal by opening, somewhere in the sprawling University of Maryland Medical Center, a two-bed unit dedicated to the treatment of severely traumatized patients—the first department of its kind. in the country. Cowley started with a survival rate of around 40%, but as he gained experience and refined his techniques, more and more patients survived. It turned out that the certain path to death for severely injured patients was not so certain. However, he also noted that even his reliable techniques could not reverse the course of death if a patient took too long to reach him.

He posited that once someone experienced major trauma, you had a window of approximately 60 minutes to communicate with them or else it was too late. The problem was that by the time other doctors transferred a patient to Cowley, that window had often already passed. The system was simply not suitable for this type of speed. Therefore, he reinvented the system. First, he pushed for

ambulances

to take trauma patients directly to him (or, eventually, to other trauma units) rather than simply to the nearest and potentially unequipped hospital, as was standard protocol at the time. Second, he convinced the Maryland State Police to use their helicopters to fly trauma patients to his unit, dramatically reducing average care time.

Cowley called this 60-minute window the Golden Hour and the principles behind it are now the central and guiding light of the Emergency Medical Service system: its purpose is to stabilize, triage and transport as quickly as possible because, according to this Golden Hour In principle, faster is always better in trauma medicine. The vast majority of the American population can reach their nearest hospital within the Golden Hour with a traditional ground ambulance system, but not all. This is a map of the US, and these are the areas that are more than a sixty-minute round trip to the nearest hospital.

There are vast areas of the sparsely populated American West where ground

ambulances

cannot meet the golden hour principle, especially given the recent spate of closures of unprofitable rural hospitals. In fact, it is not even very difficult to encounter this problem. If you were driving from Denver to Las Vegas (two major American cities), most of your trip would be on Interstate 70, which would take you through the desolate area of ​​the San Rafael Swell. If your car crashed here, the nearest hospital would be more than ninety minutes away, in Moab, and this is right on the interstate, America's central circulatory system.

It is very possible to move much, much further away from health care and so to close these gaps, so that patients in the most rural areas and in the most extreme circumstances receive care as quickly as possible, that is where the system comes in. of the country's air ambulance. In the country there are about 900 air ambulances stationed at hundreds of bases, each of which expands the number of people who can reach the hospital in an hour. Each of these planes has the potential to change lives every day and plays an important role in many people's worst days.

When your life is at stake, every minute counts, which is why these planes save lives and limbs with every flight... right? Well, to a certain person, maybe an executive at an air ambulance company, for example, the 702 words so far probably all sound right, but are they really? Until now everything has revolved around a simple principle: the more trauma patients brought to the hospital in sixty minutes, the more lives will be saved? It can't be that the central principle of emergency medicine, the Golden Hour principle, is just... wrong... right? Well, in 2001, an academic review asked exactly that question and found that "there are no large, well-controlled studies in the civilian population that strongly support or refute the idea that faster is universally better in trauma care." Essentially, it was saying that the Golden Hour principle might be true, but even though the entire EMS system operates under the collective assumption that it is true, we just didn't know for sure.

So in response, researchers searched for an answer. Many found the answer was yes (unsurprisingly, faster transport to the hospital improves survival outcomes), but many others... no. It found that “the time factor involved in handling and transporting hypotensive penetrating injury victims directly to a regional trauma center does not appear to be related to an adverse outcome.” He concluded that "no prehospital time less than 90 minutes had a significant adverse effect on survival," while he found that "there were no significant differences in survival after traumatic injury when the response time criterion was exceeded." "8 minute ambulance". Similar results were found in this study, this one, this one, this one, and many more, which failed to find a statistically significant link between total prehospital time and survival outcomes.

Twenty years after that academic review, the only certainty here is uncertainty: there is no scientific consensus on whether the Golden Hour is really relevant today. Uncertainty is fine (it's part of the scientific process), but the entire American air ambulance industry is based on a collective, unverified assumption that the Golden Hour principle is actually true. However, since we are dealing with assumptions, let's address another one. When you think of air ambulances, you probably imagine a flight from here to here: from location to hospital. Of course, that's what you see in the movies, but these types of flights only account for about a third of air ambulance trips.

The vast majority of their business involves hospital-to-hospital transfers. You see, the trauma care system that Dr. Cowley innovated evolved into a nationwide hierarchical net

work

. There are basically five levels of trauma centers (hospitals certified to treat patients with severe traumatic injuries), and as you move up the levels, the centers become more advanced and less spread out. Levels V and IV primarily deal with stabilization and initial evaluation before transfer to a higher level center, while Level III centers will have surgeons on call who could begin to resolve simpler trauma cases. Level II centers have surgeons on call 24 hours a day, rather than just on call, in addition to certain specialists.

Then, the most advanced Level I centers have everything possibly necessary for any trauma case, including specialists in all fields, and the ability to treat a case from initial presentation to rehabilitation, which can be a process of several years. Level I trauma centers are incredibly expensive to run and therefore need a critical mass of patients to cover costs. Consequently, it is quite possible to be more than 600 miles or 950 kilometers from a place in the lower 48 states, or 2,000 miles or 3,200 kilometers from a place in Alaska. Because of this potential distance, a severe trauma case outside of a major city would typically first go to a level III, IV, or V trauma center, which are much more common, where they would be stabilized and evaluated to determine if they need to be transferred to a more advanced installation.

So someone in a car accident in the San Rafael Swell on I-70 in Utah would probably go first to Moab Regional Hospital, which is a Level IV facility. If the doctors and nurses determined that the patient needed a higher level of care, they would transfer him, in this case to St. Mary's Hospital in Grand Junction, Colorado, which is a Level II facility. Then, if that hospital determined that the patient had injuries so complex and specialized that not even they could handle them, the patient would likely be transferred to Denver Health's Level I trauma center. Since each of these transfers would take hours by ground, the decision would almost certainly be made, for severe trauma cases, to use an air ambulance.

This is the bread and butter of the air ambulance business and it surely saves lives, right? Well, yes and no. In a study of severe trauma patients suffering from certain high-mortality injuries, patients admitted to level II centers had a mortality rate of 29.7%, while those admitted to a level I center alone they died 25.4% of the time. More advanced trauma centers save more lives, and therefore conventional wisdom would assume that transfers to higher-level centers save lives, but conventional wisdom almost always overlooks the nuances of a situation. According to another study, approximately a quarter of adults and half of children transferred to Level I trauma centers are taken there unnecessarily;

In other words, they have been subject to "secondary overtriage," in which the most advanced center ends up discharging them after completing treatment. which a less advanced center would have been very capable of doing. Now, some level of secondary overclassification is to be expected and even encouraged (after all, better to be safe than sorry), but again, we need that nuance. For an overclassified patient, they would have survived if they had stayed in a Level III facility, for example, and they survived when they ended up in a Level I facility, so the health outcome was the same, but for those patients transferred by an air ambulance, they received something else: an absolutely enormous bill.

A conservative estimate puts the average price of an air ambulance flight in the United States at $27,900. Others put that figure even higher, between 30 and 40 thousand, meaning that it is very possible and even common for someone to be charged more for a quick helicopter ride to or from the hospital than they earn in a year. However, there is another counterargument: a human life, to the one who possesses it, is essentially priceless (any cost to save it is worth it), but the problem is not the cost, it is the price. The cost for air ambulance companies to operate a given flight, according to the companies themselves, ranges between $6,000 and $13,000.

That should not be possible, since literally the rules of economics say that that gap between cost and price should not be possible, because in a normal free market, for normal products, competition would drive prices down much closer to their levels. costs as lower prices increase demand and companies can increase profits with greater market share, but the US air ambulance market is far from normal. Every product in the world can be represented on a graph like this: price on the y-axis, quantity purchased on the x-axis. This is what a normal product looks like: as the price drops, the quantity purchased increases.

There are some exceptions to this; For example, luxury goods certainly look like this on the chart, where higher prices actually stimulate greater demand, to some extent, although almost no products will look like this. However, this is the relationship between price and demand for air ambulances: as the price increases, it has no impact on demand. It's easy to understand why: the people who buy and pay for air ambulance flights have no power over whether to do so or not. The decision to use an air ambulance is made by first responders or doctors, not the often unconscious patient, so there is a complete lack of market forces

work

ing to lower the price.

When the free market fails to regulate the allocation of goods and services in the most advantageous configuration for society (which in this case would be the greatest possible availability of air ambulances at the lowest possible prices), economists would describe it as a failure. From the market. . In cases of market failure, even the most staunchly libertarian economist would tend to agree that the only solution, at that point, would be external intervention (usually by thegovernment) and therefore this massive and critical industry that charges vulnerable people massive and crippling prices. It can't possibly be completely unregulated, right? Incorrect: In fact, the air ambulance industry is not only unregulated, it apparently cannot be.

You see, back in 1978, Congress passed the Airline Deregulation Act, ending the government's ability to regulate airline fares. This led to a dramatic decrease in airfares and a dramatic increase in flying (essentially paving the way for the United States to become the largest aviation market in the world), but when it tried to deregulate airlines, that really He was referring to all airlines. Over the years, as various states have attempted to address the air ambulance industry's market failure, providers have successfully argued in court over and over again that because they are technically airlines and because the Act Airline Deregulation Act prevents states from regulating air fares, states therefore cannot regulate the prices charged by air ambulances.

There really is no limit to what they can charge. But wait. There is another unique market force in the American healthcare industry that could solve this problem: insurance, right? You see, most insurers in the US have a network of providers they cover, and if a patient uses an out-of-network provider, they are charged a much higher rate or subject to an annual spending limit. . In non-emergency circumstances, it is often possible to find an in-network provider, and many states and recently the federal government have also passed laws limiting out-of-network bills for emergencies, but of course, thanks to the Airline Deregulation Act, Those do not apply to air ambulances.

In the US, about 77% of air ambulance flights are billed out of network, meaning patients are on the hook for all, or at least the vast majority, of those thirty, forty, or fifty bills. thousand dollars air ambulance. This is, once again, a symptom of market failure. For most medical services, insured patients have the choice of which provider to go to, they have the choice to go to an in-network provider, which is a market force that pushes providers to accept so many types of insurance as possible. —if they didn't, they would lose business—and those insurers have the scale to negotiate prices down.

However, with air ambulances, since patients have no ability to choose which provider to use, or even if they use one, there are no market forces driving providers to bring more insurers into the network. In fact, they are often paid more by out-of-network patients, which means that not only do they lack incentives to bring insurers into the network, but market forces are pushing them to minimize the number of insurers in their network. Air ambulance providers, and more specifically the private equity firms that now own most of them, have discovered just how exploitable this market failure is. Since 2000, the number of air ambulances in the United States has more than doubled to nearly 900, and the average annual helicopter flight hours have fallen from a high of 600 in 2003 to nearly 450, as these companies continue to overwhelm plus the market.

In the same period, average prices have more than tripled. It's hard to get a good sense of how much these companies are benefiting from the plight of Americans at the most vulnerable times in their lives, largely because nearly all of the industry's major players are now owned by private equity firms, and therefore do not report their financial results. What is clear, however, is this: In 2017, according to one study, air ambulances owned by privately held companies charged about twice as much as those owned by hospitals or nonprofits. The costs of operating for-profit and non-profit air ambulances are not dramatically different, so the only reasonable conclusion is that these private for-profit air ambulances are pocketing thousands and thousands of dollars in profits per patient.

There is nothing stopping this industry from charging higher and higher rates (not market forces, not regulation, nothing) and therefore these private equity firms, realizing this, will continue to increase prices and turning road accidents and heart attacks into bigger returns for their clients. investors. Right now, this is an industry that cannot be stopped. However, there is a potential push for reform with the recently passed No Surprises Act, which limits out-of-network charges in emergencies, but it is unclear exactly how this can and will affect the air ambulance industry when it comes into effect. effective in 2022, given the protections of the Airline Deregulation Act.

Any doctor knows the words "primum non nocere," a Latin phrase that translates to "first, do no harm." It is a maxim that guides all bioethics courses in medical school and, essentially, recognizes that in medicine it is possible to do more harm than good. Therefore, when someone reaches the last days or hours of their life and the outcome is certain, the decision is normally made to suspend treatment, because it can only do harm. Treatments carry physical, emotional and financial burdens, so they are simply not worth it when the path to death is irreversible. When air ambulances are used, the goal is to reverse that path, and in many cases they succeed.

However, the best research estimates that for every 100 air ambulance flights, four lives are saved. That means that in 96 out of every 100 cases, the patient or his or her family leaves the hospital having lost a year of income. They leave after having delayed retirement by a year, having lost the ability to send their children to college, buy a house or go on vacation; They have lost a non-trivial amount of quality of life. In 96 out of 100 cases, doctors using private air ambulance providers are forced to violate their Hippocratic Oath, forced to make a split-second decision that harms and worsens lives, all because, at the end of the day, line, there's a rich investor in some private equity firm who prefers a 10.5% to 10.4% return on investment, and no one is doing anything to stop him.

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