How Air Ambulances (Don't) Work
This video was made possible by 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. Back during World War Two, 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 suffering the medical state of “shock” following a traumatic injury were placed on an often certain, but not immediate, path towards death. This exposure to those patients developed his life’s goal: he sought to take those on that certain path towards death, and nurse them back to life.
He wanted to be able to treat then-untreatable major traumatic injuries. Some years later, in 1960, he neared closer to this goal by opening, in some corner of the sprawling University of Maryland Medical Center, a two-bed unit dedicated to treating major trauma patients—the first such department in the country. Cowley started with about a 40% survival rate, but as his experience accumulated, and his techniques refined, more and more patients survived. It turned out that the certain path towards death for major trauma patients was not so certain. However, he also observed that even his reliable techniques couldn’t reverse the course of death if a patient took too long to get to him.
He posited that once someone experienced major trauma, they had a roughly 60-minute window to reach him, or else it was too late. The problem was that, by the time other doctors transferred a patient to Cowley, that window had often passed. The system just wasn’t suited for this sort of speed. Therefore, he reinvented the system. First, he lobbied for
ambulancesto bring trauma patients directly to him—or, eventually, other trauma units—rather than just to the nearest, potentially unequipped hospital, as was standard protocol at the time. Second, he convinced the Maryland State Police to use their helicopters to bring trauma patients to his unit—dramatically reducing the average time to care.
Cowley dubbed this 60-minute window the Golden Hour and the principles behind it are now the central, guiding light of the Emergency Medical Service system—its purpose is to stabilize, triage, and transport as fast as possible because, according to this Golden Hour 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-based ambulance system, but not all. This is a map of the US, and these are the areas more than a sixty-minute round-trip drive to the nearest hospital. There are vast swaths of the sparsely-populated American west where ground
ambulancescannot fulfill the golden hour principle, especially given the recent spate of closures of unprofitable rural hospitals.
In fact, it’s not even very difficult to run into this problem. If you were to drive from Denver to Las Vegas—two major American cities—most of your trip would take place on Interstate 70, which would lead you through the desolate area of the San Rafael Swell. If your car were to crash here, your nearest hospital would be over ninety minutes away in Moab, and this is just on the interstate—the central circulatory system of the US. It’s plenty possible to get much, much further from medical care and so, to plug these gaps, to get patients in the most rural areas and dire circumstances to care as fast as possible, that’s where the country’s air ambulance system steps in.
Across the nation, there are some 900 air ambulances stationed at hundreds of bases, each of which expands the number of people able to reach hospital within an hour. Each of these aircraft have the potential to change lives each and every day, and play a big part in many people’s worst days. When your life is on the line, every minute counts, so these aircraft save life and limb with every flight… right? Well, to a certain person, maybe an executive at an air ambulance company, for example, the 702 words up until now probably all sound correct, but are they really?
Everything up until now covered one simple principle: more trauma patients brought to the hospital within sixty minutes equals more lives saved? It can’t possibly be that the central tenant of emergency medicine, the Golden Hour principle, is just… wrong… right? Well, in 2001, an academic review posed that exact question and found, “no large, well-controlled studies in the civilian population that either strongly support or refute the idea that faster is universally better in trauma care.” Essentially, it said that the Golden Hour principle could be true, but despite the fact that the entire EMS system operates on the collective assumption that it is true, we just didn’t know for sure.
So, in response, researchers sought an answer. Plenty found that the answer was yes—as one would expect, faster transport to the hospital does improve survival outcomes—but plenty others… didn’t. This one found that, “the time factor involved in managing and transporting hypotensive penetrating injury victims directly to a regional trauma center does not appear to be related to an adverse outcome.” This one concluded with, “no prehospital time less than 90 minutes exerted a significant adverse effect upon survival,” while this one found, “no significant difference in survival after traumatic injury when the 8 minute ambulance response time criteria was exceeded.” Similar results, failing to find a statistically significant link between total pre-hospital time and survival outcomes, were found in this study, and this one, and this one, and this one, and countless more.
Twenty years onwards from that academic review, the only certainty here is uncertainty: there is no scientific consensus on whether the Golden Hour is truly relevant today. Uncertainty is fine—it’s part of the scientific process—but the entire American air ambulance industry is built on a collective, unverified assumption that the Golden Hour principle is indeed true. However, since we’re dealing with assumptions, let’s tackle another one. When you think of air ambulances, you probably imagine a flight from here to here: scene to hospital. Of course, that’s what you see in the movies, but these sorts 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 Doctor Cowley innovated evolved into a nationwide, hierarchical net
work. Essentially, there are five levels of trauma centers—hospitals certified to treat patients with major traumatic injuries—and as you go up in the levels, the centers become more advanced, and less widespread. Levels V and IV mainly deal with stabilization and initial evaluation prior to transport to a higher level center, while Level III centers will have on-call surgeons who could start to resolve simpler trauma cases. Level II centers have surgeons with 24-hour immediate availability, rather than just on-call, in addition to certain specialists.
Then, those most advanced, Level I centers have everything conceivably necessary for any trauma case including specialists across all fields, and the ability to treat a case all the way from initial presentation through rehabilitation—which can be a multi-year process. Level I trauma centers are incredibly expensive to run, and therefore need a critical mass of patients to cover costs. Consequently, it’s very possible to be more than 600 miles or 950 kilometers from one while in the lower 48, or 2,000 miles or 3,200 kilometers from one while in Alaska. Due to this potential distance, a major trauma case outside a major city would typically go first to a Level III, IV, or V trauma center, which are far more commonplace, where they’d be stabilized and evaluated to determine whether they need to be transferred to a more advanced facility.
So, someone in a vehicle crash in the San Rafael Swell on I-70 in Utah would likely first go to the Moab Regional Hospital, which is a Level IV center. If the doctors and nurses there determined the patient needed a higher level of care, they would be transferred—in this case to St. Mary’s Hospital in Grand Junction, Colorado, which is a Level II center. Then, if that hospital determined the patient had such complex and specialized injuries that even they couldn’t handle it, 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 major trauma cases, to use an air ambulance. This is the bread and butter of the air ambulance business and surely this saves lives, right? Well, yes and no. In one study of major trauma patients suffering from certain high-mortality injuries, patients admitted to Level II centers had a 29.7% mortality rate, while those admitted to a Level I center only died 25.4 % of the time. More advanced trauma centers do save more lives, and therefore conventional wisdom would assume that transfers to higher level centers save lives, but conventional wisdom almost always misses the nuance of a situation.
According to another study, some quarter of adults and half of children transferred to Level I trauma centers are brought there unnecessarily—in other words, they’ve been subject to “secondary overtriage” where the more advanced center ends up discharging them after completing treatment that a less advanced center would have been plenty capable of. Now, a certain level of secondary overtriage is to be expected and even encouraged—after all, it’s better to be safe than sorry—but again, we need that nuance. For an overtriaged patient, they would have survived if they had stayed in a Level III center, for example, and they did survive when they ended up in a Level I center, so the health outcome was the same, but for those patients transferred by an air ambulance, they received something else: an absolutely massive bill.
A conservative estimate puts the average price of an air ambulance flight in the US at $27,900. Others put that figure even higher, well into the 30 or 40 thousands, meaning it’s very possible and even common for someone to be charged more for a quick helicopter ride to or from the hospital than they make in a year. Another counterargument, though: a human life, to the holder of that life, is essentially invaluable—any cost to save it is worth it—but the problem is not the cost, it’s the price. The cost for air ambulance companies to operate a given flight, according to the companies themselves, is somewhere between $6,000 and $13,000.
That shouldn’t be possible—as in, quite literally, the rules of economics say that that gap between cost and price shouldn’t be possible, because in a normal free market, for normal products, competition would drive down prices far closer to costs since lower prices increase demand, and companies can increase profits with greater market share, but the American air ambulance market is very far from normal. Every product in the world can be mapped onto a graph that looks like this: price on the y axis, quantity purchased on the x. This is what a normal product looks like—as price goes down, quantity purchased goes up.
There are some exceptions to this—for example, certainly luxury goods plot like this on the graph, where higher prices actually stimulate higher demand, to an extent—although almost no product will look like this. This, however, is the relationship between price and demand for air ambulances—as price increases, it has zero impact on demand. It’s easy to understand why: the people purchasing and paying for air ambulance flights have no agency over whether or not to do so. The decision to use an air ambulance is made by first responders or doctors, not the often-unconscious patient, and so there is a complete lack of market forces
working to lower the price.
When the free market isn’t working to regulate the allocation of goods and services into the most societally advantageous configuration—which is this case would be the greatest possible availability of air ambulances at the lowest possible prices—economists would describe that as a market failure. 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—typically, by the government—and so this massive, critical industry charging vulnerable people massive, crippling prices can’t possibly be completely unregulated, right? Wrong: in fact, not only is the air ambulance industry not regulated, but it seemingly can’t be.
You see, back in 1978, Congress passed the Airline Deregulation Act, ending the government’s ability to regulate the fares of airlines. This led to a dramatic decrease in airfares and a dramatic increase in flights—essentially, it paved the way for the US to become the world’s largest aviation market—but when it sought to deregulate airlines, that truly meant all airlines. Through the years, as various states have attempted to fix the market failure of the air ambulance industry, providers have successfully argued in court time and time again that because they are technically airlines, and because the Airline Deregulation Act prevents states from regulating airfares, states therefore cannot regulate the prices air ambulances charge.
There is truly 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: that of insurance, right? You see, most insurers in the US have a network of providers that they cover and, if a patient uses an out-of-network provider, they are charged a far higher rate, or are subject to an annual spending cap. In non-emergency circumstances, it’s often possible to find an in-network provider, and many states and recently the federal government too have passed legislation limiting out-of-network bills for emergencies, but of course, thanks to the Airline Deregulation Act, those don’t apply to air ambulances.
In the US, some 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 or forty or fifty thousand dollar air ambulance bills. This is, once again, a symptom of market failure. For most medical services, insured patients have the ability to chose which provider they go to, they have the ability to chose to go to an in-network provider, which is a market force that pushes providers to accept as many types of insurance as possible—if they didn’t, they would lose business—and those insurers have the scale to negotiate prices down.
With air ambulances, though, since patients have zero ability to chose which provider they use, or even whether they use one at all, there are no market forces pushing providers to bring more insurers in-network. In fact, they often get paid more from out-of-network patients, meaning they they not only lack incentive to bring insurers in-network, but market forces are pushing them to minimize the number of carriers in their network. Air ambulance providers and, more specifically, the private equity firms that now own the majority of them, have figured out just how exploitable this market failure is. Since 2000, the number of air ambulances in the US has more than doubled to nearly 900, and the average annual flight hours per helicopter have dropped from a high of 600 in 2003 to almost 450, as these companies further saturate the market.
In the same time period, average prices have more than tripled. It’s tough to get a good gauge of just how much these companies are profiting on the plight of Americans in the most vulnerable moments of their lives, largely because almost all the major players in the industry are are now owned by private-equity firms, and therefore don’t report their financial results. What’s clear, though, is this: in 2017, according to one study, air ambulances owned by private-equity firms charged about double of what those owned by hospitals or non-profits did. The costs to operate non-profit and for-profit air ambulances are not dramatically different, so the only reasonable conclusion is that these private, for-profit air ambulances are pocketing thousands upon thousands of dollars in profit per patient.
There is nothing stopping this industry from charging higher and higher rates—not market forces, not regulation, nothing—and so these private equity companies, having realized this, will keep jacking up prices and turning highway accidents and heart attacks into higher returns for their investors. Right now, this is an industry that can’t be stopped. There is, however, potentially momentum for reform with the recently-passed No Surprises Act, which caps out-of-network charges in emergencies, but it’s unclear exactly how this can and will impact the air ambulance industry when it takes effect 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’s a maxim that guides every med-school bioethics course, and it essentially recognizes that in medicine, it is possible to do more harm than good. It’s why, when someone reaches the final days or hours of their life, and the outcome is certain, the decision is typically made to withhold treatment, because it can only harm. Treatments come with physical, emotional, and financial burdens, so they’re simply not worth it when the path towards death is irreversible. When air ambulances are used, the goal is to reverse that path, and in many cases they do.
However, the best research into the matter estimates that for every 100 air ambulance flights, four lives are saved. That means that in 96 cases out of 100, the patient or their next-of-kin walks out of the hospital having lost a year of income. They walk out having pushed back retirement by a year, having lost the ability to send their kids to college, or buy a house, or go on vacation—they’ve lost a non-trivial quantity of quality of life. In 96 cases out of 100, doctors using private air ambulance providers are forced to violate their hippocratic oath, they are forced to make a split-second decision that does harm and changes lives for the worse, all because, at the end of the line, there’s some wealthy investor in some private equity firm who prefers a 10.5% return on investment over 10.4%, and nobody’s doing anything to stop them.
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