Justin Connaher  /  The Reporter file via AP
Rescue personnel put a female accident victim into a Flight For Life helicopter near Eden, Wis. Some patients don't learn whether such flights are paid for until after dire emergencies.
By JoNel Aleccia Health writer
msnbc.com
updated 12/17/2009 8:32:06 AM ET 2009-12-17T13:32:06

Charlie Taylor was loading a four-wheeler into the back of his pickup truck last spring when the heavy rig jumped a ramp, overturned and landed on Taylor’s chest. 

The 49-year-old Lyons, N.Y., man broke seven ribs, leaving him barely able to breathe and with no detectable blood pressure, prompting paramedics to call for an air ambulance to whisk him 30 miles to the nearest hospital.

But when Taylor got the bill for that 15-minute flight, it took his breath away — again.

“It’s not that I don’t appreciate the service they gave me,” he said. “But the average citizen can’t afford $8,700 to get to the hospital.”

Eventually, insurance helped foot the bill for Taylor’s flight. But he’s one of the lucky ones.

In a country with dwindling health benefits and rising ranks of uninsured, where the rule is to fly first and ask questions later, some patients are finding emergency air flights may save their lives, but also contribute to medical debt they can’t pay.

“I know it didn’t cost $8,000 to fly from Bradford, Pa., to Erie,” said Leisa Parris, 46, who, like Taylor, responded to msnbc.com’s Dose of Reality health care series.The uninsured woman from Eldred, Pa., awoke in a hospital room six weeks after a severe car crash to find she owed $500,000 in medical bills, including fees for the 97-mile helicopter flight that saved her life.

Costs range from $12,000 to $25,000 per flight
Every year, an estimated 550,000 patients in the United States are flown by medical helicopters and small airplanes for emergencies that include car wrecks, hiking accidents and heart attacks, according to the Association of Air Medical Services. Nearly 1,200 aircraft operate from more than 830 bases across the country, with about half run by hospitals and half run as stand-alone community services.

The average distance of the trips is 52 miles, but the costs vary widely. There's no national requirement to track or report fees, but they can range from less than $12,000 to as much as $25,000 per flight, according to Craig M. Yale, vice president of corporate development for Air Methods Corp., the nation’s largest provider of air medical transport systems.

Air transport is called only after a medical crew on the ground evaluates the condition of the patient, the severity of injuries, the distance to a treatment center and factors such as traffic or rough terrain, Yale said.

Ground ambulances are generally much less expensive, with an average emergency run coming in at $800 to $2,000, depending on the region and other factors, according to J.D. Fuiten, secretary of the American Ambulance Association.

During an emergency, when the aircraft show up, there's usually no mention of money. Providers can't screen patients for ability to pay, and insured patients have to read the fine print of their policies to gauge coverage.

Patients could theoretically refuse air transport out of concern for cost. Fearing high fees, Taylor's wife questioned paramedics about calling the air ambulance, but the seriousness of his condition trumped those worries.

"She said, 'Don't you think that's a little overkill?'" Taylor recalled. "They said, 'Ma'am, your husband has no blood pressure.'"

Image: Bob and Denise Wisener
Wisener family
Bob Wisener, 60, and his wife, Denise, 52, of Republic, Wash., had to pay $8,000 for an emergency flight after Bob had a heart attack in 2006. In 2007, they joined Northwest MedStar's membership program, just in time for a second heart attack. That time, MedStar covered the bills.

To patients who face bills later, the costs can be daunting. Bob and Denise Wisener of Republic, Wash., were charged more than $11,000 for a 120-mile emergency air flight after Bob, 60, a log truck driver, suffered a heart attack in 2006. Insurance paid about $3,000 of the cost, but the Wiseners were stuck with the rest.

"My first thought was, 'How am I going to pay for that?'" recalled Denise Wisener, 52, a massage therapist.

Industry experts defend the high fees for emergency air transport, saying they're a microcosm of a health system where everyone expects immediate, expert emergency care, but patients, insurers and government providers are reluctant to pay for it.

“We’ve got to collect enough money for the service, or the service goes out of business,” said Dr. Kevin Hutton, a San Diego emergency room doctor who founded Golden Hour Data Systems, Inc., a medical billing system for air providers.

Medical helicopters and airplanes are paid only when they transport people, typically a base fee to launch an aircraft and then a fee for every loaded mile it flies. In Charlie Taylor’s case, the Mercy Flight charges included $7,000 for basic fees and then $55 a mile for the 31 miles to the hospital, his bill showed.

“I’m glad my insurance company paid it, but at the same time, I’m a little angry and put off that that’s what they were charged,” said Taylor, an auto service advisor who pays $600 a month for health insurance. “If they’re paying $8,700 for an ambulance for somebody, how long is it going to take for me to pay it off through my premiums?”

High cost of readiness
What’s not apparent from the per-mile fees is the high cost of readiness, said Yale, whose own operators transport about 98,000 patients a year in 43 states.

“You’re paying for the capacity to be able to respond,” said Yale.

Costs include aircraft that can range from $2 million to $6 million, on-board medical equipment that can include $10,000 heart monitors, and the price of round-the-clock staffing with top-tier emergency doctors and nurses, who must be not only highly trained, but also able to operate at a moment's notice under the most difficult circumstances. Jet fuel prices also fluctuate widely. 

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“We’ve been forced to pay for these services with the few unfortunate people who need it,” said Hutton.

About 40 percent of patients who require emergency air transport have some kind of private health insurance, but about only about 60 percent of insurers pay the full costs, Hutton said. Some insurers pay as little as $300 out of a $17,000 bill, for instance. Others can stall on payment, forcing air transport companies to bill and re-bill.

Federal Medicare and state Medicaid patients account for another 40 percent of those treated, but reimbursements from the agencies is notoriously low, requiring a nearly 40 percent discount, Air Methods tax records show.

Of the 20 percent of remaining patients who have no insurance or other coverage, only about 2 percent actually pay, with the rest written off to uncompensated or charity care, according to Hutton.

If a given flight costs $7,000, an ambulance operator has to charge $14,000 to make up for people who don’t pay, discounts for Medicare and Medicaid and reluctant insurers, Yale said.

“You’ve got to, in essence, charge twice,” he said.

Such logic is questionable, said Candy Butcher, chief executive of Billing Advocates of America, an agency that helps patients renegotiate high medical fees. It’s just another justification for spiking prices when patients are at their most vulnerable, she said.

Astronomical markups?
“We are all willing to pay fair and reasonable prices for services,” Butcher said. “The problem is, when people try to price-gouge with astronomical mark-ups.”

Federal tax documents show that Air Methods Corp., based in Englewood, Colo., posted gross revenues of nearly $500 million in 2008 and net income of almost $20 million. The average gross charge per transport went up more than 13 percent in the first nine months of this year, with an increase of nearly 7 percent in net fees, records showed.

Hiking the prices for per-transport fees can leave hard-hit families struggling to pay.Air medical services are called to about 20 percent of the scenes of serious motor vehicle crashes, according to one 2000 study in Massachusetts. Nationwide, severe car accidents cause 500,000 hospitalizations, more than 250,000 serious injuries and 42,000 deaths a year in the U.S., according to the AAMS.

Such crashes are a common cause of medical debt that now contributes to more than 60 percent of all U.S. bankruptcies, according to Dr. Steffie Woolhandler, a Harvard University researcher who has studied the issue. Although researchers didn't ask specifically about air ambulance rides, they may well have contributed to that growing number, she said.

After facing one air flight tab of more than $11,000 and paying the more than $8,000 that their health insurance didn't cover, Bob and Denise Wisener wanted to find a way to ward off any future big bills.

The Washington state couple became the first to join Northwest MedStar's new membership program in 2007, paying $150 for a three-year membership that guarantees emergency fees will be covered.

Image: Hayden Snyder
family photo
Hayden Snyder, 7, of Urbana, Ohio, still has scars from being kicked in the face by a horse last February. The air ambulance flight that saved his life cost about $9,000.
Such plans have become popular in rural and urban areas alike, where they're aimed at spreading the costs of services among a bigger pool of patients. They're essentially a form of supplemental insurance, although the plans often are exempted from regulations of traditional insurance plans.

As it turned out, the Wiseners were also the first to use the Northwest MedStar program. Bob Wisener suffered a second heart attack in June 2007, six months after they joined.

“I told them, this time we should not be getting a bill,” said Denise Wisener.

And they didn't. Their health insurance was billed $12,000 for the second flight, but the MedStar program made up the difference, so the Wiseners paid nothing out of pocket.

Since then, nearly 6,700 families have joined the program run by Inland Northwest Health Services based in Spokane, Wash.

For some, care is priceless
Despite big bills, some patients say that air medical transport — and the care that follows — is priceless. David Snyder, 32, of Urbana, Ohio, was uninsured last February, when his 7-year-old son, Hayden, was kicked in the face by a horse at the family farm.

The air ambulance CareFlight was on the scene within five minutes, quickly stabilizing the boy whose face was split from his eyes to his upper lip.

The bill for the 10-minute flight to the hospital was $9,200. Ohio’s state Medicaid program covered the cost, reducing the more than $38,000 in emergency care and plastic surgery debts that have left the family struggling.  

“That’s a lot of money,” said Snyder. “But at the time, I would have paid $100,000 to get him to the hospital.”

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