HEMS - taking patients for a ride

[NomadicMedic]

The education coordinator at my department sent this article to all of our providers and made it required reading. ("Read this and sign the last page stating you've read it")

http://www.consumerreports.org/medical-transportation/air-ambulances-taking-patients-for-a-ride/

While I agree that HEMS may be overused, and the costs may be excessive, I find it dangerous that, due to an article in Consumer Reports, a helicopter may not be utilized because a less experienced provider formed the impression that HEMS is too expensive and is out to fleece the patient.

Thoughts?

 

[EpiEMS]

EMS use for transport of any kind needs to be subject to good judgment. And HEMS use is no different - it just costs more, so use needs to be even more carefully considered...
That said, pretty silly to make you guys read that when there is good literature out there that is not just a screed against HEMS billing practices.


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[FLMedic311]

As a former HEMS Medic I totally agree with your concerns. I don't think that the article should have any effect on the determining the need of HEMS use by the ground provider. However I do feel that this article presents plenty of valid issues and concerns. I feel there are a lot of "simple" solutions that would get quickly muddied up by both HEMS and insurance companies because in the end they just care about the bottom line, and that is unfortunate because it will have a negative impact on people that truly do require this specialized resource. I think the issues at hand are far beyond that of the provider, and even after reading this article that for most ground providers it should be business as usual. Use your local protocol/best judgement to determine the need for HEMS, and hope that the crew that services you is also savvy enough to recognize when they are required and will not transport simply because they are requested. If you still have issues regarding the concerns of local HEMS use I would say contact your MPD and have a healthy conversation about them, and see if you can help localize more direct protocol for the use, and raise awareness regarding the issues

 

[VFlutter]

Yes, HEMS is expensive. Everything that goes into aviation as well as 24/7 staffing is not cheap. I think the issue is lack of Medicare/Medicaid reimbursement, large number of uninsured flights, and difficulty obtaining insurance approvals. I am sure there is overuse and misuse out there but in my limited experience it isn't that common. Almost all of what I fly is justified. It would be great if all ground services offered the same level of care we do but unfortunately that is not the case. For many patients HEMS is crucial.

 

[hometownmedic5]

I don't base air or ground decisions on money or ability to pay. That's not my department.

My qualifier is did this patient earn a ride on the bird. If they did, and a helo is available, they get to fly. If they didn't, or it's not, they go ground. Simple as that.

 

[Carlos Danger]

I don't base air or ground decisions on money or ability to pay. That's not my department.

My qualifier is did this patient earn a ride on the bird. If they did, and a helo is available, they get to fly. If they didn't, or it's not, they go ground. Simple as that.

And this attitude is exactly the problem. "This isn't my department". "I'm not the one paying the bill". No one has the stones to take responsibility.

The issue isn't that HEMS costs more than ground transport......it's that it costs a MASSIVE amount more than ground transport, and most insurers - quite rightfully, IMO - will only pay a small portion of the cost. Imagine you have a patient in pain, and you can give them fentanyl, which costs $2.99 per dose, or you can give them magicopioidamine, which statistically speaking isn't any better than fentanyl, yet costs $10,000 per dose. That's very often the difference between using HEMS and simply ground pounding. No one even asks the patient. Which is the more reasonable and responsible choice?

The HEMS industry is largely a racket. We know that very few patients benefit from HEMS, yet we still keep trying to increase transports annually.

Families go bankrupt over this stuff, all the time. Ignore it if you want, but It's no joke.

 

[Carlos Danger]

Just to follow up on my previous post with a scenario:

You are out on a Sunday motorcycle ride out in the country with a couple of your buddies. As you round a curve, a car swerves into your lane so you veer hard to the right in order to miss the car. Your front wheel slides out and you end up sliding into a tree. Your right leg is messed up bad and it hurts a little to breath and you feel a little dizzy, but you never lose consciousness and aren't bleeding severely anywhere.

EMS shows up, asks you some questions, looks you over, puts you in the ambulance, starts an IV, and drives you to a nearby field, where you wait 15 minutes for a helicopter to land and for the HEMS crew to perform another assessment, load you up, and take you on a 15 minute flight to the closest trauma center. By ground it would have taken 40 minutes to drive to the same trauma center, or 15 minutes to drive to the closest hospital. You get to the trauma bay about 5-10 minutes sooner than you probably would have if the ambulance had simply driven you there.

You are diagnosed with 2 non-displaced rib fractures (no treatment needed), a concussion (no treatment needed), numerous abrasions (no treatment needed), and a femur fracture, which is fixed in the OR the next morning.

You spend about a week in the hospital. A couple weeks after you get home, you receive a bill from the HEMS agency for $28,000, which is just the portion of the $34,000 bill that your insurance won't pay. Everything else was covered by you insurer are you hit your $4,000 annual out-of-pocket maximum. The ambulance crew never even talked to you about whether you preferred ground or helicopter transport.

That's the reality for probably large majority of HEMS patients.

 

[hometownmedic5]

And this attitude is exactly the problem. "This isn't my department". "I'm not the one paying the bill". No one has the stones to take responsibility.

The issue isn't that HEMS costs more than ground transport......it's that it costs a MASSIVE amount more than ground transport, and most insurers - quite rightfully, IMO - will only pay a small portion of the cost. Imagine you have a patient in pain, and you can give them fentanyl, which costs $2.99 per dose, or you can give them magicopioidamine, which statistically speaking isn't any better than fentanyl, yet costs $10,000 per dose. That's very often the difference between using HEMS and simply ground pounding. No one even asks the patient. Which is the more reasonable and responsible choice?

The HEMS industry is largely a racket. We know that very few patients benefit from HEMS, yet we still keep trying to increase transports annually.

Families go bankrupt over this stuff, all the time. Ignore it if you want, but It's no joke.

I'm not sure you fully grasped what I said, so I'll clarify.

I don't fly anybody who doesn't need to be flown. By needs to be flown, I mean will likely suffer grievous disability or death if they aren't at at a level 1 trauma center ten minutes ago(for your consideration, I'm 45 minutes from a L1 knife under optimal conditions(usually >1hr), and I work in one of the two towns in my state where Boston Med flight has a hanger, so I can get a helicopter in ten minutes under optimal conditions).

If a patient needs to be flown, I don't worry about money. I dont fly people just so I don't have to deal with them. I dont fly people because I'm bored and want to catch a quick air show. I fly people that, without that intervention, will likely die. True, its expensive and I dont care about money because I'm not paying the bill. Sure. You got me. However, you have to be alive to ***** about the bill and I'm not losing my license because I flew somebody who couldn't pay; but I might lose it for not flying somebody who then died when they otherwise might have lived.

I don't play games with HEMS for a number of reasons, but one of the main reasons is that my clinical director used to be a medflight medic. You can't BS this guy. So no, I don't play games with calling medflight, but when I need it, I call for them regardless of my patients ability to pay.

 

[NomadicMedic]

I'm curious who dies if they don't get a HEMS flight where you are?

Because really, if they're so unstable that they're going to die, they probably should not be in a helicopter. Hemodynamicly unstable trauma shouldn't be on a helicopter. At least not where I am. The flight services don't carry blood.

Isolated heads, new onset CVA and STEMIs should go... IF the airship can be to the hospital before me. But, where I am, there is often a 20-30 minute ETA (once they get off the pad) 10 minutes (or more) on the ground and then a 20 minute flight to the hospital. That's just about the same as ground pounding.

 

[RocketMedic]

Your education guy has never dealt with big city traffic or sheer distance.

 

[GMCmedic]

The one time Ive used a helicopter, they were just a transport for me. I could have drawn straws for any of the 7 patients on who was going to catch a ride.

It sucks for the patient that took the helicopter but I couldnt justify waiting 30 minutes for an ambulance when I can get a helicopter in 8 minutes. At least not for that MVA.


The other opportunity was a burn patient that met burn center criteria but did not need intubation. I chose not too, but when it was all said and done with an AMR ALS 2 bill, an ED bill, and later a "critical care" trip 2 hours away, the helicopter might have been cheaper

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[NomadicMedic]

Your education guy has never dealt with big city traffic or sheer distance.

We deal with gridlock traffic and distance frequently.

 

[NomadicMedic]

Just to follow up on my previous post with a scenario:

You are out on a Sunday motorcycle ride out in the country with a couple of your buddies. As you round a curve, a car swerves into your lane so you veer hard to the right in order to miss the car. Your front wheel slides out and you end up sliding into a tree. Your right leg is messed up bad and it hurts a little to breath and you feel a little dizzy, but you never lose consciousness and aren't bleeding severely anywhere.

EMS shows up, asks you some questions, looks you over, puts you in the ambulance, starts an IV, and drives you to a nearby field, where you wait 15 minutes for a helicopter to land and for the HEMS crew to perform another assessment, load you up, and take you on a 15 minute flight to the closest trauma center. By ground it would have taken 40 minutes to drive to the same trauma center, or 15 minutes to drive to the closest hospital. You get to the trauma bay about 5-10 minutes sooner than you probably would have if the ambulance had simply driven you there.

You are diagnosed with 2 non-displaced rib fractures (no treatment needed), a concussion (no treatment needed), numerous abrasions (no treatment needed), and a femur fracture, which is fixed in the OR the next morning.

You spend about a week in the hospital. A couple weeks after you get home, you receive a bill from the HEMS agency for $28,000, which is just the portion of the $34,000 bill that your insurance won't pay. Everything else was covered by you insurer are you hit your $4,000 annual out-of-pocket maximum. The ambulance crew never even talked to you about whether you preferred ground or helicopter transport.

That's the reality for probably large majority of HEMS patients.

This guy would most likely go ground for me. I'd guess half of the medics in my system would fly this guy. The next county over would CERTAINLY fly him.

 

[VentMonkey]

Can any of the mods move this thread to the HEMS section?

@Akulahawk, @MMiz, @Chimpie?

Good stuff so far, though. Unfortunately it is at the end of the day a billable for-profit business. Much like private ambulance companies, private air ambulance company's struggle with reimbursements, which leaves "unjustified flights" with heavy debt to pay.

The article makes mention of membership programs, but also raises a valid point by saying that the patient may in fact not have an option with which service actually shows up to their scene.

Everyone feels the ugly effects of our healthcare industry's many deficiencies. As @Remi mentioned, someone does indeed need to step up, finger pointing gets us nowhere.

 

[StCEMT]

@Chase, do yall carry blood products? There is only one area I can think of that I would call you guys and it really isn't a common area we work out of. I think I have maybe taken one or two nursing home calls out of there (Spanish Lake and the places a bit more removed around that way). But a real bad hunting accident out of Columbia bottoms, some trauma with a bad head injury, or something along those lines would be about the only thing I would consider calling for in the county, especially if it was 1600 and traffic was creeping along at 20mph.

In my area, there is just about 0 chance that I would personally call. I have too many hospitals within a reasonable driving distance. HEMS wouldn't be a benefit in treatment nor would the cost justify the end means.

 

[hometownmedic5]

It's not as much the death, although that needs to be considered, as much as the grievous disability.

Just to follow up on my previous post with a scenario:

You are out on a Sunday motorcycle ride out in the country with a couple of your buddies. As you round a curve, a car swerves into your lane so you veer hard to the right in order to miss the car. Your front wheel slides out and you end up sliding into a tree. Your right leg is messed up bad and it hurts a little to breath and you feel a little dizzy, but you never lose consciousness and aren't bleeding severely anywhere.

EMS shows up, asks you some questions, looks you over, puts you in the ambulance, starts an IV, and drives you to a nearby field, where you wait 15 minutes for a helicopter to land and for the HEMS crew to perform another assessment, load you up, and take you on a 15 minute flight to the closest trauma center. By ground it would have taken 40 minutes to drive to the same trauma center, or 15 minutes to drive to the closest hospital. You get to the trauma bay about 5-10 minutes sooner than you probably would have if the ambulance had simply driven you there.

You are diagnosed with 2 non-displaced rib fractures (no treatment needed), a concussion (no treatment needed), numerous abrasions (no treatment needed), and a femur fracture, which is fixed in the OR the next morning.

You spend about a week in the hospital. A couple weeks after you get home, you receive a bill from the HEMS agency for $28,000, which is just the portion of the $34,000 bill that your insurance won't pay. Everything else was covered by you insurer are you hit your $4,000 annual out-of-pocket maximum. The ambulance crew never even talked to you about whether you preferred ground or helicopter transport.

That's the reality for probably large majority of HEMS patients.

As described, I would not fly him.

 

[SpecialK]

We have very unambiguous national criteria for calling a helicopter (the ANTS criteria) and now have a national Air Desk where experienced helicopter Intensive Care Paramedics decide whether or not to send a helicopter and if so, which one to send. Gone are the days when Control sent one just because road personnel requested it.

The criteria are as follows:

Access: Where road access is so difficult a helicopter is the only feasible means of patient access

Number: The number and condition of patients is such sufficient personnel cannot reach the scene in a reasonable time by road.

Time: The patient has a “time-dependent” problem and use of a helicopter will significantly shorten the time for clinical personnel to first reach the scene, OR time for the patient to be transported to an appropriate hospital
Time-savings are:
Time-critical patient: more than 15 minutes faster than a road ambulance
Time-urgent) patient: more than 30 minutes faster than a road ambulance

Skill: Where the patient has a ‘skill-dependent’ problem (e.g. requires RSI) and use of a helicopter will significantly shorten the time for that skill to be delivered to the patient (see above)

A helicopter ride costs the patient $0.

 

[VFlutter]

@Chase, do yall carry blood products? There is only one area I can think of that I would call you guys and it really isn't a common area we work out of. I think I have maybe taken one or two nursing home calls out of there (Spanish Lake and the places a bit more removed around that way). But a real bad hunting accident out of Columbia bottoms, some trauma with a bad head injury, or something along those lines would be about the only thing I would consider calling for in the county, especially if it was 1600 and traffic was creeping along at 20mph.

In my area, there is just about 0 chance that I would personally call. I have too many hospitals within a reasonable driving distance. HEMS wouldn't be a benefit in treatment nor would the cost justify the end means.

We do not currently but are working on it and probably will soon.

It is really dependent on the area. Most hospitals in our area are becoming more capable as well as the EMS services. We closed my previous base because call volume steadily declined over the years. Hospitals whom used to send out all STEMI/CVA etc how are keeping and treating. Then you have ground services who are trying to do CCT so HEMS becomes harder to justify.

But over on the other side of the river you have EMS and hospitals that are much different and many call for our services not the rapid transport. I have called a 2 min ETA to the Trauma Center form a scene with a Level One. May sound crazy but for some of these patients they would not have survived the 15min drive without interventions (RSI, etc).

Personally I would love the option to have a fly car or go by ground if we are not flyable. I think the level of care we provide is what is the biggest benefit to most of the patients we serve.

 

[EpiEMS]

You know, this issue reminds me of something that @Tigger said in another thread:

To me the problem with tiered systems has always come down to "you don't know what you don't know." I am not comfortable with our lowest educated providers making the determination that the patient needs a higher level of care.

The case seems to be similar here (ground providers calling for higher levels of care by air), but the costs are of orders of magnitude higher...So how can we mitigate this risk effectively? I'm not convinced there are enough evidence-based criteria out there. Can anybody point some out? (Not to mention, there is a paucity of evidence that HEMS is cost effective, especially if not carefully used.)

Anecdotally, I am lucky in that I have never had to call for HEMS (and hopefully won't ever need to) - I am 15 minutes away from one ACS Level II (without L&S - L&S maybe save 2 minutes) , and 30 from a ACS Level I (and Level I peds). I cannot imagine many circumstances where HEMS would really save me much time or add much value over going to the Level II

 

[SpecialK]

The case seems to be similar here (ground providers calling for higher levels of care by air), but the costs are of orders of magnitude higher...So how can we mitigate this risk effectively? I'm not convinced there are enough evidence-based criteria out there. Can anybody point some out? (Not to mention, there is a paucity of evidence that HEMS is cost effective, especially if not carefully used.)

The best way I've seen, and what is used in many places, is centralised, clinically-led air ambulance dispatch be it fixed wing or helicopter. London uses it and has done for almost thirty years, Scotland uses it, Australia uses it, Ontario uses it, New Zealand now uses it (early days) and I am sure some other places I have left off.

Road personnel call Control, describe the problem and what the patient needs and experienced air ambulance Paramedics in the control room decide what is the best helicopter, or indeed the best resource, to send to the patient and from where. It might be the closest helicopter or it might not be for a number of reasons. In some places these staff also scan incidents to determine whether or not to send a helicopter first-up before the road crews request one too and can do further interrogation of callers etc particularly for bad sounding things particularly if in the middle of nowhere. They can also turn out road based responses e.g. of a HEMS team with a doctor as well.

In the absence of anything else why not see if you can give it a try?