NTSB tries to use Medicare to leverage change in helicopter regs

[wsuffa]

http://www.washingtonpost.com/wp-dy...09/01/AR2009090103557.html?hpid=moreheadlines

The National Transportation Safety Board adopted a broad set of safety recommendations Tuesday covering medical helicopters, expanding beyond equipment and technology matters to address the business models of the $2.5 billion industry.
..................
The most sweeping change was a proposal that Medicare, the nation's largest insurer, pay only for flights conducted by medical helicopter programs that abide by safety and performance standards that the Medicare program would develop.

Oh, if this discussion goes down the road of "see how government health insurance will be used to tread on our activities", this thread will either be closed or moved to Spin Zone.

 

[dmccormack]

I suppose it's within the purview of the agent paying for transport to specify the minimal standards, no?

 

[wsuffa]

I suppose it's within the purview of the agent paying for transport to specify the minimal standards, no?

I suppose so. Though it smacks of one brother whispering to another: "you're the favorite son so you ask dad to stop for ice cream".

Makes you wonder why NTSB didn't choose to make the same recommendation to other, privately-run "agents"....

 

[dmccormack]

I suppose so. Though it smacks of one brother whispering to another: "you're the favorite son so you ask dad to stop for ice cream".

Makes you wonder why NTSB didn't choose to make the same recommendation to other, privately-run "agents"....

Yeah.. the NTSB link is curious. You'd think Medicare/Aid would be Big Boy enough to make their own rules...

 

[wsuffa]

Yeah.. the NTSB link is curious. You'd think Medicare/Aid would be Big Boy enough to make their own rules...

I think it's more that NTSB feels somewhat impotent because it only makes recommendations, not rules. And that the FAA doesn't always adopt what they suggest. So they're trying another agency that they think will be more responsive because it controls the purse strings.

Suppose the NTSB went to GSA and said "here are some new airline inspection requirements and we recommend that you terminate all govt travel contracts with airlines that don't comply".

 

[dmccormack]

I think it's more that NTSB feels somewhat impotent because it only makes recommendations, not rules. And that the FAA doesn't always adopt what they suggest. So they're trying another agency that they think will be more responsive because it controls the purse strings.

Suppose the NTSB went to GSA and said "here are some new airline inspection requirements and we recommend that you terminate all govt travel contracts with airlines that don't comply".

Right -- but what motivation could NTSB have? After all, they have been the "objective, honest broker" doing investigations and making objective, unsullied recommendations to date (I know, I know -- but it's still the popular public image).

Now they want to be just another rule-making agency?

What gives? Why the power grab?

 

[Dr. O]

Lots of things going on here...
First is the horrible accident rate of medivac flights... If the FAA/NTSB will not do their jobs (and they have not) then some other bureau will have to - but since they do not have direct authority to write FAA regs they have to take a more circuitous route - and there is no quicker way to get someones attention than to strangle their cash flow...
Second is the astronomical amounts of money that care/caid are spending for medivac flights that have no rhyme or reason other than, "because we can and here is the bill"
Third is, this administrations philosophical belief that no amount of government control is too much...

denny-o

 

[dmccormack]

Lots of things going on here...
First is the horrible accident rate of medivac flights... If the FAA/NTSB will not do their jobs (and they have not) then some other bureau will have to - but since they do not have direct authority to write FAA regs they have to take a more circuitous route - and there is no quicker way to get someones attention than to strangle their cash flow...
Second is the astronomical amounts of money that care/caid are spending for medivac flights that have no rhyme or reason other than, "because we can and here is the bill"
Third is, this administrations philosophical belief that no amount of government control is too much...

denny-o

Good points.

Local Medevac outfit has a good record, but lots of birds and lots of flights.

Starting the bird costs $1k.

 

[MikePapa]

Yeah.. the NTSB link is curious. You'd think Medicare/Aid would be Big Boy enough to make their own rules...

Except that Medicare or any other medical insurance company is not really in the business of regulating aviation. They also have no real vested interest in doing so. That's not to say they can't have a say so in what they are paying for, just as they do with lots of other things.

It appears as if the NTSB is saying the smartest way to improve the standards of these operations is on the customer side, and I happen to agree. If the FAA were to take a stronger stance and more heavily regulate these operations, those stronger regulations would almost certainly apply to other operations as well, which don't appear to have a problem right now.

 

[SCCutler]

This is the fundamental essence of how government expands its power beyond that with which it is legitimately vested. If they lack the authority to do that which they choose, they confiscate money and regulate its return to those who earned it, imposing conditions thereupon.

 

[tdager]

http://www.washingtonpost.com/wp-dy...09/01/AR2009090103557.html?hpid=moreheadlines



Oh, if this discussion goes down the road of "see how government health insurance will be used to tread on our activities", this thread will either be closed or moved to Spin Zone.

The problem is Bill, this IS a good example of exactly that.

Sorry but the government has one mission, to get more control over us, period.

 

[TMetzinger]

I actually think tying standards to eligibility for federal funding is a good idea. I just think the FAA should be setting those standards, not Medicare.

 

[dmccormack]

Except that Medicare or any other medical insurance company is not really in the business of regulating aviation. They also have no real vested interest in doing so. That's not to say they can't have a say so in what they are paying for, just as they do with lots of other things.

It appears as if the NTSB is saying the smartest way to improve the standards of these operations is on the customer side, and I happen to agree. If the FAA were to take a stronger stance and more heavily regulate these operations, those stronger regulations would almost certainly apply to other operations as well, which don't appear to have a problem right now.

Right -- but the game is played thusly: "You want my money? You play by my rules."

 

[Bob Noel]

In general, if there is a problem, fix the root cause.

If the FAA won't do its job, make them. Don't have another agency do it for them.
I mean, come on, who thinks the medicare bureaucrat are qualified to establish safety standards?

 

[ScottM]

Yeah.. the NTSB link is curious. You'd think Medicare/Aid would be Big Boy enough to make their own rules...

The NTSB makes recommendations to all kinds of agencies based on what they think should be done to mitigate future accidents. The NTSB makes no rules that affects those agencies. This is exactly what they are supposed to do. Now it is up to the other agencies to decide what they may or may not do based on the process that is well defined.

The FAA barely listens to the NTSB I doubt the HHS will either. I am guessing that they will bounce this back to the FAA to deal with and state it is not their job. This is how our government works. I could be like Singapore's.

In Singapore about 15 or so years ago a passenger waiting to get onto a subway train took his chewing gum out of his mouth and put it on the electric eye that ensure the doors at the station do not close if someone is in the way. With these doors open the train cannot leave the station. This mucked up the train and all of the other trains that needed to get through, throwing the who transport system into chaos.

When the government inspectors found out why this occurred the government decided that people would no longer be allowed to use gum. No gum imports, sales or use. That happened over night without any input. Is that what we would want? I think not. I would rather have a spineless agency such as the NTSB make recommendations and then other agencies decide if they merit any rule changes.

 

[SkyHog]

In general, if there is a problem, fix the root cause.

If the FAA won't do its job, make them. Don't have another agency do it for them.
I mean, come on, who thinks the medicare bureaucrat are qualified to establish safety standards?

Anytime the FAA fails to issue new regulations, I get a little bit happier because there are too many as it is.

This is the right way to do it - force Medicare to restrict its money, don't pass rules that will somehow turn into "Oh yeah, and ASEL follows the same rules now."

 

[ScottM]

Anytime the FAA fails to issue new regulations, I get a little bit happier because there are too many as it is.

This is the right way to do it - force Medicare to restrict its money, don't pass rules that will somehow turn into "Oh yeah, and ASEL follows the same rules now."

NTSB cannot force anyone outside of their own agency to do anything.

 

[Everskyward]

I suppose it's within the purview of the agent paying for transport to specify the minimal standards, no?

True, and the US Government already has minimum standards which exceed the FAA standards for contracting out flights for government agencies to private contractors, the USDA Forest Service for example.

 

[dmccormack]

True, and the US Government already has minimum standards which exceed the FAA standards for contracting out flights for government agencies to private contractors, the USDA Forest Service for example.

...as do insurance companies -- the FAA says we can fly a HP-complex after a CFI endorsement. The insurance co require x number of hours.

 

[ScottM]

...as do insurance companies -- the FAA says we can fly a HP-complex after a CFI endorsement. The insurance co require x number of hours.

The insurance company is not stopping you from flying the plane. You could still legally be flying it with the endorsement. What they are saying is that they will not cover you if you have an accident. You are not subject to any certificate action for not meeting an insurance requirement like if you violate a FAA regulation.

 

[bbchien]

Government is government and there is already too much of it.

As in, "Hey, we're drowning here....."

 

[Everskyward]

I don't see anything sinister about Medicare setting certain standards for air medical transport. It's done all the time in the charter industry. Customers, both private and government, set their own minimum requirements as well as sometimes coming to audit us. Believe it or not, the air medical industry tries to do a certain amount of self-regulation through organizations like CAMTS. It's an accreditation process which doesn't have the weight of the law behind it but shows that the company has met a certain set of standards both for patient care and aircraft safety.

 

[dmccormack]

The insurance company is not stopping you from flying the plane. You could still legally be flying it with the endorsement. What they are saying is that they will not cover you if you have an accident. You are not subject to any certificate action for not meeting an insurance requirement like if you violate a FAA regulation.

Exactly -- the issue is -- is this a practical barrier/regulation?

For most people, it is.

 

[dmccormack]

I don't see anything sinister about Medicare setting certain standards for air medical transport. It's done all the time in the charter industry. Customers, both private and government, set their own minimum requirements as well as sometimes coming to audit us. Believe it or not, the air medical industry tries to do a certain amount of self-regulation through organizations like CAMTS. It's an accreditation process which doesn't have the weight of the law behind it but shows that the company has met a certain set of standards both for patient care and aircraft safety.

Exactly.

DoD does this with contractors. Each company must meet certain CMMI levels or ISO in order to meet the requirements of the contract.

 

[wsuffa]

I don't see anything sinister about Medicare setting certain standards for air medical transport. It's done all the time in the charter industry. Customers, both private and government, set their own minimum requirements as well as sometimes coming to audit us. Believe it or not, the air medical industry tries to do a certain amount of self-regulation through organizations like CAMTS. It's an accreditation process which doesn't have the weight of the law behind it but shows that the company has met a certain set of standards both for patient care and aircraft safety.

So, let's ask this:

Suppose a person on Medicare is critically ill or injured in a field (for the sake of argument, let's call it a bear mauling). The only way to get them to a hospital in reasonable time is by air evac (the hospital is an hour+ away by ambulance, but 10 minutes by chopper), and they won't survive without treatment in 30-45 minutes. But, the only air evac available does not meet the standards NTSB proposes, so it won't be paid for by Medicare.

Now, what do you do, knowing the person does not have the means to pay out of their own pocket? Do they have an expectation of treatment under Medicare, despite the non-comformance (because of the likelihood they'll die otherwise)? Do you hold strictly to the rule conformance and transport them by ambulance with the likelihood of death? Do you expect the air evac or hospital to eat it? Do you bankrupt the person by using the air evac anyway?

 

[ScottM]

So, let's ask this:

Suppose a person on Medicare is critically ill or injured in a field (for the sake of argument, let's call it a bear mauling). The only way to get them to a hospital in reasonable time is by air evac (the hospital is an hour+ away by ambulance, but 10 minutes by chopper), and they won't survive without treatment in 30-45 minutes. But, the only air evac available does not meet the standards NTSB proposes, so it won't be paid for by Medicare.

Now, what do you do, knowing the person does not have the means to pay out of their own pocket? Do they have an expectation of treatment under Medicare, despite the non-comformance (because of the likelihood they'll die otherwise)? Do you hold strictly to the rule conformance and transport them by ambulance with the likelihood of death? Do you expect the air evac or hospital to eat it? Do you bankrupt the person by using the air evac anyway?

Well that is exactly the system we have now.

What we would hope is that if HHS decides to act on this recommendation that they review such a scenario and come up with a solution that serves the needs of the patient, air ambulance and itself.

 

[TMetzinger]

Good question. I expect that whatever rules are passed will apply only to transport flights from one medical facility to another, not to accident responses. That's how it would be IIWK (If I Were King).

But, since the transport flights are the backbone of revenue for HEMS operators, they'll all be lining up to meet those standards, and hopefully the processes/policies/procedures put in place will also benefit accident responses.

When I was in the Coast Guard, we had similar issues about when we would or wouldn't launch a helo for a SAR mission. It's hard to tell someone who's 10 miles off shore that your response to her 70-year-old dad's heart attack is going to be a small boat and not a helicopter, but given that even a "ready" helo isn't going anywhere for ten minutes or more, you have to (or in our case the flight surgeons had to) make the risk/reward/expense call. We'd launch for kids, hypothermia, severe injuries if the patient was stable, but we didn't launch for DRT (Dead Right There) cases. Searches were similar - we had to decide if the search was viable.

 

[Everskyward]

Suppose a person on Medicare is critically ill or injured in a field (for the sake of argument, let's call it a bear mauling). The only way to get them to a hospital in reasonable time is by air evac (the hospital is an hour+ away by ambulance, but 10 minutes by chopper), and they won't survive without treatment in 30-45 minutes. But, the only air evac available does not meet the standards NTSB proposes, so it won't be paid for by Medicare.

Now, what do you do, knowing the person does not have the means to pay out of their own pocket? Do they have an expectation of treatment under Medicare, despite the non-comformance (because of the likelihood they'll die otherwise)? Do you hold strictly to the rule conformance and transport them by ambulance with the likelihood of death? Do you expect the air evac or hospital to eat it? Do you bankrupt the person by using the air evac anyway?

The way I envision it would work is that there would be a list of approved operators and the first responder agency would know who to call in that area. I think that's pretty much the way it works now. They just don't call anyone with a helicopter. If there is no approved operator then they would need to fly in from somewhere else or go by ground. If nothing else it would encourage substandard operators to raise their standards to the minimum or else lose business. It's also not like every time someone needs an air ambulance one is available. There are weather and operational considerations, among other things.

 

[kkoran]

All this stupid policy would do is screw the patient. Let's face it, someone near death out on a highway somewhere is in no condition to check up on the operator of the helicopter that shows up to take him to the hospital. If Medicare won't pay for it, I'm sure the operator will go after the patient for the money.

 

[Doggtyred]

So, let's ask this:

Suppose a person on Medicare is critically ill or injured in a field (for the sake of argument, let's call it a bear mauling). The only way to get them to a hospital in reasonable time is by air evac (the hospital is an hour+ away by ambulance, but 10 minutes by chopper), and they won't survive without treatment in 30-45 minutes. But, the only air evac available does not meet the standards NTSB proposes, so it won't be paid for by Medicare.

Now, what do you do, knowing the person does not have the means to pay out of their own pocket? Do they have an expectation of treatment under Medicare, despite the non-comformance (because of the likelihood they'll die otherwise)? Do you hold strictly to the rule conformance and transport them by ambulance with the likelihood of death? Do you expect the air evac or hospital to eat it? Do you bankrupt the person by using the air evac anyway?

The helicopter vendor that cannot meet the requirements to be reimbursed will pretty much cease to exist. Which is ok with me, because the industry has become over-saturated with for-profit vendors that focus on quantity rather than quality of care.

When a medevac is summoned the patient is not asked how they are paying, and usually are not in a condition to be asked or answer the question if asked. If they are, then perhaps they really really DONT necessitate the risks of flying by air. The SOLE reason for calling medevac should be measurable benefit to the patient. Not convenience, Not profit and not kickbacks. The patient wont be bankrupt. you cant get blood from a turnip. And lots of uninsured folks GET flown every day. The for profit guys have a hard time with it. The not for profit guys or govt supported guys incorporate it into their budgets. That $10,000 flight is a paltry compared against $5-10,000 a day trauma/critical care, and people staying days to weeks in ICU.. and sometimes months in the hospital.

Your time numbers are deceptive and the scenario is faulty.

Yea.. it may be a 10 minute flight in your example. But you are going to be on scene for 3-5 mins at least before you summon the helo. It will take them 5-7 mins MINIMUM just to spool up and lift IF weather permits - almost always VFR only. and theres no ILS to a car crash!!. Then flight time to the scene. Then their scene time. .at LEAST another 10 mins usually longer.. if the patient is not packaged properly. Then lift for the inbound leg. And thats IF the helo is coming to you from only 10 mins away.. A vendor many times will send THEIR next closest bird from 20-30 mins away rather than a competitors bird right next door.

So.. we are up to 30-40 mins now ANYWAYS.. just with a medevac.

If the patient is that sick, that helicopter likely wont make the difference. You say survive without treatment?? both the ambulance and the medevac in most of the US tend to have all of the same lifesaving equipment in them needed in the initial hour or so of your garden variety resuscitation. That equipment and knowledge is used during transport - i.e. treatment.

If you are referring to victims of the knife and gun club who need to have their chest cut open, aorta clamped and emergency lifesaving surgery to the heart performed.. well.. those folks are dead beyond recovery in your scenario.. Those folks only tend to survive if they live within 10-15 miles of the trauma center and lose their vital signs enroute to the trauma suites.. and have an aggressive trauma surgeon waiting on them when they arrive, ready to cut. That person would be unsalvegeable by the time the helo got TO the scene.

I ran EMS in the burbs of the 4th largest city in the US. Served at one time by a non-profit medevac provider. We had a beltway loop that was 15-20 miles out from downtown. Pretty much any major scene inside that radius we could scoop and go, treat enroute and be in the trauma suites before they could lift, fly out, load and return. I proved it time and time again. I'd leave from a large multipatient scene with the "less urgent" patient as directed by incident commant and have mine in the trauma bay before the "critical one" got there by air.

 

[Doggtyred]

The way I envision it would work is that there would be a list of approved operators and the first responder agency would know who to call in that area. I think that's pretty much the way it works now. They just don't call anyone with a helicopter. If there is no approved operator then they would need to fly in from somewhere else or go by ground. If nothing else it would encourage substandard operators to raise their standards to the minimum or else lose business. It's also not like every time someone needs an air ambulance one is available. There are weather and operational considerations, among other things.

No.. thats not how it would work.

Any provider that couldn't secure CMS approval (medicare/medicaid) would limit itself to for profit-transfers with insured patients.... only many insurance companies ALSO require that the folks who bill them ALSO be able to meet/demonstrate CMS compliance...

So.. cant bill medicare, medicaid or private insurance.. just how long do you think they will continue to provide service? For the most part they wont.. you have a (very) few fixed wing for profit medevac providers who already operate under this business model.. and its the realm of the patient with means..

There wont be an "approved" list and unapproved list.. There will just be a list of surviving companies that meet the standards..

 

[Everskyward]

There wont be an "approved" list and unapproved list.. There will just be a list of surviving companies that meet the standards..

That's pretty much what I was getting at. There will be a list of approved operators. I didn't say there would also be a list of unapproved operators.

 

[kkoran]

The patient wont be bankrupt. you cant get blood from a turnip. And lots of uninsured folks GET flown every day.

That's assuming the patient is a turnip. But if Medicare or insurance won't pay and the patient has the money?

 

[Doggtyred]

That's assuming the patient is a turnip. But if Medicare or insurance won't pay and the patient has the money?

The same procedure applies whether they are a turnip or not. They get sent a bill. If they dont pay or make a payment plan.. they get sent to collections. This is what we have now. Hospitals in the area are seeing over 30% of their patients being the uninsured variety. Trauma is a poor mans disease, for lack of a better term, so I am willing to gather even higher percentages of the flights fall in this category already. Federal funds, and insurance money, are the only things that keep this going.

In my state they cant take your house or garnish your wages for private debt.

The industry needs to be rightsized..

A for-profit entity moved in a few years back and marketed heavily. One area they signed an exclusive contract for saw their volume go from 8 flights in one calendar year to over 100 in the next. The demographics in question didn't change. Nor did the territory's call volume, but utilization increased 10 fold. This for-profit vendor HAS however been found to be offering kickbacks of several hundred dollars per flight to the referring agencies - fire chiefs have been quoted on camera attesting to this.

Federal funds, and insurance money, are the only things that keep this going.

 

[kkoran]

The same procedure applies whether they are a turnip or not. They get sent a bill. If they dont pay or make a payment plan.. they get sent to collections. This is what we have now. Hospitals in the area are seeing over 30% of their patients being the uninsured variety. Trauma is a poor mans disease, for lack of a better term, so I am willing to gather even higher percentages of the flights fall in this category already. Federal funds, and insurance money, are the only things that keep this going.

In my state they cant take your house or garnish your wages for private debt.

The industry needs to be rightsized..

A for-profit entity moved in a few years back and marketed heavily. One area they signed an exclusive contract for saw their volume go from 8 flights in one calendar year to over 100 in the next. The demographics in question didn't change. Nor did the territory's call volume, but utilization increased 10 fold. This for-profit vendor HAS however been found to be offering kickbacks of several hundred dollars per flight to the referring agencies - fire chiefs have been quoted on camera attesting to this.

Federal funds, and insurance money, are the only things that keep this going.

So, it's okay with you if I get stuck with a $5K bill after my insurance says they won't pay it but before the market shakes out the non-compliant operators?

 

[Doggtyred]

So, it's okay with you if I get stuck with a $5K bill after my insurance says they won't pay it but before the market shakes out the non-compliant operators?

Thats the status quo now in the "unregulated" market. Doesn't matter if I'm ok with it or not.

With regulation, the number of people UNNECESSARILY getting stuck will decline. Uninsured peeps will still get stuck.. but hopefully those flights will be reserved to cases of MEDICAL necessity, not convenience.

Unless we go to universal healthcare and coverage.. but thats another thread.

 

[SteveinIndy]

The problem is that most medical helicopter scene flights (>80% in most areas that have been closely scrutinized by independent researchers) in the US are of zero benefit to the average trauma patient. This becomes an issue because the average American thinks that the helicopter is the fastest way to get someone to a hospital when in a lot of cases it delays access to care at a closer facility with the same ability to do the initial stabilizing care that will save lives. The reason for this should be blatantly obvious to any pilot: there are delays with getting the aircraft loaded, off the ground, to the scene and back down then loading the patient (including on scene treatment which is a very common practice which eats up valuable time), back airborne, to the hospital, shutdown (in all but the most extreme cases) and unloaded. It's not a quick process as many imagine it.

As for CAMTS accreditation, it's pretty much a feel good emblem to put on the side of the helicopter and on letterhead although it's better than nothing I guess. A good portion of the operations out there thumb their nose at the standards and people get killed because of it. Also seeing as how it's effectively a puppet of the industry, I have an old adage for you: fox guarding the chickens. If this were Era Aviation losing choppers on sightseeing missions at the rate we lost medical helicopters last year, no one would bat an eye. The years of MASH, ER, etc, that have indoctrinated the average person to believe that the HEMS operator is the savior of the patient has muddied the waters and made this debate very hostile in a lot of circles. I'm not for hardcore over regulation, but I am sick and tired of burying my friends and colleagues because companies are cutting corners and thumbing their nose at safety. Remember, each of these helicopter crashes reflects badly on aviation as a whole in the public eye, not just on the service and agency involved.

I think this is probably the ideal way to deal with the safety issues in modern day HEMS. No need to involve the FAA: cut off the profits of the fly-by-night operators and you'll reduce the mortality rate among pilots, crews and patients while still allowing operators who are conscientious and professional to serve patients if and when the flights are actually necessary.

 

[SteveinIndy]

but hopefully those flights will be reserved to cases of MEDICAL necessity, not convenience.

One of my friends- and one of the best helicopter pilots I've ever flown with (and I've flown with a lot, both civilian and military)- died in the crash of a HEMS flight that was dispatched solely because the ground EMS providers did not want to be inconvenienced by having to drive to the hospital. His blood and the blood of his passengers and crew are (in part) on the hands of those EMS providers and the state EMS medical director that allowed and encouraged the ground providers to fly every person they could find the slightest excuse to shove into the back of a helicopter.

 

[alaskaflyer]

I think it's more that NTSB feels somewhat impotent because it only makes recommendations, not rules. And that the FAA doesn't always adopt what they suggest. So they're trying another agency that they think will be more responsive because it controls the purse strings.

Suppose the NTSB went to GSA and said "here are some new airline inspection requirements and we recommend that you terminate all govt travel contracts with airlines that don't comply".

GSA already restricts federal employees from staying in hotels which don't meet their fire safety standards seperate from local or state codes.

Something about people dying in a fire.

The minute the industry stops killing so many people they are supposed to be saving, I imagine the regulators will ease up. Sound familiar?

Government control blah blah blah. This is management by crises and the poor babies in the medivac business are the ones driving the process. I love those guys I work with them regularly but cry me a river it will do no good.