Air ambulance companies grow as rural areas lose specialized services

When Lorelei Plagman went into labor six months into her pregnancy, she went to Valley Hospital, hoping doctors could make her contractions stop.

Less than an hour later, she was in a helicopter bound for Providence Sacred Heart Medical Center, where she delivered her son in the neonatal intensive care unit.

Plagman’s short flight took place in 1997 in a Northwest MedStar helicopter. Back then, the Spokane-based company was the only air medical service in the Inland Northwest, operating just one base.

In the 18 years since, the air medical industry has grown significantly, spurred by increased demand as hospitals and specialized care have become less available in many rural areas.

Helicopters, once the purview of well-equipped urban hospitals, have become an integral part of the medical system, used to expand rural medical access, provide rapid transport for trauma patients and move patients between hospitals to access higher-level care.

Rapid industry growth over the past 15 years also has fueled safety concerns, particularly in higher-density urban areas where multiple companies, some for-profit, compete for patients. Though neither of the companies operating in the Inland Northwest ever have had a helicopter crash, a spike in crashes across the U.S. in 2008 prompted the FAA to issue new safety regulations tightening controls about on-board safety equipment and flight procedures.

In the Inland Northwest, MedStar has grown to five bases across Eastern Washington and one in Montana, all dispatched from their headquarters in Spokane. In 2013, the company flew more than 2,500 patients by helicopter or small airplane and brought in nearly $28 million in revenue, according to tax records.

The growing demand has brought competition: Oregon-based Life Flight has opened bases in Sandpoint, Coeur d’Alene and Lewiston over the past five years as hospitals in those communities wanted their own air medical service.

Nationwide, 75 air ambulance companies were operating a total of 1,515 helicopters in 2014, according to the Federal Aviation Administration.

Helicopters often are called to respond to serious car crashes or accidents in remote rural areas where ground transportation would take too long or is otherwise impractical. But about three-quarters of their flights are between hospitals, taking patients like Plagman to another facility that offers higher-level or specialized care.

While in the air, a two-person medical team provides care similar to what a patient receives in a hospital’s intensive care unit.

MedStar flies with one nurse who’s usually dual-trained as a paramedic and one respiratory therapist, a certification typically requiring two years of study. They also staff a specialized perinatal nurse for calls involving pregnant women, premature babies, infants and children at bases in Spokane and the Tri-Cities.

Life Flight teams include a nurse and paramedic.

In Plagman’s case, doctors couldn’t get her contractions to slow down and didn’t want to risk her giving birth on the road to Sacred Heart, so they called a MedStar perinatal team.

“They knew it was imminent,” she said. “They were prepared to deliver him on board if it had come to that, but luckily it didn’t.”

Her son, who weighed just two pounds, seven ounces at birth, started college at Eastern Washington University this fall with a full-ride scholarship.

Industry growth and safety

Early air medical programs were based out of hospitals, but airline industry deregulation in the 1980s opened the doors for independent providers to enter the market.

MedStar and Life Flight grew out of hospital-based programs in Spokane and Portland. Life Flight was formed in 1993 after two hospital systems merged, and it became an independent nonprofit in 2007.

MedStar was born in 1994 through the consolidation of Providence Health Care and Empire Health Service flight programs, and it is run through a parent nonprofit, Inland Northwest Health Services.

Both companies fly patients in small airplanes from some bases, allowing them greater flexibility over long distances or in bad weather.

Shrinking access to care in rural areas increased demand for transport between facilities, and increased Medicare reimbursement rates for air medical transport in 2002 provided some financial stability for operators. Those factors led to industry growth, with more operators, some for-profit, entering the market.

MedStar and Life Flight representatives say their expansion in the Inland Northwest has been driven chiefly by demand from local communities and service providers.

“The fire service in Spokane relies on them on a daily basis. If we didn’t have air evac capability in the rural area, we’d be in a lot of trouble,” said Spokane Fire Department Assistant Chief Brian Schaeffer.

MedStar has expanded from Spokane into the Tri-Cities, Pullman, Brewster, Moses Lake and Missoula.

Life Flight operates a total of 16 helicopter bases across Oregon, southern Washington, Idaho and Montana.

As the industry grew in the 2000s, the number of crashes also increased. The deadliest year on record was 2008, when eight medical helicopters crashed in the U.S., killing 29 people and prompting the National Transportation Safety Board to hold a hearing on helicopter EMS safety in 2009.

Witnesses testified that a hyper-competitive environment in some regions led to operators, particularly for-profit ones, cutting safety corners by flying in questionable weather and responding to calls they hadn’t been dispatched on in an effort to get more patients.

The number of medical helicopter crashes in the U.S. has since decreased. From 2011 to 2013, there were seven medical helicopter crashes with 19 fatalities, according to the FAA.

The only medical helicopter crash in the Inland Northwest over the past 30 years was in 1989, when a Sacred Heart helicopter went down in Blanchard, Idaho, while transporting an injured Canadian fugitive who attempted to hijack the helicopter in flight.

All four people on board, including the fugitive, were killed.

MedStar and Life Flight both have strong safety records, company representatives say, and neither company ever has had a helicopter crash.

“Our safety record is so good in the air I’m more uncomfortable in a ground ambulance,” said David Olmsted, a respiratory therapist and EMT who flies with MedStar.

When air ambulances get called into the field, they’re dispatched through local first responders, who often call both companies to get an estimate of how quickly they can be on scene.

“It’s always based on time, because the only time we do use air medical is with critical patients,” Schaeffer said.

MedStar and Life Flight territory overlaps somewhat, particularly in rural areas north of Spokane, but the hypercompetitive environment that’s caused safety issues in other parts of the U.S. doesn’t exist here, company representatives and crew members say.

Once a helicopter is called out, it’s up to the pilot to decide if it’s safe to make the flight. Weather and its effect on visibility is a prime consideration.

“If you can’t see where you’re going and you’re flying 170 mph, bad things can happen,” said Dominic Pomponio, Life Flight’s regional director for bases in North Idaho and Montana.

At both companies, any member of the crew, including the pilot, can decline a flight for any reason. If one person says they don’t feel comfortable, the helicopter doesn’t take off.

Pilots carry military-grade night vision goggles on night flights. Life Flight requires pilots to have 3,000 hours of flight time to work for them, and MedStar contracts with Metro Aviation, Inc., for pilots who average 3,000 to 5,000 hours of flight time.

To discourage emotions overriding safety, pilots aren’t told anything about the patient, including age or condition.

“We don’t want them to know that, because they may have a grandkid or a son or a daughter the same age,” said Nicole Stewart, a spokeswoman for Inland Northwest Health Services, MedStar’s parent organization.

Medical care

In the Inland Northwest, medical crew members typically have decades of experience before they begin flying with an air medical company.

Many say they enjoy working in an environment where they’re constantly learning new skills and can work autonomously, outside the daily grind of a hospital emergency room.

“No two days are the same,” Olmsted said.

Crew members work 12- or 24-hour shifts and spend their time at bases, which operate much like fire stations. When they’re not out on a call, they do everything from watching TV to practicing intubation, sticking a breathing tube down the windpipe of a dummy head.

Helicopter flight is regulated by the FAA, but the medical care provided on board is regulated by Washington’s Department of Health. Air ambulances have to comply with most requirements for ground ambulances but have specialized rules about equipment required on board and crew training.

Helicopters are configured for two crew members to sit in the back, buckled in, with a patient on a stretcher. Crews can give IVs, hook a patient up to a ventilator, monitor vital signs and provide other critical care.

“It’s always good when you can transport someone in when they’re in bad shape and you see them a few days later and they’re up and talking with their family,” said Eric Melone, a nurse with Life Flight.

That level of care doesn’t come cheap, and flights can regularly cost tens of thousands of dollars. Like ground ambulances, both companies charge a fixed amount to transport a patient, plus a per-mile fee: $121 for MedStar and $176 for Life Flight in 2013, according to data submitted to Medicare. The base cost of a helicopter ride averaged $14,220 with MedStar and $16,817 with Life Flight in 2013.

High fees don’t mean companies are turning large profits. Air medical companies have high fixed costs to maintain medical equipment, base facilities, aircraft and on-call staffing.

“We have the same cost of providing medical services as any other medical treatment program. On top of that, we also have all the costs of an on-demand aviation service,” said Rick Sherlock, CEO of the Association of Air Medical Services, an industry group.

Most health insurance plans cover some portion of air emergency medical transportation if it’s medically necessary, but for plans with cost-sharing or high deductibles, a single flight can lead to thousands of dollars in charges.

To provide a stable revenue base, more air medical companies now are offering membership programs, popular with people who live in or spend a lot of time in remote areas. A MedStar membership is $59 for a year and covers out-of-pocket transportation costs for the family of an enrolled person. Life Flight memberships are $60 with similar benefits, and both companies have reciprocal memberships with each other.

Membership doesn’t change how helicopters are dispatched but ensures the patient won’t pay out of pocket for flight costs insurance doesn’t cover.

Anthony Beam was airlifted by MedStar from Colville National Forest after a hiking accident in 2011. He stepped on a large rock, which rolled onto his leg.

At the time, Beam thought his leg was broken, though it turned out he had a puncture wound caused by the rock forcing a root through his leg.

His friends were able to reach emergency dispatchers through a ham radio. They called for a helicopter to take him to the hospital.

Beam didn’t have health insurance, but his mother had just bought MedStar coverage for the family a few weeks prior because they lived in rural Stevens County.

En route, he asked the crew what the flight would cost normally and was told it would have been about $29,000.

“Because of that it cost me nothing,” he said. “It was a shock when we actually used it and it was literally like a week after my mom got it. We haven’t let it lapse since.”

Patients often are unconscious and usually spend a short amount of time with the medical team, but some get back in touch years later.

Olmsted still remembers a call about seven years ago where he went to pick up a high school basketball player who had collapsed on the court during a game. The patient’s heart wasn’t working properly, but the MedStar crew was able to take him to the hospital, where he made a full recovery.

Two years later, Olmsted ran into the young man at a PR event and learned he was now in college and had become a volunteer EMT so he could help other people.

“He didn’t take for granted that his life was saved,” Olmsted said.

Theresa Bowden, a critical care perinatal nurse with MedStar, said it’s not uncommon for her to get cards around the holidays from families after she helped care for their premature babies.

“They will come find you at the fair, the grocery store, Wal-Mart … You really are touched by that because you think you did make a difference,” she said.