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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 ambulances to 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 ambulances cannot
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 network.
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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