Friday, March 21, 2014

Our Cup of Goodwill...

I sipped my Jameson, put down the glass, and said "I take sick people to the hospital in helicopters." 

Helicopter Air Ambulance image courtesy David Lear

A while back Jeanne and I went on a Smooth Jazz Cruise. We had a great time going to the shows each night, hanging with cool people, and soaking up the tropical vibe. The best part of the trip took place the night before we stopped in Key West. We went to the early evening show in which Marcus Miller did things with a bass guitar that were mind and eardrum blowing, and were then walking back toward our stateroom. We passed by a small, almost empty piano bar and I suggested we stop in for a drink. The room was dark, and the ships piano player was "tickling the ivories," I stood there for a minute and as my eyes adjusted I noticed Jonathan Butler - one of the featured musicians on board - sitting at a table with his family. "Hey Jeanne, that's Jonathan Butler. Let's sit at the piano for minute..."

I sat down and exchanged hellos with the piano player, an older fellow with a tired grin and a vast talent. We ordered drinks. After a few minutes, in this dark little space, J.B. got up from his table and walked over to the piano.

"Oh snap, he's gonna play!"

The house-player gave up his seat at the piano and then Rick Braun walked in with his horn in his hand. He and J.B. started talking and smiling. Then the fellow who had chartered the boat, the entire boat with 2000 passengers, came in and sat down. Then a couple more performers bellied up to the piano, and the cruise host... Someone said, "close the doors."

I don't know what your favorite music is, but imagine if you had the chance to sit in a dark bar with the people who make it, and listen to them talk and play for each other. We sat there and took it in, loving every minute of it.

Then it happened. Someone from across the piano didn't recognize us and asked "who are you, and what do you do?"

I sipped my Jameson, put down the glass, and said "I take sick people to the hospital in helicopters." 

"Wow." "Cool man." "That must be really something..."  We were made to feel welcome, and J.B. played Jeanne a love song for her birthday. J.B. and Rick Braun played a couple of songs together, and then the others took turns performing.

It was a really good time. A once in a lifetime kind of thing.

Jeanne and I were welcomed because of what we do. She takes care of sick people and I fly them.

Society - today - looks up to us, literally and figuratively. We enjoy significant good will and support from the communities we serve, and will continue to do so unless we lose our way and get out of touch with the "service" aspect of our business

I know that operating a HEMS business is challenging. The risks are significant. The amount of capital required is staggering. There is no guarantee of success. The old joke about making a small fortune (by starting with a big one and buying a helicopter) has played itself out time and again. It is understandable, and rational, that as business people in the business of transporting ill and injured persons for profit, we  attempt to maximize our profits, and perform as many transports as possible.

We don't check for insurance before flying someone, and some people don't pay a single dollar. We also don't get paid for airborne standby flights that get cancelled. Or other community-services we provide. But obviously there is money to be made because the number of EMS helicopters has exploded in just over a decade.

Occasionally, profit-motive can run over caring and compassion like a squirrel in the road and leave the caring aspect a little flat.

An anecdote:  A rural hospital employee suffered a stroke and was transported by helicopter to definitive care at a stroke-center. She recovered, and got a bill approaching $20,000 for a 15 minute flight. She was contacted by the transport service's billing department and the discussion went something like this:

"Well ma'am, your insurance has authorized payment of $5000.00 for this transport which leaves you with a balance of $15,000.00. How do you intend to pay this?"

"Sir, I don't have $15,000.00 to pay this bill. I work in a country hospital and don't make much. I can come up with another $5,000 and hope that can be acceptable to settle my bill."

"No ma'am that will not settle your account. Do you thing you might get your church to have a fund-raiser? Or perhaps you could have your husband come out of retirement and get another job..."

Now consider that if this patient had been a Medicare beneficiary - thanks to "assignment," whatever Medicare had paid would have amounted to 80% of the total allowable charge. This woman's obligation would been only 20% of that allowable amount. And the company would have been satisfied. But she wasn't under Medicare and was stuck.

This is the kind of story that goes viral. It smacks of greedy helicopter companies sticking it to people at their worst and weakest point of life, and if the word gets out that this is the way our industry is, that good will I was mentioning earlier will be...

Courtesy AP
In the state of Georgia, rural hospitals are closing their doors one-after-the-other. The state is considering changing the rules to allow for alternative facilities, a sort of "hospital-lite" to allow for stabilization prior to transfer (flight). Mentioned in the same article about this was the statement that Georgia has allocated $12 million dollars for EMS helicopter trips in southwest Georgia. Everyone knows that helicopters save lives and shore up an underfunded, overburdened healthcare system. well, almost everyone.

There is no doubt, at least in my mind. I transported sick people for 17 years. In my case, the plural of anecdote is data. The vast majority of primary and secondary care facilities are not staffed or equipped to treat the sickest and most injured victims of trauma. These patients must be moved to tertiary care - quickly. Helicopters reduce "out-of-hospital" time, and foster good outcomes. 

But if the people running the companies don't cotton to the fact that law-makers respond to stories like this, and use some common sense regarding business development, billing, and utilization-review, the rules we operate under will get changed.

Thus far, the primary defense against any state or local government interference in how HEMS conducts business has been the stipulations in the Civil Aeronautics act of 1938. This act was created to foster the growth of commercial aviation nationally, and to prevent state and local rules and regulations from the stifling such growth.

On April 14, 1938, McCarran introduced S. 3845, a bill to establish an independent civil aeronautics authority to regulate aviation-related commerce and safety. In floor debate, McCarran emphasized the likely increases in air traffic, the growing segment of the economy represented by aviation, and the reality that aviation would soon be a major source of inter-state transportation in the United States. On this last point, McCarran observed, "If we are ever to have safe, regular, and economically sound air transport, it must be administered by a strictly nonpolitical body. Safety regulations are largely nullified by political influences, and, in my opinion, the time is not far distant when the air-traveling public will rise up and demand reasonably safe air transportation."  (courtesy Encyclopedia.com. Click here to read full article...)

But HEMS operators would be foolish to think that the force of public opinion and government-action can forever be held back by an act of Congress dating back to a time before ambulances - much less helicopter-air-ambulances - were even imagined. The original stated-purpose of air transport was to move mail. Then people - people who were awake, alert, and oriented - and knew up front what a trip was going to cost. There was no element of duress. There was no maze of insurance rules to decipher. There was no price-discrimination. The same logic that tells us that torture is not a source of valid intelligence regarding enemy activity also tells us that people under duress will opt for any lifeline tossed their way. They are not in a position to make rational decisions about accepting or refusing such offers of assistance.

The surest way for a politician to win over our hearts and minds will be for her to "protect" Americans against unscrupulous, greedy "body-snatchers."  If the media trend continues, this is coming. (Do you remember a certain New York attorney-general who, before hiring a hooker, made a name for himself by "protecting" New Yorkers?)

Here's another threat to consider. An ambitious young attorney contacts a group of recently-transported patients; all of whom were balance-billed amounts far exceeding what companies accept from Medicare (or Medicaid). These "victims" form a class-action lawsuit demanding that the maximum allowable amount for any patient not fortunate enough to be 65 years old or older (and thus entitled to Medicare's price-controls) be limited to the amount they would pay. And the lawsuit demands reimbursement of the difference in dollars paid. I am not a very smart guy - if I can think of this, so will someone else.

There are some universal truths regarding the treatment of the sick, the weak, the very old and the very young. Everyone - everyone - understands that these souls should be, to a certain extent, protected by public policy. This understanding is what created Medicare and Medicaid in the first place. When the idea that HEMS companies are preying on people at a time when they cannot protect themselves, and are taking advantage of peoples fear, an upheaval will occur.

There will be a backlash. And AMOA won't stop it.

So, for now what are some things that HEMS can do? For starters, it's time for damage control. The first complaint from "victims" of unfair billing practices is that "there is no way it cost (insert amount here) to transport my daughter." And the people hearing these stories think, "yeah, no way!"

But wait! What does it cost to buy or lease a helicopter, hire, train, and compensate twelve to twenty professionals, rent or buy a base of operations, and cover the myriad associated expenses. Then pay for all of this 24 hours a day, 365 days a year, not just for the hour or so that one person needs the service. Then add that we still must make enough profit to present an attraction to investors who must pony-up the millions in advance? When investors put their money at work and at risk, they expect a reward. No one is explaining the back story of that helicopter landing on I-95. Why not?

The patient is not simply paying for a transport. The patient is paying for the transports capability to be exist.

Finally, here is another idea. Most HEMS companies offer a "subscription" for less than a hundred dollars a year. This "membership" provides that whatever insurance a patient has will be good enough to satisfy the financial obligation of being transported. But there are many HEMS companies, and many subscription programs. A sure-fire way to mute public backlash is for the biggest players in the market to get together and agree to honor each other's subscriptions. If we can say to a person, "buy this and your worries about a helicopter transport bill are over," we take the wind out of the sails of discontent. Such a mutual agreement has been in existence in the northwest U.S. for twenty years. Between multiple providers. First, agree to honor. Then sell like hell.

And hopefully, our cup of goodwill will never run empty...

edited 3/25/16

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