SOAR and Partners Call on Congress to Oppose Sec. 105 of Lower Health Care Costs Act
Policymakers Should Preserve Patient Access to Emergency Air Medical Services
WASHINGTON, D.C.- In a letter to the Senate Committee on Health, Education, Labor, and Pensions (HELP), the Save Our Air Medical Resources (SOAR) campaign and its partners urged the committee to reject Section 105 of the Lower Health Care Costs Act, noting that it could limit access to air medical services for millions of Americans, especially those living in rural areas. The groups, which include the Brain Injury Association of America, Consumer Action, the Consumer Health Coalition, the Association of Air Medical Services, and the International Association of Flight and Critical Care Paramedics, called on Congress to look at the variety of factors affecting air ambulance costs in order to adopt a more comprehensive, data-driven solution to surprise billing issues.
Full text of the groups’ letter to the Senate HELP Committee:
September 16, 2019
Dear Chairman Alexander and Ranking Member Murray,
We are writing to you today to urge you to protect and preserve access to emergency air medical services in S. 1895, the Lower Health Care Costs Act. Emergency air ambulances provide the critical care and quick transport needed to keep patients alive in times of medical emergencies. Air medical services are especially critical in rural communities, where hospital closures have significantly reduced access to care. Since 2010, more than 110 rural hospitals have shut their doors, which has left approximately 85 million Americans more than an hour drive away from a Level 1 or Level 2 trauma center.
Unfortunately, air ambulances have come under fire due to isolated, but highly-publicized issues related to patients’ surprise medical bills.
We agree that surprise medical billing must be addressed, and we appreciate the considerable time and effort your committee has dedicated to crafting S.1895. Although it was conceived with the best intentions, this legislation – most notably section 105 – will further restrict access to air medical services and cause more harm to rural communities.
Section 105 will allow insurance companies to pay air medical providers a median in-network rate. However, many insurers refuse to bring providers in-network in the first place or, in some cases, only bring in one emergency air medical provider. This means that insurers will be able to essentially set their own prices because an accurate median in-network rate cannot be set if there are no, or only one, providers in-network.
Arbitrary median in-network rates will do nothing to solve the issue of surprise billing. In fact, these rates are likely to result in even larger bills for patients with private insurance.
Currently, Medicaid and Medicare patients – along with those who are uninsured – account for more than 70 percent of all air ambulance flights. Despite the significant amount of deployments that these two programs are responsible for, both programs chronically under-reimburse the providers, leaving privately insured patients to cover the difference.
Dangerously low reimbursement rates impact more than individual patients; they also threaten the air medical industry as a whole. Since January 2019, 35 air medical bases throughout the country have closed leaving four million Americans without medical coverage within a ten-minute response time.
Surprise medical billing is a complex issue that must be addressed with comprehensive legislation based on thorough and accurate data from both providers and insurers. A variety of factors – including reimbursement rates which have not been updated in 20 years – impact the costs of air ambulance transports. We urge you to reject Section 105 and consider a more data-driven approach to this issue so that patient access to life-saving air medical services is preserved.
Brain Injury Association of America (BIAA)
Consumer Health Coalition
International Association of Flight and Critical Care Paramedics (IAFCCP)
Alaska Center for Rural Health and Health Workforce
Save Our Air Medical Resources (SOAR) Campaign
Association of Air Medical Services (AAMS)
CC. Members of the Senate Committee on Health, Education, Labor and Pensions
SOAR Statement on the Department of Transportation Establishing the Advisory Committee on Air Ambulance and Patient Billing:
September 12, 2019
“We support the process established by Congress last year when it directed the Department of Transportation to collect data from the air medical industry and develop recommendations for protecting patients from balance billing, improving disclosure and informing consumers of insurance options. This is important work that must get underway immediately. Congress should not rely on anecdotes when crafting legislation to address balance billing, but rather benefit from real cost data so that it can address the underlying cause of surprise bills – the chronic under-reimbursement by government payers and private insurers. Only then will access to these life-saving services be protected and patients be taken out of the middle.”
Joint AAMS/SOAR Letter RE: Misleading Insurance Commissioners Letter of September 4, 2019
Link to letter found here:
Dear Chairman Alexander and Ranking Member Murray:
We agree that patients should not receive “surprise” bills because bad actors in the insurance industry force insured patients into reimbursement disputes that should be between healthcare providers and insurers. We support efforts to ensure patients in need of emergency medical services across America, especially in rural areas where hospitals are closing at an alarming rate, have access to emergency air ambulance services without their insurance companies sticking them with the bill.
Unfortunately, we find it necessary to correct three misleading accusations a number of insurance commissioners sent you in a letter on September 4th.
1. The laws in North Dakota did not affect access to care, because they were overturned by the courts.
The Commissioners claim that they have “learned from the experience of North Dakota,” where the legislature passed laws in 2015 and 2017 regulating air ambulance rates, but air ambulance providers did not leave the state.
The Commissioners fail to mention that both laws were immediately overturned by the courts, as Mr. Jon Godfread, the Commissioner from North Dakota and lead signatory of this letter, should know well—he was the defendant who lost this case in January of 2019:
“The Court concludes, as a matter of law, that Section 26.1-47-09(3) of the North Dakota Century Code is preempted by the Airline Deregulation Act of 1978. . . . Congress has assumed the field in the area of air carrier regulation. Insurance regulation remains the province of the states. If the State wishes to protect patients who need air ambulance services it would do well to mandate insurance providers pay a larger percentage of the charges rather than trying to regulate how much the air ambulance bills for its services.”
Guardian Flight, LLC v. Godfread, 359 F. Supp. 3d 744, 755 (D.N.D. 2019) (emphasis added).
While this decision is under appeal, the industry is confident it will again be upheld, and this iteration of the law will be rendered permanently unenforceable. North Dakota similarly lost in the courts over its 2015 law. (See Valley Med Flight, Inc. v. Dwelle, 171 F. Supp. 3d 930, 947 (D.N.D. 2016)).
Air ambulance companies in North Dakota have made a business decision to accept temporary losses, on some flights, to ensure continued coverage for North Dakotans in need of emergency care, while this temporary issue was resolved. That is very different from claiming a cap on emergency air ambulance reimbursement would not affect access to care in rural America. Over 35 air medical bases have closed across the United States this year  alone, most of them in rural areas, citing low reimbursement rates as the factor driving them to close. Mandating lower reimbursement guarantees will cause many more to close.
2. Air ambulance companies want to negotiate in-network agreements. Some insurance companies simply refuse to enter those negotiations.
All of the major emergency air ambulance providers are working diligently to negotiate, in good faith, to go in-network with insurance companies around the United States, with marked success in recent years, while the Commissioners’ letter makes unsubstantiated claims to the contrary. We have attached two examples of letters the emergency air ambulance industry has received from insurance companies refusing to even enter into negotiations for in-network agreements. (See attached.)
3. Insurance companies who deny critical emergency air ambulance transportation services create balance bills.
Emergency Air Ambulances only respond to requests that come from a physician or medically-trained first responder who determines the patient’s situation is so dire there is no other appropriate choice. Almost half of all claims for out-of-network emergency transports are immediately denied for medical necessity, a business strategy some insurance companies use to negotiate lower reimbursement rates.
This insurance company denial or dramatic underpayment is the tactic that leads to patients receiving balance bills. Insurance companies then force emergency air ambulance companies to work with the insured patient to appeal unreasonable denials for medical necessity to their insurance carrier. Balance bills are not an air ambulance business model; they are a strategic decision by some bad actors in the insurance industry to avoid paying a reasonable rate for emergency services.
A Federal Solution should be balanced, and should encourage the market to work.
We agree insurance companies should not put insured patients in the middle of negotiations with healthcare providers by sticking them with balance bills. We want to ensure people in rural America have access to trauma centers when their lives and future wellbeing are at risk. As more critical access hospitals close across the United States, emergency air ambulances become the only link for people in those areas to reach life-saving emergency medical services in a timely manner.
Instead of establishing arbitrary median in-network rates, data from both insurers and providers should be collected and analyzed. Meaningful and sustainable legislation can only be introduced once the real cost of service is known. An integral first step of this process is to begin the work of the Department of Transportation Advisory Committee as enacted by Congress last year, which we hope will be underway soon.
We support a federal solution that encourages the market to work and incentivizes both sides, insurance companies and emergency air ambulance providers, to come to the table to negotiate fair in-network agreements. Unfortunately, the current language in the Lower Health Care Costs Act sets rates that will force more bases to close, further limiting access to emergency medical care in rural America.
We look forward to working with you on a solution that protects patients’ lives, ensures network adequacy, and protects patients from balance bills.
Richard Sherlock Carter Johnson
President and CEO Spokesperson
Association of Air Medical Services Save Our Air Medical Resources Campaign
SOAR Campaign Applauds Lujan Amendment to No Surprises Act
Requiring Data Collection from Air Medical Providers and Full Transparency from Insurers Will Get to the Root Cause of Surprise Billing
WASHINGTON, D.C. – The Save Our Air Medical Resources (SOAR) Campaign today applauded Rep. Ben Ray Lujan’s (D-NM) amendment to the House Energy and Commerce Committee’s No Surprises Act (HR 3630).
The amendment would require the Department of Health and Human Services (HHS) and the Government Accountability Office (GAO) to collect cost data from air medical providers and claims data from insurers, and report to Congress on the overall cost of providing air medical services.
“To solve the issue of surprise billing for patients, policy makers must first look at real data and address the root cause – denials by private insurers and chronic under-reimbursement by government payers,” said SOAR spokeswoman Carter Johnson. “Air medical providers have long called on Congress to collect data to address these underlying issues. We applaud Congressman Lujan for recognizing the need for full data transparency, particularly from insurers, and encourage Congress to enact this amendment.”
When data on the industry has been collected, it has dispelled inaccuracies and misperceptions about balance billing within the air medical industry. A recent state of Wyoming’s Department of Public Health report shows that most air medical transport patients pay little or nothing for these emergency services.
“Thirty percent of all emergency air medical transports are for patients with private insurance and balance bills occur when a patient’s private insurer refuses to pay for the life-saving service,” said Johnson. “The State of Wyoming’s report demonstrates that anecdotal stories about large balance bills don’t measure up to the data. When Congress collects data about the industry on a national level, a similar trend will emerge, allowing for sound policies that will once and for all take patients out of the middle after insurer denials.”
Consumer and Health Groups: Senate H.E.L.P. Legislation Could Limit Access to Air Medical Service for Rural Americans
WASHINGTON, D.C. -- In a letter to the Senate Committee on Health, Education, Labor, and Pensions (HELP), seven consumer, health and air medical organizations expressed concern over the bill’s unintended threat to access to air medical service in rural America. Specifically, the groups cited Section 105 of the Lower Health Care Costs Act, and noted that 32 air medical bases have already closed since the beginning of 2019. The letter urges the committee to instead address one of the root causes of cost-shifting to the private sector by updating the Medicare reimbursement rate for air medical services and having insurers cover these critical services.
Full text of the groups’ letter to the Senate HELP Committee is below.
July 16, 2019
Dear Chairman Alexander and Ranking Member Murray,
We applaud your work to address the problem of balance billing in the context of air medical transportation. This is a matter of great concern because today, approximately 85 million Americans, or 1 in 4, can only reach a Level 1 or Level 2 trauma center within an hour if they are flown by an air medical helicopter. In addition, 22 percent of rural hospitals have shuttered since 1990 and many more are on the brink of closure. Emergency care is becoming increasingly scarce, and thus air medical services are increasingly essential.
Ninety percent of emergency air medical transports treat patients experiencing a stroke, a cardiac event, or a traumatic injury. Air medical services are clearly needed and indeed, are often the only option for patients to get access to life-saving care quickly.
In this vein, we are concerned that Section 105 of the recently introduced Lower Health Care Costs Act, while undoubtedly well-intentioned, could inadvertently limit access to air medical services for millions of Americans, especially those living in rural areas. We recommend that Congress instead address the underlying problem by updating the Medicare reimbursement rate, which has not been changed in two decades.
More than 70 percent of patients transported by air ambulance have Medicare, Medicaid, another form of government insurance, or are uninsured. When government programs reimburse far below the cost of service, those costs are shifted, and balance bills increase for people with insurance. The balance billing problem must be addressed in a way that is fair to all parties – patients, providers, taxpayers who support federal health care programs, and insurance companies – and access to emergency air medical services must be protected for the 85 million Americans who, as noted above, currently can only reach a Level 1 or Level 2 trauma center within an hour if they are flown by an air medical helicopter.
There is an urgency to our concerns. Since January of this year, 32 air medical bases have closed. We urge you to look at the variety of factors affecting air ambulance service costs and reimbursement policies and take action to ensure that Congress adopts thoughtful, fair and comprehensive reimbursement and coverage rules. We thank you for your attention to this important issue.
National Consumers League
Brain Injury Association of America
Consumer Health Coalition
International Association of Flight and Critical Care Paramedics (IAFCCP)
Association of Air Medical Services (AAMS)
Save Our Air Medical Resources (SOAR) Campaign
cc: Members of the Senate HELP Committee
Wyoming State Report: Air Ambulance Balance Billing Stories Don’t Match The Facts
Policymakers Should Collect Data and Get to the Root Cause of Surprise Billing
WASHINGTON, D.C. – A recent state of Wyoming’s Department of Public Health report shows that most air medical transport patients pay little or nothing for these emergency services, dispelling inaccuracies and misperceptions about balance billing within the industry.
The May report analyzed balance billing by emergency air medical providers and provided policy proposals to take patients out of the middle. The report found that the average out-of-pocket payment for emergency air ambulance transports by patients with private insurance is $300, with approximately 90 percent of those patients paying nothing. According to the report, of the 10 percent who do pay something for their transport, the median amount paid is $700. This aligns with research conducted by Xcenda which found that the average cost paid out-of-pocket by patients is $600.
“Thirty percent of all emergency air medical transports are for patients with private insurance and balance bills occur when a patient’s private insurer refuses to pay for the life-saving service,” said SOAR spokeswoman Carter Johnson. “The State of Wyoming’s report demonstrates that anecdotal stories about large balance bills don’t measure up to the data.”
Americans think insurers should pay for emergency air transport. A survey by the American College of Emergency Physicians found that 81 percent of Americans believe their insurance companies should pay for surprise medical bills and more than half – 54 percent - of survey respondents said they received a surprise bill because their insurance did not cover the medical treatment they received.
“If policy makers want solutions to this issue, they must first look at real data and address the root cause – chronic under-reimbursement by government payers and denials by private insurers,” continued Johnson. “Seventy percent of emergency air medical flights are covered by Medicare, Medicaid or are for patients with no insurance. Medicare only reimburses 59 percent of the cost of transport and Medicaid on average only reimburses 34 percent. This has led to immense financial challenges for the industry, as evidenced by the 32 air bases that have closed across the country since the start of this year.”
Private insurers also deny reimbursement for these services. Approximately half of all air medical claims are denied by insurance companies, either on the basis of network status or medical necessity. This despite the fact that 100 percent of emergency transports are ordered by an EMT or attending physician based on medical necessity.
“The legislative remedies to balance billing currently under consideration in Congress, while perhaps well intentioned, are misguided. But there is a better way. Congress already passed legislation last year calling for the U.S. Department of Transportation to collect cost data from the industry and develop recommendations for protecting patients from balance billing. This process must be allowed to move forward, before harmful legislation can be passed that puts these services at risk. By working together to address private insurer and government payer reimbursement, we can take patients out of the middle and protect access to the care they need in an emergency.”
SOAR Statement on Chairman Alexander’s Remarks About Air Medical
The following statement was released today by Carter Johnson, spokesperson for the Save Our Air Medical Resources (SOAR) Campaign, in response to Chairman Lamar Alexander’s remarks pertaining to air medical during today’s legislative hearing on S. 1895 in the Senate Health, Education, Labor & Pensions Committee.
“This proposal is dangerous, unworkable, and puts patient lives at risk. 85 million Americans live in rural areas where it takes more than an hour to get to a Level I or Level II trauma center by ground. Air medical transport is the lifeline that delivers patients to the health care facility they need in emergency situations. This bill, which puts insurance companies ahead of patients and by letting insurance companies decide what they want to pay for this service, will decimate essential air medical services and leave patients without access to the care they need in an emergency.
“The concept behind benchmarking is simply unworkable when applied to air medical transportation because in most places, there is no meaningful median network rate. Some insurance providers have refused to allow any emergency air medical providers to go in-network, and others have only one in-network emergency air medical provider. Further, it is completely inaccurate to say that 70% of air medical transports are out of network — in fact, 70% of air medical patients are either uninsured or covered by Medicare, Medicaid or other Government insurance. Only 30% of air medical patients have private insurance coverage, and if one applies the GAO’s questionable estimate that 69% of this smaller group is transported by providers that are out-of-network, this represents about 1 in 5 air medical transports overall.
“These and other facts should raise concerns among policymakers about the notion of benchmarking. If 69% of the small group of patients who have private insurance are transported by air medical providers that are outside of their insurance network, isn’t it obvious that the data necessary for benchmarking are missing? How could appropriate rates be set without factoring hard data on rural vs. suburban transports, provider type (hospital system v. community v. standalone provider), type of transport, patient outcome, and patient claim experience, to name a few crucial considerations? This is policymaking in the dark with a blindfold.
“If this proposal becomes law and insurance companies are allowed to reimburse air medical providers at either an illusory median network rate or the minimum allowable rate, insurance companies will default to the minimum allowable rate, which is not based on negotiated market data or actual market conditions. The result will be that insurance companies will increase their profits, air bases will close, and millions of Americans will lose access to the care they need when they need it most.
“There is a better way. The government should get the data it needs before approving this dangerous and impractical proposal. Last year, Congress directed the U.S. Department of Transportation to collect data from the air medical industry and develop recommendations for protecting patients from balance billing, improving disclosure and informing consumers of insurance options. We support this process and want it to work so that patients are taken out of the middle and get the care they need.”
ADDITIONAL KEY FACTS ABOUT AIR MEDICAL
90% of all emergency air transports are for cardiac, stroke, or other trauma conditions. The remaining 10% encompass specialty pediatric care, burns, neonatal, high-risk obstetrics, neurological, and other conditions.
100% of emergency air transports are ordered by an EMT or attending physician based on medical necessity.
100% of emergency patients are transported without regard to insurance status or ability to pay.
20% of Americans, or 85 million, live in areas where it takes more than one hour to get to Level I or II trauma center.
More than 70% of patients transported are covered by Medicare, Medicaid, other government insurance, or have no insurance at all. The Government Accountability Office estimates that about 20% of all air medical transports, or 1 in 5, are of patients who have insurance but are transported by an out-of-network air medical provider.
Medicare drastically under-reimburses for the cost of an emergency air medical transport, covering only 59% of the cost (in 2015 dollars). The average Medicaid reimbursement is even worse, covering only 34% of the cost.
SOAR Statement on Provisions of Lower Health Care Costs Act
“Recently proposed legislation by the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP) would destroy access to life-saving emergency air medical service for millions of Americans, especially those in rural areas.
The Lower Health Care Costs Act includes a provision – Section 105 - that hurts patients, cuts air medical providers out at the knees, removes vital care from rural America—and only benefits health insurance companies. The language would allow insurers to continue paying ever lower rates while continuing to question the emergency medical decisions of doctors and first responders. It would also leave no recourse against some insurers who refuse to negotiate in-network agreements with air ambulance providers. The unintended consequences of Section 105 will decimate the air medical safety net in rural America so that the cardiac, stroke and trauma patients air medical crew members care for 24 hours a day, 365 days a year, will have no chance to receive definitive care in an adequate amount of time.
This public policy gives the insurance industry all of the cards and could lead to the elimination of emergency air medical services at a time when large swaths of the country and millions of Americans are losing hospitals and other health care facilities. We urge members of Congress to reject this ill-conceived legislation.”
SOAR Statement on the House Hearing regarding “No More Surprises: Protecting Patients from Surprise Medical Bills”
“The Save Our Air Medical Resources (SOAR) Campaign supports efforts to protect patients from balance bills and ensure access to life-saving emergency air medical care. We urge Congress to get to the root of the problem by fixing Medicare’s chronic under-reimbursement for air medical services, and we call on insurance companies to do right by their patients and consistently cover this emergency service.
“Last year, Congress took a step in the right direction when it directed the U.S. Department of Transportation to collect data from the air medical industry and develop recommendations for improving disclosure, informing consumers of insurance options, and protecting patients from balance billing. We support this work and want it to succeed. Adding a new billing requirement to separate the health care and transportation aspects of an emergency air medical transport would be a step backward, however. Not only is such a separation impossible due to the nature of the service, it would do nothing to protect patients from balance bills or lower costs.
“We applaud the Subcommittee for taking up this issue and look forward to working with it to preserve access to emergency air medical services and protect patients from balance bills.”
SOAR Statement on the House Hearing regarding “Examining Surprise Billing: Protecting Patients from Financial Pain”
The SOAR Campaign thanks Chairwoman Frederica Wilson (FL-24) and all the members of the Committee for calling today’s hearing to explore strategies on the important issue of surprise billing. This is a welcome first step toward finding real solutions to take patients out of the middle.
Largely missing from today’s discussion was the role that private insurers play in surprise billing. For example, narrow networks and medical necessity are routine ways in which insurers deny coverage of patient claims in order to increase profits. Recent media coverage has shown that Health Care Services Corporation, which runs Blue Cross Blue Shield plans in five states, spent only 63 percent of premiums on actual medical costs. Insurer Centene was recently fined $1.5 million because their networks provided inadequate access to providers. These practices by private insurers leave patients at risk from surprise bills.
Emergency air medical providers never want to see a patient receive a bill they did not expect or cannot afford. Air ambulances are called by first responders or medical professionals to transport patients to the closest, most appropriate healthcare facility in an emergency. Air ambulances never self-dispatch: they go when they are called, regardless of the patient’s ability to pay or their network status. Yet some private insurers leave patients with large bills because they refuse to negotiate. As a result, air ambulance providers have patient advocates who work with the patient to navigate the insurance appeals process and, in many cases, provide the patient with a discount on their bill. But insurance denials beg the question - if patients can’t rely on private insurance in an emergency, what is insurance for?
To take patients out of the middle, private insurers must negotiate a fair reimbursement to bring air medical providers in-network, which air ambulance providers want to do. This can be accomplished for a small increase in premium as shown by a Montana legislative study which found that for only $1.70 a month more in premium costs, air ambulance services would be covered. A similar study in Kentucky estimated that the increase would be between $0.92 and $3.69 per person per month.
Beyond that, however, Congress must pass legislation that would require the collection of data from the air medical industry so that Medicare reimbursement rates can be updated to reflect the actual cost of care. Seventy percent of patients flown by air are covered by Medicare, Medicaid or have no insurance, and rates haven’t been updated in almost 20 years. This is unsustainable.
The SOAR Campaign appreciates the Committee’s attention to this issue. Working together on solutions that address the root of the problem will protect patient access to these life-saving services.
SOAR Statement on 2019 GAO Report
The Government Accountability (GAO) report issued Wednesday (3/21) confirms what the SOAR Campaign has been saying for some time – that the majority of patients covered by private insurance (two-thirds according to the GAO data) are out-of-network and therefore at financial risk of receiving a balance bill. Air medical providers are committed to going in network – and aggressively work to do so – but some private insurers refuse to even negotiate.
Even though the GAO found that only one in five Americans flown by air medical have private insurance and the number of large balance bills they receive is quite small, air ambulance providers never want to see a patient with a bill they didn’t’ expect or can’t afford. That’s why they have patient advocates who work side-by-side with the patient to navigate the insurance appeals process and, in many cases, discount the final bill.
The report also found that 60 percent of new air bases are in rural areas, where hospitals, and specialty services like maternity and emergency care, are closing at alarming rates. In those areas, air medical is filling the gap by transporting patients to the nearest, most appropriate health care facility. This is critical for patient outcomes in an emergency.
The solution to balance bills is twofold.
First, Congress must pass legislation that would require the collection of data for the air medical industry so that Medicare reimbursement rates can be updated to reflect the actual cost of care. Because 70 percent of patients flown by air are covered by Medicare, Medicaid or have no insurance, and rates haven’t been updated in almost 20 years, this is an important step toward preserving access to these life-saving services.
Second, private insurers must do right by patients by going in-network with air medical providers. The fact is emergency air medical transport can be covered by private insurance for a small increase in premium. A Montana legislative study found that for only $1.70 a month more in premium, air ambulance services would be covered. A similar study in Kentucky estimated that the increase would be between $0.92 and $3.69 per person per month.
We are grateful that the GAO has focused its attention on the role that private insurers play, and we look forward to working with members of Congress and private insurers to find solutions that get to the root of the problem, to take patients out of the middle.