After a 10-year old boy and a Tuolumne County Sheriff’s Office Community Service pickup truck collided in the intersection of South Washington Street and Stockton Road on June 5, the boy was transported by ground ambulance to Sonora Regional Medical Center for treatment of non-life-threatening injuries to his foot.
But the injuries were so severe that the boy required additional treatment. So a presiding physician called in a helicopter emergency air ambulance service to transport the boy to the closest child trauma center: UC Davis Medical Center in Sacramento.
Because her son is covered by Medi-Cal, the California Medicaid program that serves low-income individuals, his mother, Sarah Guzman, said she is simply lying in wait for an inevitable bill to cover the cost of the flight.
“I don't know how much it's going to cost,” she said, “How can I afford it if it's like $10,000?”
But air ambulance services have been asking the same question: How can we afford to provide the service of these flights when Medi-Cal reimbursement rates are far below the cost of the bill?
Assembly Bill 583, introduced by Jim Wood (2nd-District), has sought to extend the Emergency Medical Air Transportation Act (EMATA) to Jan. 1, 2028, in anticipation of the bill’s sunset date on Jan. 1, 2018, which levies a $4 penalty fee on Vehicle Code and local ordinance violations (except parking offenses) to provide reimbursement for emergency air ambulance services provided to Californians.
The bill is stalled in the California Assembly Appropriations Committee.
According to a California Department of Health Care Services’ fiscal impact report of EMATA, augmented payment amounts including the funds acquired by the fee for rotary wing aircraft (helicopters) totalled $4,310 per flight, and $3,053 per flight for fixed wing aircraft (airplanes).
The baseline Medi-Cal reimbursement is $1,800 and $1,200, respectively, a rate which was fixed in 1993.
According to an Association of Air Medical Services Cost Study Report, conducted by an independent research firm, the national median reported cost of an emergency air medical transport is $10,199.
Bill Bryant, a healthcare consultant, native of Twain Harte and former Sonora ground ambulance and Modesto based Medi-Flight air ambulance paramedic, called the figure “misleading,” and indicated that judging by the total flights taken by air ambulances over a year, and because about 70 percent of flights were taken by indigent patients without insurance who couldn’t pay for coverage, the actual cost to an individual client was more like $40,000.
“It’s an easy mathematical equation, but it's a meaningless number,” he said, noting that the average cost to put up a helicopter base and staff it with a pilot, paramedic and nurse, 24 hours a day is about $3 million a year. If the helicopter at the base took the average one to two flights a day, the figure could be seen as $10,000, but the price was often increased to make up for the large number of patients who couldn’t pay anything at all.
Air ambulance coverage in rural counties
Tuolumne County’s primary provider of air ambulance services is PHI Air Medical, a private entity that provides its services across the United States.
One helicopter is based in Tuolumne County, the bumblebee yellow Medic 42. The craft is staffed by a pilot, paramedic and a nurse 24 hours a day and responds to emergency and non-emergency calls at the request of Tuolumne County Emergency Medical Services and local dispatch centers.
Through a contract with the county, PHI is locally regulated by Tuolumne EMS to adhere to staffing and equipment requirements, a task that they do “easily,” said Tuolumne County Emergency Medical Services Coordinator Clarence Teem.
In coordination with a ground ambulance fleet that is managed by the county, both services provide emergency shuttling to area hospitals for severe trauma and major cardiac patients.
If Medic 42 is not available, Tuolumne County can additionally utilize air transport services from PHI Air Medical based in Modesto; Mercy Air in Merced and Riggs Air Ambulance in Merced.
Teem said that an airlift medical transport from Tuolumne County to the closest urban tertiary care hospitals (trauma centers, heart/stroke centers and burn units) Doctors Medical Center and Memorial Medical Center in Modesto was about 20 minutes “as the crow flies” at a speed of about 200 miles an hour. Ground ambulances to those locations could take from 45 minutes to an hour driving at about 75 miles an hour on road networks and through vehicle traffic.
Without the service of air ambulances in Tuolumne County, Teem said, “the odds of someone succumbing to major trauma would increase because you would have longer transport times to trauma centers and more poor outcomes for cardiac patients.”
Bryant, recalling his experience up in the skies as an air ambulance paramedic, said his team was often sent into Yosemite National Park, maybe three times a week, to respond to “traffic accidents, heart attacks and everything in between.”
“When you're outbound without a patient, it is a great view and you have a chance to look around,” he said. “But when you have a patient on board you are so completely focused on a patient it's not that much different that being in a ground ambulance. You’re completely focused on the patient and taking care of a patient.”
The only difference, he noted, was that air ambulances were often tasked with caring for the most critically ill or injured patient from a specific incident or situation.
Calaveras County is a part of a five-county Mountain Valley EMS Agency, which also includes Alpine, Amador, Mariposa and Stanislaus counties.
Executive Director of Mountain Valley EMS Richard Murdock indicated that the geography of the rural locales throughout the five-county area mandated the use of air ambulances as a vital emergency service. With a PHI location in Auburn, as well as two air ambulances in Modesto owned by CalStar and Mercy Air, each of the services coordinated with EMS to determine where and when they are dispatched.
“Any reduction of any air medical services is going to impact our services,” he said. “It's really going to put some of the most vulnerable residents at risk that live in the mountain counties.”
Private air ambulance services pay a small contract fee to operate within the Mountain Valley EMS region, Murdock said, $5,000 if they have a base within the five-county system and $1,000 a year if they fly into the region from an outside county.
If the bill were to sunset, it would have no bearing on the contract, he said, but in a “worst-case scenario” they could “mutually agree to terminate the contract” because of a lack of financial sustainability.
Tuolumne County EMS, by comparison, does not charge a fee per contract or per call, Teem said, in order not to impinge on the “fiscal viability” of air ambulance services.
Lobbying for AB 583
For private air ambulance service providers contracted with local EMS agencies, the augmented Medi-Cal reimbursement is characterized as a necessary component of a company’s revenue structure.
“Our focus with this funding has not changed,” said PHI spokesperson Brad Deutser. “We are continuing to work on the renewal of the EMATA funding, and we are hopeful that it will be successful and we will be successful with working with CA legislature.”
Deutser declined to speculate on how rural county services would be affected if AB 583 was discontinued.
“We can't speculate as to the future,” he said. “We know what we are working on. We know what's important and we are hopeful that the California legislature will see the importance of the continued funding as well.”
But the concern of local politicians, such as 5th District Assemblyman Frank Bigelow, is how the sunsetting of EMATA could diminish, or even extinguish, air ambulance transportation from rural California counties such as Tuolumne and Calaveras.
Bigelow, a co-author of AB 583 with Sen. Jim Beall, District 15; Sen. Jim Nielsen, 4th District; Assemblyman Jim Cooper, 9th District; and Assemblyman Jim Patterson, 23rd District, said in an emailed statement: “Air ambulances provide a vital resource for rural Californians who face geographical, environmental, and climatic hurdles when seeking emergency medical care. As a coauthor of the extension of the Emergency Medical Air Transportation Act, I have worked diligently to ensure this program continues to receive its current funding. This funding provides the difference in life or death for rural Californians.”
Bigelow additionally went on to register his support for the vehicle code violation fee that funds EMATA’s reimbursements.
“Unfortunately, without the extension of this funding, air ambulance services will face severe financial cuts, threatening emergency response times throughout Rural California,” he said.
The total EMATA funds acquired from the $4 fee in 2016-17 was about $8.69 million, according to a state AB 583 bill analysis. Less than 20 percent of that value, about $1.44 million, was contributed to the General Fund to offset the state’s portion of the Medi-Cal reimbursement rate for emergency air transportation services. The remaining $7.25 million is matched by Federal Financial Participation, totalling $14.5 million to be distributed among California emergency air transportation services in augmented supplemental payments.
The analysis notes 1,993 rotary-wing transports and 602 fixed-wing transports were eligible for an augmentation payment during 2015-16.
Users of private air ambulance services fall into three categories of a county’s “payer mix”: private pay, or through a private medical insurance plan that covers all or a portion of the cost of a flight; government pay, such as people on Medi-Cal; and self pay, where someone with no insurance could be required to cover the cost of an air ambulance out of pocket.
According to a 2015 California Department of Health Care Services Statewide Medi-Cal enrollment fact sheet, about 27 percent of Tuolumne County residents and 26 percent of Calaveras County residents are enrolled in Medi-Cal.
Statewide, about 33.4 percent of Californians are enrolled in Medi-Cal, or about 12.7 million people.
Neal Cline, a secretary with the California Association of Air Medical Services, the main sponsor of the bill, explained that the intent of EMATA was to “help support these programs that are not being reimbursed for the services that they provide.”
But alternatively, private air ambulance companies have also pursued opportunities to “balance a bill,” or aggressively pursue overdue payment for a service. But according to Cline, this practice is not so pervasive, as air ambulance services are more interested in maintaining and ensuring services in rural area.
“A lot of companies will write this off as a business loss,” he said. “They can't afford it. So why waste the time and effort?”