JOHN DAY — Northeast Oregon is a land of wide-open spaces and natural solitude, far from the hustle and bustle of city life.
Most people out here prefer it that way. But in a medical emergency, the isolation that goes with the region’s rural lifestyle can be a problem.
The six counties that make up Oregon’s upper right corner cover more than 18,000 square miles, an area two-thirds the size of West Virginia and larger than nine U.S. states. Scattered across this far-flung region are seven critical access hospitals, each licensed for a maximum of 25 beds.
In Northeast Oregon, if someone falls gravely ill on a remote ranch or is severely injured in a car wreck on a lonely two-lane highway, the nearest hospital can be an hour or more away by ambulance — if one is available. And if a patient’s medical condition requires specialized treatment, that can mean a three-hour drive or more to get to a larger hospital in Bend, Boise or Portland.
That’s where air ambulance service comes in.
There are a number of private companies that provide medically staffed helicopter or fixed-wing aircraft to transport patients quickly in an emergency.
In remote rural areas like Northeast Oregon, that can mean the difference between life and death — but it can also mean a hefty bill, especially for people who lack the proper insurance coverage.
“There’s no two ways around it — air ambulance transport is expensive,” said Natalie Hannah, a spokesperson for Life Flight, a not-for-profit air medical transportation company that operates in Oregon, Washington, Idaho and Montana.
“The cost of 24/7/365 readiness, state-of-the-art medical and transport equipment, employing the foremost emergency care providers, as well as the level of care and medications administered, and distance of transport all contribute to the overall cost.”
How it works
In Northeast Oregon, there are three companies that provide air ambulance transport, either by helicopter for shorter trips or fixed-wing plane for longer flights. All three offer membership plans at a cost ranging from $60 to $99 a year, depending on the provider.
Air ambulance memberships are not a form of insurance. Rather, when a member uses the service, the air ambulance company bills the patient’s primary medical insurance and, if applicable, the patient’s secondary insurance plan. This includes Medicare.
Normally, a patient without a membership would then pay the balance of charges up to the allowed amount — a figure that could total in the tens of thousands of dollars, depending on the circumstances.
For example, under one Asuris Northwest Health plan, after the patient’s deductible is met, Asuris will cover 80% of the allowed amount for any air ambulance provider and the insured party is responsible for the remaining 20% of the bill. Coverage varies between insurance providers and individual plans.
However, the picture is a little more complicated than that. Not all air ambulance providers will sell memberships to those without primary medical insurance that includes benefit provisions for air ambulance transport, though they will still provide transport to uninsured patients. This does not pertain to Medicaid recipients, who, by federal law, cannot be held liable for air ambulance charges.
Sticker shock
In a study published in 2019, the U.S. Government Accountability Office analyzed air ambulance transport data among privately insured patients from 2017. GAO found that the median price charged by air ambulance providers at that time was about $36,400 for a helicopter transport and $40,600 for a fixed-wing transport.
For those living in rural areas, the cost of emergency transport can trend even higher due to the longer distances that must be traveled by air ambulance providers.
Out of 60 consumer complaints received by two states collecting data on individual balance bills analyzed by GAO, all but one complaint regarded a balance bill of over $10,000.
At that time, GAO found that over two-thirds of ambulance transports for patients with private insurance were out of network. Generally, out-of-network providers are covered at a lower rate by insurance companies than those they are contracted with — meaning consumers wind up paying more of the cost.
Unlike when one is browsing local health care providers and checking network status with one’s medical insurance, in an emergency medical situation, a patient doesn’t have a choice in which air ambulance provider is dispatched to transport them.
According to the GAO study, which air ambulance company is called largely depends on proximity or established relationships between hospitals and air ambulance providers, followed by who is available to provide transport. First responders or hospital personnel are the ones who ultimately make this decision, which can leave patients who might not even be conscious when the call is made holding a hefty bill if they don’t have a membership with the provider that responds.
Although the state does not regulate air ambulance membership programs, Oregonians enrolled in commercial health insurance are somewhat insulated from high air ambulance costs by a federal law that went into effect at the start of last year.
“Protections are in place to ensure coverage of air ambulance services and prevent consumers from receiving large out-of-network bills,” said Jason Horton, public information officer for the Division of Financial Regulation at the Oregon Department of Consumer and Business Services.
“The No Surprises Act prohibits air ambulance companies from billing beyond the applicable in-network amount and requires the insurer or employer payer to reimburse an amount subject to binding arbitration. Out-of-network providers of air ambulance services cannot bill or hold liable participants, beneficiaries, or enrollees in group health plans or group or individual health insurance coverage who received covered air ambulance services for an amount greater than the in-network cost-sharing requirement for those services,” he explained.
Horton added that the cost-sharing requirement is generally based on the lesser of the median of contracted rates payable to in-network providers of air ambulance services or the billed amount for the services.
This, however, doesn’t resolve the issue of expensive in-network patient responsibility, the cost of which still has the ability to cripple many people’s budgets.
If one has a membership with the air ambulance company that provided transport, though, then there is no further patient responsibility beyond what one’s insurance pays. As long as membership is established prior to air ambulance transport being called, it will be honored.
Multiple providers
Another complicating factor in this equation, though, is that there are often multiple air ambulance providers operating in a given area, all owned by different companies. Depending on where one lives, it begs the question: Which memberships do I need to be reasonably protected in the event of an emergency medical situation?
In Northeast Oregon, there are three companies that might be called: Aurora-based Life Flight Network, Air St. Luke’s of Boise or Bend-based AirLink Critical Care.
Some providers have multiple bases strategically placed around the state to respond to calls. For those affiliated with a hospital system, transport is not solely tied to that hospital; air ambulances will deliver patients to wherever staff conducting the transfer specify.
Fortunately for prospective patients, some of these providers honor one another’s memberships through reciprocal agreements. For example, Life Flight and Air St. Luke’s both belong to the Association of Air Ambulance Membership Programs. Essentially, if a patient is a member of one AAMP company, that patient is a member of all. So if a patient has a Life Flight membership but Air St. Luke’s shows up to provide transport, Air St. Luke’s will honor the Life Flight membership and not hold the patient responsible for any additional billing beyond what their insurance pays.
In Northeast Oregon, AirLink is the exception to that rule. While AirLink is part of AirMedCare Network, which provides members with protection at over 320 locations across 38 other states, the company does not have reciprocal agreements with all of the other providers in Northeast Oregon.
That can be an issue in places like Grant County, where air ambulance coverage is provided by both AirLink and Life Flight.
Rebekah Rand, director of emergency medical services for the John Day-based Blue Mountain Hospital District, said people who live in the area need a policy for each provider.
If someone were to be in an automobile accident and that person has a Life Flight membership but is picked up by AirLink, Life Flight will not cover the cost of the transportation. It is the same for an AirLink member being transported by Life Flight.
“We recommend people have coverage with both agencies,” Rand said.
Membership services representatives at all air ambulance providers contacted for this story recommended that individuals reach out to their local hospital to find out in what order air ambulance providers in their region are contacted to determine which memberships would be most advantageous for them.
All providers operating in Northeast Oregon offer one-year, multi-year and, in some cases, even lifetime memberships which can discount the annual cost of renewal.
Cost factors
Why is air ambulance service so expensive? It’s not just the high cost of aviation fuel.
The helicopters and airplanes used to transport critically ill or severely injured patients are not simply flying taxis — they’re airborne treatment centers with the sophisticated equipment and trained medical personnel needed to keep people alive while they’re being transported to the hospital.
Take the Life Flight Network as an example.
“Our aircraft (both helicopters and fixed wing) are mobile intensive care units, featuring the same state-of-the-art equipment that you would find in a hospital ICU,” said Hannah, the company spokesperson.
“Our aircraft are staffed by highly trained pilots, flight nurses, flight paramedics and flight respiratory therapists who undergo regular advanced training to remain proficient in their skills and to ensure that we are operating at the highest levels of safety.”
From the moment the patient comes aboard the aircraft, the medical personnel can provide treatment and stabilization for a host of life-threatening conditions, ranging from heart attack to stroke, trauma, airway obstruction and blood loss, among others, Hannah said.
Another cost factor is the overhead that goes into making sure those services are available when they’re needed.
Life Flight maintains helicopter bases and 10 fixed-wing bases across four states. Pilots and medical crew members are required to be available 24 hours a day and are housed at the company’s bases to ensure rapid response times.
“Our helicopters are typically off the ground within 8-10 minutes from the time of dispatch, and this state of readiness is costly,” Hannah said. “It includes the behind-the-scenes operations of our communications center, our maintenance staff, training personnel and administrative operations.”
