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Out-of-pocket payments made by patients transported by Helicopter Emergency Medical Services (HEMS)

Journal logoUnlabelled imageAmerican Journal of Emergency Medicine 58 (2022) 192-196

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage:

Out-of-pocket payments made by patients transported by helicopter emergency medical services (HEMS)

Brian Gooley, MD, Sela Sherr, MD, Timothy J. Lenz, MD; MPH ?

Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America

a r t i c l e i n f o

Article history:

Received 19 January 2022

Received in revised form 2 May 2022 Accepted 1 June 2022

Keywords:

HEMS

Cost Payments

a b s t r a c t

Objective: Recent news media have reported that Helicopter Emergency Medical Service programs use the practice of balanced billing, resulting in exorbitant charges not covered by insurance companies and financially burdening patients. To date, no study has described the billing practices of HEMS programs. We look to provide transparent billing practices and average patient payment of one midwestern non-profit HEMS program and report the reimbursement data of both federal and private insurance policies for transports.

Methods: Collated billing data were obtained from a HEMS program for two time periods from January 2017 through June 2018 (P1) and July 2018 through December 2019 (P2). From P1 to P2 the base charge per transport was increased. All transports that generated a bill during the periods were included and descriptive statistics were used to depict the findings.

Results: Per flight, base charge was $19,158 in P1 and $33,023 in P2. On average, patients paid $158.09 and

$178.99 out-of-pocket, respectively. Reimbursement practices of insurance companies varied widely across time periods and among each other.

Conclusion: The amount charged by this HEMS program and amount patients paid on average for flights was less than has been commonly reported in recent news media. More transparency in costs and payments between non-profit and for-profit HEMS agencies should occur.

(C) 2022

  1. Background

helicopter emergency services (HEMS) provide a crucial role in the triage and transport of patients experiencing time sensitive emergen- cies, such as trauma, heart attacks, acute strokes, and brain injuries [1]. HEMS has the potential to reduce long-distance transport times, enhance access of Rural communities to Tertiary care centers, and improve mortality and morbidity outcomes when compared with ground ambulance [2,3].

The systematic use of helicopters as air medical transport in the United States first began during the Korean War and was further refined in the Vietnam War. Integration into civilian emergency medical ser- vices (EMS) began in the late 1960s and early 1970s in the form of hospital-based Air ambulance programs [4].

The Airline Deregulation Act of 1978 (ADA), which included the de- regulation of the nascent air ambulance industry, was an important driver for the steady increase of air ambulance providers [5,6]. In 1980, there were 39 air ambulance helicopters in operation. As of

* Corresponding author.

E-mail address: [email protected] (T.J. Lenz).

2016, there were 1045, with the most rapid expansion of programs occurring since 2002 after Medicare raised its reimbursement rates [7]. Currently, for-profit corporations account for the majority of air ambulance providers. Recently, media coverage has been growing on increasing out-of-pocket costs and the refusal of insurance companies to cover HEMS transport charges. In particular, there has been an outcry regarding the practice of balance billing, sometimes called “surprise bill- ing.” Balance billing occurs when healthcare providers bill patients for the difference between a provider’s charge and the reimbursed amount by an insurance company [8]. The concept of balance billing has been at

the center of news articles.

Many popular media outlets have reported bills as high as $50,000. These reports have often highlighted how such bills have led to detri- mental financial stressors to the patient and their families in the form of high interest debt, aggressive bill collection, worsening credit, and even bankruptcy and loss of home [9-15]. One such example includes a bill to the mother of a newborn who needed an emergent heart trans- plant and was transported by a for-profit HEMS company. His mother was later billed nearly $60,000 [16].

Although there are numerous anecdotal reports, such as those high- lighted in the news media, there is a paucity of systemic literature on the Financial impact on patients. It is documented in the literature that

https://doi.org/10.1016/j.ajem.2022.06.001

0735-6757/(C) 2022

air ambulance median charges have increased. Between the years 2010 and 2014, there was a doubling in overall charge of rotary wing trans- port from an average of $15,000 to $30,000 [5]. However, data about the total bill sent to patients and the extent of balance billing is lacking.

Table 1

Flight and revenue breakdown.

Charge per flight Average amount paid to HEMS per flight

  1. Study aims

The purpose of this study is to determine the true, total out-of- pocket amount paid by patients per flight served by a midwestern re- gional non-profit HEMS program prior to and following a rate increase. In addition, the extent of balance billing will be trended between the two pay periods by comparing bills submitted to patients covered by Medicare or Medicaid, private insurance, or no insurance.

  1. Study data and methods

Institutional Review Board approval for the survey was obtained from the xxxxxx.

  1. Data source

To quantify the true out-of-pocket amount paid by patients flown by a midwestern non-profit HEMS program, we obtained a revenue pay- ment analysis of all flights between two time periods – January 1, 2017 through June 30, 2018 (referred to as P1, the period immediately before the rate increase) and July 1, 2018 through December 31, 2019 (referred to as P2, the period immediately after the rate increase). In 2017, an independent HEMS consulting firm recommended an increase in charges, as the program was below the 50th percentile when com- pared to other programs across the country. Therefore, between P1 and P2, there was a price increase in the base charge for all flights by this non-profit HEMS program.

Our cohort included commercially insured, government (public) in- sured, and self-payer patients who required medical helicopter trans- portation during the above years. Flights that did not generate a bill, regardless of reason, including Search and rescue flights, stand-by- flights, and canceled flights that did not result in transport, were not in- cluded in the study.

The HEMS program provided us with their collated billing data, which we used to generate payment data for each payer group. The bill- ing data provided did not contain individual transport records. Rather, we were provided with averages across varying payer groups. These payer groups included Medicare, Medicaid, private market insurances with a pre-existing contract, private insurance without contracts, and self-payers.

  1. Analysis

We utilized descriptive statistics by payer group. 568 transports dur- ing period P1 and 555 during period P2 were reviewed. For each pay pe- riod, collated data with the total number of transports, average charge per flight, average total payment per flight, average contractual pay- ment, average insurance payment, average secondary payment, and av- erage write-off was provided by the non-profit HEMS service. Average charge refers to the mean charge billed by the program per flight prior to any payment. Average total payment is the mean reimbursement amount to the HEMS program per flight from all parties at the time of data collection. Average contractual payment is the mean per flight pay- ment made by hospitals who had standing service contracts with the HEMS program. Average insurance payment refers to the mean amount paid by insurance companies prior to any bill sent to the patient. Aver- age secondary payment refers to the mean amount paid per flight made by patients after any insurer payments toward the flight charge. Aver- age write-off is the mean amount of revenue this HEMS program lost per flight due to the difference between the charge and that which is ac- tually paid by all parties. To estimate the average out-of-pocket

Jan 2017-Jun 2018 $19,158 $14,761

Jul 2018-Dec 2019 $33,023 $13,507

expenses per patient, we divided the total actual payments made by pa- tients by the total number of transports for each study period. We then directly compared these values between P1 and P2.

  1. Study results

On average, Medicare and Medicaid paid 32% and 12% of the flight charge respectively during P1, and 14% and 11% respectively during P2. Write-off increased from P1 to P2 from 5.58% to 16.12%. The average payment per flight across payer groups decreased from $14,761 to

$13,507, while the average charge increased from $19,158 to $33,029 (Table 1).

During P1, the average out-of-pocket payment per patient was

$158.09 compared to $178.99 during P2 (Table 2, $20.90 average in- crease). Private insurance payouts increased from P1 to P2, from

$15,156 to $24,060 respectively (Table 2).

During P1, for all payers, the average charge was $19,152.60, with an average payment of $13,071.31. The median charge was $17,937.50, with a median payment of $17,412.50. The range in charge was

$30,275.00, with a payment range of $45,375.00. The minimum charge was $15,100.00 and maximum charge was $43,375.00, while the mini- mum payment was $0 and maximum payment was $43,375.00. The in- terquartile minimum charge was $17,412.50 and interquartile maximum charge was $18,987.50, for a range of $1575.00. The inter- quartile minimum payment was $3228.15 and interquartile maximum payment was $18,237.50, for a range of $15,009.35.

During P1, for self-pay patients, the average charge was $17,662.50, with an average payment of $2232.61. The median charge was

$17,312.50. The range in charge was $5337.50, with a payment range of $16,275.00. The minimum charge was $15,100.00 and maximum charge was $20,437.50, while the minimum payment was $0 and max- imum payment was $16,725.00. The interquartile minimum charge was

$16,737.50 and interquartile maximum charge was $18,500.00, for a range of $1762.50. The interquartile minimum payment was $0 and the interquartile maximum payment was $16,725.00.

During P2, for all payers, the average charge was $33,019.06, with an average payment of $13,797.38. The median charge was $31,285.00, with a median payment of $6584.47. The range in charge was

$32,550.00, with a payment range of $53,475.00. The minimum charge was $27,225.00 and maximum charge was $59,775.00, while the mini- mum payment was $0 and maximum payment was $53,475.00. The in- terquartile minimum charge was $30,322.50 and interquartile maximum charge was $33,507.50, for a range of $3185.00. The inter- quartile minimum payment was $3594.33 and interquartile maximum payment was $21,337.50, for a range of $17,743.17.

During P2, for self-pay patients, the average charge was $31,632.50, with an average payment of $1049.86. The median charge was

$30,725.00. The range in charge was $16,100.00, with a payment range of $33,2455.00. The minimum charge was $27,925.00 and maxi- mum charge was $44,025.00, while the minimum payment was $0 and maximum payment was $33,245.00. The interquartile minimum charge was $30,025.00 and interquartile maximum charge was

$32,300.00, for a range of $2275.00.

There were differences due to payer mix and smaller sample size in P2 for scene calls. The average charge was $30,766.94, with an average payment of $13,035.21. The median charge was $30,655.00, with a me- dian payment of $4628.27. The range in charge was $7700.00, with a payment range of $35,100.00. The minimum charge was $27,400.00

Table 2

Payment data.

Average payment by Medicare|Medicaid (% of total charge)

Average payment by private insurance (% of total charge)

Average amount paid by patient (% of total charge)

Jan 2017-Jun 2018 $6112 (32%) | $2513 (12%) $15,156 (79%) $158.09 (0.83%)

Jul 2018-Dec 2019 $4547 (14%) | $3535 (11%) $24,060 (73%) $178.99 (0.54%)

P1: 568 TRANSPORTS BY PAYER TYPE

in addition to transport charges, making it very difficult to collect these

Image of Fig. 1SELF PAY 4% (n = 23)

INSURANCE 8% (n = 47)

CONTRACT 67%

(n =379)

MEDICARE 4% (n = 23)

MEDICAID 17%

(n = 96)

unpaid charges. Subsequently, this has led this program to write off these charges.

At the time of this study, this HEMS services did not have in-network or contract Commercial insurance payers because many contract pay- ment amounts offered by insurance companies is so low, they have cho- sen not to contract with any insurance companies. The percent of the total bill paid by commercial insurers for P1 and P2 is elucidated in Fig. 3 and Fig. 4, respectively. In P1 and P2, there was a wide range (30% to 100%) in what insurance companies paid for HEMS transport. Some insurance companies were represented in both P1 and P2, while others were represented in only one time period.

Fig. 1. P1: 568 transports by Payer type.

and maximum charge was $35,100.00, while the minimum payment was $0 and maximum payment was $35,100. The interquartile mini- mum charge was $29,325.00 and interquartile maximum charge was

$32,300.00, for a range of $2975.00. The interquartile minimum pay- ment was $1410.00 and interquartile maximum payment was

$28,800.00, for a range of $27,390.00.

Payer mix during P1 (Fig. 1) included 379 payments by contracted payers (66.7%), 96 by Medicaid (16.9%), 47 by non-contracted insurers

(8.3%), 23 by Medicare (4.0%), and 23 by self-payers (4.0%). Payer mix during P2 (Fig. 2) included 110 payments by contracted payers (19.8%), 103 by Medicaid (18.6%), 180 by non-contracted insurers

(32.4%), 127 by Medicare (22.9%), and 35 by self-payers (6.3%). The contracted insurers in each pay period refers to contractual agreements with hospitals, in which the hospital directly pays the HEMS services and then charges the patient. The decrease in payments by contracted payers in P2 was due to severance of contracts with one major regional hospital system.

Self-payers account for very few paid bills. While the average bill to self-payers was $17,716.30 in P1 and $31,632.50 in P2, only $84,977.70 (20.9%) total was paid in P1, which accounts for approximately 4 bills out of 24 transports paid, and $36,745 (3.3%) total was paid in P2, which accounts for approximately one and one-tenth of bills paid out of 35 transports. The remaining $322,497.30 (79.1%) in P1 and

$1,070,392.50 (96.7%) in P2 was written off by the program. Often the transported patient is subject to large medical bills from hospitalization,

P2: 555 TRANSPORTS BY PAYER TYPE

  1. Discussion

In this study we found that insured patients who underwent air am- bulance transportation by this HEMS program did not receive large out- of-pocket charges. In fact, we found that patients who underwent HEMS transport on average paid less than $180 out-of-pocket despite an in- crease in transport charge between P1 and P2 in both study periods. This is in stark contrast to numerous recent popular media reports of in- sured patients, in various areas of the U.S., receiving “surprise” bills in the tens of thousands of dollars. Those who were uninsured received bills for the full amount of transport, but more than 96% of the charges were written off by this HEMS program. This resulted in greater finan- cial burden to the program and decreased the overall average payment per transport.

Patients only paid slightly more out-of-pocket despite the increase across periods, which may be related to several factors. As the price for transport increased, relative insurance payout also increased. Thus, the actual impact to the patient did not substan- tially rise. Another possibility relates to the patient population. Often, the patients flown by HEMS are critically ill, and require pro- longed hospitalization and advanced medical procedures. This may result in Financial burdens related to hospital bills, missed work, disability, and other expenses in addition to a bill for air transport. Therefore, patients may simply be unable to afford absorbing the increased charge per flight.

While out-of-pocket costs to patients did not increase much be-

tween P1 and P2, average charge per flight did. The complexity of the health insurance design in the U.S. is well documented. [24] Cost trans- parency and billing practices of insurance companies, as well as healthcare agencies, remain elusive. Thus, determining the exact rea- sons for the increase in charge per-flight was challenging. During our

Image of Fig. 2SELF PAY 6% (n = 35)

INSURANCE 32%

(n = 180)

CONTRACT 20% (n = 110)

MEDICARE 23%

(n = 127)

MEDICAID 19%

(n = 103)

study period, we identified four main themes:

(1) underpayment by Medicare and Medicaid, (2) increase in pro- portion of Medicare and Medicaid transports relative to private insur- ances, (3) large variability in private insurance reimbursement per flight, and (4) loss of previously hospital-contracted flights.

Medicare and Medicaid reimbursed a flat rate, far below the actual

cost to transport a patient (Table 1) and reimbursed far less compared private insurances (Table 2). The observed underpayment may be one reason charge-per-flight increased. In addition, a form of balance billing may occur as costs are shifted to private insurers and then to patients by charging more than the true cost for a flight.

In our study, there was an increase over P1 and P2 of total Medicare

Fig. 2. P2: 555 transports by payer type.

and Medicaid transports (5% to 13%) relative to privately insured

120%

100%

100%

100%

100%

100%

100%

99%

84%

81%

73%

60%

100%

80%

60%

40%

20%

0%

Fig. 3. Percent of Bill Paid by Private Insurers 2017-2018.

patients. If this trend were to continue, it may further drive up the flight charge and jeopardize the viability of this HEMS program.

Importantly, HEMS flights were provided to patients covered by Medicaid and Medicare without cost to the patient. Due to current laws and regulations, balance billing for Medicare is not allowed and these patients never received a bill from this non-profit HEMS program regardless of the air ambulance cost. As a vulnerable population, due to poverty, chronic illness, or advanced age [17], these patients may be targeted by brokers and insurance companies to buy additional cover- age at a cost of hundreds of dollars per year. Several private companies offer additional out-of-network coverage, as well as a promise to submit claims to Medicare or Medicaid. [22,23]

This study also revealed large variations in the amounts paid by different insurance companies. For example, for P1, umr.com paid 100% of the flight cost, while BCBS Illinois paid only 60% of the bill. These variations did not correlate with the amount of out-of- pocket paid by patients, but did result in a larger average write-off when an insurance company paid less than 100% of the bill. Some variations also occurred between P1 and P2 for the same insurance company. For example, BCBS Illinois compensated for 60% of the flight cost in P1 and 90% in P2 after the price increase. Conversely, progressive.com paid 100% of the flight cost in P1 and only 30% in P2. Still, most insurance companies paid all or most of the bill, which is not consistent with the recent media reports of exorbitant charges to patients transported by HEMS. Nevertheless, uninsured individuals were charged the full cost of the flight, which did lead to patient bills in the tens of thousands of dollars.

The variation in insurance payouts may be related to several causes. At the time of this study, this non-profit HEMS agency did not have any in-network or contracted commercial insurance payers, as is typical in the HEMS industry. Case by case variability, including insurance plan type, may play an important role in insurance payout differences.

84%

73%

65%

62%

56%

52%

34%

30%

Another factor may be insurance companies’ refusal to pay based on “medical necessity.” For example, a recent article in Annals of Emergency Medicine described cases of HEMS bills being denied to island residents having chest pain or preterm labor needing evacuation to mainland hospitals on the basis of lack of medical necessity [18]. The same article discussed another case of an island resident whose care was delayed due to concern that his insurance company would not pay for the flight. There were far more private insurance companies that paid less than 100% of the flight charge in P2 compared to P1. Charge per flight may have increased to offset the lost revenue and lack of reliable reimburse- ment from private insurance companies. If this association were to con- tinue, one concern would be further cost transfer directly to patients.

A large decrease in contracted flights, as well as revenue from these flights, was seen between P1 and P2 (86% vs. 28% of total revenue, re- spectively). The decrease in contracted flights was due to loss of several HEMS transport contracts with local hospitals, which was associated with increased write-offs.

We propose several solutions to reduce cost of HEMS transport to patients. Based on our data, contracted flights lead to the most reliable compensation for a HEMS program. Contracted flights paid 100% of the total charge, resulted in no write-off, and were associated with the lowest average flight cost to patients. Thus, increasing contracted flights would potentially drive the cost of flights down and would reduce the financial burden for patients. For example, obtaining several more con- tracts from major tertiary hospitals in the region to compensate for the lost contracts from P1 to P2, may have a substantial decrease in cost to the HEMS operator, as well as patients.

Another solution would be partial or full funding of the HEMS by multiple regional municipalities, for example, via a small increase in local tax collection, similar to funding for police or fire departments. In return, all residents would be covered in the event of HEMS trans- port and out-of-pocket expenses would be eliminated. Since 1992,

100%

100% 100% 100% 100% 100% 90%

87%

80%

60%

40%

20%

0%

Fig. 4. Percent of Bill Paid by Private Insurers 2018-2019.

Maryland’s state-wide EMS system, including HEMS, is supported by a surcharge on vehicle registration fees and moving violations. This model has been recognized as crucial to the viability of Maryland’s EMS [19,20]. However, Maryland’s HEMS system only completes trans- ports from scenes and does not participate in interfacility transfers. Wide-spread implantation of the Maryland model in other states or re- gions of the U.S. would likely be challenging, as it would first have to be proposed in legislature and then made into law. Currently, there are no systems that provide all needed HEMS transports, including scene calls and interfacility transfers, and are supported by government fees and taxes exists in the United States.

To our knowledge, this is the only study to date to report the actual patient payment out-of-pocket for HEMS transports. The data reported have implications in the concept of balance “surprise” billing. These data and the general media attention on HEMS billing highlight the impor- tance of future transparency in both the HEMS industry and healthcare in general. Therefore, an objective study of the true costs and charges of HEMS care has the potential benefit of increasing transparency to the public and maintaining patient trust.

In summary, patients paid, on average, less than $180 out of pocket per transport by this non-profit regional HEMS program. This contrasts with popular media reports of large out-of-pocket pa- tient charges and payments. HEMS payment was dependent on payer type, and insurers have a wide range of reimbursement prac- tices. Further studies reporting billing practices and cost to patient between non-profit and for-profit HEMS programs should be under- taken to gain a better understanding of what patients nationwide pay out-of-pocket for transport.

  1. Limitations

Our study had several limitations. First, our study contained data from a single, non-profit HEMS program. As a result, it may not be rep- resentative of other regions in the United States where private, for- profit HEMS providers dominate or where multiple HEMS providers compete. Second, our calculations of the true out-of-pocket costs to pa- tients are based on averages provided by the program, which may have obscured the range distribution of payments. We were also unable to determine if price reductions, discounts, or negotiations were done prior to the final payment by individual patients. Third, we were unable to determine if individual patients refused transport based on insurance status. It is possible that some patients refused transport based on lack of or insufficient insurance coverage. Fourth, we did not adjust for infla- tion through the three-year study period. This is unlikely to have sub- stantial effect given the short study period with relatively low and stable inflation rates (2.1%, 2.4%, and 1.8% respectively) [21]. Lastly, since this service does not directly contract with any commercial insur- ances, the reimbursement practices of each individual company is unknown.

Declaration of interests”>Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influ- ence the work reported in this paper.

Credit authorship contribution statement

Brian Gooley: Writing – original draft. Sela Sherr: Writing – original draft. Timothy J. Lenz: Conceptualization, Investigation, Supervision, Writing – original draft, Writing – review & editing.

References

  1. Susan Wilcox R, William Tollefsen W. Air transport of the critically ill emergency department patient. EM Crit Care. 2012;2(4):1-16.
  2. Joshua Brown B, Nicole Stassen A, Paul Bankey E, Ayodele Sangosanya T, et al. Heli- copters and the civilian Trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury. Trauma. 2010;69(5):1030-6.
  3. Galvango Jr M Samuel, Elliot Haut R, Nabeel Zafar, Michael Millin G, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA. 2012;307(15):1602-10.
  4. Meier Jr R Dudley, Edward Samper R. Evolution of civil aeromedical helicopter aviation. South Med J. 1989;82(7):885-91.
  5. Air Ambulance: Data collection and transparency needed to enhance DOT oversight. Report to the committee on transportation and infrastructure, house of representa- tives; July 2017.
  6. Pub. L. No. 95-504, 92 Stat. 1705; 1978.
  7. Rosato Donna. Air ambulances: taking patients for a ride. Consumer report; April 06,

2017.

  1. https://www.healthcare.gov/glossary/balance-billing/. Accessed on 1/29/2021.
  2. Bluth Rachel. Why air ambulance bills are still sky-high. NPR; June 19th, 2019. https://www.npr.org/sections/health-shots/2019/06/14/732174170/why-air- ambulance-bills-are-still-sky-high.
  3. Carmen Rodriguez H. Summer bummer: a young camper’s $142,938 snakebite. NPR;

April 29, 2019. https://www.npr.org/sections/health-shots/2019/04/29/717467217/ summer-bummer-a-young-campers-142-938-snakebite.

  1. Kodjak Alison. Taken for a ride: M.D. injured in ATV crash gets $56,603 bill for air ambulance trip. NPR; September 25, 2018. https://www.npr.org/sections/health- shots/2018/09/25/647531500/taken-for-a-ride-doctor-injured-in-atv-crash-gets-5 6-603-bill-for-air-ambulance.
  2. Christensen Jen. Sky-high prices for air ambulances hurt those they are helping. CNN; November 26, 2018. https://www.cnn.com/2018/11/26/health/air-ambulance-high- price/index.html.
  3. Tozzi John. Air ambulances are flying more patients than ever, and leaving massive bills behind. Bloomberg; June 11, 2018. https://www.bloomberg.com/news/features/2018- 06-11/private-equity-backed-air-ambulances-leave-behind-massive-bills.
  4. Villarreal Mireya. “It would’ve destroyed us”: family left with unexpected

$40,000 bill for son’s air ambulance. CBS News; April 2, 2019. https://www. cbsnews.com/news/family-left-with-unexpected-40000-bill-for-sons-air- ambulance-2019-04-02/.

  1. Eavis Peter. Air ambulances offer a lifeline, and then a sky-high bill. NY Times; May 5, 2015. https://www.nytimes.com/2015/05/06/business/rescued-by-an-air- ambulance-but-stunned-at-the-sky-high-bill.html.
  2. Caron C. Families fight back against surprise air ambulance bills. https://www. nytimes.com/2020/04/17/parenting/air-ambulance-bills.html.
  3. Joszt Laura. vulnerable populations: who are they? Supplements and featured pub- lications, prescription drug copays and their effect on vulnerable populations. Am J Manag Care. 2006;12(13).
  4. Weiser S. On an island and in distress; insurance covers the evacuation, right? Ann Emerg Med. February 2020;77(2).
  5. Wis R, John Long, B, William, Edlich, Richard. Better trauma care. How Maryland does it. J Long Term Eff Med Implants. 2005;15:79-90.
  6. Hogan Larry. State of Maryland budget testimony for physical year 2018. Accessed from web on April 4th, 2021. http://pilot.dbm.maryland.gov/budget/FY201 8Testimony/D53T00.pdf.
  7. U.S. Inflation rate 1990-2020. Accessed from web on April 4th, 2021. https://www. statista.com/statistics/191077/inflation-rate-in-the-usa-since-1990/.
  8. Advanced Air Ambulance. Accessed from web on April 5th, 2021. https://www.

flyambu.com/about/frequently-asked-questions/.

  1. Medical Transport Solutions, MASA. Accessed from the web on April 5th, 2021. https://get.getmasamts.com/helicopter-freetrial/?gclid=CjwKCAjw6qqDBhB- EiwACBs6xxf_Ph0661IBkH29Zq989NRf6Boxl1XwtOAyzqHjNdF3GiZktq0 UrhoCzP8QAvD_BwE.
  2. Schoen C, Osborn R, Squires D, Doty MM. Access, affordability, and insurance com- plexity are often worse in the United States compared to ten other countries. Health Aff. 2013;32(12):2205-15. https://doi.org/10.1377/hlthaff.2013.0879.