Alive,

JACKSON HOLE NEWS&GUIDE, Wednesday, July 24, 2019 - 25A

ably a bigger increase than what in- 2018 AIR AMBULANCE FLIGHTS
flation should account for.” FROM ST. JOHN’S MEDICAL CENTER
Greenbaum often sees patients
stuck with expensive air ambulance
bills.
10%
“Then you get to be alive and bank-
rupt, versus dead and financially sol-
vent,” he said. “It happens all over the
country. It’s really rotten.”
Who pays depends on a maddening
list of variables. 35%
55%
Making the call

but at what cost?

Air ambulance service
If a patient’s injuries or condition
exceeds what St. John’s can handle,
doctors like Greenbaum start calling
air ambulances.
In 2018 hospital patients took about Emergency department
200 air ambulance flights, about half
Primary and intensive care units
port but concluded the other wasn’t plane and half helicopter. About 110
medically necessary, so it wouldn’t transports were recorded from the Obstetrics patients

in rural communities is pay the bill. emergency department alone for cas- Source: Wyoming Department of Health
necessary but expensive. Air ambulances can mean the dif- es like heart attacks and strokes, with
ference between life and death or an additional 20 called for obstetrics AIR AMBULANCE TRANSFERS
By Kylie Mohr between suffering irreversible organ patients like the Bresslers, plus about IN WYOMING BY TYPE

This is the first of a two-part

damage and walking away relatively 70 from the primary and intensive
unscathed. Patients can find them- care units.
Who St. John’s
series. selves stuck in the middle between Several helicopters and airplanes doctors call
8.5%
(in no
Next week: Solutions and pa- insurance companies and air ambu- are available in the region. Green-
tient stories. How a neighboring lance operators. Combined with little baum said they all do a similar job particular order)
community coped with a lack transparency and regulation around and one isn’t superior to another.
of regional services, what local an industry increasingly owned by “If we determine that somebody • Guardian Flight, owned by Air Medical
businesses are doing for employ- private hedge needs a flight, 51.4%
Group Holdings
ees and how Western states are fund companies, we start calling • Air Idaho Rescue, owned by 40.1%
Air Methods
attempting to bring patient costs that means pa- “Then you based upon prox- • Omniflight, owned by Air Methods
under control. tients and their imity,” Green- • University of Utah AirMed
loved ones have get to be alive baum said. “Es-

T
win sisters struggled to breathe little say and no sentially, we’re • Intermountain Healthcare Life Flight
when they were born prema- way to anticipate and bankrupt, going down a • Classic Air Medical
turely at St. John’s Medical their costs. Some list.”
Center during the summer of 2017. are hit with an versus dead and If the bird is 911 scene response by helicopter
weather clear?
After days without improvement, $80,000 bill and ready in Driggs, Hospital-to-hospital transfer by helicopter
doctors decided the babies needed to insurance cov- financially solvent.” Idaho, great. Greenbaum will next try aircraft
based inHospital-to-hospital
Rexburg, Idaho, or Rock
transfer by airplane
leave the valley, quickly and safely, ers the entire That is the quick-
for advanced neonatal intensive care amount. Others — Dr. Jeffrey Greenbaum est option — back Springs and go from there. In some cas-
in Idaho Falls. Only one infant could find themselves Emergency room physician and forth from
es, patients
Source: Wyomingmight
Departmentneed to be packaged
of Health

be transported at a time. So Summer
and Emma Bressler, just days old and
three weeks early, took back-to-back
air ambulance flights.
Precious minutes ticked by as one
twin went, and then the other. Both
survived.
Medical crisis averted, Eric and
Stacy Bressler’s stress had only be-
gun. The couple’s insurance company
eventually covered one twin’s trans-
fighting insur- Driggs to St. at the hospital and then transferred to
ance and air am- John’s to Eastern the airport when a plane is deemed the
bulance operators over unpaid bills Idaho Regional Medical Center takes best option.
exceeding $10,000. about an hour or less — and cheaper In rare instances air ambulance
“My recollection when I first got to for the patient. helicopters will make what’s called
Jackson Hole in 2000 is that a trans- “That’s the best-case scenario,” “scene runs” and land directly on the
port to Idaho Falls was in the $10,000 Greenbaum said. highway or at Teton Village, skipping
to $14,000 range,” said Dr. Jeffrey But is the aircraft already in use? the hospital completely. First respond-
Greenbaum, an emergency room phy- Is it down for maintenance? Is the ers, rescuers, physicians and law en-
sician. “Currently, it’s in the $30,000 pilot well rested per Federal Avia- forcement make that determination.
to $50,000 range. I think that’s prob- tion Administration standards? Is the See Alive on 32A

RYAN DORGAN / NEWS&GUIDE

An Air Idaho Rescue helicopter comes in for a landing June 12 at St. John’s Medical Center.
32A - JACKSON HOLE NEWS&GUIDE, Wednesday, July 24, 2019
Emergency department
helicopter swooping from the sky professionals.” transport is safe, he will consider it as
Alive Primary and intensive care units to the side of a bad highway wreck, Blue Cross Blue Shield of Wyoming an option.
Continued from 25A what people envision is actually not spokeswoman Wendy Curran said “And when EMS has resources to do
Obstetrics patients
Although the scenario that is the norm in Wyoming. Department “insurance companies generally base that, it is certainly our preference,” he
described time
Source: Wyoming and oftime
Department Health again is a of Health data shows that most air their coverage on medically necessary said. “We don’t want to put anybody’s
ambulance trips are hospital-to- services,” and air transport is no dif- bill up. We don’t want to freak people
AIR AMBULANCE TRANSFERS hospital transfers. In a recent year ferent. out by putting them in a helicopter.
IN WYOMING BY TYPE only 8.5%, or 342 flights out of 4,046 “We will pay for something if your But sometimes it’s just not reasonable
total, are a 911 scene response. doctor or your hospital shows us that to go via ground. It takes too long, and
8.5% this is a medically necessary service,” there’s too many unknowns.”
Is it medically necessary? she said. “It’s a utilization control Having been an emergency medi-
Doctors decide that a transport is used to keep out unnecessary costs for cine practitioner for decades, Green-
“medically necessary.” But that can care that is not medically needed. The baum said he’s “very, very sensitive”
be challenged. Greenbaum called it a same standard applies for air trans- to the hardships patients may face
“weaselly way for insurance compa- port.” after taking a pricey ride.
51.4%
nies and flight services to get the pa- While Greenbaum said he never “We know how hard it is on pa-
40.1%
tient to pay out of pocket” and said if calls a plane or helicopter unless it’s tients to get big bills,” he said. “But
he sends a patient to another facility, necessary, Curran countered that we’re also stuck in the position where,
it’s always necessary from his point of insurers need more information to if you have a medical necessity, it’s
view. agree. very difficult for me to say, ‘Well, God,
That puts hospitals and insurers at “When you get into Wyoming that you know, I guess you could get in a
odds. gets to be a little more difficult,” she car, but then again, you might not
911 scene response by helicopter
“Typically, the insurance company said. “It’s an area that creates a lot of ever make it.’ How can I justify that?”
disputes that with you all day long,” confusion about what are the alterna-
Hospital-to-hospital transfer by helicopter said Dr. Paul Beaupre, CEO of St. tives to flying when you live in a large County faces challenges
Hospital-to-hospital transfer by airplane John’s Medical Center. “So it’s their rural state. We’ve tried to make sure The “rotten” scenario Greenbaum
version of that versus the medical when we work with air ambulance describes has hit several Teton Coun-
Source: Wyoming Department of Health companies and hospi- ty employees in the past decade.
tals that they are giving Human Resources Manager Juli-
AIR AMBULANCE SUPPLY 2007—2018 us as much detail about anne Fries has seen her workers face
the flight as they can financial challenges and stress when
U.S. WYOMING — weather conditions, they require air ambulance service.
road conditions, con- She’s seen four or five claims over her
1,600 16 struction — to say, ‘This tenure of nine years.
1,400 14 is the right alternative.’ “It’s really a hardship on the em-
1,200 12 We don’t have as much ployee,” she said. “The problem is that
1,000 10 luck getting that infor- costs are exorbitant, and they don’t
800 8
mation as we’d like, and have a choice.”
600 6 that adds to the confu- As a self-insured entity the county
400 4
sion.” is in a unique position. Instead of pay-
200 2
When ambulance ing an insurance company for medical
transport is medically claims, the county covers the claims
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018

2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018

feasible, Greenbaum itself (at 250% of Medicare rates) and

said, that’s his prefer- uses a third-party administrator to
Fixed wing Rotary wing ence. Battalion Chief process claims on its behalf.
Mike Moyer of Jackson When air ambulance charges pop
Source: ADAMSAIRMED.ORG ANDY EDWARDS / NEWS&GUIDE Hole Fire/EMS said hos- up, that isn’t a problem just for the
pital-to-hospital ground patient or for the county.
transfer numbers have “That means the taxpayers are
AIR AMBULANCE BASES IN THE MOUNTAIN WEST increased over the paying the bill,” Fries said.
past few years — from Allegiance is Teton County’s third-
19 in 2010 to 88 in party administrator and Cigna acts
2018, with a spike of as its network. But no companies that
2 91 in 2016. The bulk fly in Wyoming are in network with
2 KALISPELL of those transports go Cigna. Cigna’s public relations senior
2
to Eastern Idaho Re- advisor Mark Slitt blamed air ambu-
gional Medical Cen- lance providers, saying the companies
90
GREAT FALLS ter, or EIRMC. “expressed a desire to remain ‘out of
“If they don’t have network.’
MISSOULA to fly it’s a signifi- “Unfortunately, this strategy has
94 cant savings to the kept prices high for our customers,”
HELENA MONTANA patient costwise,” Slitt said. “We would very much like
he said. to negotiate contracts with air ambu-
But Moyer said a lance providers so that our customers
BILLINGS ground ambulance could avoid surprise bills and have
BOZEMAN 90 to Salt Lake City, the peace of mind that comes from
13 hours roundtrip, having predictable and reasonable in-
has a “significant network rates.”
15
impact on our ser- The county once hired Sentinel Air
vice to transfer Medical Alliance, a company that ad-
IDAHO patients.” In 2018 vocates for “safe, high quality, reason-
93 CODY
that happened ably priced air ambulance services” to
GILLETTE
16 seven times. conduct an outside review of an Oc-
BOISE REXBURG WORLAND “It takes a crew tober 2015 claim for a flight to Idaho
DRIGGS
HAILEY out of service for Falls. Sentinel’s independent analysis
IDAHO FALLS
JACKSON
WYOMING other 911 calls found that Air Methods charged 327
84 26 26
and so forth,” percent above the Medicare rate and
RIVERTON CASPER
POCATELLO Moyer said. “It 343 percent above the cost of provid-
TWIN FALLS 86 LANDER drops our staffing ing the service.
down in the val- Jeff Frazier, a partner at Sentinel,
84 15 ley.” said his company is used to reviewing
Greenbaum claims from around the region. He’s
LOGAN
80 said if ground concluded that “money drives these
KEY/LEGEND ROCK SPRINGS LARAMIE things and not necessarily patient
EVANSTON CHEYENNE care.”
OGDEN
Back in Jackson, Fries said county
80
70
employees get threats from collection
SALT LAKE CITY FORT COLLINS services.
Base and
10 minute 40 “For the employee it’s a burden,
fly circle 13 BOULDER and it’s scary,” Fries said.
DENVER 385
The county is disputing a billing is-
sue with Rocky Mountain Holdings,
Base which double-billed miles and billed
for a helicopter when an airplane was
UTAH GRAND JUNCTION used. Fries said that based on actual
COLORADO SPRINGS
70 air miles and what’s allowable under
Hospital
50 Medicare, the charges should be just
15 MONTROSE PUEBLO over $20,000 — not $67,500.
Source: COLORADO A 2017 U.S. Government Account-
ADAMSAIRMED.ORG 10 ability Office report found that the
CEDAR CITY median prices providers charged for
MONTE VISTA
ANDY EDWARDS
50
helicopter air ambulance transport
/ NEWS&GUIDE service doubled between 2010 and
ST. GEORGE
See Big bills on 33A

An Air Methods air ambulance lands in Grand Teton National Park in 2017. Air transport was called after Mike Connolly, 63, had a heart attack.
Big Bills
Continued from 32A
2014, from about $15,000 to $30,000
per transport.
The report states that Air Methods,
the largest air ambulance provider,
increased the average price per trans-
port 283% over the past decade, from
$13,000 in 2007 to $49,800 in 2016. In
contrast, the Consumer Price Index
inflation for that same time period
was 15.75%.
“The presence of private equity in
the air ambulance industry indicates
that investors see profit opportunities
in the industry,” the government re-
port reads.
Industry organizations say if there
were no profit motive, innovation
wouldn’t occur.
Documents filed with the U.S. Se-
curities and Exchange Commission
show that the CEO of Air Methods’
total compensation package was $4.1
million in 2016 and that the company
recorded $97.9 million in net income
in 2016.
Many companies are no longer pub-
licly held and are shielded from filing
periodic reports. Air Methods was
acquired by a private equity firm for
approximately $2.5 billion in 2017.
Air Medical Group Holdings was pur-
chased in 2015 for $2 billion by an-
other firm.
Air ambulance industry represen-
tatives say their prices are less about
profit and reflect how costly it is to op-
erate the service and how little they
are paid to do so. Costs are high and
relatively fixed, and the only way to
increase revenue is to increase the
number of transports — difficult in
a rural state with a relatively static,
if not declining, population — or in-
crease its prices charged.
Bases, like those scattered around
the Intermountain West, are staffed
24 hours a day, 365 days a year.
“In order to provide lifesaving care
our programs have to be ready to re-
spond to you, your family members,
or anyone, 24 hours a day,” said Rich
Sherlock, the president and CEO of the
Association of Air Medical Services.
The industry organization, short-
ened to AAMS, represents more than
600 bases and ground locations across
the country.
Sherlock said it costs over $3 mil-
lion a year to run a base, “because
what goes into it is the readiness.” In
addition to staff salary and benefits,
he rattled off a long list of expenses:
training and continuing education,
advanced aircraft, gallons of jet fuel
burned every minute, operational con-
trol centers to process flight requests
and all the equipment.
“You can’t take a generic helicopter
and make it an air medical helicop-
ter,” Sherlock said. “A heli these days
for use in the air medical services is
somewhere around $4 million, and
then that has to be modified to the
tune of another $1 million to trans-
port patients.”
Sentinel’s Frazier disputes some
of those claims. He pointed to a New
York newspaper story in which a com-
pany claimed its helicopter was worth
$5 million, but an aircraft valuation
by VRef, like the Kelley Blue Book for
aircraft values, showed it was only
$2.9 million new and had a market
value of $1.6 million.
Frazier also said that the total cost
to operate a base is about $200,000 a
month, or $2.4 million a year, includ-
ing crew salaries and benefits as well
as training, and that his cost data has
been validated within 3% in court.
The ambulances are full of both
medical professionals and supplies.
For example, Guardian’s medical
crew consists of a flight nurse, a flight
paramedic and a pilot.
The ship is full of ventilators, 12-
lead ECGs and other advanced moni-
tors, defibrillators, IV medication
pumps, a variety of medications to
manage critical care patients and, on
aircraft originating from Gillette, an
intra-aortic balloon pump.
Air ambulance aircraft follow Fed-
eral Aviation Administration safety
requirements.
“We want every medical helicopter
to be the safest possible working envi-
JACKSON HOLE NEWS&GUIDE, Wednesday, July 24, 2019 - 33A
ronment,” Sherlock said. “Not just for
the patients in need but every nurse,
every paramedic, every pilot that
climbs onboard and calls it their office
every day.”
That means following rest guide-
lines and having almost all pilots
wear night vision goggles when ap-
propriate, something the FAA hasn’t
mandated.
There’s no way to know the actual
costs. The News&Guide asked AAMS,
Guardian Flight, the Wyoming De-
partment of Health and the Wyoming
Department of Insurance for such in-
formation, with limited success.
The University of Utah’s AirMed
did not follow through on requests
for an interview about its opera-
tions. Guardian declined to answer
questions about the cost to oper-
ate a flight, how prices are deter-
mined, what an average price is and
how it’s composed, as did the in-
dustry organization it referred the
News&Guide to.
Sherlock, of the Association of Air
Medical Services, referred questions
back to individual providers but said
his organization was “working on a so-
lution to try and provide more trans-
parency in the industry” through leg-
islative means.
“We are actually trying to increase
visibility across the industry by man-
dating industry cost reporting and
starting into quality of care report-
ing,” Sherlock said.
Tom Glause, who was interviewed
when he was Wyoming’s insurance
commissioner, said his department
received pricing information from
Blue Cross Blue Shield, but he said
it wasn’t a public document and he
couldn’t share it.
The 2017 government report iden-
tified lack of transparent data as a
problem. Should numbers be made
available, the Department of Health
and Human Services has reported
there is no national comprehensive
help database of ambulance service
costs to fully understand how the
amounts line up.
The report recommends the secre-
tary of transportation take four ma-
jor actions to “increase transparency
COURTESY PHOTO
Air ambulance
fee schedule
The Centers for Medicare and Medicaid
Services puts together what’s called a
fee schedule for physicians, ambulance
services, clinical laboratory services and
medical equipment. This comprehensive
list of fee maximums is used by Medicare
to pay doctors and other providers on a
fee-for-service basis.
Keep in mind this is the maximum
Medicare will pay — not the maximum
companies charge or might expect to be
paid by private insurance companies.
In fact, air ambulance companies say
Medicare reimbursements are far too low.
The base rate is a nationally uniform
dollar amount, updated each year with an
ambulance inflation factor. The payment
for an ambulance transport is based on
the ZIP code of the point of the ambulance
pickup.
Since Teton County (and most of the
rest of the state) is considered rural or
super rural, fees are 1.5 times an urban
base rate. For 2019, the numbers are:
• Fixed-wing air ambulance rural base
rate: $4,679.75
• Rotary-wing air ambulance rural
base rate: $5,440.91
• Fixed-wing per statute/land mile
rural: $13.28
• Rotary-wing per statute/land mile
rural: $35.43
Billed mileage includes only the one
leg a patient is transported, not the trips to
or from the base.
and obtain information to better in-
form decisions on whether to inves-
tigate potentially unfair or decep-
tive practices in the air ambulance
industry.”
Frazier agreed there needs to be
more transparency.
“There needs to be a market in
place, but the last thing these guys
want is to participate in a market,”
Frazier said. “They typically per-
form their business by the element
of surprise. That’s their business
See no transparency on 34A
34A - JACKSON HOLE NEWS&GUIDE, Wednesday, July 24, 2019
No transparency
Continued from 33A
strategy.”
Neighboring Montana might offer a
glimpse of how widely charges swing.
Staffers at the Office of the Mon-
tana State Auditor, Commissioner of
Securities and Insurance compiled a
spreadsheet during air ambulance
hearings in 2016 that detailed fixed-
and rotor-wing transport liftoff charg-
es and mileage charges in the state.
Liftoff charges for planes and he-
licopters ranged from $9,916.80 to
$22,998.64, and mileage charges var-
ied between $29.95 to $275.
Montana’s insurance communica-
tions director, Kyle Schmauch, said,
“No current employee has seen this
spreadsheet before” when provided
a copy, and the information is “likely
now obsolete, partially due to statu-
tory changes that have occurred since
then.”
The office doesn’t have updated
data and said some of the providers
in question had since gone in-network
with additional insurance providers.
The numbers still provide a look at
what Montana air ambulance pro-
viders, not identified by name in the
spreadsheet, charged in recent years.
A game of hot potato
Who’s fault is it that patients are
being stuck with unpredictable, ex-
pensive bills? The answer depends on
who you ask.
Air ambulance providers point to
the costs of running a base (roughly
$3 million a year), staffed with highly
trained medical professionals.
Covered by a labyrinth of tubing a critically ill patient puts the Jackson
Hole Air Ambulance into high gear in 1987.
They also blame Medicare, a fed-
eral program for people who are 65
or older and certain younger people
with disabilities, and Medicaid, a
joint federal and state program for
people with limited income and re-
sources. The root of the issue, air am-
bulance providers say, is that Medi-
care and Medicaid rates do not match
the costs for their services and need
to be adjusted.
“Medicare’s rates haven’t been ad-
justed, other than less than an infla-
tionary rate, since they were put in
in 2002,” Sherlock said, “while all the
other costs with regard to the indus-
try have really soared well in excess
of that.”
A consultant’s study prepared for
his organization found that industry
expansion — triple the number of
bases over the past 20 years result-
ing in 15% more Americans within
a 15- to 20-minute response area in
the process — has increased over-
head costs.
Sherlock pointed to the CMS fee
schedule as being fractional and said
the average cost of a flight is $10,200
— almost double a Medicare payment
($5,900) and roughly triple what Med-
icaid pays on average ($3,500).
Frazier said Sentinel recommends
a reimbursement of between $14,000
and $16,000 per transport — some-
thing, he said, would provide the
operator with a 100% gross margin
— but said raising Medicare reim-
bursements any higher “would be
like throwing gasoline on a fire” and
wouldn’t keep companies from charg-
ing private insurers more, too.
Like the fairy tale “Goldilocks and
TED WOOD / NEWS&GUIDE FILE
the Three Bears,” it’s a balancing act to
find a price that’s just right and doesn’t
keep companies from flying at all.
Between Medicaid, Medicare and
uninsured patients who pay an aver-
age of $450, Sherlock said seven of ev-
ery 10 patients pay “significantly less
than the cost of services.”
“That affects pricing,” he said. “And
so we’re trying to eliminate that. If
we can get Medicare’s rates adjusted
and you end up getting 65% or close
to 70% of the patients paying at the
cost of providing the services based on
actual cost data, then you eliminate
the need for balanced billing.”
Balance billing is the difference
between prices charged by providers
and payments by insurance. When air
ambulance providers are out of a pa-
tient’s insurance network and haven’t
agreed on an amount the provider will
accept as payment in full, the patient
is at risk of being billed for the differ-
ence.
A 2019 United States Government
Accountability Office report found
that about 69% of 20,700 transports
nationwide in 2017 were out of net-
work. A 2017 report from the same
office stated that there is a lack of na-
tional data on balance billing but that
some states are attempting to collect
more information from patients.
Meanwhile, insurance companies
say patient costs could be reduced if
more providers were in network with
them.
“Balance billing is such a problem,”
Curran said. “We try to get people in
network as often as we can.”
Most Blue Cross policies cover
emergency air ambulance services
Head nurse Ruthanne Reichert holds a cardiac monitor while colleague Becky
Hawkins relaxes after a three-mission day.
Taking a breather before a flight to Salt Lake, head pilot Pete Mead stands
beside the Citation medical jet in 1987.
In-network providers
Jackson residents: In network providers,
Blue Cross Blue Shield of Wyoming
– Guardian Flight
– Classic Air Medical
– Medical Air Rescue
In discussion with:
– Air Methods (Rocky Mountain Holdings)
– Health One
Teton Valley, Idaho, residents: In-network
providers, Blue Cross Blue Shield of Idaho
– Life Flight Network
– Classic Air Medical
– Air Methods (Rocky Mountain Holdings)
– Air St. Luke’s
when it’s deemed medically necessary.
“It is one of the essential health
benefits that are required to be of-
fered under the Affordable Care Act,”
Curran said. “Long before that provi-
sion was in effect, our policies tended
to cover that.”
The insurance company has a
single statewide fee reimbursement
schedule for both takeoff and mile-
age charges for providers in network.
Curran declined to share that infor-
mation, saying it is proprietary.
Sources said at least one private
insurer in the state reimburses in the
$20,000 to $30,000 range. For com-
parison, the state insurance plan pays
$36,000.
But Curran said getting air
ambulance companies to enter into a
network agreement has been “difficult
over the past few years.” During some
See Network issues on 35A
TED WOOD / NEWS&GUIDE FILE
TED WOOD / NEWS&GUIDE FILE

Network issues
Continued from 34A
of 2016 and 2017, she said, none were
in network at all.
“Of course that’s very problematic
because it’s that network protection,
then you won’t balance bill the pa-
tient,” Curran said. “That leads to all
those stories you hear nationally.”
Sherlock disputes that at an indus-
trywide level. He said in-network ne-
gotiations went up by 30 percent last
year for providers under his umbrella.
“There’s no one in our industry that
wants a patient to receive a bill they
can’t pay or they didn’t expect,” he said.
“I don’t understand what insurance
is for if they won’t pay for emergency
medical services ordered by a medi-
cal provider. They need to step up
and do the right thing. We’re willing
to negotiate where we have a level
playing field, and we want patients
taken out of the process.”
In 2018 patients filed a dozen com-
plaints with the Wyoming Depart-
ment of Insurance, which regulates
about 15% of the market.
“It is an issue in Wyoming that is of
paramount concern,” Insurance Com-
missioner Glause said.
Complaints fell largely into two cate-
gories: A flight wasn’t deemed medically
necessary and was denied by insurance,
or the company was out of network with
the patient’s insurance. But compared
with the statewide buzz, Glause said
not many file complaints.
That’s largely in part due to the
state’s inability to act, thanks to the
Federal Airline Deregulation Act
(see part 2 for more) which says air-
Locals launch Jackson Hole’s first air ambulance
Former Navy flight
surgeon and special
forces medic brought
vital service to valley.
When Richard Sugden and Paul
King started Jackson Hole Air Am-
bulance in 1981, the closest air am-
bulance sat in Salt Lake City.
“It became apparent that we
didn’t have any way of getting se-
riously ill or injured patients to
Idaho Falls or Salt Lake,” former
medical director Sugden said.
Sugden’s experience as a Navy
flight surgeon and King’s special
forces medic background fit nicely
together. Sugden, who has since
been inducted into the Wyoming
Aviation Hall of Fame, had an
airplane he could use to carry pa-
tients, and the two men trained
more than 20 emergency medical
technicians and some of the hos-
pital’s intensive care unit nurses
to be flight nurses. They also had
friends who were commercial pilots
willing to fly.
“It was pretty rewarding,” Sug-
den said. “We took care of a lot of
sick and injured patients. We never
lost a patient.”
Cardiac patients and women in
premature labor were their most
frequent flyers. Sugden had ex-
perience delivering babies on the
ground as a family medicine doctor
in the region.
Sugden remembered a particular
woman who kept “thrashing” in the
back of the helicopter and kicked a
door so hard she dented it.
“Both of us kept thinking we
might deliver in the back,” he said.
The company owned several air-
planes and leased one when need-
ed.
“They were business jets,” Sug-
den said. “We took the seats out
and put stretchers in.”
Respirators, suction machines,
line carrier prices, routes and ser-
vices can’t be regulated. Despite not
being commercial airlines, air am-
bulance companies have tied them-
selves into the act, a strategy that
has held up in court.
“A lot of times our inquiries are
much higher,” Glause said. “But when
we explain to them the consequences
of the Federal Airline Deregulation
Act, then they choose not to file a com-
plaint. I would say it’s significantly
higher than the number of complaints
that are formalized.”
Complaints include a 65-mile flight
from Laramie to Fort Collins, Colo-
rado, for $50,000, a 350-mile flight
from Gillette to Aurora, Colorado,
for $105,000 and a 117-mile flight
from Rawlins to Casper for $72,000.
Glause said there’s a substantial dif-
ference between average rates com-
panies may provide to his department
versus the numbers they see.
In the least populous state in the
nation, a dozen complaints matter.
The department receives about 250
complaints total in a year.
“In a small state like Wyoming
it’s more significant than it sounds,”
Glause said.
After raising her concerns with the
hospital and legislators, Teton Coun-
ty’s Fries feels like she has “hit a wall”
trying to advocate for more transpar-
ency and patient-first practices with-
in the air ambulance industry.
“Who can help solve the problem?”
Fries asked. “It’s a community issue,
it’s a state issue. But you’re going up
against the big dog. I’m at a loss of
where to go.”
For now that leaves families like the
A photo from the late 1980s shows Jackson Hole Air Ambulance pilot, EMTs and flight nurses in front of their
aircraft. The outfit ran for 12 years before larger companies moved into the area.
stretchers, litters and IV poles
filled the aircraft.
“Everything’s got to be tailored
for the airplane so it fits and works
in the airplane and also works with
changes in altitude,” Sugden said.
So he knows how expensive bas-
es are to operate and staff 24 hours
a day.
“The other big problem was get-
ting paid,” Sugden said. “We felt
obligated to fly anyone that had a
life-threatening injury or illness.
We flew and worked on collecting
payments later. It wasn’t success-
ful all that often.”
JACKSON HOLE NEWS&GUIDE, Wednesday, July 24, 2019 - 35A
Bresslers, with twins who needed help
and only one flight covered, in the lurch.
Two years later the Bresslers are
locked in litigation with the state
of Wyoming, which employed Eric
Bressler at the time and provided his
self-funded insurance, and Cigna,
the third-party insurance adminis-
trator. The lawsuit is bogged down
as lawyers squabble over timing and
wording nuances.
During a hearing in district court
July 17, lawyer Ewa Dawson argued
the family hadn’t properly exhausted
the appeal process before moving to
civil litigation and asked Judge Timo-
thy Day to dismiss the case.
One of the Bresslers’ attorneys,
Rob Stepans, disagreed. He pointed
out discrepancies between the state’s
legal argument and what’s written in
the couple’s insurance policy that set
up competing instructions — needing
to wait 60 days to proceed with liti-
gation but also act within 30 to con-
tinue with the appeal process — that
put his clients “in a bind they couldn’t
possibly get out of.”
Court documents say the fam-
ily resorted to taking out personal
loans to pay for the flight. While
their bills aren’t publicly available,
an average Air Methods flight is just
under $50,000.
Judge Day’s decision is pend-
ing. But while the wheels of justice
slowly turn for the Bresslers, visi-
tors and locals alike — like earlier
this month, when a man fell 1,200
feet down rock and ice near Paint-
brush Divide and when three people
were killed and two were injured in
a head-on collision — still require
Jackson Hole Air Ambulance op-
erated for 12 years, amassing more
than 1,000 flights.
“Once an air ambulance showed
up in Idaho Falls and two or three
more showed up in Salt Lake City,
we said, ‘OK, you guys can do it
now,’” Sugden said. “And they do a
really good job.”
Air ambulances have since pro-
liferated in the region. Air Idaho
Rescue started in 1990 as part of
Eastern Idaho Regional Medical
Center. In 2009, Air Methods Cor-
poration purchased the operation.
Now Air Idaho Rescue operates
The difference
between air
ambulances and
Search and Rescue
Air ambulances and Teton County
Search and Rescue helicopters aren’t
the same thing.
Air ambulances — planes and
helicopters — are operated by private
companies and charge for their services.
They are outfitted for medical transport,
with a pilot, a medic and a nurse. Air
ambulances fly local patients to larger
medical facilities in the area after, in
some cases, they’ve been rescued by a
Search and Rescue helicopter.
Search and Rescue helicopters are
staffed with volunteers who do not
charge for their rescue services. The
helicopters can pick up patients from
rural areas and take them to landing
pads or to St. John’s Medical Center,
where a variety of transport options —
ground, air — exist if necessary.
Bottom line: Being picked up by a
Search and Rescue helicopter won’t
cost you anything, but that doesn’t
mean you won’t be transferred to an air
ambulance that will.
planes and helicopters to access life-
saving medical care.
See part 2 of this story next week.
Contact Kylie Mohr via Managing
Editor Rebecca Huntington at 732-7078
or rebecca@jhnewsandguide.com.
COURTESY PHOTO
four bases, including a fixed-wing
operation in Idaho Falls and three
helicopter operations in Driggs and
Soda Springs, Idaho, and West Yel-
lowstone, Montana. The Driggs,
Idaho, base opened in 2015.
With the current bases “we are
closer to the patients and critical-
access hospitals across our area,”
said Megan Smith of Air Methods.
“This way we are able to quicker
pick up patients in need and trans-
fer them to tertiary care facilities
like EIRMC and others in the re-
gion,” she said.
— Kylie Mohr