Use of life-saving air ambulances under scrutiny in Northern Colorado

LIVERMORE — Dee Judd was home alone July 12 when her blood pressure spiked to dangerous levels. Her brain fuzzy and her body aching and burning from head to toe, life moved in slow motion.

Thinking she might be dehydrated from working in the garden on a hot summer day, she steadied herself along the wall in her Glacier View home to get to the couch, drank water and took her blood pressure: 312 over 218, a life-threatening reading.

She didn't trust the number and thought, "The cuff must be broken. I just need to rest."

Her husband, Al, was on a motorcycle trip in Oregon with his son and wasn't expected home for days. 

When water and rest didn't help, "something in my head said to call 911," Dee said.

As soon as she told the dispatcher her blood pressure, the dispatcher called for LifeLine, UCHealth's helicopter emergency medical service.  

More available than ever

Medical helicopters can provide faster access to life-saving care, especially from rural Colorado, but arrive with a cost. Bills can range from $10,000 to $50,000, or more.

Nationally, horror stories abound about patients left with huge bills from air transports even after insurance companies have paid their share, but those tales seem to occur less frequently in Northern Colorado. 

The Colorado Division of Insurance reports about six complaints per year statewide on everything from cost to care received by air ambulance patients.

Over the past two decades, there has been an increase in the number of medical helicopters and flights in Colorado, said Randy Kuykendall, director of health facilities and the emergency medical division at Colorado Public Health and Environment.

Prior to 2002, hospitals owned most air ambulances, but after Medicare increased its reimbursement rate, for-profit operators expanded their presence, according to a Consumersunion.org report.  

In 2003 there were 545 helicopters flying our of 472 air bases across the United States; by 2015, the numbers nearly doubled, with 1,045 helicopters at 864 bases, the report estimated. 

Poudre Valley Hospital and Medical Center of the Rockies, which share a helicopter, provided 288 transports from accident scenes and between facilities last year, according to UCHealth. The hospitals' helicopter has flown 217 transports so far this year, 54 were on-scene pick ups. The remainder were transfers between medical facilities.  

Banner Health, with three aircraft stationed in Akron, Greeley and Boulder, made between 500 and 600 transports, said Pamela Howes, spokeswoman for Medevac, Banner's air ambulance service.

Given their increased prevalence and associated costs, there is a growing debate among Northern Colorado emergency responders whether choppers are being overused.

Herb Brady, fire chief of the Windsor-Severance Fire Rescue, won't allow his crews to call for a helicopter because ground transport is generally faster. His ambulances can get patients to trauma centers in "usually well under 30 minutes," he said.

Situated between Greeley, Loveland and Fort Collins, Windsor-Severance has five hospitals within reasonable driving distance: North Colorado Medical Center in Greeley, McKee and Medical Center of the Rockies in Loveland and Banner Health and Poudre Valley Hospital in Fort Collins, Brady said.

Windsor-Severance has four ground ambulances, fast response times and high clinical ability, he said. "I've seen some crews get off the scene in three minutes," he said. 

"An ambulance charge is about $2,000, and a helicopter is $28,000 to $38,000 and it adds zero to patients' outcome," Brady said. "If you can drive to a trauma center in 30 minutes, you shouldn't even think of a helicopter. Outside (that distance) there has to be a lot more thoughtful consideration before you saddle a family with this debt." 

Local:These hiking hot spots draw the most Larimer County rescue calls

Randy Lesher, chief of Thompson Valley EMS, shares much of Brady's thinking. "It's pretty rare for us to call a helicopter," he said. Thompson Valley covers Loveland, Johnstown, Berthoud and west into the foothills. 

"Sometimes up in Storm Mountain or Rist Canyon that are quite a ways up there ... getting folks out of those areas" may require helicopter services, he said. "Most times we can have the patient to the hospital faster by ground." 

Data from UCHealth shows no helicopters were sent to pick up patients in Loveland or Windsor in 2017. 

Thompson Valley calls for a helicopter less than once a month.

Lesher isn't against air transport when it makes sense. "When you are talking about trauma or cardiac events, the only things that help these people are surgeons and cardiologists," he said. And time is critical.

When transporting long distances, such as to the burn unit in Greeley or Children's Hospital in Denver, air medical services "start to make sense big time," he said.

'Helicopters are too expensive'

Dee Judd, 66, didn't want to be air lifted. Drifting in and out of consciousness, she told Glacier View Volunteer Fire paramedics, "It's OK, I'll wait for the ambulance. Helicopters are too expensive."

Worried she was having a stroke, paramedics convinced her every minute and every second mattered.

"The next thing I knew I was being put in a helicopter" en route to Medical Center of the Rockies, a 1-hour-and-20-minute drive from Glacier View, but only 28 minutes by air. 

"I went from being scared to thinking, 'God, please let me come home again.'" 

Patients over pocketbooks

Today, there are 22 air ambulance agencies licensed to operate in Colorado, Kuykendall said, up from 17 in 2010, according to the state. Only eight have business addresses in Colorado.

Although the agencies are registered in Colorado, the state can only oversee the medical component of the helicopter, Kuykendall said. The federal government regulates the routes and desinations within its air space. Like with commercial airlines, the government does not regulate pricing. 

The relationship between the medical helicopters and health systems vary. UCHealth partners with Reach Air Medical Services to provide the UCHealth LifeLine medical helicopter services in Northern Colorado.

Reach provides and pays for the pilots, mechanic and helicopter, and reimburses UCHealth for services provided by clinical staff. UCHealth employs the clinical staff and covers most of the costs of operation, training and use of equipment. 

"UCHealth got in the business to use the transportation when needed for life-threatening calls. We are not incentivized by meeting a certain amount of calls," said Duane Rorie, nurse manager of the UCHealth LifeLine air medical program. 

Banner works much the same way. The medical crew is employed by Banner, while the pilot and aircraft are contracted with Banner. "Medtrans Corporation of Texas has an agreement to provide the mechanics and aircraft and pay of portion of our salaries and expenses to Banner," Howes said. 

Kevin Waters, EMS battalion chief for Poudre Fire Authority, said decisions to use an air ambulance are based on their best medical knowledge and assessments. PFA called for helicopter transports about 10 times last year and about 11 so far this year. 

"We generally know how long it will take to get to the hospital based on the time of day, traffic conditions, etc.," Waters said. 

PFA decides whether to put a helicopter on standby or in the air the moment a call comes in. That allows the flight crew to be in the air and minutes closer to the scene if needed. If crews on the ground determine a helicopter is not needed, it will return to base. No patient is charged for that level of preparedness. 

About 85 percent of standbys return to base without transporting a patient, Rorie said.

"If we think the best decision is to put a patient in the chopper, we will put the patient in the chopper," Waters said. "We are not unaware the costs associated with helicopters are high, but we have to make decisions based on what is medically necessary."

Related:RMNP's rugged beauty ups need for search and rescue

First responders know it's more expensive to fly patients to hospitals, but "we want to make sure we are doing the right thing for the patient," Waters said. "If someone is having a heart attack and needs to get to the catheterization lab and it's the difference between a 15-minute flight and 45 minutes on the ground, we know the outcome will be significantly better" with quicker treatment, he said. 

UCHealth monitors the outcome of every air-lifted patient, he said, and fewer than 10 percent are discharged from the emergency room the same day. "Just because they discharge someone from the ER doesn't mean it's not a good transport," he said. 

'The best mistake I ever made'

Al Judd caught the first flight home from Oregon after learning his wife was in the hospital. Had he been home when his wife initially protested a helicopter ride, he could have eased her mind.

A month earlier he had purchased a LifeLine "membership."

The $65 annual fee covers any costs related to an air transport that insurance doesn't cover.

"When I signed up, I kind of poo-pooed it, thinking we didn't need it, but what the heck, it was only $65," he said. "It was the best mistake I ever made."

The couple isn't exactly sure if their insurance paid the entire bill or if Reach — the umbrella company for LifeLine — paid the balance. They only know it didn't cost them a dime.  

Now the Judds recommend everyone living in the remote areas of Larimer County have a membership. Glacier View Meadows is about 35 miles northwest of Fort Collins in Livermore. Many of its year-round residents, like the Judds, are retirees.

About 33 percent of LifeLine's scene responses are in Glacier View, Livermore and Red Feather Lakes, about an hour northwest of Fort Collins, according to LifeLine statistics. About 10 percent come from within Fort Collins. 

The membership pays the balance as long as the service is available. If it's not, the helicopter that comes to pick you up may not be part of the plan. It's rare, but it does happen, Rorie said. 

"Ninety percent of the time we will get the call," he said. "If we are encumbered, you would get the next available chopper," which might be Greeley's Medevac, which is also part of the membership program. "I try to keep that in the back of my mind," Rorie said. "We work together with our competitors."

Like this story? Support our journalism

If the insurance company balks, Rorie said the medical director will go to bat for the consumer.

No 'wallet biopsy'

Don Wharton, director of development for Reach, said life flights are no different than health care in general these days, with costs rising and reimbursement rates either declining or stagnating. 

Medicaid and Medicare, federal programs for poor, older or disabled Americans, pay pennies on the dollar. "The rest is shifted into the commercial market," just as it is with other medical costs.

Consumers Union, which recently issued a policy report on medical air transports, said situations where patients are left to foot the bill are more common when an insurance company does not have a contract with the air ambulance provider. For an out-of-network bill, the health plan will pay nothing or pay less than the billed charges and the patient is responsible for the balance, the report said.

"There is a stark difference between what is charged and what is actually collected," Wharton said. But what happens to the uninsured or underinsured patient who needs a medical air transport? Wharton said his company works with all patients to come to an agreement on what they owe. 

"Our service is much like any public safety entity whose mission is to serve the public first; billing is after the fact. We don't do wallet biopsy before we transport," Wharton said. Many patients don't have the ability to pay anything, and that falls into charity care the company writes off, he said.  

The conversation comes down to what we want as a country, he said. Without air transports, "we run the risk of someone who needs a chopper doesn't get one and dies."

Eighty million people, particularly in rural communities, rely on air ambulances, he said. "Without it, they are hours away from definitive treatment." 

Reach has 60 bases in seven states with helicopters available 24/7. The availability and readiness of helicopters and crew come with a cost.

"There's much more benefit even with the current system," he said. "It's not perfect, but what can make it perfect is if the government and insurance companies step up. You would see those top line bills come down."  

'They saved my life'

When Al Judd walked into his wife's hospital room at MCR, expecting to find her close to death's door, she was alert, sitting on the edge of the bed, talking with doctors and nurses. 

The flight saved her life.

"Another 20 minutes and she would have been dead," Al Judd said he was told later. The billed cost of the flight was $36,058, but the Judds paid nothing.   

"Even if we had no insurance and had this horrible bill, I don't know that I would be upset because they saved my life," Dee said. 

No one is certain what happened. There was no stroke, no heart attack. Nothing but electrolyte levels that were at "near death levels" and perhaps shorted out Dee's nervous system for a time, Al said. 

Dee had been drinking water for days, which apparently flushed her electrolytes, causing her body to begin shutting down. Once she got IV sodium serum, "I was normal again," she said.

Doctors still don't know what caused her electrolytes to drop, but they "were amazed and pleased with her response," Al Judd said.  

Pat Ferrier is a senior reporter covering business and health care.

More:Fort Collins firefighters increasingly respond to more medical calls