By David Wren
The Sun News
Copyright 2008 The Sun News
HORRY COUNTY, S.C. — Carolina Lifecare, the only emergency medical helicopter in Horry County, could be grounded this month amid charges the company flies patients to trauma centers to boost revenue, not because those patients need specialized care.
Carolina Lifecare officials deny the accusations.
A federal judge is scheduled to decide Carolina Lifecare’s fate during a March 24 hearing in Columbia.
Medserv Air Medical Transport LLC, a competitor, is suing Carolina Lifecare over an alleged contract violation.
A key issue in the lawsuit, however, is the rapid growth in emergency helicopter transports from Horry County in recent years.
There were 291 such transports in 2006-07, the first two full years of operation for Carolina Lifecare.
Horry County had 17 emergency helicopter transports in 2005.
Those numbers do not include hospital-to-hospital transports.
Carolina Lifecare, which is based at Myrtle Beach International Airport, conducts 85 percent to 90 percent of helicopter transports from Horry County.
Carolina Lifecare’s critics — which include Medserv, emergency room doctors and hospital administrators — say in court documents that the company “operates in an irresponsible manner” by making unnecessary flights that cost patients and insurance companies thousands of dollars.
Carolina Lifecare says patient care, not profit, drives the decision to fly.
Kelvin Oakley, the helicopter company’s clinical manager and flight nurse, said the allegations are partly sour grapes by a competitor who lost business and medical officials who are resistant to change.
“Hospitals used to provide their own transports, but many of them don’t want to assume that cost any more, so you’re seeing more private, non-traditional companies,” Oakley said. “It’s not the way some people are used to doing business, and they start to worry that they will lose power and control.”
Patients usually have no say in that decision, yet a helicopter flight can cost an average of $10,000. Horry County’s ground ambulance fees start at $250.
The extra cost often is justified, experts say, because helicopters shave precious minutes off transport times — especially in traffic-congested Horry County — and can be the difference between life and death for a trauma victim.
“We in emergency medicine sometimes speak of the ‘golden hour,’ referring to the first hour during which time a trauma patient has a much greater chance of survival,” Mel Hecker, an emergency room doctor at Conway Medical Center for more than 16 years, said in court documents supporting Carolina Lifecare.
Too many times, critics say, Carolina Lifecare flights don’t warrant trauma care.
A troubled system
McLeod Regional Medical Center in Florence dropped its trauma rating in 2006 specifically to stop Carolina Lifecare from bringing patients that administrators there said could have been treated at Grand Strand hospitals.
That move left eastern South Carolina without a Level II trauma center.
An analysis by The Sun News of Horry County Fire Rescue medical reports showed 60 percent of helicopter transports during a 21-month period in 2006-07 were for individuals who would not have been considered trauma patients under a nationally recognized triage scoring system.
Those medical reports did not include information that would have identified the patients.
That analysis mirrors national studies that show 60 percent of all medical helicopter flights involve patients with only minor injuries.
Experts say the scoring system — called a Revised Trauma Score — is just one factor in many, often subjective, observations first responders must make quickly before deciding on a transport that could affect lives and careers.
That kind of pressure “is like standing at the bottom of a volcano that’s rumbling and you don’t know if the lava is coming or not,” said Matthew Smith, battalion chief of medical operations for Horry County Fire Rescue.
Not every call is perfect, he said.
An administrative flaw also might cause Horry County’s first responders to give some patients a higher trauma score than they deserve so the responder’s work won’t be questioned by supervisors.
Smith said there is an administrative review of all medical reports in which a patient’s trauma score is nine or below.
“They [first responders] know if they put down a nine, I’m going to review their paperwork,” Smith said. “So they might give a patient a 12 when they really qualify for a nine.”
Smith said he also reviews all medical reports in which a helicopter transport is involved.
Smith said he has found three instances since 2005 where helicopter transport was not justified. The first responders who called for the helicopters in those instances were reprimanded, Smith said, and had to take mandatory training.
“Three is too many, but if that’s what I have to take to have this program, I’ll take it,” Smith said.
Tough decisions
Oakley said statistics show first responders here make the correct call most of the time.
 If they [first responders] ever pass on a flight and call for ground transport, and that patient dies, that person’s career could be on the line.  | ||
| — Jeff Wright President, Air Medical Consultants | ||
Twenty-nine percent of patients flown by medical helicopters nationwide are released from the hospital within 24 hours, an indication the flight was not warranted.
Carolina Lifecare’s rate is 16 percent.
“That is proof that our team, as well as the local areas and county organizations in which we work, do an outstanding job in their decision-making and triage of patients,” Oakley said.
Carolina Lifecare is owned by Dallas-based Omniflight Helicopters Inc., one of the nation’s largest air medical transport companies with operations in 16 states. Its Carolina Lifecare subsidiary was the first successful private-venture service of its kind in South Carolina.
As a private, for-profit business, Carolina Lifecare “has a financial incentive to transport as many patients as possible,” according to an affidavit by William Gerard, an emergency room doctor at Palmetto Health Richland hospital in Columbia.
Gerard also was director of that hospital’s helicopter transport program, which was operated by Medserv.
Medserv says in court documents that Carolina Lifecare’s existence is dependent on the number of patients flown, and “the gain or loss of as few as 20 to 25 flights per year can make the difference between a profit or loss.”
State and national air medical associations have published guidelines for when an emergency helicopter should be used, but there are no mandatory standards and the air medical transport industry operates with few regulations and little government oversight.
Measuring need
The debate over whether helicopter flights are medically necessary has heated up nationwide as health care costs have risen.
“Scrutiny of helicopter transports by insurance payers, including Medicare, is becoming more and more prevalent because helicopter reimbursement is very costly,” said Chris Kelly, an Atlanta lawyer who specializes in ambulance industry regulations.
The federal Medicare program has launched investigations into fraudulent billing practices in at least seven states, and has forced some helicopter companies to pay back money they received for unnecessary flights.
When insurance companies deny claims, patients can be stuck with helicopter charges totaling thousands of dollars.
“It’s easy to second-guess [a first responder’s] decisions after the fact, and that’s what health insurance companies do,” said Jeff Wright, president of Air Medical Consultants in Atlanta.
“A lot of families get stuck with these [air transport] bills because insurance companies review the records and say the flights are unnecessary,” said Wright, whose company is an advocate for patients. “That puts those families in a difficult predicament.”
One measure of whether a flight is necessary, experts say, is the Revised Trauma Score, which ranges from 0 to 12 and is used to quickly assess the severity of injuries. Blood pressure, respiratory rate and motor responses are factors in the score.
A higher score means a patient has a greater chance for survival.
Revised Trauma Scores were included on 218 of the 260 medical reports reviewed by The Sun News.
Sixty percent of the 2006-07 helicopter transports for which scores were available were for patients with trauma scores of 12, the highest score available.
Most state and national trauma guidelines say patients with a score of 12 often are not in need of immediate attention.
Scores of 11 and less usually do require an airlift to a trauma center, according to state and national guidelines.
Other factors
Oakley said trauma scores should not be the only factor in determining whether a flight is necessary because the results can be misleading.
For example, a patient could have a life-threatening epidural hematoma — which is trauma-induced bleeding that occurs between the brain and skull — and still score a 12.
On the other hand, a diabetic patient whose glucose level drops could score an 8 or 9 on the trauma scale.
“According to the numbers, this individual should be immediately flown to a trauma center, but all they really need is dextrose,” Oakley said. “When we make decisions based on numbers instead of the entire picture, patients do not always get what they really need.”
Robert Zirkelbach, spokesman for America’s Health Insurance Plans, said there are no specific red flags — such as a high trauma score — that would cause an insurer to reject a helicopter transport claim.
“However, I do know that the severity of the injury is one of the things health plans will look at,” said Zirkelbach, whose group is a trade association that represents 1,300 health plans nationwide.
Other factors insurers consider, Zirkelbach said, are the location of the nearest trauma facility and whether ground transportation was available.
Smith said no insurance company has ever questioned his department about the necessity of a helicopter transport from Horry County.
Wright, who did not speak specifically about Carolina Lifecare, said there might be helicopter companies around the country that fly patients needlessly, but proving that intent is often impossible.
He said first responders usually have a patient’s best interests in mind, even if they err too much on the side of caution and call for an unneeded helicopter transport.
“If they [first responders] ever pass on a flight and call for ground transport, and that patient dies, that person’s career could be on the line,” Wright said.
“They’re the ones on the scene and they have to make that determination. You never know what their motivation might be, but it’s really hard to evaluate what might have been the right call if you weren’t there.”