A decision to ‘stay-and-pay’ can depend as much on a patient’s particular needs as on their geographical location. For instance, the availability of appropriate medical care in a country like the US won’t necessarily mean that a patient should remain there for treatment if they are fit to fly to suitable care at home.
The underwriter always has the interests of the patient at heart. Their preferred option will be to admit the patient to a medical facility with a known standard of excellence and an ability to treat their needs. It follows that a stay-and-pay decision is not likely to be taken in remote and developing parts of the world where medical treatment may be suboptimal. In these situations, local medical facilities may only be used for initial stabilisation before a patient is transferred to alternative suitable care, according to Dr Lynn Gordon, Chief Medical Officer at Charles Taylor Assistance.
She comments: “The stay-and-pay or scoop-and-run decision is not always cut and dried – and it often involves taking multiple factors into account. For example, an oncology patient may be so severely ill that there’s no window of opportunity to transfer them home safely, whereas a patient who would not usually be considered fit to fly may only have a chance of survival if they are transferred to superior care. An individual falling ill overseas during the pandemic may have to become a stay-and-pay patient if there are no hospital beds available back in the UK.”
Air medical transports could be more expensive than medical bills
Meanwhile, Covid has not made the situation any easier for assistance providers. “At the beginning of the pandemic, moving patients was difficult,” said Dr Amira Jacob, Operations Manager at assistance provider Egypt in Touch, “as there was not much information about the virus and its transmission. Now, after we have gained more understanding about the pandemic, a lot of measures and processes have been implemented for safe evacuations.”
The stay-and-pay or scoop-and-run decision is not always cut and dried – and it often involves taking multiple factors into account
With travel restrictions in place, a decision to transport the patient was made more difficult, as it could make the evacuation more expensive. However, operators, and their insurer clients, may have benefitted in 2020 from the plunge in jet fuel prices that resulted from the first global lockdown in April, when the cost of fuel fell due to the lack of demand from commercial carriers. Since then, however, the cost has been gradually, and predictably, working its way back up again. Albeit not to the same levels as seen in 2019 quite yet, but once travel confidence returns and commercial carriers can raise their revenues per passenger kilometre again, that price will inevitably continue its upwards trajectory. And with that upwards trajectory will come increasing air ambulance costs.
What makes missions expensive, more than medical costs, is if they are very long: the more flight hours, the more costly they will be. The use of a larger aircraft can also add to the cost, but often it has the benefit of increased range and more cabin space: for example, a Learjet 35 has a nonstop range of some 2,500NM (nautical miles, approximately 4,630km) before a fuel stop, whereas a Bombardier Challenger 604 covers some 3,850nm (or 6,900km) nonstop. A Challenger 604 can carry up to three stretchers or, for example, a larger mobile isolation unit for infectious patients and potentially more luggage and crews.
According to Gordon, most travel and health insurance policies have generous medical coverage limits, but the patient must have the right policy to meet their needs. It’s also essential for an assistance provider to predict future costs when managing a stay-and-pay claim: for instance, to ask what the patient may need next week or the week after, or to assess air ambulance costs in the context of total medical spend.
Between paying the people involved in an air ambulance mission, paying for fuel and aircraft use, as well as medical equipment and take-off fees, the bill that covers a mission can be broken down into several constituent parts.
Bryce Nelson, Business Development Director at AirCARE1, told ITIJ for a feature about air ambulance bills: “A few of the factors might include the lift-off fee, per-patient loaded mile, crews remain overnight, specialty medical crew, international fees/permits etc. I have also seen an additional fee for being launched between the hours of 6:00 pm and 8:00 am. Here at AirCARE1, we do have a standard process while putting together a quote, to keep a consistent and ethical price for all parties involved. We work with many insurance companies that have guided us in the direction of building the majority of the price from the Current Procedural Terminology codes.”
A patient can accept or decline an insurer’s decision to scoop and run, says Gordon, but they may need to accept that staying in-situ for treatment, against the underwriter’s advice, could halt their insurance cover. In some of these cases, insurers may contribute the equivalent cost of an air ambulance to a patient’s care. Every policy is different, but the best will allow each case to be assessed individually.
A quick decision could save patient lives
However, in some cases, a quick decision might make the difference between life or death, independent of insurance cover. Amira Jacob recalls a recent case where a quick decision saved their patient’s life. “The right decision for the patient’s health at the right time, regardless of any other considerations, is not always easy to make,” she said.
The right decision for the patient’s health at the right time, regardless of any other considerations, is not always easy to make
This patient was a 57-year-old woman, arriving at a hospital in Egypt with pain and bruises after falling from a bicycle in a remote area. The patient was diagnosed with a post-traumatic contusion to the chest and a fissure fracture at the eighth rib. She was in severe pain even after receiving potent doses of analgesics.
“Our medical platform had attributed the severe pain to other reasons,” explained Jacob. “That is why the decision was taken to evacuate the case to another place, which was chosen based on its capabilities to conduct advanced examinations, as well as the presence of good medical staff.”
Astonishingly, after a CT scan, the team discovered that the patient was suffering from a partial compression collapse of her lower lung, which required urgent cardiothoracic surgery. It was immediately done in the new facility. The patient’s general condition improved notably, with regression of the severe pain.
“The decision was made not just because of the high bills at remote areas, but also because of other medical suspicions,” said Jacob.
Basing decisions on experience and guidelines
To decide when to leave a hospital and when to stay, Egypt in Touch has clear rules in place. Jacob says: “We have our rules based upon international guidelines since we began in 2007, where patient safety comes first.”
Doctors’ evaluations of cases play a significant role, as well as the answers to the following questions:
- Is the place capable of treating the patient efficiently?
- If not, what is the best and nearest facility?
- What are the estimated costs for the treatment?
- What will the treatment cost if the patient is repatriated for treatment in their home country?
- Does the cost of evacuation plus the estimated cost of treatment make a noticeable difference?
- Is it worth exposing the patient’s life to the risks of evacuation?
However, even with these guidelines in place, a decision to pay-and-stay or scoop-and-run depends on the patient’s individual situation, which often means decisions have to be made quickly and in the moment. Particularly during the global pandemic, this can be a complex life-or-death decision.