What was touted as a key product differentiator when first introduced, accreditation is now arguably commonplace, yet some air ambulance companies successfully carry on business without being accredited, while insurance and assistance companies still follow their own rules and audits when choosing an ambulance partner. Does everybody know what they’re getting anyway – for instance, would an insurer or assistance company choosing an accredited provider know exactly what standards that provider is adhering to, or would it simply accept that it is ‘accredited’ and therefore ‘better’? European Aeromedical Institute (EURAMI) and Commission on Accreditation of Medical Transport Services (CAMTS) are not mutually exclusive and both have a geographical bias in an increasingly global industry. And from a political perspective, would a body such as the recently formed (2009) International Air Ambulance Alliance (IAAA) better serve the industry? There is a chance that with too many cooks in the kitchen, accreditation could get too confused, onerous and overwhelming for its own good.
Air ambulance companies asked to comment on the importance of accreditation were fairly unanimous in their response. “At Air Ambulance Professionals we feel that accreditation is both desirable and essential for our business ... it makes us stand out in an industry which, until recent years, has had very little regulation,” says Jacqueline Farley, director of clinical services. “Much of our business is done with insurance and travel assist companies, who are increasingly asking for much of the same standards that are required by both CAMTS and EURAMI.”
Some 90 per cent of this Fort Lauderdale, Florida-based company’s flights are international, “and we work a great deal with European agencies. We felt it would be beneficial to have both [accreditations], to show that we meet and exceed not only US standards of care, but also European standards, which are a bit different.”
accreditation is both desirable and essential for our business
EURAMI-accredited Air Medical Ltd (the first UK air ambulance operator to be awarded Full Accreditation ‘Special Care’ from EURAMI) maintains it is essential if you are to be publicly regarded as a ‘first class’ air ambulance expert provider. Chief flight nurse David Quayle said: “Our market is extremely competitive and while competing with lower quality air ambulance companies who have not adopted the very high standards set by EURAMI and CAMTS makes for an unlevel playing field, differentiation based on quality is very important for the best assistance companies.”
Quayle believes that accreditation takes away an element of uncertainty for insurers in that they ‘simply know that this air ambulance is a good one’. Given that patient transport is not risk free, he added, ‘it will be increasingly likely that assistance companies will want to use only accredited providers’ when balancing risk against benefit. However, while any unaccredited company is able to operate as an air ambulance ‘without placing quality at the heart of their operation and are able to get work based upon being cheap’, no one can be certain that high quality will remain financially sustainable. The failure of an accredited air ambulance operator because of uneven competition ‘would be a significant diminution of the quality available for patients’.
Paul Smith, national manager of CareFlight International in Australia, agrees that credentialing, through EURAMI, CAMTS and ISO 9002 (specifically ‘core standards in health care’) – or at least a combination of two of these three – will be an essential stamp of quality, going forward, given the changes
occurring in the industry. Pricing pressures have led to a situation where four or more assistance companies are contacting aviation providers about the same patient, he says; and a slowed charter market has seen aircraft operators the world over dusting off its aeromedical assets to move into the medevac industry by aiming at the lower acuity, low-risk demograph. “Demonstration of appropriate credentialing would represent a low-clinical-risk option for the insurer,” says Smith, “as well as investing in the industry to ensure a sustainable future.”
the expense (of accreditation) isn't justified
AirMed International (US) is another advocate for accreditation. The company has several contractual agreements that require this distinction. Also, as an approved air carrier for the US Department of Defense it must maintain its CAMTS accreditation in good standing. Executive vice-president Denise Treadwell, who’s been a CAMTS site surveyor for US programmes since 2008, states: “We would strive to achieve these standards regardless of contractual requirements. The accreditation demonstrates commitment to quality and validates your service level to customers, clients and partners.”
Treadwell believes that all companies should go through the CAMTS process every year. Yes, it is timely and costly but it serves to identify areas in which the programme excels and other areas that could be improved. Treadwell added that as there is no US government agency ‘that regulates our industry, this self-reporting is very vital to ongoing safety and service’.
CAMTS is seen as a very expensive process, but nonetheless an essential part of business by Beau Brooks, communications center manager at Air Ambulance Specialists International (AASI). “It is a validation of our service from all perspectives – financial, aviation and medical. It requires a high level of dedication from our management to fulfill all the necessary requirements, but also aids us in maintaining the highest standards. And, of course, it is the standard bearer with US insurance and assistance companies.”
Most companies choosing not to do the CAMTS accreditation do so because of the cost and invasiveness of the evaluation.Bart Gray, president of Global Jetcare, a company not accredited with either CAMTS or EURAMI, maintains: “From our point of view, the expense isn’t justified. We still need the same amount of insurance cover – medical, flight etc – whether accredited or not, and we have to meet the costs of complying with Federal Aviation Administration rules, which would be duplicated with CAMTS accreditation; why spend money twice over when there’s no reason to and we get enough business anyway?” He points out that CAMTS and EURAMI are businesses after all and need to sell their services. Nonetheless, he added: “Their standards are fantastic and we use them as guidelines.”
Meanwhile, Brooks feels ‘the triage’ effect provides the necessary level of inspection that contractual and private-paying customers need to be comfortable with the ‘uncomfortability’ related to long-range medical transport. He notes a trend among US companies in recent times to acquire EURAMI accreditation and recognises the logic of this for those with clients and operating aircraft within Europe.
Some claim accreditation is unnecessary because their own standards are higher than those set by EURAMI or CAMTS
The EURAMI accreditation procedure is described as a very slim and practical process by the Institute’s president Dr Michael Weinlich. The main difference (compared to CAMTS) lies in measuring quality by looking at the outcomes instead of telling air ambulance providers how they should do certain things. The question asked during the audit is: “Is there evidence that the expected quality level in each field is being reached?” The view of CAMTS executive director Eileen Frazer is that the EURAMI process is focused on patient care and medical standards. “We address these aspects as well, but also address operational safety, pilots, maintenance, ground ambulances, ethical business practices, medical escorts etc. We are expanding the fixed-wing standards to address some of the issues regarding long-range fixed-wing medical transports.”
Weinlich sees both accreditation processes as having a benefit for the air ambulance industry but says EURAMI has never understood the benefits of IAAA. “The quality level reached ... is already very high and there is no scientific evidence that another system different from constant improvement within the companies would really make a significant change.” Brooks of AASI believes that: “The more hands we get in the accreditation pot – just like anything else in life – makes things more confusing and often times convoluted.” Whilst Quayle of Air Med UK maintains: “EURAMI and CAMTS are the only recognised organisations undertaking this type of work. The IAAA has yet to persuade [the industry] that they have a role given the excellence provided by the likes of EURAMI.”
The IAAA naturally begs to differ. President Gary Andrews points out that three of the fundamental aspects of what the Alliance stands for are: ensuring that complete transparency of operations, pricing and patient care management exists between air ambulance operators and insurance/assistance companies; ensuring that a commitment to continuous improvement of patient care and operational management is in place; and holding members accountable to the IAAA for non-compliance of agreed standards.
In many instances insurance companies go to, and overspend with, an accredited company, which then subcontracts the flight (to an unaccredited provider)
Andrews says: “I know that EURAMI and CAMTS accreditation for some operators is simply a means to be seen with the right credentials. When an assistance or insurance company seeks to appoint an air ambulance operator, some will look for accreditation, if the choice is available. However, the other side is that payers will use whoever is available for repatriation at the time and, if two or more are available, simply choose the cheapest, which has its own consequences.”
Andrews continues: “What is generally true is that insurers and assistance companies don’t know enough about the air ambulance industry and what an accreditation represents ... most don’t know that it is a voluntary code of compliance. Part of what the IAAA stands for is educating (such) companies to fully understand the responsibilities and obligations that reputable fixed-wing operators need to comply with and the logistics and pressures they endure.”
Having their own standards and proven abilities in their field explains why several air ambulance companies operate successfully without accreditation. Some claim accreditation is unnecessary because their own standards are higher than those set by EURAMI or CAMTS and that they enjoy a creditable reputation with assistance and insurance companies. Doubtless the larger assistance companies, especially, will expect some form of accreditation but as Mariano Moretti, global operations group director for Europ Assistance, notes: “We’re organised from the standpoint of our internal auditing approach. Accreditation is a plus factor, but is not fundamental or a prerequisite; air ambulance companies have to be compliant with our own requirements. Reputation is often enough. However, this is a globally sensitive market and air ambulance companies can come and go, so accreditation does demonstrate that a company is prepared to invest in the long term and intends to be a serious player.”
Global Jetcare relies on its reputation. “We don’t need to look for new customers,” says Gray. “I believe it’s better to stay ‘neutral’ and do business either with brokers or with insurance companies who are prepared to accept us as an unaccredited air ambulance company. In many instances insurance companies go to, and overspend with, an accredited company, which then subcontracts the flight. I’ve just done a trip from Italy to the US on behalf of an accredited company.”
On the other hand, the economic pressures of running an air ambulance are forcing some operators to evaluate overheads with a consequent decision that accreditation is not worth the cost, though the IAAA believes such operators will continue to ‘maintain the standards expected and will be successful with the payer relationships they have’.
On a final note, Brooks argues that if accreditation is meant to provide validation for some of the larger insurers who contract for air ambulance services, then the insurer carries some level of responsibility for due diligence as it is placing a very high level of trust in the air ambulance provider.