Air ambulance industry copes well with Covid-19 fallout

A drop in commercial flights

Speaking to Lepetit, it became clear that the cancellation of commercial flights sparked widespread complications for the medical assistance industry, and that air ambulance operations have quickly become integral to maintaining travel assistance services for international insurers.

Lepetit explained that every year, Allianz usually organises more than 17,000 medical repatriations from all around the globe – two-thirds of which are performed by commercial airlines. Air ambulances used to be used mainly for local or regional emergency evacuations, and for longer distances when stretchers were not available in a timely manner, she notes. With commercial flights less available, has this resulted in more air ambulance transfers?

in cases where local healthcare systems were not adequately equipped for patient needs, or were overwhelmed by Covid-19 patients, air ambulances played a pivotal role in helping the company transfer emergency cases

“2020 has completely changed this way of working,” said Lepetit. “We have needed to adapt to multiple constraints: the cancellation of commercial flights; authorities reluctant to allow any medical transport; and the requirement for our medical teams to quarantine upon arrival and/or upon return to their home country, to name a few. As a result, we have tried to organise all urgent treatments for our customers in the best facilities locally, enabling us to transport them later as normal passengers. This has led to a decrease in our medical transports by five times.”

All is not lost, though, as Lepitit added that in cases where local healthcare systems were not adequately equipped for patient needs, or were overwhelmed by Covid-19 patients, air ambulances played a pivotal role in helping the company transfer emergency cases. Lepetit specifically referenced an incident in Sub-Saharan Africa, where four patients required emergency transfer and air ambulances were the ‘only adapted response’.

Commenting on some of the many ways that air ambulance operations had allowed Allianz to navigate the new landscape of emergency patient care, Lepetit said: “For non-infected patients, air ambulances had a great availability to transport our patients, even greater than usual, probably due to the loss of other travel activity. Furthermore, we utilised this means of transport to perform long-haul flights from countries such as the US to Europe, compensating for the lack of stretchers on commercial flights. Overall, from March to August 2020, our air ambulance transports increased by 25 per cent compared to the same period of time in 2019.”

Air ambulance operators adapt to a multitude of assistance challenges

But for these air ambulance firms that have been picking up the slack, it hasn’t exactly been smooth sailing. ITIJ spoke to both Air Alliance and Air Ambulance Worldwide to identify some of the key challenges that Covid-19 had presented to air ambulance operators when it came to international patient assistance services.

Eva Kluge, Chief Commercial Officer at Air Alliance, told ITIJ that, overall, for her company, missions have become longer, and logistics are the biggest challenge: “Every country has its own way of dealing with Covid-19: aviation and health authorities frequently change their rules for permits and it may happen (rarely, but it does) that an already issued permit is revoked after setting out on a mission. Some countries require ‘diplomatic clearances’ for patients, which can take several days. Many countries do not allow our crews to overnight at their airports any longer, and we need to look for a country nearby that still accepts air and medical crews.”

Covid-19 testing and additional measures for strict infection control, patient mobile isolation units (PMIU) and special training were all hurdles that had to be overcome

Lauren Dulin, Chief Operations Officer at Air Ambulance Worldwide, points out that delays caused by many of these requirements, which also included closed airspace, presented additional challenges to the team. And Kluge notes that due to quarantine and restrictive immigration rules, Air Alliance rarely carry out bed-to-bed transports any more, with tarmac transfers becoming more regular. “The handover of the patient often takes place at the airport as we cannot enter the country to visit the patient prior to transport (or our crews would need to self-isolate in the respective country for 14 days),” Kluge said. “The lack of commercial flights means that crew changes have become very difficult and that we need, for many missions, to carry the entire crew along.” She notes that Air Alliance have transported some 40 Covid-19 patients from/to more than 20 countries, including Japan and Venezuela, since May 2020.

Both Kluge and Dulin also identified that Covid-19 testing and additional measures for strict infection control, patient mobile isolation units (PMIU) and special training were all hurdles that had to be overcome.

Kluge noted that Air Alliance’s fleet had been pivotal in keeping the firm afloat while assisting with patient transfers: “For us, a major asset has been the fact that we own two long-range Challenger 604 aircraft,” Kluge said. “This helps, on the one hand, to be faster and save complicated overnights. On the Challenger, we also can conduct air ambulance missions for Covid-19 patients with our own PMIU (‘EpiShuttle’).

“At present, we are expanding our capacities for the transport of non-critical Covid-19 patients on short trips onboard the smaller Learjet 35 with a special isolation unit. In collaboration with the Medical University of Vienna, we have access to a fast mobile PCR test (LAMP) which was just officially CE marked and is undergoing field testing in a clinical environment.”

The cost of medical assistance goes up

Commenting empathetically on the many hurdles that air ambulance operators have faced during the pandemic, Lepetit said: “Air ambulance providers had to cope with a drastic increase in regulations and authorisations to transport infected and non-infected patients. These regulations have also increased the delay to transport patients, with the necessity to comply with regulations from all countries flown over, and their approval more complicated to obtain, during this pandemic.”

Lepetit also notes, however, that the increased involvement of air ambulance operations has had a knock-on effect on cost for Allianz Partners: “With fixed-wing air ambulance costs being at least two-times higher than commercial aircrafts, the financial impact of Covid on our medical assistance activity has also been significant.”

Covid highlights inefficiencies in travel insurance cover 

But, while air ambulance operations come at a [high] price, they are also ‘highly dependent on the tourist market’, as Kluge notes, and so these firms have also taken a considerable financial hit from the ongoing Covid-19 pandemic. Indeed, Dulin identifies that ‘the biggest challenge’ for Air Ambulance Worldwide has been ‘the drop in volume, corresponding with the decrease in travellers, as well as the immediate shift in the nature of transfers that are performed’.

And Kluge also identifies that patients have also suffered as a result of the pandemic – and not just the pandemic, but the gaps in travel insurance cover that it has also highlighted.

While the tourist market ‘practically vanished overnight’, she said, there were still a substantial number of patients scattered around the globe – many of them expatriates working in the oil and gas, mining or maritime business, as well as military personnel and diplomats, who found themselves in environments with limited healthcare systems. However, during the global pandemic – and the travel hiatus that it caused – Air Alliance also received increased requests directly from governments or international organisations, as well as from the private pay/uninsured market.

Kluge tells ITIJ that the increased number of direct requests from governments, international organisations and private requests reflects the fact that insurance coverage was unclear or not granted. She reasoned: “Meanwhile, the situation seems to change, and insurers are already developing new services and products specifically for a pandemic, for example a coverage for healthy travellers getting stranded due to the lack of commercial flights,” she added.

Elsewhere, Dulin tells ITIJ that the decrease in traditional travel assistance flights has resulted in a greater emphasis being placed on internet inquiries, the company’s hospital programmes, and organ transfer flights. She added: “We have also been chosen as the transport solution provider for a major American sports league for the 2020-2021 season.”

Good relationships a lynchpin for the travel assistance industry

Looking at how the relationship between air ambulance operators and insurers has worn throughout the pandemic, Dulin gives a pretty positive view: “To a great extent, our clients have handled the Covid crisis well and immediately understood that a flight that usually took several hours to obtain permits for might now require several days.

“Over the years, we have made an effort to invite our clients’ key personnel to sit with us in our operations center for a day or two and assess our workflow and procedures. This has allowed them to critique and contribute to our processes, as well as return to their team with a better understanding of how and why we do the things we do.” Dulin explained that this collaborative effort has led to a ‘better mutual understanding’ between the two parties and has paid dividends in eliminating many inefficiencies resulting from operational errors. “This is as true during Covid-19 as any other time,” she said.

Overall, Allianz Partners’ Lepetit commended both assistance and air ambulance companies’ ability to adapt and work together. “We see the future in the medium term to continue this way and we intend to reinforce the involvement of our medical teams in air ambulance transports,” she told ITIJ.

A slow recovery for the air ambulance industry

After a tumultuous year for the travel, travel assistance and travel insurance industries, it seems that the health of the air ambulance industry hangs in the balance. Dulin explained: “While we perform a number of missions for managed care partners and private pay clients – how the travel insurance industry reacts and recovers from this will largely be the barometer by which we measure our own recovery.”

Kluge mused that how fast the industry was likely to recover would depend on the effectiveness and availability of vaccines, which she acknowledged had started to be rolled out in several countries. “It may take the industry one to two years to fully recover. At present, after speaking to many clients and other partners in the industry, we are confident that things will gradually move back to normal (not fully recover) from the second half of 2021.”

Kluge added that initiatives like the International Civil Aviation Organization’s Council Aviation Recovery Task Force (CART) – in co-operation with the World Health Organization – provide wide-ranging recommendations to States and industry stakeholders that are underpinning the co-ordinated and safe re-opening of commercial air services. “Global connectivity is vital for air ambulance operators who work in the transnational sector,” she said.

And, as, Dulin noted, the demand for travel is there, ready and waiting for a time when the industry is ready to cater for it: “What we see now is an indication of a pent-up demand for life to return to normal, including in large part a return to leisure and business travel. We will continue to apply the lessons learned from Covid going forth.”