Since the end of the pandemic, assistance firms have reported a clear rise in demand from insurance companies for repatriations on commercial airliners – a trend that medical escort and assistance firms are moving rapidly to meet. But what are the driving factors behind this rise in interest, and what can businesses do to respond to it?

“I believe many insurers are looking for more cost-effective options than traditional air ambulances, especially when the patient’s condition is stable enough to travel on a commercial flight with medical supervision,” said Margaret O’Donnell, Director and Clinical Services Manager at the Australian Medical Escort Service (AMES).

She explained that, for that type of case, using a commercial medical escort is viewed as the “practical solution”, offering a “safe and professional level of care” without imposing additional costs.

Philipp Bauer, CEO of Medical Flight Service, agreed, saying that alongside cost-effectiveness, a “primary driver … is the broader availability of commercial flight routes. Insurers recognise that escorted repatriations via commercial airlines offer a more economical solution for non-critical cases without compromising patient care. Availability checks and routing can be completed within minutes with high reliability.”

He added that he was confident that the demand for airline-based repatriations would continue to rise in the coming years: “With improved medical escort services and clearer regulatory frameworks, commercial airline repatriations are becoming an increasingly accepted standard for non-urgent cases.”

For Rudy de Kort, CEO of Jet Companion, international migration is a core driver of business at his own firm.

“Typically, immigrants don’t cut ties with their home country,” he said. “Instead, travelling between places becomes an essential part of family life, often involving older and sicker visitors who rely on travel insurance for extended periods of time.”

With some regions served by Jet Companion expected to see “a yearly population growth of 3–6% due to immigration”, De Kort said that he was expecting demand for commercial repatriations to rise accordingly.

Dr Stephan Klose, Managing Director of AMTRAS aeromed, said that while emergency repatriations remain a core part of his company’s business, AMTRAS is “increasingly supporting planned travel”.

Driving much of this demand, he said, was a “broader shift towards personalised, medically supported travel beyond acute medical emergencies”. Examples of this may include catering to elderly or chronically ill individuals who are travelling internationally for family events or to reach their retirement destination.

Stuart Phillips, Director of Medical Services and Co-Founder of assistance firm MedResQ, added that clients are becoming more cost-conscious: “There is a growing tendency to explore multiple repatriation options for a single patient.”

He continued: “For instance, they may weigh the benefits of an immediate but costly air ambulance transfer against the more economical option of a delayed commercial repatriation.”

He noted, however, that the selection of such transfers is dependent on the condition of the patient – based on careful medical assessment and clear communication from all parties. Additionally, factors such as pressure from patients, their families, and hospital staff, as well as the risk of complications and the financial burden of extended hospital stays, may also guide the choice to conduct an airline repatriation.

Looking to the future

Klose added that from his company’s perspective, demand for airline repatriations was expected to continue due to a number of longer-term trends. Most notably, advances in healthcare and access to digital services are enabling people to live longer and travel more – even if they have complex medical conditions.Additionally, new travel patterns have emerged since the pandemic, he explained, with growing demand for “medical support during late-life relocations, specialist treatments abroad – medical tourism – and non-urgent but medically necessary journeys”. All of these are accelerating demand for cost-effective repatriation options.

O’Donnell agreed, saying that insurance companies are “placing greater emphasis on patient comfort and logistical efficiency” and that “commercial repatriation, when done with proper medical oversight, can offer both”.

She also noted that alongside medical tourism and a more mobile older population, there has been a rise in the number of people who work remotely overseas.

Insurance companies are placing greater emphasis on patient comfort and logistical ‎efficiency ‎

Types of illnesses and injuries

While demand is rising, the kind of afflictions that those seeking an escorted repatriation on a commercial airliner have remain consistent.

Phillips explained that, typically, such patients have “significant cardiac or respiratory pathologies, or … have suffered a functional change, such as stroke or trauma”. He added, however, that most patients served by his company are of “average working age”, between 18 and 65.

Phillips also said that MedResQ was seeing a rising number of “older travellers and individuals with multiple comorbidities who have declined or no travel insurance”.

“As this group must self-fund both their care and repatriation, the demand for cost-effective yet safe commercial repatriation options is expected to grow,” he concluded.

De Kort added that his company had seen a gradual increase in end-of-life transport requests, driven by palliative cancer and advanced dementia patients.

These requests are often made when “the only other alternative is to transfer the patient to a local hospice”.

Klose agreed, adding that hip fractures were also a “classic acute condition” that they responded to on a regular basis. Beyond this, he said, AMTRAS was also seeing a rise in medical escorts for psychiatric cases, “particularly among younger travellers” – something that poses “legal and logistical challenges” due to “jurisdictional and decision-making complexities”.

On the subject of comorbidities, Klose also said that chronic, lifestyle-related conditions like obesity are becoming more common, leading to complications. This often results in issues like sleep apnoea that require the patient to have medical devices, such as continuous positive airway pressure (CPAP) machines or ventilatory support, while in transit.

“Increasingly, we must manage not just the acute issue, but multiple chronic conditions throughout the journey,” he said.

For O’Donnell, there has been a growing number of neurological cases, including strokes or conditions involving cognitive decline. “These patients often need to be monitored, but don’t always need a full air ambulance set-up,” she said.

Alongside this, she noted a rise in demand for commercial flight escorts from patients with injuries incurred through extreme sports such as skiing. “These kinds of injuries usually need things like immobilisation, pain management, and help with mobility,” she explained. “Some may require stretcher repatriation.” 

Rethinking logistics

To meet this rise in demand for commercial flight repatriations, assistance firms are exploring a range of options to improve capacity. For O’Donnell, the change has meant a push to hire more staff – nurses, paramedics and physicians – as well as strengthening AMES’s partnerships with major airlines “to streamline medical clearance processes and arrange appropriate seat allocations or stretcher availability as needed”.

However, she added that there were some hurdles to her company’s plans for expansion in this area, namely limited airline availability, limited access to provider markets, and higher operational costs due to the demand for more equipment, staff, training, and better administrative systems.

“Gaining consistent access to stretcher-equipped seating or other specialised accommodations on commercial flights can be challenging,” she said. 

Increasingly, we must manage not just the acute issue, but multiple chronic conditions ‎throughout the journey

Additionally: “Established relationships and preferred supplier lists often limit access, making it challenging for newer providers to demonstrate their capabilities and earn trust.”

De Kort added: “Industry-wide, we see a steady shift from generalist flight nurses to aeromedical specialists, to medical escorts with a subspecialty like paediatric transfers, psychogeriatrics, or nurses who speak a specific language and are familiar with the healthcare practice in certain countries.”

Klose, meanwhile, said that for his company, the rise required a “rethinking” of how it managed its logistics, with an aim to improve efficiency in what is a “mature and resource-sensitive market”.

“One promising approach,” he explained, “is to use ‘floating bases’, where medical escorts stay abroad and assist multiple patients consecutively, rather than flying back after each mission. This maximises capacity and reduces turnaround time.”

He added that AMTRAS was exploring the concept of scheduled “mass transport” routes from specific high-demand regions. This would see the company securing fixed seat allocations on commercial flights along routes that have a high demand for medical escort services. Examples include the Bangkok–Frankfurt and Antalya–Frankfurt routes. AMTRAS would then deploy dedicated medical teams in advance, capable of accompanying multiple patients on the same flight.

Klose explained that this creative strategy was driven in part by a limited pool of “experienced medical escorts” in Germany, with many of those already in the sector operating as freelancers for multiple providers. “This,” he said, “leads to fluctuating availability, and complicates flight planning due to overlapping commitments.

“Compounding this issue, recent legal developments have made it increasingly difficult to maintain freelancer status,” he continued. “Social security authorities are more frequently reclassifying freelancers as employees, which can trigger retroactive contribution demands and significant legal uncertainty for providers and medical escorts alike.

One promising approach is to use ‘floating bases’, where medical escorts stay abroad ‎and assist multiple patients consecutively

“As a result, companies are being forced to reconsider employment structures – an expensive and complex move in a highly seasonal and politically sensitive market. Attracting and retaining qualified staff under these conditions is a major issue for the industry moving forward,” he concluded.

Phillips agreed, saying that “escort availability presents a significant challenge”, with the sourcing of high-quality medical personnel becoming “increasingly difficult”.

“At MedResQ, the average repatriation assignment lasts between four and eight days,” he said. “For many potential escorts, this level of time commitment does not align well with their personal or professional obligations, further narrowing the candidate pool.”

He mentioned that competition over a core pool of freelance medical escorts was also an issue for UK-based assistance providers – something that is often worsened by the need for “specific clinical roles” when making a repatriation.

Overcoming limitations

When exploring new equipment to meet the growing demand for airline repatriations, Bauer noted that a slight uptick in “elderly patients with complex needs” has led to increased demand for advanced medical equipment during flights – especially portable oxygen concentrators (POCs), which are critical for patients with pre-existing conditions.

However, Bauer warned, the use of such battery-powered equipment comes with its own challenges – particularly when it comes to regulations. He pointed out that many airlines impose clear limitations on the number, size, and capacity (watt-hours) of these batteries, while those that exceed “certain capacity thresholds are entirely excluded from transport”, he said.

“These restrictions are particularly impactful on long-haul flights, where higher-capacity devices may be required, yet the technical limits of permissible battery sizes are quickly reached,” he continued. This often results in a reduced choice of airlines, as not all carriers are equipped with or willing to accommodate such equipment under current regulations – an issue compounded by a lack of alternatives, such as Wenoll systems or onboard oxygen cylinders.

“To address these issues,” Bauer concluded, “service providers must maintain close coordination with airline medical departments, stay informed about regulatory updates, and ensure that medical equipment and battery supplies are fully compliant and optimised for each individual mission.”

Klose agreed that regulations around battery-powered medical equipment were a “key challenge”.

Attracting and retaining qualified staff under these conditions is a major issue for the ‎industry moving forward

“To address this,” he said, “we propose creating an evidence-based scoring system to assess the feasibility of business class transport. A simple yet robust checklist could help standardise decisions, reduce unnecessary costs, and ensure safe, appropriate care.”

Phillips noted that his company had seen growing interest in repatriations involving patients who were intubated, adding that such missions go “far beyond simply upgrading medical equipment”.

He affirmed that “the transfer of such highly complex cases requires a fundamentally different approach”, requiring “an experienced, specialist clinical team and close collaboration with the airline to meticulously plan every aspect of the journey”.

“Comprehensive risk assessments, contingency planning, and proactive coordination are essential to safeguard the patient’s wellbeing throughout the transfer,” he said. However, he concluded, “such decisions must never compromise patient safety in favour of convenience or savings”.

Conclusion

While there is clear, growing demand for patient repatriation via commercial airliner, it is not always easy for assistance providers to meet this demand. Despite this, challenges can be overcome – a shortage of experienced medical staff needn’t mean a hard ceiling on a company’s expansion to serve the market. A creative approach to efficiency can help firms meet higher demand with the assets they already have to hand.