City seeks better ambulance service

Havre community leaders have begun talking about upgrading the city's ground ambulance service.

The reason is so patients who are taken from Havre's Northern Montana Hospital to more-equipped hospitals, such as Benefis Hospital in Great Falls, will not have to be taken by costly, and oftentimes, more time-consuming air ambulances.

Air ambulances are vital in a rural state like Montana. But the costs patients can incur have been a source of controversy and concern.

In an April 17 press release, Sen. Jon Tester cited a Missoula woman who was charged $80,000 for air ambulance ride, of which $17,000 was covered by insurance paid, leaving her with a $63,000 bill.

The Missoulian article "Montana hospitals: Air ambulances too expensive, often mean high bills for patients" says there are three types of air ambulance models: operations run by hospitals that own or lease the aircraft, nonprofit operators that are affiliated with hospitals and standalone companies.

Multiple variables determine the cost of an air ambulance ride: how much insurance covers, whether the particular ambulance company contracts with that insurance company at all and the distance the patient is flown. Air ambulance companies usually have a base takeoff rate and additional costs for every loaded mile - the distance traveled with the patient in the ambulance. The Missoulian reported that some private air ambulance companies don't contract with any insurance companies and there are no regulations that can compel them to do so.

Northern Montana Hospital President and CEO Dave Henry said air ambulance fees, although still costly from Havre to hospitals such as Benefis, do not get as costly as that of the Missoula woman mentioned in Tester's press release.

He said air ambulance transportion from Northern Montana Hospital to Benefis, the hospital patients from Havre are most often flown to, usually ranges between $20,000 and $30,000.

Jerald Malkuch, 67, from Havre said he was was flown in August 2015 from Northern Montana to Benefis when he had double pneumonia. He said he incurred a bill of nearly $30,000, but Medicare negotiated it down to $8,700. Medicare then paid everything but $1,752.

"Benefis saved my life," he said. "But I don't want to buy the aircraft, I just want to fly in it."

Havre Mayor Tim Solomon said the high costs of air ambulance transports is a legitimate concern, and city leaders have recently begun discussions about upgrading the city's emergency medical services.

"We're at the beginning phases of a long discussion," Solomon said.

Officials did say the Havre Fire Department, which provides ambulance service for the city, will stay in the ambulance business, and it would make sense for the department to upgrade to a level that will enable it to provide the kind of care that normally requires an air ambulance transport - advanced life support, ALS, which encompasses advanced cardiac life support, ACLS. As of now, the ambulance service can only provide BLS, basic life support.

The reason someone would need to be taken to Benefis is to receive care Northern Montana Hospital is not equipped to give, interventional cardiac care, for instance. The point of an ALS-trained crew is to be able to treat patients in case there is trouble en route to the hospital.

Dr. Marc Whitacre of Northern Montana Vision Center had a heart attack January 2014 and was flown to Benefis on an aircraft that came from Kalispell Regional Medical Center. Whitacre has been a vocal proponent of upgrading Havre's emergency transport system.

"We are all one motor vehicle accident away from a helicopter ride to Benefis. That could financially ruin someone who is not well-covered or has a very high-deductible," Whitacre said. "Now you come home from the hospital, you're glad to be alive but you have a $20,000 bill you need to deal with - and that is frightening."

Whitacre's bill from the transport totaled almost $10,000, of which nearly $4,000 was paid out of pocket. The price is a fraction of what the Missoula woman paid, and below the range Henry cited. But Whitacre could have done even better had he been transported by an ALS certified road ambulance.

Havre Fire Department Chief Tim Hedges said the cost for an ALS transport to Benefis is $2,030, total, almost half of what Whitacre paid just out of pocket and one-fifth of the total cost.

A common misconception is that air ambulances are more costly because they provide faster and more reliable service. This, according to chairman of the project report "Mission Lifeline: Montana," Dr. Douglas Waldo, is usually inaccurate. Waldo is an interventional cardiologist at Benefis.

"Mission Lifeline: Montana," an American Heart Association project, is intended to improve the care of rural heart attack patients. Waldo said when someone needs to be airlifted from Northern Montana Hospital to Benefis, the helicopter usually comes from Kalispell or Benefis. By the time the hospital receives the call, the helicopter receives weather clearance and takes off, lands and then loads the patient, takes off again, the patient could already be at Benefis via a speeding road ambulance.

Waldo said bad weather will stop air ambulances from flying before it will stop road ambulances from driving. Road ambulances can drive through fog, bad rain, snow, even ice, but those types of conditions can stop helicopters from getting flight clearance, he said.

Waldo said he has confidence that Havre can become a regional medical hub for the area. Because Havre is in north-central Montana and surrounded by many small towns, an emergency medical transport system upgrade would be ideal and beneficial to the area, he said.

Hedges said the fire department plans on becoming an ALS-certified emergency transport system, but it will take time, years perhaps. It will also take money for training purposes mainly, he said.

Hedges said he sees two ways to get there.

The first option is for firefighters who are working for the department to be trained as paramedics. Hedges said many have said they are willing to be trained, but he cautioned that there's a difference between them saying so and following through.

The second option is for Hedges to hire paramedics from here on out when positions open up. But he was wary about this option as well. The department is fully-staffed and there aren't a lot of guys near retirement. He hasn't ruled out a combination of both, either.

Since it will take years for the long-term plan to be realized, if it's to be realized at all, Hedges said he also had a short-term plan.

Hedges said it would be best if the hospital provided ALS-trained nurses, while on its payroll, to ride in the ambulances during emergency transports. He said many years ago, "10 or 15," nurses used to ride in the ambulances when needed. He said the arrangement makes sense because the patient and the nurses are already at the hospital by the time a transport is usually needed.

Henry said Hedges long-term plan is great, but his short-term plan would need to be altered because the hospital cannot require a nurse to ride in an ambulance because of its fear of malpractice lawsuits. He did offer a potential solution.

"If the chief were to put out an ad or ask nurses to become an employee of the city, and in their spare time be available for transport, that's probably the best way for him to find quality folks. ... His best short-term plan would be to find nurses in the community that may or may not work for us that have ACLS qualifications, that are willing to ride in a van on his beck and call," Henry said. "The challenge there is finding enough nurses who will provide him that guaranteed coverage that he needs."

Hedges said he would never claim to be an expert on malpractice laws, adding that he couldn't help but wonder what has changed since the hospital used to allow nurses to ride in the ambulance.

Hedges said the notion of developing a pool of nurses, paid for by the city, would greatly impede the implementation of his short-term plan. Aside from the city already scrounging for money, it would be a lot of trouble to put together a pool of 10 nurses in the hopes that one would be available when needed.

"Imagine," Hedges said, "the difference between having to find a nurse after finding out someone needs a transport versus just getting one from the hospital to jump in and ride to the hospital."

Solomon said that the city should "talk to all the groups," referring to the surrounding areas - Blaine County, Rocky Boy's Indian Reservation, Fort Belknap Indian Reservation - when it comes to providing the money needed to launch the new and improved emergency medical transport system. Those areas all benefit at times from Havre's ambulance service.

Hedges said the fire department never turns down a ride to anyone. But even when people outside of Havre have insurance, he said, it's common for the city to lose money on the transports. And sometimes the transport can be a total loss. If someone from, say Blaine County, is transported from Northern Montana Hospital to Benefis and they have no insurance, the ride is a total loss to Havre taxpayers.

"Right now, the only solution I can think of is we need paramedics. But I don't have a $200,000 training budget," Hedges said.