Good morning! I’m Molly Castle Work, a KFF Health News correspondent based in Los Angeles. Before reporting this story, I didn’t know anything about the air-ambulance industry. Now, I’m telling all my friends about it. Send tips to mollyw@kff.org. Not a subscriber? Sign up here.
ER doctors say federal law plays part in insurance denials for air-ambulance rides
Emergency room doctors say insurers are increasingly declining to cover costly air-ambulance rides for critically ill patients, claiming they aren’t medically necessary. And the National Association of EMS Physicians says the No Surprises Act, enacted in 2022, is partly to blame.
The law protects patients from many out-of-network medical bills by requiring insurers and providers to haggle over fair payment. But insurers can sidestep the law if they determine care is “not medically necessary” — and insurers themselves get to decide what that means.
In the fall of 2022, Sara England of Salinas, Calif., learned about this firsthand when ER doctors at a hospital in her town had her 3-month-old, Amari, transferred by air to the University of California at San Francisco Medical Center for what turned out to be an RSV infection. Her insurer, Cigna, determined the baby’s plane ride wasn’t necessary because his medical records didn’t show a ground ambulance would “impede timely and appropriate medical care.”
(Ground ambulances are exempt from the No Surprises Act.)
England is on the hook for the full cost of the air-ambulance ride: more than $97,000. “I thought there must have been a mistake,” England said. “There’s no way we can pay this. Is this a real thing?”
Cigna spokesperson Justine Sessions called the bill “egregious” and said, “We are working diligently to try to resolve this for the family.”
The emergency physician association said it frequently encounters denials like England’s. The group wrote to Health and Human Services Secretary Xavier Becerra, acting labor secretary Julie Su and Treasury Secretary Janet L. Yellen in February urging the federal government to require insurers to presume medical necessity for air-ambulance use, subject to retrospective review.
“Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan,” read the letter from José Cabañas, the group’s president. The Association of Critical Care Transport has made a similar request.
HHS spokesperson Sara Lonardo said the agency is committed to strengthening protections in the No Surprises Act.
Insurers point the finger at air-ambulance providers. Robert Traynham, a spokesperson for industry group AHIP, said providers often don’t submit medical records, impeding a full evaluation. He said AHIP also suspects that air-ambulance companies sometimes favor more distant hospitals that contract with them over closer facilities.
The air-ambulance industry — much of it controlled by private equity firms — is known for fast-growing prices, limited in-network contracting and surprise out-of-network bills averaging nearly $20,000. And the Centers for Medicare and Medicaid Services data shows that when insurers and providers go head-to-head in No Surprises arbitration, 8 in 10 cases are settled in the provider’s favor, incentivizing them to raise prices higher.
Lack of medical necessity is cited in the bulk of air-ambulance claims denials, said Loren Adler, who studies the industry for the Brookings Institution.
More than a year later, England is still fighting her bill. “I don't know what else to do other than to be a squeaky wheel and make as much noise about it as possible, because it's not right,” she said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling and journalism.
In the courts
Supreme Court skeptical of efforts to restrict access to abortion pill
The Supreme Court on Tuesday seemed unlikely to limit access to a key medication that is used in more than 60 percent of abortions in the United States, The Post’s Ann E. Marimow and Caroline Kitchener report.
During nearly two hours of oral argument yesterday, a majority of justices from across the ideological spectrum expressed skepticism that the antiabortion doctors challenging the government’s relaxation of mifepristone restrictions have sufficient legal grounds to bring the case.
Notably, several justices seemed interested in a narrow ruling that wouldn’t address the regulatory or safety concerns raised in the suit but would uphold the current regulations that have made it easier for patients to access mifepristone, including allowing it to be sent through the mail.
One red flag for abortion rights advocates: Conservative Justices Samuel A. Alito Jr. and Clarence Thomas repeatedly invoked the Comstock Act during the proceedings, pressing lawyers about whether the 1873 law banning the mailing of “obscene” materials should apply to abortion drugs today, our colleague Dan Diamond reports.
- On our radar: Some experts and Biden administration officials fear that Alito and Thomas might draft a separate opinion arguing that the long-dormant law remains viable, providing legal coverage to a future administration that seeks to invoke it.
The bigger picture: The case has emerged as the next front in the battle over how and whether Americans can terminate their pregnancies, with implications for abortion access even in states where the procedure is legal. The pharmaceutical industry has also warned that a ruling in favor of the plaintiffs could disrupt the nation’s drug-approval process and stymie private investment in research.
A decision is expected in June or early July.
Marjorie Dannenfelser, president of Susan B. Anthony Pro-Life America:
Today I was proud to stand with women harmed by abortion drugs courageously sharing their stories, and with the doctors caring for them, in contrast to the abortion industry that leaves women to suffer alone. They all know the true cost of the FDA’s recklessness first-hand.… pic.twitter.com/LWSa65jGaY
— Marjorie Dannenfelser (@marjoriesba) March 26, 2024
Rep. Barbara Lee (D-Calif.), co-chair of the House Pro-Choice Caucus:
Today, #SCOTUS is hearing a case that threatens to turn the clock back on access to safe abortion care.
— Rep. Barbara Lee (@RepBarbaraLee) March 26, 2024
We cannot afford to go back. That’s why I’m leading @ProChoiceCaucus in urging the justices to protect access to safe, effective medication abortion. https://t.co/m5ria37QWu
Want to dive deeper into the case? Check out some of The Post’s other coverage:
Reproductive Wars
Ala. Democrat who ran on abortion rights, IVF wins special election
Democrat Marilyn Lands won a decisive victory in an Alabama state House race yesterday – the first electoral showdown between a Democrat and a Republican in Alabama since the state’s Supreme Court ruled that frozen embryos are people, Colby Itkowitz reports for The Washington Post. Lands ran heavily on abortion rights and in vitro fertilization while her opponent, Republican Teddy Powell, shied away from the issues. Nationally, Democrats are using the race as a test case for their 2024 messaging on reproductive rights.
Agency alert
Pentagon's reproductive health travel policy used sparingly
A Pentagon policy offering reimbursements for service members forced to travel out-of-state to access reproductive health care was used 12 times from June to December of last year, deputy press secretary Sabrina Singh told reporters yesterday.
Over the seven-month period, the Pentagon spent roughly $40,000 to cover expenses such as transportation, lodging and meals. None of the funds went toward medical procedures. Singh said the agency hasn’t kept tabs on the specifics of the health care sought by service members or their dependents due to medical privacy concerns.
Flashback: Sen. Tommy Tuberville (R-Ala.) drew bipartisan criticism last year for single-handedly stalling hundreds of military promotions in an unsuccessful bid to pressure the Pentagon into rescinding its travel policy. Tuberville ended the nearly 10-month standoff in December.
State scan
AstraZeneca challenges Arkansas law expanding federal drug discounts
Drugmaker AstraZeneca sued to block an Arkansas law that aims to expand a federal drug-discount program to include for-profit pharmacy chains like CVS and Walgreens, Mike Scarcella reports for Reuters.
The lawsuit claims state-imposed price caps on patented goods are prohibited under federal law and that the mandated discounts violate the constitutional prohibition against government “takings” of private property. Arkansas said it will challenge the lawsuit.
Meanwhile, in Colorado …
Pharmaceutical giant Amgen has filed a lawsuit seeking to block an upcoming vote by the state’s newly established Prescription Drug Affordability Review Board.
Key context: The board is set to soon recommend an “upper payment limit” for Enbrel, Amgen’s blockbuster treatment for autoimmune conditions, which carries a list price of $1,850 per week.
In its lawsuit, Amgen argued the panel’s actions are unconstitutional because they flout federal law, violate due process and seek to regulate business outside of Colorado.
In other health news
- The American Civil Liberties Union and others sued Ohio yesterday, asking the courts to halt the implementation of a state law next month that would restrict access to gender-affirming care for young people.
- Federal regulators approved Merck’s drug to treat pulmonary arterial hypertension, a rare and potentially fatal cardiovascular disorder. The injectable therapy will be sold under the brand name Winrevair.
- Medicare beneficiaries will see lower coinsurance rates for 41 Part B drugs from April through June of this year due to an Inflation Reduction Act policy that requires pharmaceutical companies to pay rebates if they hike prices faster than inflation, according to HHS.
