NTSB Ties Helicopter Payments To Safety

The National Transportation Safety Board adopted a broad set of safety recommendations Tuesday covering medical helicopters, expanding beyond equipment and technology matters to address the business models of the $2.5 billion industry.

The board also recommended extending federal oversight to government helicopter operations such as that of the Maryland State Police.

The most sweeping change was a proposal that Medicare, the nation's largest insurer, pay only for flights conducted by medical helicopter programs that abide by safety and performance standards that the Medicare program would develop.

The NTSB has no regulatory authority, but it can make safety recommendations to other agencies to remedy problems it uncovers during accident investigations. Most of the proposals adopted Tuesday were directed to the Federal Aviation Administration and the Centers for Medicare and Medicaid Services.

Private, for-profit companies dominate the medical helicopter industry, with about 830 medical helicopters vying for patients, a recent investigation by The Washington Post found. The number of aircraft has doubled every decade since 1980, leaving some firms with fleets as large as that of US Airways. But unlike commercial airlines, medical helicopters can fly without safety features such as terrain warning systems or flight data recorders.

The recommendations come after the industry's deadliest year, with 23 crew members and five patients killed in seven accidents in 2008.

The NTSB noted that hundreds of thousands of patients have been safely transported by helicopter and that there has not been a fatal crash this year. However, board staff members also noted that there have been cyclical spikes and that the so-far accident-free year might be due to the "significantly increased attention" focused on the industry.

The recommendations include requiring terrain warning systems, flight data recorders, night vision systems, use of autopilot to help single pilots and enhanced pilot training, as well as establishing national guidelines for when to transport a patient by helicopter and annual data collection of flight hours and trips to improve analysis of safety records.

Dawn Mancuso, executive director of the Association of Air Medical Services, a trade group, said some companies have adopted some of the equipment called for and that "none of what we heard asked for here would be viewed in a wholly negative way by our members who are committed to safety." Tying Medicare payments to a safety review "was surprising to us, but it is an innovative approach" that "will keep the discussions lively."

In 2002, Medicare boosted reimbursements for medical helicopter transports, fueling growth and saturating some regions with bases.

Medicare pays ground ambulances depending on the sophistication of the care they provide. Medical helicopters all are treated the same. The NTSB recommended that the Medicare program evaluate paying more for more advanced programs.

Board member Robert L. Sumwalt recommended tying Medicare payments to safety audits, saying the board had "an opportunity to really make a difference" and use money as an incentive to hasten improvements.

"We agree with evaluating air ambulance transportation standards and look forward to reviewing the NTSB's recommendations," said CMS spokesman Peter Ashkenaz.

NTSB Board Chairman Deborah A.P. Hersman said the board is "frustrated with the delays in FAA rulemaking." Three of four improvements for medical helicopters that NTSB suggested in 2006 to the FAA have yet to be required, she said.

The FAA announced this spring that rules requiring terrain warning systems could be in place by 2011. Spokesman Les Dorr said Tuesday that the agency has relied on voluntary guidelines as "the quickest way to get safety improvements into the cockpit."