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Is medevac worth NIS 4 a month to you?
By Dan Even and Ronny Linder-Ganz

Helicopter evacuation of civilian casualties may have a bright new future, thanks to a drive by the Health Ministry to regulate a private-sector parallel to emergency service provided by the army.

At present, if you fall down a crevasse while trekking in the desert, or, say, drive into a tree that crosses your path, you might be whisked off to hospital by Air Force helicopter. But in certain areas of northern Israel, you might be chauffeured to the emergency room on a chopper operated by Lahak Aviation, the only company that provides medical air evacuation service.
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The snag is that it does so largely on a volunteer basis, which it may not be able to do for much longer.

Lahak has to work for free in many cases because certain insurance companies and kupot holim healthcare funds) have refused to cover civilian casualty evacuation. Therefore, Lahak has its difficulties, which places the future of civilian evacuation in peril. Hence the Health Ministry drive to build a framework.

"To date, 70% to 80% of the insurance companies do pay for casualty evacuation," says Mehanem Levy, managing partner at Lahak. "There are three insurance companies with which we haven't yet reached arrangements. Altogether, the insurance companies owe us NIS 2 million."

The trouble is that Lahak's situation vis-a-vis the kupot holim is much worse. "They owe us NIS 4 million, and argue that the service isn't included in the health basket [of subsidized services]," says Levy.

The upshot is that Lahak has to confine its services to northern Israel, and only certain areas of northern Israel at that. It evacuates 10 to 15 people by helicopter each month. Lahak bills the insurance companies around NIS 30,000 for each evacuation, which doesn't necessarily mean that its invoices are honored: at present Lahak often has to cover the costs itself, and finds its own survival in peril.

The company's survival is therefore a month-to-month effort, Levy says. The company owners, three American Jews who came on board a year ago and "suddenly found themselves alone," provide most of the money. But how long can that go on? "Just this month they injected $120,000, but they can't inject any more. I don't believe we'll survive beyond 2009 without immediate intervention by the Health Ministry," he says.

And indeed, the Health Ministry is stepping up to bat with the formation of a committee to make recommendations on helicopter medical evacuation to certain hospitals in Israel by private companies.

The committee is headed by Dr. Ari Shamiss, Director of the General Hospital at Sheba Medical Center, Tel Hashomer. The civilian emergency medevac services are to operate in parallel with those provided by the Israel Air Force.

Dr. Eran Tal-Or, trauma coordinator at the trauma center in Haifa's Rambam Medical Center, which fields emergency cases in northern Israel, recently described the importance of helicopter evacuation to the Knesset Economics Committee. "A 20-year-old woman injured in a car accident at Tsemah reached the hospital in less than an hour," he told them. "Inside an hour and a half [from the time of the crash], she was in surgery, having the hemorrhage in her brain drained."

The woman survived thanks to the rapid helicopter evacuation, Tal-Or emphasized to the parliamentarians. "You can't give up on such service. It saves lives."

Sources at the kupot holim and at some of the insurance companies, however, argue that certain evacuations are carried out more for economic reasons than medical ones. At another deliberation by the Knesset Economics Committee, in November, Shmuel Malkis, head of the Economic Department at the Israel Insurance Association, argued that it's in Lahak's interest to scramble as many helicopters as possible.

"We think their motive isn't always medical," he charged.

Lahak rejects the allegations. "At Rambam they checked our evacuations, with hindsight, and found that the proportion of evacuations that hadn't been necessary ran at 15% to 20%, which is a pretty good rate considering the error level of 40% around the world," counters Levy. "If we had two centers, one in the north and one in the south, operating 24 hours a day, the cost would be NIS 17 million a year. And it would mean fewer fatalities from road accidents."

The Health Ministry is well aware of the importance of air evacuation. Its chiefs have every intention of saving and even even expanding it.

The committee headed by Shamiss concurs with Lahak: Israel needs two medevac dispatch centers, one be in the south, in the middle of the Arava, and one in the north, in the Golan Heights or Upper Galilee.

The goal would be to get the critically ill or injured, whether as a result of accident, terror attack or stroke, for example, to designated hospitals within an hour.

The designated hospitals would be able to provide extreme emergency treatment, for head injuries, burns or severed limbs, among other types of trauma.

In cases of stroke, the committee recommends that the helicopters evacuate the victims to hospitals that can administer tissue plasminogen activator (tPA), a drug that can save their lives. TPA dissolves the blood clots that cause most ischemic strokes, if administered quickly.

Presently most medical evacuations are done by ambulance, which can take a long time. In some cases - and not only those involving strokes - the delay in receiving treatment is fatal.

Money is the main obstacle to the Health Ministry's quest to create a medical air evacuation service, and for weeks its officials have been searching for sources.

Last week ministry deputy director-general Boaz Lev met with the heads of the country's four kopot holim at his office. He suggested the HMOs transfer a fixed sum each month to the ministry to finance air evacuation. The kupot holim chiefs firmly rejected the suggestion. They suggested that the Health Ministry finance evacuation itself, as needed, rather than charging fixed amounts. Quite the impasse.

Shamiss' committee suggests increasing that civilian medevac air evacuation be financed by increasing mandatory car insurance by four shekels a year. In a sense, the NIS 4 would buy coverage for helicopter evacuation in case of accident. The ministry is thinking that one over.

In any case, the Health Ministry would probably have to hold a tender process before choosing a service provider. The ministry estimates that the cost of each helicopter evacuation by a company chosen by tender would run between NIS 39,600 to NIS 87,900 - rather more than the figures provided by Lahak.

The committee even reached the conclusion that helicopter medevac is actually worthwhile, from the taxpayer's perspective, to finance air evacuation. It concluded that in terms of QUALY - an insurance term that actually means Quality-Adjusted Life Year - the cost of evacuation is NIS 4,006, which can be considered a phenomenal cost-benefit ratio.

"The ministry has adopted the recommendations of the air evacuation committee, which was appointed by the director-general, and intends to execute them," the Health Ministry commented. "The ministry is now considering the choice of service provider, and will accordingly decide whether to publish a tender. The Health Ministry is looking at various options for financing the service, including through revision of the drugs and technologies basket, direct financing through a designated budget, or raising mandatory car insurance rates."
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