Mark Huber is an aviation industry veteran who has worked in the flight training, aircraft sales, aircraft component, and airport development businesses. He has flight time in more than 50 different and diverse aircraft, including helicopters, aerobatic aircraft, vintage warbirds, jet fighters, business jets and turboprops, and transport-category aircraft. He has jumped out of several of these—on purpose—with a parachute. His defense and aviation journalism has been published in a variety of national and international periodicals.

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Mark Huber

Kenny Morrow needs to hire 35 more pilots. The market is slim pickings and Morrow is happy that his company’s need is not greater. The COO&nbsp;of Metro Aviation oversees pilots and mechanics supporting 160 helicopter air ambulances—around 85 percent of them light twins—that primarily fly for hospital programs nationwide. Metro’s fleet flies roughly 130 missions per day, and Covid has definitely accelerated that pace.&nbsp;
Over the last two years, helicopter air ambulances have flown into the eye of the great pandemic burnout, a microcosm of an overtaxed healthcare system that seems at times held together with little more than paper clips and duct tape. The increased flight volume is being driven by what Morrow calls health care “Tetris,” a reference to the computer puzzle game. Covid has created stresses and shortages in the healthcare system as a whole and more patients need to be moved&nbsp;between facilities to get appropriate care due to capacity and medical personnel shortages. While many of these transports are far from exigent, ground ambulances alone can’t handle the load.
“They call it bed management. They play this giant game of Tetris trying to fit people in where they belong with the right healthcare providers,” Morrow said. “The ground [ambulance] providers have been struggling to keep up with the demand and that has pushed a lot of these transports to the air side.” The trend means healthcare facilities must meticulously justify each air transport and document that no other patient conveyance is available.&nbsp;
Covid has also complicated air ambulance scheduling and outfitting, Morrow said. While a program used to be able to turn around a helicopter in 30 minutes, due to Covid disinfection protocols, that time has grown to two hours or more. And when it does pick up a patient, the demand for onboard oxygen is much higher when transporting a breathing-compromised Covid patient. He added, “The treatment that they’re [flight nurses, paramedics, and doctors] providing to patients while in transport consumes a lot more oxygen supply than what we have been accustomed to and now we have to carry additional oxygen tanks. Things like that just change the landscape.”
But the biggest change has been among Metro’s pilots and mechanics, who, along with an outfitted helicopter, are typically provided as part of the company’s contract with each medical program it serves. The current competitive employment environment means that Metro has had to pay these team members signing and retention bonuses, improve base wages, substantially increase overtime incentives, and offer a more liberal vacation/personal days off policy, Morrow said. And sometimes that isn’t even enough to combat occupational burnout. Metro was offering time and half overtime pay and bumped that to double time starting this year for pilots who cover open shifts to which they were not originally assigned. It has also liberalized its work-from-home policy—when possible—and now allows employees to use days off as they are accrued, as opposed to requiring them to bank them for use in the next calendar year.&nbsp;
The pandemic has shifted how employees view work-life balance not just for Metro, but for the rest of the U.S., Morrow believes. “It’s not about the money anymore, it’s quality of life. There’s a shift. People want to spend more time with their families. And it’s not just pilots, but people in general.”
<h2>Workforce Issues</h2>
Cameron Curtis, CEO of the Association of Air Medical Services (AAMS), the air ambulance transport lobby, agrees. She said AAMS is developing tools and programs to address air ambulance personnel issues in the pandemic era. “We're going to focus on workforce issues and how we can support our members,” she said. This includes formation of a “workforce issues council.”&nbsp;
“People are burned out, everyone in health care is just exhausted,” she said. “What you are seeing in the greater healthcare industry is happening everywhere. There’s more wage competition and offers of more benefits, more time off, that sort of thing.” In addition to education and patient outcome programs, Curtis said AAMS is focusing on the “Taking Care of Our Own” program through the Medevac Foundation to address air ambulance crew needs exacerbated by the stress of the pandemic. “The program is focused on working with frontline first responders with regard to substance abuse, suicide prevention, and mental health and wellness.” Curtis added that these crews have endured conditions “that are unimaginable to many of us who haven’t [been there]. Everyone is just stressed out and needs a break. We’re working to create solutions and resources that not only support our members but everyone from the bottom up.”&nbsp;
Against this backdrop, AAMS members, particularly community-based programs—as opposed to hospital-based programs-- are struggling with the interim final rules created by administrating agencies related to the federal “No Surprises” medical billing act, which took effect earlier this year. While AAMS and its members support that legislation, they are at odds with its implementation. At issue are the rules governing the independent dispute resolution (IDR) process to settle billing and compensation differences between insurers and medical providers. AAMS claims they are skewed in favor of health insurers, allowing them to underpay all health care providers including the air ambulance sector.&nbsp;&nbsp;
AAMS has sued in federal court on behalf of its members, claiming that the implementation governing the IDR process is unfair. Chris Eastlee, AAMS v-p of public affairs, claims at least one large health insurer, bolstered by the rules related to the No Surprises act, is no longer entering into in-network agreements with air ambulance companies. This has potential long-term negative consequences for broad swaths of the air ambulance business and imposes arbitrary rules that do not consider “the quality of the medical care or capabilities of the crew.”&nbsp;
AAMS is not alone in its opposition to the rules, Eastlee said, noting that they are also opposed by the American Medical Association and a variety of group medical practices. But for AAMS the implementation rules “and the effect [they] may have on the sustainability of emergency medical transport” looms large, he said.&nbsp;
For now, at least, Eastlee said the economic state of the industry remains robust, albeit under increasing cost and staffing pressures. “I would say that the overall health of the industry is still very, very strong," he said. "While the pandemic has caused issues with both the supply chain and staffing, we've never seen a greater need for emergency medical transport.”&nbsp; 
<figure style="margin:0;">
<div style="margin-bottom:5px;"><img alt="Metro Aviation Airbus H160 aeromedical cabin" data-entity-type="file" data-entity-uuid="366d627c-80e1-44c5-9e82-6326ee76f267" src="/sites/default/files/h160-metro-aviation_air-medical-cabin-at-heliexpo2019_0.jpg" width="2000" height="1000" loading="lazy"></div>
<figcaption style="font-size:1.5rem;line-height:1.2;font-style:italic;">Metro Aviation’s Airbus H160 aeromedical cabin, on display at Heli-Expo 2019.</figcaption>
</figure>

<h2>Lower-cost Options</h2>
But cost pressures continue to lurk in the background. Metro’s Morrow points to the success of its EC145e program as an example. Metro has negotiated for the delivery of 37 of these lower-priced Airbus Helicopters light twins in recent years, and the program has been a hit with both customers of its own programs and competitors it supplies that are looking for a cost-effective solution for an IFR-capable twin with the ability to transport outsized equipment such as patient isolettes, carry extra medical crew, and fly longer missions.&nbsp;&nbsp;
He also said the company is in discussions with customers over the implementation of drones as a further cost-cutting measure. Metro&nbsp;is studying the use of drones in-house as a means of cutting its helicopter parts inventory costs. Each Metro base stocks roughly $200,000 worth of parts, he said. By using drones to ferry parts between proximate bases on an as-needed basis, Metro can potentially cut those inventory costs substantially. “We could cut the amount of inventory that we have to keep on hand probably in half, which is huge. We’re talking real money.” Unmanned and drone delivery aircraft are “obviously the way of the future and there is going to be demand, but there is a lot of work that has to be done airspace- and certification-wise,” Morrow said.&nbsp;
Metro is also experimenting with the use of weather cameras as a way to minimize canceled flights due to off-site weather reporting.&nbsp;
Blade Air Mobility CEO Rob Wiesenthal already sees both current helicopter and future unmanned medical transport as an expanding profit center for his company, which recently acquired Trinity Air, a firm that specializes in arranging human organ and medical supply transport, adding it to its own growing MediMobility organ transport business.&nbsp;While Blade is best-known as a per-seat helicopter booking platform, organ transport at the end of 2021 accounted for more than 25 percent of its total revenues. “There’s a lot of growth opportunity there,” Weisenthal said, adding that Blade can cut the cost of organ transport by up to 75 percent flying organs in helicopters&nbsp;and eventually other VTOL aircraft, compared to the current patchwork of a combination of ground ambulances and fixed-wing aircraft for the missions.&nbsp;“It lowers the costs for hospitals and patients,” he said.&nbsp;
Sikorsky’s&nbsp;Igor Cherepinsky, director of innovations, sees a role for its Matrix autonomous flight technology in future air medical applications, and this can be scaled to aircraft as small as eVTOLs and “even smaller” aircraft. “You can scale the Matrix architecture for the use case," he said.

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