1.) The hospital pays the operator for services supplied. 2.) Industry Has Expanded and Safety Concerns Have Grown in Recent Years

		Available Data Suggest Industry Growth and Increased Competition

According to industry experts and observers, the air ambulance industry  has grown, but data limitations make it difficult to determine by how  much. 3). According to the  officials we interviewed and others who have studied the industry, the  increase in the stand-alone provider business model is linked to the  development, mandated in 1997, of a Medicare fee schedule for ambulance  transports, which has increased the potential for profit making. Industry Experienced Highest Number of Fatal Accidents in 2008, but Data Limitations Preclude Complete Understanding of Safety Record

From 1998 through 2008, the air ambulance industry averaged 13 accidents  per year, according to NTSB data. Since 2003, the  number of accidents has slightly declined, fluctuating between 11 and 15  accidents per year. 4). Industry and FAA Have Acted to Address Air Ambulance Accident Trends and Causes

		Increase in Number of Accidents Has Led to Greater Industry Focus on Safety

In 2007, we reported that the air ambulance industry’s response to the  higher number of accidents has taken a variety of forms, including  research into accident causes and training. FAA has changed its oversight to reflect the varying sizes of  operators. Provided technical resources. Launched accident mitigation program. Revised minimum standards for weather and safe cruise altitudes:  To enhance safety, FAA revised its minimal requirements for weather and  safe cruise altitudes for helicopter air ambulances in November 2008. Potential Strategies for Improving Air Ambulance Safety

Despite the actions taken by the industry and the federal government, 2008  was the deadliest year on record for the air ambulance industry. As a  board member noted at the recent NTSB hearing on air ambulance safety,  the recent accident record of the industry is unacceptable. Based on our  body of work on aviation safety, including air ambulance safety; a review  of the published literature; and interviews with government and industry  officials, we have identified several potential strategies for improving air  ambulance safety. Obtain complete and accurate data on air ambulance operations: As  we reported in 2007, FAA lacks basic industry information, such as the  number of flights and flight hours. Increase use of safety technologies: We have previously reported that  using appropriate technology and infrastructure can help improve aviation  safety. Sustain recent efforts to improve air ambulance safety: Our past  aviation safety work and anecdotal information on air ambulance accident  trends suggest that the industry and federal government must sustain  recent efforts to improve air ambulance safety. The study contained 19 safety  recommendations to FAA and others. Fully Address NTSB recommendations: In 2006, NTSB published a  special report focusing on the air ambulance industry, which included four  recommendations to FAA to improve air ambulance safety. Clarify the role of states in overseeing air ambulance services: Air  ambulance industry stakeholders disagree on the role that states should  play in overseeing broader aspects of air medical operations. Agency Comments

We provided a draft copy of this testimony to FAA for review and  comment. FAA provided technical clarifications, which we incorporated  as appropriate.
Why GAO Did This Study

Air ambulance transport is widely regarded as improving the chances of survival for trauma victims and other critical patients. However, recent increases in the number of air ambulance accidents have led to greater industry scrutiny by government agencies, the public, the media, and the industry itself. The National Transportation Safety Board (NTSB) and others have called on the Federal Aviation Administration (FAA), which provides safety oversight, to issue more stringent safety requirements for the industry. This testimony discusses (1) recent trends in the air ambulance industry with regard to its size, composition, and safety record; (2) recent industry and government efforts to improve air ambulance safety; and (3) potential strategies for improving air ambulance safety. This testimony is based primarily on GAO's February 2007 study on air ambulance safety (GAO-07-353). To update and supplement this 2007 report, GAO analyzed the latest safety information from NTSB and FAA, reviewed published literature on the state of the air ambulance industry, and interviewed FAA officials and industry representatives. GAO provided a copy of the draft testimony statement to FAA. FAA provided technical comments, which GAO incorporated as appropriate.

What GAO Found

The air ambulance industry has increased in size, and concerns about its safety have grown in recent years. Available data suggest that the industry grew, most notably in the number of stand alone (independent or community-based) as opposed to hospital-based operators, and competition increased among operators, from 2003 through 2008. During this period, the number of air ambulance accidents remained at historical levels, fluctuating between 11 and 15 accidents per year, and in 2008, the number of fatal accidents peaked at 9. This accident record is cause for concern. However, a lack of reliable data on flight hours precludes calculation of the industry accident rate--a critical piece of information in determining whether the increased number of accidents reflects industry growth or a declining safety record. The air ambulance industry and FAA have acted to address accident trends and causes. For example, FAA enhanced its oversight to reflect the varying sizes of operators, provided technical resources to the industry, launched an accident mitigation program, and revised the minimum standards for weather and safe cruising altitudes that apply to air ambulance operations. Despite the actions to improve air ambulance safety, 2008 was the deadliest year on record for the industry. Through its work on aviation safety, including air ambulance safety; review of the published literature; and interviews with government and industry officials, GAO has identified several potential strategies for improving air ambulance safety, including the following: (1) Obtain complete and accurate data on air ambulance operations. (2) Increase the use of safety technologies. (3) Sustain recent efforts to improve air ambulance safety. (4) Fully address NTSB's recommendations. (5) Adopt safety management systems within the air ambulance industry. (6) Clarify the role of states in overseeing air medical services. (7) Determine the appropriate use of air ambulance services.