The following is a Joint Statement by the Ministry of Health (MoH), the Health Services Authority (HSA) and the Cayman Islands National Insurance Company (CINICO) in response to the Auditor General’s Public Interest Report on the Provision of Air Ambulance Services:

For the reassurance of those individuals who have utilized air ambulance services in the past, or who may do so in the present, the Ministry of Health, CINICO and the HSA would like to share with the public their joint response to the recent report by the Office of the Auditor General (OAG) on this subject.

The OAG questioned the management of operations relating to the provision, costs and oversight of air ambulance services, and raised the potential of uncertain value-for-money services solicited through the air ambulance broker. It argued that this also resulted in an unmanaged risk for Government.

The Ministry, HSA and CINICO would like to stress that their chief concern is the well-being of any persons who may require an emergency air evacuation (EAE). It has been our experience that depending on a patient’s unique needs, the most cost-effective solution is not always what is required in each case.

Yet we strive whole heartedly to ensure that the EAE process is managed efficiently from start to finish, and to secure the best possible outcomes for each patient. While our system is not without flaws, which we are determined to address, its effectiveness has also been repeatedly proven.

As the Auditor General noted, EAEs involve functions that fall within the remit of the HSA, CINICO, as well as the Cayman Islands Airports Authority (CIAA). In some cases there may also be involvement by private insurers.

Background

At the HSA the process begins with a written request on a referral form by the patient’s attending physician. This request indicates: the urgency of the transfer, type of care, the type of institution, the medical specialty or specialist services required, whether or not the transfer needs to be made by an air ambulance or other means, and the type of air ambulance crew required.

As soon as the HSA Referrals Office receives this form, the assigned coordinator begins the process of the air ambulance transfer. They do this by contacting the patient’s insurance company, or the third party administrator (TPA); these entities are responsible for the actual procurement of air ambulance services.

Where CINICO is the insurance provider, in the case of civil servants, indigents and seamen, the contract for referrals to the United States, and some to Jamaica, has been awarded to Canadian Medical Network (CMN).  A local broker handles referrals to Jamaica, and some to the United States.

The insurance company or the TPA then begins the process of identifying which air ambulance company will be used for the transfer.

The next step involves probably the most critical decision made by the insurance company or TPA, and that is to determine what overseas facilities/physicians are capable of meeting the patient’s needs and are willing to receive them.

This phase requires multiple steps, including, but not limited to, enquiries of acceptance along with emailed or faxed communications of the appropriate medical records, to multiple hospitals. It may extend to individual physicians or specialist teams of physicians, and, in some cases, over different countries at the same time.

Simultaneously, the financial capacity of the patient is also ascertained. This is guaranteed by either the individual (and/or their family), or the insurance company and sometimes the CI Government.  Once these steps are completed, then the process of procuring an air ambulance by the insurance company or TPA for the purpose of transferring a patient to an overseas facility for additional healthcare begins.

Throughout this process the HSA referral coordinators have no referring responsibility to any broker of air ambulance services. The coordinator is kept informed by the insurance company or the TPA about the various steps in the process: the institution chosen, the receiving doctor, the air ambulance company, the crew and the expected time of arrival. In turn the coordinator informs the attending doctors and family members.

The HSA coordinator also creates a ‘run sheet’ at the beginning of each air ambulance transfer, to document each step in the process for each patient being transferred for quality assurance purposes.

There are occasional variations in procurement practices. As an example there are instances where air ambulance transfers may start before the attending doctor submits the written referral to the Referrals Office, or before a patient reaches the HSA, as in the case of cruise ship passengers or persons with private insurance.

In such situations the arrangements for an air ambulance transfer may be initiated by the doctor on board the ship, or a family member; however the referrals coordinator would take no action without the written approval of the insurance company or the third party administrator. Once approval is received, the Referrals Coordinator proceeds following the steps outlined above.

Procurement

In the case of CINICO, both CMN and the broker that CINICO utilizes as mentioned in the report, have been instructed to utilize only the services of CIAA licensed and authorized providers. The terms of the contract require CMN to present the request to three or more providers, subject to the peculiar needs of the case, and then assess the respondents’ quotes based on three criteria:

1. Ability to meet the peculiar needs of a case,

2. Travel times: to and from the Cayman Islands and

3. Price

The services of the local broker are utilized, provided that the prudent medical care analysis along with the selection of, and acceptance by, the facility/physician described above, has been accomplished by the referring physician or the HSA, rather than the company in question.

As such, when this broker solicits an air ambulance, they are not required to confirm a facility or physician, but must administer the same three protocols as CMN, i.e. needs peculiarity, travel times and pricing. To date they perform such services with no direct fee to CINICO.

It is acknowledged however, that as no contract exists between CINICO and the broker, the requirement for evidence & results of the bidding process is not mandatory. At the same time it must be noted that the majority of EAE’s produced by the broker have yielded similar value to those procured by CMN.

Neither the broker nor CMN actually transports, handles or provides any physical care for the patient being transported.

Instead, the true exposures exist with the service providers: HSA (medical triage, stabilization etc. and transport to the air ambulance) then the air ambulance provider (maintenance of medical stabilization and any care administered during the transportation to the overseas receiving facility).

As such, the local broker’s exposure to risk—and through them any risk that might accrue to the Government– would essentially exist with the solicitation of an unlicensed provider. At this point we would like to emphasise that the local broker has held an exemplary record of service for well over 20 years.

The remainder of this statement will directly address specific concerns raised by the Auditor General.

Tendering process for TPA contract for air ambulance procurement

Under CINICO’s previous overseas services structure, CMN provided three services to CINICO: medical care utilization & coordination, air ambulance coordination, and network access & repricing. Following changes to this structure, CINICO contracted (MMSI) as its new medical care utilization and coordination provider and retained CMN as our network access & repricing provider.

CINICO evaluated the remaining service of air ambulance coordination based on a number of factors, including but not limited to, the bidder’s capacity to;

1.     Obtain priority access to a hospital bed in a trauma services facility,

2.     Demonstrate a history of provision of such services,

3.     Provide both the service on a 24 hours and 365 days per year basis,

4.     Provide such services cost effectively and in compliance with the protocols required.

On examination of all the variables for the provision of these services, it found that CMN was best suited and retained their services on a fixed fee basis.

Documentation of air ambulance procedures

The first part of this statement outlines the procedures in place at the HSA and at CINICO. The HSA has had standardized procedures in place for a number of years, which are presently being updated again. It acknowledges that the relevant documents were not in its organisational template for policies and procedures and promises that this will remedied shortly.

Contract with the air ambulance broker

There are a number of reasons why there is presently no contract in place with the air ambulance broker.

1.     There is only one licensed air ambulance broker in the Cayman Islands.

2.     The broker currently charges no direct fees to CINICO for the limited services they provide.

3.     To facilitate a contract with any broker could possibly expose CINICO to even greater risk in a situation whereby,

a.     it is limited to the use of that particular broker,

b.     it is limited to that particular brokers’ air ambulance provider(s),

c.      the limited choice may fail to meet the needs of a peculiar case,

d.     the limited choice exposes CINICO to price gouging and no real value.

The fees earned by the broker are not directly paid by CINICO, but through a commission from the individual air ambulance companies, and the prices of EAE services show no material variance to those procured by either CMN or the broker.

License or authorization for ground handling services—

The broker in question possesses a Trade and Business License (TBL) for an Air Ambulance Broker. We are unaware of any other category of TBL required to provide such services.

The “ground handler” license is a requirement of the CIAA for the provision of services related to the handling of commercial aircraft.

Billing for ground handling

Under the terms of their contract, CMN may not accept any broker fees for their solicitation of air ambulance services. They are paid directly by CINICO on a per use basis.

While air ambulance fees invoices received by CINICO do not identify or separate any broker fees paid, CINICO will be pleased to investigate any evidence of the $900 fee for ground handling alleged by the Office of the Auditor General, such as copies of invoices that the OAG, or other persons, may provide.

The Ministry of Health, HSA and CINICO are committed to continuously improving our treatment and care of patients and we work tirelessly on their behalf. We have been aware of many of the issues mentioned by the OAG for some time and it is our belief upcoming changes to the structure of the EAE will help to mitigate most if not all of these concerns. It is our hope that by outlining these procedures we have helped to minimize any anxiety that any users of the air ambulance may have felt following the report.