New operations need to make careful diagnosis

October 2009

MEDEVAC IAC examines Middle East potential

Medical repatriation is a big global market but many air charter brokers struggle to do large volumes of business with the major charter providers of services. There are many reasons why it is a difficult market for brokers, but some providers would welcome more broker business. Charter Broker examines what brokers need to take on board to gain and expand a market share.

Air charter brokers battling to combat lower passenger charter demand during the global economic downturn could be forgiven for casting envious glances at rivals with steady referrals for government contracts or the relatively recession-proof air ambulance and medevac sector.

But brokers new to the medical charter sector tempted to build business with aircraft providers face a steep learning curve. They need to familiarise themselves with the risk inherent in a difficult specialised discipline. This discipline involves knowing how to relay patient needs to the aircraft provider. And, in a sector where operators of air ambulances are geared to liaise directly with patients and doctors, the broker has to establish a clear, dependable and sensitive referral and remuneration system. It is also vital to know the aircraft, equipment and depth of expertise of provider to whom business might be referred. Air ambulance and medical repatriation is big business. Many companies, including AirMed, FAI, EAA and CEGA, will consider ad hoc ambulance charter but they have regular contracts and busy schedules to service.

Checklists need to be carried out before medical operations

Brokers needing an air ambulance flight for a client in the Middle East or North Africa will doubtless have a long list of charter companies, many of which advertise air ambulance capabilities. They will also have heard horror stories, or even experienced difficulties, where medical flights have gone wrong across a region where the development of regulation is in its infancy and there are many aircraft operators trying to turn a profit by entering this highly specialised field.

Brokers experienced in air ambulance will know that it is important for the broker to have either a medical report or a contact number for the treating medical doctor. Without this a medevac operator cannot determine the best solution for the patient – or even if they are stable enough to fly.

It is important not to simply quote prices without fully considering the medical condition of the patient. Operators that give a professional service based on factual information are adding value to the service that can be provided by the broker and this can be used by brokers to increase their potential profit margin.

Trust is a very important factor in the process but due diligence is the key to successfully commissioning an air ambulance operator.

As a broker you can find yourself with heavy lawsuits if anything goes wrong.

Medical flights are not just another passenger or cargo move, they involve sick and dying people and are always associated with highly emotional family members who are rightfully unforgiving if anything happens to their loved one.

The downturn in vip jet charters has lead to many operators advertising air ambulance flights. But medical evacuation is a specialised field that cannot just be thrown together by passenger operators simply as a way to get aircraft flying. Such thinking could result in deaths and serious legal accountability for operators and brokers that don't do their homework.

Key points need to be addressed when considering the commissioning of an air ambulance operator. If any of the following points are not addressed adequately, a broker would be well advised not to risk the company's reputation, the responsible broker's career and, most importantly, the life of a person relying on the broker to provide a professional service through a competent operator.

The broker needs to establish whether the company:

1. is a full-time air ambulance/medical company, or simply a charter or logistics company advertising medical flights as an add-on to generally non-medical operations;

2. holds appropriate medical licences and medical indemnity insurance while maintaining current written clinical practice protocols and procedures; 3. utilises dedicated and flight specialist medical teams and equipment, or relies on hiring any doctor and nurse with a bag of non-aviation medical equipment and an oxygen cylinder;

4. uses medical staff specialised in aviation medicine, as the titles doctor, nurse or paramedic do not automatically equate to a clinical level acceptable in air ambulance operations;

5. employs staff with the commensurate years of flight experience in a location where standards are assured and medical staff must be qualified for the field;

6. is equipped to provide a rapid response to bespoke needs as opposed to a muddled reality of the flight being conducted one or two days later and involving re-positioning, finding a medical team and a struggle with air clearances and the securing of ground ambulances;

7. offers a true ‘bed-to-bed’ service as opposed to requiring the broker to get the patient to the airport;

8. will allow the broker to verify qualifications, insurances, experience and actual medical capabilities of the people they contract for the client.

Brokers aiming to specialise in medical transfers also need to investigate insurance because unwelcome lawsuits must be guarded against, especially where litigious jurisdictions such as the United States are concerned. Strong finances enabling pre-payment or an account arrangement are a prerequisite.

However, while recognising that medevac business in markets such as Europe and the United States might be low in percentage terms, brokers do feel that their expertise in medical repatriation and air ambulance could win them business in the Middle East and Asia.

Hugh Courtenay (cover photo), ceo of International Air Charter (IAC), who recently reviewed the company's Dubai-based business, says the company is exploring the possibility of an operation focused on medevac in conjunction with a quality Swiss operation. "The discussions have been taking place for some weeks now. International Air Charter tends to be asked to help out on the occasions when providers or clients need to source aircraft in difficult areas or situations. It is also a big company with the resources and expertise. The demand in the Middle East is obviously for repatriation or specialist treatment in hospitals in Europe and the US and we will be taking a business view on that as a result of our talks. While the potential in Europe is limited the business opportunities might be greater in countries such as Saudi Arabia, Qatar, Kuwait and the Yemen."

Rupert Dent, ceo of the Oxford, UK-based AirMed, says: "I think there is definitely a role for brokers but they have to know what they are doing and be prepared to deal with the problems that arise."

Dent says that it makes sense for brokers setting up a medevac service to conduct a thorough feasibility study, perhaps starting with ascertaining which operators are on the books of insurance companies. "The insurance companies will have done their due diligence on operators that they use regularly for those who have taken policies guarding against accidents or ill health abroad and specifying repatriation by air ambulance. The broker could make contact with these and then build up a knowledge of those operators and their capabilities, establish due process and put acceptable and practical financial arrangements in place for their remuneration in the event of referrals."

Dent points out that brokers will probably have to take calls from distressed relatives of emergency patients who are not insured and who may not be in a position to make an immediate down-payment.

"Additionally, medical malpractice insurance is a must to cover any liabilities as those organising the repatriation can be held responsible for the level of resource and care employed," he warns.

Aircraft must be entirely fit for the mission. Brokers will need to know what equipment is available and whether it can be matched to the requirements of the emergency. Dent points out: "Charter passengers might agree to an aircraft that cannot make a flight in one hop. But it is no good commissioning an aircraft that needs several stop-overs to get medevac patients to the required destination."

Brokers who do due diligence will find that their business arrangements gravitate towards operators for whom air ambulance is a core business. Dent says: "In this sector experience counts for a great deal. Companies that have operated in the sector for a number of years can anticipate and pre-empt problems. They have properly trained staff to call on, can provide the right equipment for the task, and will be able to undertake the commission in a fast responsible manner. Firms that dip in and out of the medevac sector according to how much their aircraft are being utilised for vip charter obviously do not have the same continuity or advantages. From a practical point of view the occasional operators might only be able to make a delayed response to an emergency because they might have to set up ad hoc arrangements."

Clients will always require a fast response. They might be receiving expensive local hospital care, and wish to get to their home jurisdiction where treatment is either free or much cheaper. Or the emergency might be such that fast repatriation will save a life or limit the risk of long-term health problems.

Dent points out that air ambulance is "very much a 24-7 business and brokers need to be staffed to cope." He says: "If I had to summarise the role that a broker might target it would be to emulate the way that responsive insurance companies operate for their policy holders. The broker would need to find the best service provider, ensure that the client's medical needs are met in the air and on the ground, make the required financial arrange-ments and coordinate both with the air ambulance operator and the relatives. It is a demanding role that also requires the ability to empathise with people who may be in a very traumatic situation. However, once the broker acquires the knowledge and expertise, the medevac sector can be rewarding in both the vocational and remuneration senses." Brokers will find there are exceptions to the general guideline only to use the services and aircraft of operators for whom medevac service is a core operation. Twinjet Aircraft has a Luton, UK-based ACJ that is regularly used by heads of state and overseas royal families. The aircraft can be fitted with a special medical stretcher. Commercial director Stephen Wells says: "It is probably the only one in the world on this size of vip jet and this has its attractions for broker and operator referrals for certain situations. The ACJ is an aircraft with a 10-hour plus range with medevac potential, offering a stretcher, two beds and 24 lie flat seats. That said, we do not claim to offer a full air ambulance service and brokers would need to take this into account when assessing patient needs complementary to the charter of such a unique aircraft."

Patrick Schomaker, director sales and marketing, has some general advice for brokers dealing with providers in general and European Air Ambulance (EAA) in particular. "It might sound obvious but, when requesting a quotation for air ambulance repatriation, the broker should provide as much information as possible. The more information we get the more accurately we can calculate the quotation and the less chance there is for a later change in the price or planning.

"If available it is also important to provide the requested time for the mission, thus the provider can already roughly plan the availability of the fleet. On a general basis EAA always tries to find the right balance between the most adequate repatriation and cheapest solution for the patient, taking into account all the requests submitted beforehand and the fleet of aircraft available."

EAA coordinates the deployment of a fleet that includes five Learjet 35As and a King Air 200. It says it usually answers quotation requests within 30 minutes but more complicated cases can take up to one hour.

Providers will not guarantee aircraft availability without firm flight confirmation. Schomaker warns: "If some other client confirms another mission first, the availability might change and the mission might have to be performed at a later time than the one originally requested. With the confirmation order the broker/client also accepts the general terms and conditions of the air ambulance operator."

Clients or brokers unknown to the air ambulance provider usually have to pay up front. "The broker should be able to make payment at any time and not be dependent on a bank's opening time," Schomaker says.

Brokers, therefore, need a major credit card with a high limit – an air ambulance flight from Far East Asia to Europe can cost over €100,000. Some brokers prefer to pay with an invoice after the mission and organise a general agreement with the air ambulance provider which might involve a bank guarantee.

Providers tend to insist on pre-payment because, once the mission is confirmed, the operator blocks and prepares the aircraft and activates the crew to meet the agreed schedule, prepares the flight plan and starts medically assessing the patient.

Schomaker points out: "The preparation also includes the bed-to-bed transfer with an adequate ground ambulance on both sides if requested. For EAA the activation time for a mission can be as short as two hours, depending on the destination. A complete and up-to-date medical report on the patient is of utmost importance.

"During the mission EAA provides regular updates so the broker can follow the development and keep clients informed at all times about the patient's condition and location."

EAA provides a full medical record shortly after the flight. "This will detail any changes in the patient's condition during transport and any treatment the flight physician performed," Schomaker adds.

Volker Lemke, FAI rent-a-jet's director sales and marketing, points out that brokers usually ask several ambulance operators for quotations, put their mark-up on the most competitive price, and deal directly with the client on the financial side. "The medical repatriation market is driven by the three main factors – quality, price and reliability – and remains pretty complex on the operational side," Lemke says.

This complexity does limit brokers to a small percentage of the business conducted. Out of more than 600 missions last year the company booked in some 83% from medical assistance companies. This insurance driven business was complemented by 9% sourced from government and 3.6% from private sources. Hospitals provided 0.6% and a membership programme 1.2%. This left a broker contribution of around 2.6%.

FAI receives around 10,000 requests for air ambulance flights, flying around 600 missions per year and producing more than 6,000 hours of flight time resulted in a probably top five position for FAI in the worldwide air ambulance market.

Lemke says: "There are some brokers in the field specialising in air ambulance flights, particularly in Italy, Turkey and Israel, but there are complexities. From an operator perspective our hands-on centralised and integrated management allows us to take into account all the operational, aviation, medical and financial considerations at once, and to provide the clients with adapted solutions suited to their individual needs. Quality and reliability are prerequisites but, equally, there is the price consideration which drives the market from the client's standpoint.

"Being a charter broker it is impossible to provide the same combination of service and assets as a major provider. Therefore only a small group of potential customers, usually private clients who do not know the air ambulance market in detail and need advice, tend to involve a broker."

Lemke adds: "We systematically highlight the fact that we are an independent owner and operator, and that we can therefore vouch for the quality of our aircraft and that of the related aviation and operation services, and that we are directly answerable for those. This allows us to get the client's input on their views as to what developments or improvements we ought to strive to achieve."

Brokers, as intermediaries, he says, have to work hard to compete on the price available for direct bookings. Lemke says: "All major clients for the air ambulance market, such as travel insurance or medical assistance companies, know who they need to talk to get the service they need. They know the way they want it organised, even to the extent of catering to very complex medical cases in very difficult areas in the world, and they do not want to pay any extra fees to intermediaries."

Charter brokers, he predicts, will find it difficult to expand their share of the market. "Brokers do manage mostly private clients and in those cases the operator usually gets in touch with the end customer to secure a safe and smooth air transfer of the patient paying, typically, a commission to the broker."

FAI recently expanded its Learjet fleet to 11 which includes a long range version of the Learjet 55, which is equipped with an additional 1,000 lb fuel tank and is a dedicated air ambulance. It reorganised after acquiring a majority stake in Swiss Challenger operator Nomad Aviation and is also building a new 2,500 m2 hangar combined with 1,000 m2 additional office space at Nuernberg airport.

Chairman Siegfried Axtmann says: "FAI has bundled most of its activities in high-end executive charter aircraft and aircraft management within its new Swiss subsidiary while FAI Germany will focus on air ambulance and NGO contract services."

FAI says it has invested more than €5m in the new hangar project at Nuernberg with ground-breaking scheduled for September this year. It will be able to accommodate aircraft up to the BBJ. FAI recently became a member of the Marfin Investment Group (MIG), one of Greece's largest buy-in firms, which is taking over Greece's national carrier Olympic Airlines.

Mark Ponsford, gm aviation of the UK Bournemouth-based operator Cega Air Ambulance, also points out that, in the majority of cases, the air ambulance operator will liaise directly with the client and/or patient rather than through a broker.

"This is because the majority of patients requiring repatriation, whether overseas on holiday or for business, will have some form of travel insurance in place," he says. "In such cases it is the patient's insurer, or more especially the medical assistance company acting on their behalf, that will have the relationship with the air ambulance company. They fulfill the role of broker, as it is their responsibility to find the most cost-effective solution."

Ponsford says: "There are, however, some scenarios where a charter broker might play a part. Firstly, there will inevitably be clients who, for whatever reason, cannot fall back on travel insurance, either because the circumstances of their injury or sickness is in breach of the policy terms and conditions, or because they have not taken out insurance. In the case of the former, if an assistance company is already involved, they will offer their services on a private basis and would probably still source the air ambulance provider. In the case of the latter, the patient would have to source his own provider. It might be easier and to his advantage to contact a broker, rather than ring round the suppliers directly."

Secondly, Ponsford points out, a specialist broker can be useful when dealing with countries such as the United States where there are many different providers to choose from. "Thirdly, there are brokers working for medical teams from the UK National Health Service (NHS) or private hospitals. In most cases their contact with the air ambulance company will be restricted to sourcing an appropriate aircraft at the best price – a straightforward process."

However, there will be occasions where the relationship is a more complex one. An example, Ponsford says, is when the broker is looking to outsource the whole job to include the medical team. "In such circumstances, the provider must be allowed the freedom to liaise directly with the treating hospital and the relatives, as it needs first hand information on the patient's condition, especially just before the aircraft departs from its base."

Ponsford reiterates the need for prompt payment arrangements. "When it comes to accepting payment from brokers, it depends whether we have worked with them before and if they have an account with us. If not, it is 'money up-front, please'. This can cause a problem if the job is urgent, but credit card payments can be made within minutes."

A broker can range from regular charter brokers through to private road ambulance companies. "Excluding specialist medical assistance companies, the number of jobs Cega Air Ambulance does for brokers is less than 1%. We would welcome an increase in this number. Cega is just as happy to receive a job through a broker as it is to receive a commission direct from a private individual."

Synergy Aviation Limited, based at London Fairoaks, has been involved with medical air ambulance flights since 2004. At the start of 2009, it launched its dedicated air ambulance, a King Air 200 equipped with two Lifeport stretchers and additional seating for up to four escorts.

"The B200 is the ideal air ambulance for European operations," says director Paddy Magan. "Our two stretcher configuration offers flexibility and significant cost savings to repatriation companies, hospitals, brokers and agents. Compared to many air ambulances the larger cabin of the King Air provides a more comfortable and smoother ride. It is important to add that, when there is a medical emergency, the time from the initial request to the aircraft actually getting airborne usually needs to be very short. Synergy Aviation operates 24 hours with crews on standby 24 hours a day."

Magan points out: "There are a great many dynamics involved in medical flights and a wide range of skills are needed from medical teams, doctors, technicians and pilots. The key is safety and speed, often there is a degree of urgency to medical flights. Over the years Synergy has mastered the art of dispatching aircraft within 45 minutes of confirmation. Our pilots are accustomed to medical flights and aware of the range of scenarios associated with this type of flying".

He says Synergy's London Fairoaks base is on London's doorstep and less than five minutes drive to the M25 motorway. "This means that transport times from the airport to a London hospital are usually less than 30 minutes."

Royal Jet, which sponsored a healthcare expansion congress in Abu Dhabi in May, has a medical evacuation and repatriation services division, Royal Med. The company, chaired by HE Sheikh Hamdan bin Mubarak Al Nahyan, says medical evacuation flights months ago passed the 1,000 mark.

"Demand for this service is forecast to rise, even though there continues to be huge investment in healthcare infrastructure and services across the Arab world," John Morgan, vp commercial, predicts. "Royal Jet continues to invest in staff and equipment so as to better serve every patient's need."

The company's team includes 15 paramedics and intensive care nurses, as well as 10 doctors and consultants who specialise in neonatal, paediatric and adult clinical disciplines. All the aircraft used for medevac can be equipped with intensive care facilities for a range of specialised needs ranging from ventilators and electrocardiograms to neonatal transport incubators.

Morgan says: "Royal Med's expertise extends across neonatal, paediatric and adult clinical disciplines and the company already serves destinations as far afield as Europe, Asia, the Indian subcontinent, the US and other destinations within the Middle East."

Wayne Fuller, operations manager of the UK's Zephyr Aviation Ltd, says that, while cost is an important benchmark, the "added value" which air ambulance operators must deliver is 100% reliability and maximum time savings. He adds: "It's not simply medical repatriation. We're frequently involved in life-saving transplant operations where, literally, minutes mean lives potentially saved. For example, last week we received a no-notice call at 01:17 to take a heart transplant team to the island of Jersey from London Stansted. We were cockpit ready at our base at 02:50, awaiting the call from the coordinator via the broker and Zephyr operations to launch. The aircraft was airborne at 03:28 and on the ground at Stansted and ready to launch at 03:50. The team had requested a 04:15 departure from Stansted.

"On arrival at Jersey, the team was immediately transported to the hospital. The aircraft waited ready to launch as once the heart is removed, it is time critical to get it to the aircraft and onto the next hospital. We were advised by the team as they were leaving the hospital of their transit time to the aircraft. With the captain already onboard, the team was flown to Biggin Hill in 45 minutes, where an ambulance was already coordinated and standing by to take them on to the hospital to perform the transplant operation on the patient receiving the heart. That sort of service requires immediate contact and impeccable coordination, not with patients but with the broker, the medical teams involved, the ground ambulance operators and sometimes hospital management.

"We maintain a 24 hour flight watch service for these flights and are in regular communication with the broker, aircraft crew, handling agents, air traffic agencies and the road ambulance/transport to ensure all parties know what is happening at any time during the journey, the broker being a key player in this team. In the highly specialised field of transplants, it's fair to say that without fast, flexible air ambulances, many of these life-saving operations just couldn't take place."

Countries in Europe and North America tend to have more long-established air ambulance operators than states in Africa, the Middle East and parts of Asia. Operating companies, as well as brokers such as ACS, have seen the potential in offering a medevac service that is local to the clients.

RMSI has established its global headquarters and main air ambulance hub in Dubai and boasts a bespoke service to brokers. Paul Hoatson, operations coordinator, says: "We have large supporting on-the-ground contingents in the UAE, Afghanistan, Iraq and Sudan. From its presence in the UAE, RMSI medevac services focus on rapid regional response not just in conflict areas, but also on fulfilling local market requests through various brokers. In alliance with Empire Aviation, RMSI offers jet air ambulances capable of being airborne within two to three hours from activation."

Hoatson says RMSI offers access to full-time in-house doctors on 24-7 standby. "From the moment the broker makes an enquiry, RMSI can set up a conference call between the broker's customer and RMSI ops coordinator and flight doctor. At all times the initiating broker is present and remains the primary contact to the customer."

A UAE broker who used the service after receiving an urgent medevac request from an established client, Hoatson adds, benefited from just such a conference call between all parties. "The team approach adopted by the broker and RMSI was effective, the client confirmed the flight 30 minutes later and an RMSI air ambulance was airborne shortly after."

But Hoatson points out that arranging the flight was a just part of a complex operation involving a military hospital, a civilian domestic airport in Afghanistan, multiple air space clearances in civilian and military sectors, ground ambulances at both ends and the ability to find a neurosurgeon and organise admission to a UAE hospital at short notice.

RMSI says it appreciates the needs of brokers and that business relationships have to be built on trust. "RMSI's interest is in keeping brokers' direct relationships with private clients and companies strong," he adds.

Brokers who are able to handle medevac emergencies for their clients can expect such successes to build loyalty that may feed through to private charter commissions. But the logical first step to building a successful air ambulance arm is a feasibility study which might begin by establishing which operators the insurance companies trust. The hard work of due diligence and building contacts, systems and procedures then logically follows. For brokers, medevac should be a long-term commitment, not a casual add-on to oper-ations in times of reduced business.