Healthcare has spent the last decade trying to make care more digital, more predictive, and more coordinated. Yet one of the most consequential parts of the patient journey is still deeply physical: moving a patient from one place to another.
In a recent Strategy of Health podcast episode, I spoke with Ken Van Cara, Chief Executive Officer of Alacura Medical Transportation Management, and Steven J. Fox, Alacura's Chief Growth Officer, about a part of healthcare that most leaders know exists but few have had to analyze closely.
It sounds simple until you look at the actual workflow. A patient is in one facility and needs care somewhere else. A hospital needs to free a bed, access a specialty service, or move a patient to the right site of care. The health plan may not be in the decision loop. The transporter may be the party with the clearest operational visibility. The patient and family are often in one of the most stressful moments of their lives. That is where the transport decision becomes more than a ride.
The visible decision is whether a patient needs to move. The hidden decision is how that patient should move. That distinction drives the entire episode. A patient may need a helicopter, a fixed-wing aircraft, a critical care ground unit, advanced life support, basic life support, or something less intensive. The correct answer depends on acuity, distance, weather, traffic, time sensitivity, receiving facility capability, network status, and benefit design.
Van Cara framed the issue around a basic healthcare truth: "Better care is less expensive than bad care." That line matters because it moves the conversation away from a narrow cost-containment frame. The objective is not to deny transport. The objective is to match the transport to the clinical need. The system has to ask, "What does the patient need? And then let's match that patient need with the transport." That is the piece that has often been missing.
Fox described medical transportation from the payer side as an "unseen liability." Even after years in network strategy, claims, provider contracting, and growth leadership, he said he did not fully appreciate how unmanaged this category was until he spent time inside the transport benefit itself. "Really the last place in healthcare it feels like where it just hasn't been managed," Fox said.
That is a striking statement because healthcare is already filled with management infrastructure. Pharmacy has PBMs. Radiology and oncology have benefit management. Specialty drugs have prior authorization, network design, and utilization review. But transportation, especially high-acuity medical transportation, has historically sat between departments.
The clearest failure is the disconnect between acuity and transport mode.
In the conversation, Van Cara described the common scenario: hospitals need to move patients for many legitimate reasons. Some patients need emergency transport. Some need planned transport. Some need discharge support. Some need specialized care that is not available at the sending facility. The issue is not that these patients move. The issue is that the transport mode can become disconnected from the patient's actual time sensitivity or clinical condition.
"Lots of people get flown on a rotor," Van Cara said, "and it's because it's convenient and not necessarily because it's related to the time sensitivity or the acuity of their need."
For the patient, the wrong transport can be frightening, confusing, or embarrassing. I shared in the episode a real example from neurology: a patient brought to an outpatient facility by critical care transport, with a full stretcher and an entire team, despite not needing that level of support. That is not just waste. It is a human experience that tells us the system is not matching the service to the person. For the hospital, transport is often about throughput. A patient needs to move, a bed needs to open, and the care team needs the process to work quickly. For the plan, the claim may arrive later as a high-dollar event that was never clinically or operationally visible at the point of decision. For the healthcare system overall, the result is a category that is expensive, opaque, and emotionally charged.
The financial numbers are significant. Public research supports the concern that air ambulance charges have grown rapidly. Brookings researchers noted that GAO reported Air Methods increased its average price charged per transport from $13,000 in 2007 to $49,800 in 2016 (Brookings). Brookings has also reported that air ambulance carriers owned by private equity or publicly traded parent organizations generated higher allowed amounts and larger potential surprise bills than other carrier types (Brookings).
One of the most important clarifications from the Alacura team came after the formal recording. Van Cara emphasized that this topic cannot be presented as only a financial story. Fox further made this point well when discussing the kinds of cases Alacura is trying to help manage.
"We know this for every patient that has to go by these forms of transport, these are some of the worst days of their life," he said.
A medical transport is not a commodity transaction. It usually happens during uncertainty, fear, deterioration, trauma, discharge complexity, or family stress. A good process reduces that burden. A bad process adds to it. Transportation is also one of the clearest social drivers of access. The American Hospital Association has cited the estimate that 3.6 million people in the United States do not obtain medical care each year because of transportation issues (AHA).
Because of this, when a physician calls Alacura, it does not go to a generic queue. Fox emphasized that "there is a live clinical person." He described a physician- and nurse-led conversation supported by staff with emergency medicine, critical care, ICU, flight nursing, and transport backgrounds. Van Cara explained why that matters for hospital clinicians: "They're talking to someone that speaks their clinical language on the other end of the phone."
That is a much different model than asking a hospital team to make a rushed transport decision with limited visibility into benefits, network status, weather, traffic, receiving beds, and available transport assets. This is not about interfering with life-or-limb emergency response but rather bringing clinical and logistical oversight to the large category of non-scene and interfacility transports where a fast expert review can improve the decision.
From a payer perspective, the challenge is visibility. Fox described the problem like an iceberg: many plans do not believe they have a transportation problem because they cannot see the full shape of the category. Claims may be difficult to identify. Transport modes may be fragmented. Vendors may differ across geographies. Air, ground, rotor, fixed-wing, basic life support, advanced life support, specialty care transport, and critical care transport can all sit in different operational lanes.
The payer opportunity is to ask a different set of questions:
This is the difference between seeing medical transportation as a claims line and seeing it as a managed benefit.
The No Surprises Act was a major patient protection. CMS explains that, as of January 1, 2022, consumers gained protections for emergency care, certain out-of-network care at in-network facilities, and air ambulance services from out-of-network providers (CMS). CMS also notes a key limitation: ground ambulance services generally are not covered by the No Surprises Act's billing protections unless state law applies (CMS Medical Bill Rights).
For patients, the air ambulance protections matter. Before the law, a patient could be transported by an out-of-network air ambulance and receive a balance bill they had no practical ability to avoid.
For plans, however, the dispute did not disappear. CMS describes federal Independent Dispute Resolution as the process used after open negotiation fails between out-of-network providers, facilities, air ambulance providers, and plans or issuers (CMS IDR Reports).
CRS reported that IDR entities closed more than 1.37 million disputes in 2024, including 41,338 out-of-network air ambulance disputes. CRS also reported that air ambulance providers prevailed in 85% of such disputes in 2023 and 87% in 2024. In 2024, Global Medical Response, Air Methods, and Apollo MedFlight initiated 65% to 72% of all out-of-network air ambulance disputes in each quarter, according to CRS's analysis of federal data (CRS).
Said more practically: if a plan cannot defend the clinical story, it may not be ready for the financial fight.
Plans should segment transport claims by mode, urgency, network status, geography, provider, and clinical context. They should separate true scene-based emergency response from interfacility transfers. They should understand whether the same transport providers are driving utilization, out-of-network exposure, and IDR volume.
Health systems should examine the workflow before the transport is ordered. Who chooses the mode? Is there a clinical transport review? Does the ordering clinician know the downstream patient and payer implications? How often is the fastest available option assumed to be the safest option?
Alacura's model is built around answering those questions and taking medical transport from an "unseen liability" to a "strategic lever" through safe outcomes, satisfaction, compliance, savings, and reporting (Alacura Health Plans).
Actionable steps include:
Medical transportation is one of healthcare's last unmanaged benefits because it has been treated as something adjacent to care. It is not adjacent. It is part of the care journey. It determines whether a patient reaches the right facility. It affects emergency department throughput. It influences patient safety, family stress, claims exposure, network strategy, and regulatory disputes.
"We have a system where we don't have aligned incentives."
That is what makes this topic so important. When incentives are misaligned, healthcare leaders have two options. They can keep treating the category as an occasional high-cost surprise, or they can build the management infrastructure the category has always needed. The future of healthcare strategy will not be defined only by better digital front doors, better algorithms, or better payment models. It will also be defined by whether the industry can manage the physical movement of patients with the same rigor it applies to other benefits.
That is why medical transportation is healthcare's next frontier.
And why it will not stay unmanaged for long.
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