Concern has been raised over mismanagement of air ambulance services to fly seriously ill patients overseas for medical treatment.
Auditor General Alastair Swarbrick warns that patient care could be jeopardised and the Cayman Islands government potentially exposed to lawsuits if the existing system continues.
The most serious concerns focus chiefly on the use of an “air ambulance broker” – identified by the auditor in a press briefing as Executive Air – which, according to the report, has no direct contract with government health insurance company CINICO, no relevant trade and business licence and no permit to operate as a “ground handler” at the airport.
The firm is used in many cases to liaise with air ambulance companies – the businesses which actually provide the pilots and the planes – to arrange flights. They also provide ground handling services, for a $900 fee, to the air ambulances while they are at Owen Roberts International Airport in Grand Cayman.
In a special public interest report filed with the Legislative Assembly this week, Mr. Swarbrick warned the absence of a contract laying out the broker’s obligations and responsibilities created significant risks about oversight of the quality and value for money of the services provided. These included:
Lack of transparency on fees;
Uncertainty on how air ambulances are selected and if value for money is achieved;
Uncertainty over whether medical professionals are consulted in that selection process;
Uncertainty over the services provided;
Potential exposure to lawsuits if the relevant liability insurance is not carried.
He concludes: “The operations relating to the provision, costs and oversight of the air ambulance services have not been managed effectively, resulting in uncertain value for money for services solicited through the air ambulance broker.
“Furthermore, we believe that the practice of utilising the services of a non-contracted air ambulance broker, if continued, represents an unmanaged risk to the government in the event of a catastrophic incident because of a lack of prudent management of public resources.”
If, for example, a patient were injured or died in the care of the broker, the absence of a contract, permit or licence, could be a factor in a lawsuit against government. Similar concerns could be raised if an air ambulance recruited by the broker did not have the appropriate medical staff or equipment.
Lonny Tibbetts, CEO of CINICO, had not responded to requests for comment as of press time Thursday.
CINICO, which is ultimately responsible for the provision, cost and oversight of air ambulance services, paid out slightly more than $800,000 for 71 emergency evacuations in the financial year ending July 2012, the auditor’s report states.
The procedure for flying patients overseas is a complex multistep process. The chief medical officer must authorise every transfer.
The Health Services Authority is responsible for passing on the paperwork and medical notes to one of two private companies – referred to in the report as a “third party administrator” and the “air ambulance broker”.
Those firms, which are not directly named in the report, then recruit from a network of air ambulance companies, largely based in the US, and arrange the transfer.
The auditor flags several other areas of concern, including the lack of clear documented operating procedures on the part of the Health Services Authority, lack of a complete tendering process from CINICO in the recruitment of the third party administrator and allegations of political interference in the process of licensing firms that operate at the airport. And he questions whether ground handling services are even necessary for air ambulance carriers, which are permitted to self handle.
The report also highlights issues with the Cayman Islands Airports Authority’s role in the process. The absence of a valid, relevant trade and business licence or a permit to operate as a ground handler at the airport is flagged as the main concern.
The auditor suggests efforts to introduce a proper system of licensing for companies operating at the airport, including the air ambulance broker, were hindered by the intervention of former Premier McKeeva Bush.
The report warns: “The air ambulance broker does not hold a permit or licence issued by the CIAA to operate as a ground handler or otherwise at the airport …
“We found evidence that the former Premier McKeeva Bush had informed the board of CIAA to restrict ground handling licenses to only three companies. There was no rationale or reason provided. The former managing director informed us that he had recommended the licensing of all companies operating at the airport, but was precluded from doing so by the direction of the former premier.”
Minutes from board meetings of the Cayman Islands Airports Authority board and a statement from chairman Richard Arch, obtained by the Compass, indicate that the three firms sanctioned by the Premier were Air Agencies, Cayman Airways and Island Air. None of those three firms is the air ambulance broker, identified as a Grand Cayman firm called Executive Air.
However the minutes, from 2010 and 2011, suggest that at that time only Island Air, which handles small private air craft, actually had a valid licence.
The issue of licensing ground handling firms that operate at the airport came up several times through 2010 and 2011 and a draft policy was drawn up but no concrete action appears to have been taken.
Kerith McCoy, acting CEO of the Cayman Islands Airports Authority, said yesterday that the authority would implement any new policy directives following the appointment of a new board of directors.
Asked if he was concerned about the potential legal implications of a patient being hurt at the airport in the care of an unlicensed broker, operating without a permit, he said: “The CIAA has established assurances, which protects our liability risks in all such instances.”
The auditor’s report also highlights issues with the Health Service’s Authority’s role in the process.
He writes: “We expected to find current and clear procedures for how the referral’s office of the authority initiates the process of air ambulance procurement. What we found was a collection of undated procedures that are not consistently followed.”
In some cases, the auditor said, family members were dealing directly with the air ambulance broker, potentially without the knowledge of the authority.
Lizzette Yearwood, CEO of the Health Services Authority, did not answer direct questions on the report posed by the Compass this week.
She said: “The HSA’s referrals office offers a service to both public and private insurance companies to facilitate patient referrals to other providers and institutions where the necessary services are available.”