Illustration: Rebecca Zisser/Axios

Air ambulances have become a lucrative business over the last few decades, at patients' expense, fueled by private equity and aided by the industry's relationships with providers, John Hopkins' Marty Makary writes in a new book out today.

Why it matters: The rise of the air ambulance industry has resulted in massive surprise medical bills and a spike in unnecessary use.

  • Congress has included air ambulances in its effort to crack down on surprise medical bills, and the industry is fighting to avoid this regulation.

Background: Air ambulances used to be owned and operated by hospitals, which sometimes took financial losses on their helicopter programs.

  • But that changed when investors saw a profit opportunity and began buying the ambulance services from hospitals. They then billed patients directly for rides.

By the numbers: Between 2007 and 2016, the average price charged by one air ambulance company for a transport rose from $13,000 to $50,000.

  • With this kind of money on the table, the number of air ambulance companies rose by 1,000% between the 1980s and 2017.

People in rural areas are hit the hardest. While some of these transports are necessary and life-saving, many others could be avoided, Makary writes.

  • Of the more than half a million ambulance flights a year, 80% aren't emergencies, but rather more like routine transfers.
  • To grow their business, companies began paying paramedics, nurses and doctors to become advisers with "informal agreements" to promote the company to emergency personnel and other providers.

The other side: Air ambulances say that they have to charge higher rates to commercially insured patients to make up for lower government rates.

The bottom line: "The air ambulance industry has become big business in America," Makary writes.

Go deeper: Air ambulances are expensive and most likely out of network

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