Because Hawai'i is a small market, state law requires major medical facilities and services to obtain certificates of need to protect existing care. The concern is that competition could weaken providers of essential healthcare services and possibly leave Hawai'i without the services altogether if they are unable to remain in business.

HAA is the only company holding a certificate of need for aeromedical services, and there were no challenges to the company's position until the crash on Maui on March 8. HAA has been providing fixed-wing aeromedical services for 27 years, carrying more than 37,500 patients during that time.

NOT LUCRATIVE WORK

Lucas-Legg said that even as the sole provider, HAA has broken even or made a slim profit in only two or three of the last 10 years, in part due to insufficient health insurance reimbursements. She said the company averages 200 flights a month.

"Having more than one company would make everyone fail," she said.

The only other business in recent years to win state approval as an air ambulance provider was Mercy Air, which received a certificate of need in 1993 for helicopter service because the Maui-based program did not attempt to compete head-to-head with HAA, said healthcare consultant William Bryant, who helped Mercy with its certificate of need application.

But Mercy quit in 1997 because of low volume and higher costs associated with helicopter operations, said Bryant, who works for Sierra Health Group in Dallas. He said he doubts much has changed to make it more feasible for additional air ambulance companies.

"The medical community wants an air ambulance there when they want one in short order, but they may not fully understand the facts of what is sustainable," he said.

AirMed Hawaii's local representative, Sandy Apter, said "There's room for two companies, especially with the increase in patients every year ... You don't need a rocket scientist to tell you that."

Arguing against the emergency applications is state Rep. Joshua Green, D-6th (N. Kona, Keauhou, Kailua), who said they are premature and should be denied. Green is an emergency-room physician at the Pahala and Kohala hospitals on the Big Island and vice chairman of the House Committee on Health.

NEED DISPUTED

In a letter Sunday to SHPDA administrator David Sakamoto, Green said SHPDA rules require that in order for emergency applications to be considered, there must be a substantial injury to public health or a "clear and present danger of such injury."

With the Coast Guard and HAA providing some level of service, that has not occurred, Green said.

"No doubt, HAA's temporary grounding of its planes is worrisome and unfortunate. However, now is not the time to panic or overreact," he said in his letter.

Dr. Linda Rosen, acting chief of the DOH's Emergency Medical Services Branch, has said the situation has not caused any "negative" patient outcomes.

Green told The Advertiser yesterday that he is uncomfortable with the sudden interest by companies wanting to provide air ambulance services, and said the applications should be closely scrutinized.

"If there is this massive problem, then why weren't there five or eight applications before this? It makes me nervous to see people swoop in that way," he said.

Green said he works at the state's two most remote hospitals, and "I haven't felt that my patients were taking too long to get transferred. ... I'm quite confident in the ability of Hawaii Air Ambulance to get my patients to safety. They've done it before."

He said the state should welcome regular certificate-of-need applications from potential providers, and that health leaders should hold discussions several times a year to assess the adequacy of aeromedical services.

None of the companies applying for an emergency certificate of need has said whether it would file for a regular certificate of need.

Reach Christie Wilson at cwilson@honoluluadvertiser.com.