In a novel experiment, the Pentagon is going to pay civilian ambulances for lifesaving blood

• The Pentagon will reimburse civilian ambulances for blood before patients reach a hospital.
• Military trauma surgeons say earlier blood transfusions save lives but remain rare in civilian EMS.
• Experts hope the pilot persuades Medicare and private insurers to adopt similar payment models.

American ambulances arrive at car crashes and shootings carrying oxygen, medications, defibrillators, and other tools to open an airway or relieve pressure around a collapsed lung. But the vast majority lack one of the most precious resources for a hemorrhaging trauma patient — blood.

In an unusual experiment born from the lessons of two decades of war in the Middle East, the Pentagon's health insurance program will test whether paying ambulance providers separately for blood transfusions can help change that.

The Defense Health Agency's five-year TRICARE demonstration project, which is scheduled to begin in January, will reimburse authorized ground and air ambulance providers that administer "medically necessary" whole blood or blood components, such as red blood cells or plasma, to military personnel, family members, and retirees, according to a recent government posting.

If the experiment proves effective, it could help address a major barrier to carrying blood on ambulances, potentially convincing insurers to adopt new payment models that reduce the cost burdens for providers for life-saving interventions.

Right now, the national trauma system is not getting blood to many patients when they need it, said Donald Jenkins, a professor of surgery at UT Health San Antonio and chair of the Southwest Texas Regional Advisory Council's Regional Whole Blood Committee, which has overseen an expansion of whole blood across the state's trauma system. The problem is particularly acute for patients in rural areas who may be farther from hospitals that stock blood.

"If the patient is bleeding so much that you have to give them their entire blood volume back at the hospital, don't you think maybe they could have benefited from a transfusion before they got to the hospital?" Jenkins told Business Insider.

"They're stuck in a paradigm where blood goes to a hospital, and inside the brick walls of that building is where transfusions happen," he said. "Nowhere else."

Jenkins, a retired Air Force surgeon, like certain other top military trauma leaders, became convinced that blood belongs closer to critically injured patients while serving as military trauma surgeons during the Global War on Terror.

During the decadeslong wars in Iraq and Afghanistan, military medical teams increasingly administered blood aboard helicopters evacuating wounded troops, at small outposts with pre-positioned supplies, and through "walking blood banks," in which medical personnel collected blood from prescreened troops for immediate transfusion to injured teammates.

These practices helped move combat medicine away from relying on ineffective fluids such as saline, which restores volume but dilutes the remaining blood's ability to clot and carry oxygen.

A 2017 study of US troops wounded in Afghanistan found that those who received blood while being flown from the battlefield — or shortly after they were wounded — were more likely to survive for at least 24 hours than those who received blood later or not at all. They were also more likely to survive at least 30 days than those who didn't receive the same care. Other research has also highlighted the benefits of quickly transfused blood and blood products.

"It's game-changing when you can do that, when you provide the patient what they need, when and where they need it," Jenkins said. "The timeliness of that saves lives."

"Prehospital blood comes from the military," said John Holcomb,a professor of surgery at the University of Alabama at Birmingham, retired Army surgeon, and leading advocate for civilian prehospital transfusion.

The TRICARE project, he said, is "a very good story of the military translating its knowledge from the battlefield into the homeland."

Civilian adoption has grown, but it remains limited. More than 400 ground EMS agencies now carry blood products, according to the Prehospital Blood Transfusion Initiative Coalition, a small fraction of the thousands of EMS organizations operating across the country.

Emergency medical services occupy a fragmented place in the American healthcare system. States and localities regulate and organize ambulance services, while the federal government's EMS office sits within the Department of Transportation.

Medicare, meanwhile, sets ambulance reimbursement through the Department of Health and Human Services and generally pays for transportation and level of care rather than reimbursing each medical intervention separately. "It is transportation," Holcomb said. "But it's healthcare while they're being transported."

That fragmented structure can leave ambulance services spending more to provide blood than insurers reimburse, making such programs difficult to sustain financially.

Jenkins pointed to research from his team, published last year, showing that among pediatric patients who received blood transfusions before reaching a hospital, one in every six was classified as an "unexpected survivor."

It's not just trauma patients who benefit from blood, Holcomb said. A 2016 Mayo Clinic study found more than one-third of patients receiving blood before reaching a hospital had non-traumatic bleeding. That might include women in labor who are hemorrhaging, recovering surgical patients, and those suffering from gastrointestinal bleeds, he said.

Local advocates have sought ways to put blood on ambulances for years now, but the Tricare effort is poised to garner deeper attention.

"Whether the long-term result is expansion or modification, the significance today is that financing is now part of the national conversation in a way that it has not been previously," Jennifer Rataj, vice president of market development at Vitalant, a national nonprofit blood supplier, said at the National Blood Summit last week in San Antonio.

The project will examine whether separate payments improve trauma outcomes, reduce patients' overall healthcare costs, and expand access to blood before patients reach a hospital.

John Hagins, chair of the Association for the Advancement of Blood and Biotherapies' disaster task force, said that the experiment will provide more data on whether earlier transfusions improve survival, potentially helping persuade Medicare, Medicaid, and private insurers to adopt similar reimbursement models.

Paying for the blood, however, addresses only part of what is required to put it safely on an ambulance. Storing blood on ambulances — or delivering it to troops overseas — requires more than tossing full bags in a cooler.

The blood's temperature must be meticulously maintained and checked, and ambulance crews must be trained to store, handle, and administer the products. To minimize waste, blood suppliers, hospitals, and ambulance agencies must coordinate deliveries and rotation schedules, moving unused blood off the ambulances and into hospitals where it can be used for planned procedures.

"When people ask us why more states have not implemented prehospital blood programs, the answer is clearly not a lack of clinical interest," Rataj said. "The barriers are usually much more practical. The funding, the governance, the operational ownership."

"Having Tricare come on board and pay for the blood for their beneficiaries is a huge step forward," Holcomb said. "We hope that this will spur other insurance agencies to pay for prehospital blood."

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