Removing Transportation Barriers Key to Improving Care Coordination

September 5, 2019

A 2017 American Hospital Association (AHA) report concluded that only 20 percent of good health outcomes could be attributed to direct patient care. The most significant factor – 40 percent – relied on successfully managing social detriments of health (SDoH).

SDoH is defined by the AHA as a lack of access to healthy/adequate food, housing, education, and transportation. Further, the AHA noted that 3.6 million people in the U.S. do not obtain medical care due to barriers to transportation. In other words, they cannot get to a doctor’s appointment, to a pharmacy, or to a grocery store, all-important self-help action for a patient to manage their health. No-shows for medical appointments, especially after a patient is discharged from the hospital, is high as 30 percent in areas with transportation barriers. Also, data from the Bureau for Labor and Statistics reveal that people earning between $5,000 and $30,000 a year spend 24 percent of their income on transportation.

This reality is especially prevalent among Medicaid patients. A National Institute of Health Study found that 59 percent of Medicaid beneficiaries had at least one emergency room visit in the past year because of difficulty accessing transportation to their nonemergency primary care provider. Such SDoH challenges are significant challenges to hospitals and social providers, who seek care coordination under value-based healthcare delivery mandates to reduce costs and increase the quality of health outcomes. Beginning in 2016, most hospitals, for example, are financially penalized if a Medicare patient is readmitted within 30 days. Missed appointments result in the delay of care that costs the U.S. health system $150 billion annually, according to the AHA study.

Such costs create an opportunity for new solutions to nonemergency medical transportation (NEMT). The NEMT Medicaid transportation market is estimated to be worth over $3 billion (less than one percent of the total Medicaid budget) to ride companies such as Lyft and Uber. Both companies have formed a healthcare division to serve the NEMT sector with low-cost ride options. High ride costs are a significant barrier for NEMT solutions, along with lack of personal vehicles, limited bus and train routes, distance and time burdens, lack of bank accounts and credit card, driver’s license barriers, and lack of adequate transit service in underserved areas.

Lyft has recently announced developments to its NEMT ride services. Accession, the nation’s largest non-profit hospital system, is working with Lyft – and subsidizing NEMT rides for its patients. In May, the company signed contracts with several Medicare Advantage (M.A.) plans, including for BCBS and Humana – for ride-sharing trips to medical providers. The company expects to be working with most M.A. plans by 2020. It also just announced that it had become a certified Medicaid provider in Arizona as a referral solution to SDoH of care coordination. About 23 percent of the population of Arizona is enrolled in Medicaid. Lyft is seeking to expand the model in other states, with Texas and Florida looking to roll out similar programs. Lyft projects that if such ride-sharing service were available nationwide, SDoH access would improve for 65 million Americans – about one-fifth of the population.

Meanwhile, Uber is also actively striking agreements as a NEMT provider. It is working with more than 1,000 healthcare organizations, including MedStar Health and the Cleveland Clinic. Uber also just penned an agreement with San Francisco-based Grand Rounds, which helps companies across the country manage and navigate the healthcare system for 4.5 million employees.

“Three years ago, the conversation was, ‘What the heck is Uber doing in healthcare? You’re just taking a millennial to a bar on a Friday night,'” Dan Trigub, head of Uber health said during a June 19 interview with Becker’s Hospital Review. “But that couldn’t be further from the truth in terms of how we can help underserved populations.”

Health systems are also finding NEMT solutions using their resources to overcome SDoH barriers. The goal is to better coordinate care for patients who need to keep referral obligations, such as doctors’ appointments and to get prescriptions refilled. Hospitals and health systems have significant influence and reach in their communities and are uniquely positioned to offer NEMT solutions. In Cleveland, three major health systems sponsor a Bus Rapid Transit (BRT) to help patients reach their services. Denver Health Medical Center offers free bus tickets, cab vouchers and donated free vehicles (as well as an agreement with Lyft). Grace Cottage Family Health & Hospital in Vermont initiated a volunteer driver to meet the emergent needs of patients, provided they are physically and cognitively independent and have an assistant to aid during transportation. And, Taylor Regional Hospital in rural Kentucky operates a hospitality van sponsored by 14 local business and community organizations.

Regardless of the delivery method of NEMT-SDoH reducing services, the programs save money and improve health outcomes. According to the Medical Transportation Access Coalition (MTAC), NEMT offers a significant return on investment (ROI). MTAC estimates a $40 million savings for just three chronic conditions – end-stage renal disease, diabetic wound care, and treatment for substance abuse. When Georgia and Kentucky offered healthcare transportation services between 1996 to 1999, the program yielded a 13 percent healthcare cost reduction for children with asthma. In 2008, a Florida State University study found for every $1 spent on medical transportation for disadvantaged populations, the state realized an $11.08 ROI.

For ambulatory, cognitively fit patients, NEMT strategies are a proven element of good care coordination. The data suggests it is worth creating a healthcare, transportation provider referral network.