Mobility is instrumental to living independently. And for many, transportation is a barrier to getting much-needed healthcare — care that improves quality of life and reduces emergency medical expenses.
In a recent webinar, “NEMT: Emerging Research and Trends,” sponsored by the National Center for Mobility Management, Community Transportation Association of America Executive Director Dale Marsico gave background on the NEMT benefit and why it was created.
In a federal court case from the 1970s, Smith vs. Vowell, a judge found limitations in transportation to healthcare created a “false sense of economy.” The court found that for patients needing non-emergency treatments, such as physical and occupational therapy or dialysis, the medical needs were, “of such a magnitude that no single doctor or clinic” could meet their needs. The court ruling stated, “the deprivation of medically necessary transportation is disadvantageous to the state” and “a kind of false economy that only results, in the end, in higher medical costs.”
A key concept of that litigation is that providing health coverage in Medicaid includes a guarantee of access to health care. Marsico stressed they don’t need just access, they need treatment, which often means ongoing transportation needs.
Centers for Medicare & Medicaid Services established transportation as a mandatory benefit to provide people with access to healthcare services. Providing access to preventative care resulted in lower healthcare costs by keeping people out of hospitals and nursing homes. Studies have shown transportation to treatment lowered missed appointments, reduced lengths of stays and lowered emergency room visits.
A 2008 Florida State University study, “Florida Transportation Disadvantaged Programs Return On Investment Study” illustrated that if one percent of medical trips funded resulted in the avoidance of a trip to the emergency room, the payback to the state would be about $11.08 for each dollar the state invested in its medical transportation program.
Marsico pointed out how much has changed since that ruling. At that time there was very limited Medicaid coverage outside of institutional settings; hardly any outpatient care. “Common treatments today available as outpatient, didn’t even exist then.” Along with that, a whole new set of demands.
Simon & Co. LLC recently released a report, “Medicaid Expansion and Premium Assistance: The Importance of Non-Emergency Medical Transportation (NEMT) to Coordinated Care for Chronically Ill Patients.” With the Affordable Care Act there is an alternative that states are looking at. ACA allows states to expand Medicaid to nearly all individuals with incomes up to 138 percent of the federal poverty level. Instead of expanding theirtraditional Medicaid programs, some states have proposed to adopt an insurance model based on premium assistance. Under this option states use Medicaid funds to purchase commercial insurance including qualified health plans for some or all newly eligible Medicaid beneficiaries. In order to offer premium assistance, the state must file an amendment or a waiver with The Centers for Medicare and Medicaid Services.
CMS said states opting to cover this new population with premium assistance instead of the traditional Medicaid program are required to provide wrap-around benefits to cover all mandatory services, including NEMT.
Simon & Co. LLC President Marsha Simon, PhD, said there has been significant debate in some states on this point. With ACA being the Administration’s highest priority to implement, they’ve been pretty flexible to compromise, she said. States have proposed that QHPs are commercial plans that do not offer NEMT services so CMS is considering waiving states from this for a year, in which time the state is required to collect date to evaluate the impact.
The Case for Access
Data from the largest intermediary managing approximately 48 million rides last year in 39 states showed 60 percent of NEMT trips are for ongoing service. These are for special needs that can only be served in specific time slots in specific locations.
Mary Leary, Easter Seal’s vice president, Transportation Group, said during the webinar that chronic conditions are driving increased levels of disability and cost. At the community level, transportation options can mitigate chronic conditions. Exercise is beneficial and for those mobile, Leary said access to transportation helps people maintain fitness and reduce unnecessary hospital readmissions.
There’s a lot of information mobility managers can use to create a business case, Leary said. As the healthcare system barely has time to care for patients, she said mobility managers need to help them understand and there are ways to quantify it. Anytime you talk to a hospital, one big area they focus on is reducing the unnecessary hospital readmission.
Leary said, “For many conditions, check-up appointments are critical to avoid readmission.” She said if you’re trying to partner with a hospital, find out their readmission rate and apply recent research suggesting that about 11 percent of that is preventable. Apply an agreed upon average for what percent of these was related to lack of transportation.
As an example, a hospital with the 11 percent unnecessary readmissions associated with approximately 2,000 patients, 220 patients are costing them an average of $5,000 per readmission, or $1.1 million.
Changes in Benefit
There are several states likely to expand Medicaid using premium assistance, some asking for a waiver of the NEMT benefit. One of those states is Pennsylvania. On Feb. 19, Gov. Tom Corbett submitted a 1115 waiver for CMS approval, asking for a waiver of the NEMT benefit and CMS must wait until April 12 before making a decision.
Eric Kiehl, director of communications with the department of public welfare in Pennsylvania, said the state’s Healthy PA proposal has no changes for individuals currently on Medicaid. Part of the proposal to create the private coverage option would be for those that are 100 to 138 percent of the federal poverty level. Because it will be a private insurance, the state does not have to provide the NEMT benefit. Kiehl said public comments are due up until April 10. There have not been a lot of comments on it, but it is a point that the staff will be discussing with CMS, he said.
Marsico said demand for NEMT is going to increase; people with chronic illnesses will be requiring more outpatient care because of the advancing technology.
As the industry looks at positioning itself for advocacy, he asked if the transportation system we have today is up to provide the kinds of services required for increasingly frail individuals.
As we deal with complex healthcare issues, Marsico said it reaffirms the courts original discussion that we need mobility management now and we need it as a we develop ways to assist patients and transportation agencies meeting their needs. “People need special understanding on their abilities to utilize our transportation services,” he said, and that a mobility management concept needs to look at people. Whether a service is door-to-door or door-through-door, needs to be assessed with so many people living at home longer.
“If you’re in the mobility management field, we think this issue is critical to helping people meet their future transportation needs.”