Too Early to Cut Transportation Benefits From Medicaid Enrollees

Abstract

Some state governments are considering cuts to the non-emergency medical transportation (NEMT) benefit for Medicaid enrollees, and some Federal officials have proposed making this easier. Yet, there is clear demand. In 2015 alone, low-income patients used 59 million rides for medical appointments. NEMT’s future is under threat because evidence that NEMT improves health care access and downstream outcomes is incomplete. Second, it remains largely unknown whether scarce public resources for transportation are being driven to those who benefit from its availability. This knowledge gap is answerable but unknown because of variations in how states administer NEMT. As a result, tracking who uses the services is inconsistent, and states are unable to link NEMT data with health care outcomes. Instead of cutting NEMT benefits, we believe an alternative path involves improved tracking and evaluations of the benefit first. Better informed policy decisions are needed. Otherwise, if policymakers implement blanket reductions in NEMT spending, they run the risk of causing more harm than good.

Since 1966, states have been required to provide Medicaid beneficiaries with non-emergency medical transportation (NEMT)—free or subsidized transportation to health care appointments using livery vehicles, vans, ambulettes, or public transit. However, transportation as a Medicaid benefit is being reconsidered at the federal level and some states. During the Obama Administration, Iowa and Indiana were permitted to remove NEMT for their Medicaid Expansion population through the approval of 1115 waivers by the Centers for Medicare & Medicaid Services (CMS). ¹ Under the current administration, CMS has become publicly receptive to additional states requesting waivers to curtail the benefit for Medicaid populations. ² Going further, President Trump’s 2019 Department of Health and Human Services (DHHS) budget proposal included regulation that would make it easier for states to curtail NEMT without requiring a waiver. ³ While challenging to predict how each state’s Medicaid program will ultimately proceed, these policy shifts create uncertainty for the future of NEMT. In particular, states with political pressure to address short-term budgetary shortfalls may move to contain the rising costs of Medicaid by shifting dollars away from NEMT. This move may prove harmful.

There is clear demand for transportation services. First, the lack of transportation is often cited as a major barrier to health care. In large surveys of low-income populations, 24% to 51% report missing or rescheduling an outpatient appointment because of unreliable transportation.^4,5 Second, NEMT is commonly used among Medicaid patients. In 2015 alone, 59 million trips were used for outpatient appointments. ⁶ With 38% of those rides being used for behavioral health appointments, NEMT may have been vital for connecting patients to mental health treatment and substance abuse rehabilitation services. An analysis of Medicaid claims finds that the costs of NEMT are small in comparison with the savings associated with keeping patients with two expensive needs—dialysis for kidney failure and wound treatment for diabetes—adherent with clinical guidelines. ⁷

More recently, transportation as an essential need for individuals with Medicaid has come under question. A large pragmatic trial in Philadelphia—led by one of our co-authors—concluded that a one-time rideshare offer did not, by itself, increase Medicaid beneficiary attendance to primary care appointments. ⁸ Combined with policy shifts, these findings raise questions about transportation as a mechanism for improving health care access among low-income patients and question future efforts to expand medical transportation. Indeed, previous federal and state cuts to NEMT have been approved, in part, because research assessing the impact of NEMT or transportation on health care access and downstream outcomes (eg access, utilization, total costs of care, treatment outcomes, and who benefits) is severely lacking.

The current debates about NEMT’s future have proceeded blindly: is demand being driven by those who maximally benefit from its availability or are scarce resources provided to those who achieve marginal or little utility? This fundamental question should drive policymaking. Yet, we do not know the answer.

The ability to answer critical questions about NEMT’s utility have largely evaded policymakers and researchers because of how states deliver and monitor the program. Some states have not modernized the benefit, leading to inefficiencies and concerns over program integrity. For example, despite the availability of NEMT services, an estimated 3.6 million Medicaid recipients report missing or delayed medical care because they lack transportation.^9,10 Most of these individuals are children, the poor, elderly, or those living in rural or underserved areas. Even those who can access NEMT may face barriers—beneficiaries need to be educated about scheduling rides in advance, travel times can be long because of indirect routes related to picking up and dropping off other passengers, pick-up wait times can be long, and when medical appointments end may not align with pre-planned pick-up times.

Tracking who uses these services, how often, and for what appointments has been lacking. Third-party vendors have faced different state-based requirements to track and report these metrics to state agencies and for public review. Combined with gaps in Medicaid claims data and an inability to link with travel data, assessing NEMT’s effect on health care outcomes is challenging. As a result, the duration of the benefit may not match individual health needs. Patients with permanent disabilities might benefit from long-term transportation benefits. Those diagnosed with cancer might use NEMT for predetermined treatment periods to access specialized care. Without adequate data, rigorous evaluations determining who benefits (or who does not) from NEMT based on improved health care outcomes are largely absent. As a result, current decisions about NEMT’s future continue to be based on poor-quality evidence.

What is the path forward? One option may be the current political trajectory: increasing state flexibility to curtail NEMT, or cutting out NEMT’s Medicaid mandate entirely. However, if NEMT’s major challenge is one of inefficient reporting and not that it lacks benefit to patients, this path may prove perilous to those who depend on and need transportation. Accessible health care has two basic ingredients: affordability and getting to health care facilities. By removing NEMT from these Medicaid beneficiaries, getting there may become very challenging.

Using a different approach, commercial insurers, who have historically not provided transportation benefits, have begun experimenting with transportation because they perceive the demand to be real and common. Transportation benefits are offered within 14% of Medicare Advantage Plans and for two-thirds of Medicare Advantage Special Needs Plans. ⁷ The Blue Cross Blue Shield Association has formalized a national partnership with Lyft to begin offering plan members ridesharing to their medical appointments. ¹¹ Thus, while state Medicaid programs consider cutting transportation from the States’ most vulnerable citizens, commercial insurers are ramping up efforts to provide transportation services for those, relatively speaking, less vulnerable.

These crisscrossing trends may inadvertently unmask the causal effect of transportation on health care access and downstream outcomes by creating comparisons between those who gain and those who lose the benefit. If health care access and health outcomes worsen because of these policies, however, low-income populations will bear the burden.

We believe that a better path for NEMT consist of CMS and state Medicaid programs re-shifting their policy approach in the following ways:

• State transparency of NEMT data should be enhanced so the efficiency of transportation services improves. This will require the creation of consistent national data collection and performance standards for vendors and timely reporting of who uses this service, where, when, and for what conditions. These data should be available to state Medicaid officials and for public review.

• NEMT data should be easily linkable with medical claims data so that administrators and researchers can better study their impact on health care outcomes. ¹²

• Medicaid managed care organizations (MCOs) should be leveraged to pave the way. With over 80% of Medicaid recipients being enrolled in a managed care plan, ¹³ MCOs that receive a capitated rate from states could be financially incentivized to track the impact of NEMT on medical costs and health care outcomes.

• CMS should promote state-led efforts to create laboratories for testing NEMT’s value: when does it work, who gains better access or improved health with NEMT, and at what costs. Advancing knowledge in these arenas would improve the nimbleness of NEMT and give evidence-driven guidelines for matching the availability of NEMT services with need and modified to the appropriate intensity (ie the type of vehicle) and duration of travel benefit based on evidence showing better health care outcomes.

Questions about the role of transportation could also be framed within larger efforts to understand and address the social determinants of health. Through home- and community-based waivers and CMS’s Innovation Center models, states are exploring the impact of social interventions like short-term housing, food assistance, and other non-medical benefits which may reduce unnecessary emergency department visits and hospitalizations.^12,14 As Medicaid work requirements are increasingly being considered, ¹⁵ maintaining employment may be dependent on reliable and accessible transportation. And if transportation can improve or maintain health, employers may see less absenteeism and greater employee retention. States need the infrastructure to explore and test whether accessible transportation can improve the physical and financial well-being of its citizens.

If states can provide a transportation service which results in better health care outcomes and improves the livelihood of its vulnerable citizens, it is surely a laudable place to spend public funds. Medicaid programs should be challenged to innovate and find the best, most efficient system to deliver any benefit, medical or non-medical. All the while, states should have evidence driving decisions about cost-benefit trade-offs when deciding to spend public funds in one direction or another. These sorts of evidence-generating evaluations need to be rigorous and free of political influence.

Although recent policy efforts and research have challenged NEMT’s role in helping Medicaid beneficiaries, we believe the fundamental role of transportation as a tool for better health is promising. But the value proposition has not yet been determined. The ability to generate quality evidence for or against NEMT remains severely limited. NEMT’s fate should be decided only after better evidence is available and efforts to innovate have undergone rigorous evaluation. Current policy moves toward cutting NEMT may reduce today’s public spending but runs the risk of causing significant harm for those who have real transportation needs.