Historic NEMT infrastructure, program challenges and solutions

Part 2 of 2

In part one of this series on non-emergency medical transportation (NEMT), we explored how transportation is a crucial part of mitigating the effects of social determinants of health on underserved populations. In part two, we explore NEMT nationwide, the challenges the program faces and several solutions that are already in place.

A nationwide transportation infrastructure was put in place to help relieve some of the issues people face due to the need to get to healthcare appointments. Today, there are “130 federally-subsidized transportation programs which provide services primarily for users who are low-income, 60 or older, have a disability, or are veterans,” according to Renee Autumn Ray, who authored a report for Eno Center for Transportation.

Each state decides how it wants to offer NEMT through Medicaid, making it difficult to compare challenges, understand ROI and make direct comparisons.

NEMT currently exists in seven different models:

1. In-house management
2. Managed care organization (MCO)
3. Statewide broker
4. Regional broker
5. In-house management and MCO
6. In-house management and regional broker
7. MCO and regional broker

Of these examples, most states (13) use the statewide broker model. Overall, 29 states use a broker in some capacity.

Program funding, challenges

Primary funding comes from the Department of Health & Human Services (HHS), as they fund Medicaid NEMT. In addition to being the program with the largest amount of funding (it makes up about 25% of the annual federal transit allowance), NEMT “has an outsize ability to impact and influence the performance of the entire subsidized transportation ecosystem,” according to Ray.

While NEMT may garner the most federal funds, it comprises only 1% of total costs. Nevertheless, NEMT is often considered first when it comes to cutting costs, and, consequently, a significant metric for selecting and assessing the success of an NEMT program is how the program contains cost.

NEMT, therefore, is commonly seen as an entity separate from other facets of healthcare instead of a part of a larger, comprehensive healthcare solution. This poses a challenge when it comes to implementing a value-based care model, as private insurers are less motivated to incorporate transportation as part of their care catalog or include transportation metrics when evaluating the success of their program as a whole.

Two of the largest programs, paratransit and NEMT, experience their own challenges, as they are required to provide service and unable to refuse rides to qualified passengers. “NEMT is intended to guarantee that every Medicaid beneficiary without their own transportation resources can access necessary healthcare.” These requirements, although beneficial for the rider, can cause the NEMT provider to incur additional costs, such as having wheelchair-accessible vehicles, driver training and ensuring they have HIPAA-compliant software and procedures.

Possible solutions

Although these challenges make it difficult to ensure that each program operates as effectively as possible, recent innovations by both healthcare and transportation entities may help alleviate some of the issues experienced. These include Center for Medicare and Medicaid Services (CMS) innovations such as:

• Section 1115 waivers and the corresponding “Healthy Opportunities Pilots,” which aims to “reimburse evidence-based non-medical services to address specific social needs, including transportation insecurity as well as funds for housing, food, and interpersonal safety.”
• “Accountable Health Communities,” which awarded 32 grants across 22 states for a five-year program with two focus areas: helping underserved patients navigate the available “community-based social services” and alignment of the various partners within the social services sector to improve the performance of services such as transportation, housing and access to food.
• Medicare Advantage (MA) innovations, such as amending a rule in 2017 to allow some MA healthcare providers pay for transportation to their facility. More recently, CMS announced in 2018 that MA could offer reimbursable benefits that would help combat SDoH like transportation, regardless of if they’re provided by a healthcare provider.

Innovations by different groups also exist:

• Partnerships between NEMT providers and transportation network companies (TNCs) along with direct TNC participation
• Expansion of food benefits to permit delivery or curbside service

Moving forward

Finally, Ray provides recommendations on how to improve access to essential services that can help negate SDoH effects and promote positive health outcomes. It’s stressed that:

“These recommendations focus on pragmatic changes to policy or regulations that agencies or public authorities can handle administratively without passing new legislation. This includes more widespread adoption and implementation of a HiAP-type approach for transportation.”

HiAP, as mentioned above, is “Health in All Policies,” and posits that “health considerations should be interwoven into policies collaboratively and proactively across all sectors.” More specifically, “applying HiAP helps government identify areas of opportunity within its existing policy goals to better integrate health-supporting approaches,” according to the Centers for Disease Control and Prevention.

While Ray provides several specific examples of the ways each party can improve transportation operations and health outcomes, there’s a common thread in many methods: using the HiAP framework to identify ways to weave health-focused ideology into current policy objectives and integrate public health into the fabric of everyday life.

In doing so, all parties can increase coordination with each other and other groups involved in transportation and healthcare. For example, USDOT and the Veterans Administration could investigate potential ways to integrate or collaborate to improve access to locations that promote positive health outcomes, especially for underserved populations.

Regardless of the method used to get people where they need to go, the goal remains the same: create an environment where transportation isn’t a barrier and good health is achievable by all.