Average Cost Of Non Emergency Medical Transportation

Health Affairs Blog

According to APTA (based on data from the 2002 NTD), the national average operating cost for fixed-route service (including buses, trolley buses, and rail) is $2.38 per unlinked trip (these calculations are. Lack of transportation can be a barrier to accessing health care, particularly for elderly, disabled, or low-income individuals. To address this concern, federal Medicaid regulations require that states ensure transportation to and from providers, a benefit known as non-emergency medical transportation.

Limited access to reliable transportation causes millions of Americans to forgo important medical care every year. Transportation barriers are most prominent among the poor, elderly, and chronically ill—populations for whom routine access to ambulatory and preventive care is most important.

Payers that focus on vulnerable populations have taken steps to address transportation barriers by providing non-emergency medical transportation (NEMT) benefits to select beneficiaries. A majority of Medicare Advantage (MA) plans and state Medicaid programs currently provide NEMT benefits.

NEMT benefits are typically administered by specialized brokers that coordinate and dispatch private cars, taxis, or specialized vehicles to bring patients to medical appointments. Multiplereports have highlighted challenges with traditional approaches to NEMT delivery, including poor customer service, inadequate responsiveness, and fraud and abuse. In the face of these challenges, payers and health care delivery organizations have been experimenting with new strategies for delivering NEMT.

An approach that has attracted considerable attention is the use of transportation network companies (TNCs)—such as Uber or Lyft—to provide NEMT services. NEMT brokers such as such as American Logistics Corporation, National MedTrans, American Medical Response, and Access2Care are all now piloting TNC-based rides. New companies, such as Circulation and RoundTrip, have emerged to help hospitals and health plans offer TNC-based rides. And both Lyft and Uber are contracting directly with health plans and delivery organizations to provide NEMT services.

Despite the proliferation of these programs, there is scantdata regarding their impact. Here we report the results from a large-scale, system-wide implementation of Lyft-based NEMT services at CareMore Health.

CareMore Health is a physician-founded, physician-led integrated care delivery system. For many patients enrolled in its MA plans, CareMore provides a diverse range of NEMT services free of charge. Curb-to-curb (C2C) rides are most similar to traditional taxi or private car services. Patients that require extra assistance or specialized transport have access to door-to-door (D2D) and wheelchair accessible van (WAV) services.

As is typical for MA plans, CareMore contracts with brokers to administer its NEMT benefits. Historically, these NEMT brokers arranged for rides using private car services. In 2016, CareMore launched a pilot program to evaluate the impact of Lyft-based C2C rides on patient experience and costs. The pilot ran for two months at select CareMore locations in Southern California, during which a total of 479 rides were provided. Results were encouraging: wait times decreased by 30 percent and per-ride costs decreased by 32 percent, and satisfaction rates were 80 percent.

In light of the encouraging results from the pilot, CareMore expanded the program system wide. Partnering with NEMT broker American Logistics Corporation (ALC), CareMore began offering Lyft-based rides throughout all MA markets in August 2016, which included 75,000 members across 18 counties in California, Nevada, Arizona, and Virginia.

During the pilot, Lyft-based services occasionally led to confusion. Accustomed to branded vehicles, and inexperienced with Lyft and other TNCs, patients were sometimes confused when an unfamiliar car arrived to bring them to their medical appointments.

Based on this feedback, adjustments were made to improve patient experience. First, the experience of booking did not change—patients call a CareMore associate who takes down information regarding time, pick-up, and drop-off locations. This information is then securely relayed to ALC, who uses custom-built software to schedule a Lyft driver at the requested time. Second, CareMore makes clear that Lyft, not the car services that patients may be accustomed to, will be providing the ride. This occurs when the ride is booked, and again when CareMore calls to confirm the ride. Members that would like to know the specific make and model of the car that has been dispatched are able to call a CareMore associate to obtain that information. Third, CareMore and ALC released a smart phone application—MyRide Manager—that allows patients, caregivers, and care team members to track and manage rides via an interface that resembles Lyft’s or other TNCs’ native applications.

The CareMore-Lyft-ALC partnership was launched across all CareMore MA markets in August 2016. Within three months, half of all C2C rides were Lyft-based. By the end of 2017, CareMore provided 91 percent of all C2C rides through Lyft, accounting for up to 7,000 rides per month, and a total of 68,993 rides over the course of 2017 (See Exhibit 1). At this point, the absence of Lyft availability in certain counties has limited the ability to scale the program any further.

Exhibit 1: Percentage Of CareMore NEMT Rides Provided By Lyft

Source: CareMore Health

Results through the end of 2017 are in line with those reported during the pilot:

• On Time Performance: On time performance (rides arriving within 20 minutes of scheduled pick-up time) for Lyft-based C2C rides was 92 percent, compared to 74 percent for non-Lyft rides.

• Wait Times: The average wait time for Lyft-based C2C rides was 9.2 minutes, compared to 16.6 minutes for non-Lyft C2C rides, a 45 percent decrease. Reductions in wait times were most pronounced among “on-demand,” return rides from clinics or other health care settings.

• Patient Experience: Patient satisfaction results exceeded those from the pilot program, possibly reflecting the strategies discussed above aimed at reducing confusion. In a survey of CareMore patients using Lyft-based rides, 96 percent reported feeling “Safe” or “Very Safe” during their ride and 98 percent reported being “Satisfied” or “Very Satisfied” with the service (timeliness, cleanliness, and professionalism of the driver).

• Costs: Lyft-based C2C rides cost CareMore 39 percent less, on average, than non-Lyft C2C rides. Reducing per-ride costs allowed CareMore to expand its NEMT benefit throughout the course of 2017, providing an additional 28,000 rides (a 12 percent increase) at no additional cost to the system.

From late 2016 through 2017, CareMore Health rapidly scaled access to Lyft-based NEMT rides across its MA patients. Lyft now provides the vast majority of C2C rides for CareMore patients, and doing so has improved patient experience, reduced wait times, and increased the overall efficiency of CareMore’s NEMT benefit.

Although these results are encouraging, it is important to remember that TNC-based NEMT is not a panacea. Rural areas remain under-served by TNCs and there does not yet exist a robust TNC offering for older, sicker patients who require D2D or WAV services. Nonetheless, the cost-savings generated by switching to Lyft for C2C rides can help support increased access to NEMT for patients requiring specialized services.

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It remains to be seen whether or not the benefits of TNC-based NEMT extend beyond improved satisfaction and lower costs to fewer missed appointments and better health outcomes. The structure of the CareMore-Lyft-ALC partnership did not permit a formal evaluation on these dimensions. Though there are anecdotal reports that TNC-based NEMT can reduce missed appointments, rigorous analyses have not shown an effect. As TNC-based NEMT grows, attention should be paid to better clarifying this potential impact.