Michael Adelberg

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Non-emergency medical transportation (NEMT) has been a part of the Medicaid program since its establishment. It was first codified in regulation in 1973, and Congress reiterated that NEMT is a mandatory Medicaid benefit in the 2020s Consolidated Appropriations Act. Medicare generally does not provide non-emergency transportation, with the exception of beneficiaries who are unable to be transported in any vehicle other than an ambulance. 

Health plans that participate in Medicare Advantage (MA) and capitated providers such as Accountable Care Organizations can choose to offer non-emergency transportation but are not required to do so. Whether covered by Medicaid or Medicare, most non-emergency transportation is to medical sites; transportation to non-medical sites is uncommon.

The growing focus on the social determinants of health (SDOH) increases attention on the appropriate role of transportation to both medical and non-medical sites. While there is a body of research on the value of transportation to medical care, there is limited research on transportation’s role in supporting access to non-medical sites (e.g., grocery stores, fitness centers, social services) and on how improved access to non-medical needs via transportation services may ultimately improve people’s health.

Medicare and Medicaid programs that serve the most-vulnerable Americans facing SDOH barriers can be major facilitators of appropriate non-emergency transportation to non-medical sites. But how do we determine what is appropriate, and what do we know about transportation services to non-medical sites today?

Based on a survey of 91 organizations, the Medical Transportation Access Coalition (MTAC) assessed (1) the value of transportation for vulnerable Medicare beneficiaries by analyzing claims from a regional MA plan and (2) the variety of non-medical sites that Medicaid and Medicare plans and providers support with transportation. By undertaking two distinct but complementary analyses, we highlight the role that non-emergency transportation could play in addressing the SDOH needs of Medicare and Medicaid beneficiaries.

Actuaries analyzed claims from a regional MA plan with a large Dual Eligible Special Needs Plan (D-SNP) and general-market MA Health Maintenance Organization (HMO) plans. These plans have a NEMT benefit — with the MA plan benefit augmenting Medicaid’s NEMT benefit for dual-eligible beneficiaries. The analysis compared transportation utilizers against non-utilizers on a variety of medical and pharmacy cost-and-use data elements.

Transportation positively correlates with primary care utilization. Transportation users see their primary care physicians 1.5 times more than non-utilizers do.

Transportation utilizers tend to be sicker than non-utilizers are. This assertion is based on the Hierarchical Condition Category codes assigned to them as part of the MA risk adjustment program. The average risk score of transportation utilizers is 1.97 vs. 1.35 for non-utilizers, based on the most recent complete risk adjustment coding year (2019). This demonstrates that NEMT expenditures cluster toward members with the greatest medical needs.

MTAC, with the help of the coalition’s allied members, conducted a first-of-its-kind survey of organizations that provide transportation to Medicare and Medicaid beneficiaries.We received 91 responses from organizations that provide transportation to Medicare or Medicaid beneficiaries.

Forty-three responding organizations reported that they provide non-medical transportation to Medicaid beneficiaries. Respondents provided Medicaid beneficiaries with non-medical transportation for as many as 500,000 and as few as 60. Twenty-seven survey respondents provided non-medical transportation to Medicare beneficiaries for as many as 500,000 and as few as 100 beneficiaries.

Importantly, there is no single “consensus” destination served by a majority of responding organizations. Permissible sites for MA plans trended toward destinations with an obvious correlation with physical health (e.g., grocery stores, fitness centers); Medicaid destinations had a broader focus that often included social services and vocational destinations.

Organizations frequently put utilization limits on their non-medical transportation services. For example, 48% of Medicare respondents placed limits on the number of round trips per period, and 33% used prior authorization to contain unnecessary trips. Among Medicaid plans, 41% of respondents opted to implement tools such as prior authorization, while 34% chose to limit rides based on a maximum number of trips per time period.

This study highlights how non-emergency transportation helps vulnerable people access healthcare and essential services (e.g., grocery stores, fitness centers, social services) and is a driver of people’s health and well-being. Over time, additional research will be needed to understand how these sorts of interventions directly lead to better health outcomes and impact overall spending within public insurance plans. If non-medical transportation improves the health and well-being of Americans, policymakers should consider the case for financing comprehensive, appropriate transportation based on medical and social needs.

Vincent Giglierano is a Faegre Drinker Consulting advisor.

Michael Adelberg is a Faegre Drinker Consulting principal.

Krisda H. Chaiyachati is an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine.

Articles

Medicare and Medicaid programs that serve the most-vulnerable Americans facing SDOH barriers can be major facilitators of appropriate non-emergency transportation to non-medical sites. But how do we determine what is appropriate, and what do we know about transportation services to non-medical sites today?



Considering the Ideal Role for Non-Emergency Medical Transportation in Addressing SDoH in Medicaid and Medicare Populations

The number of aging Americans 65 years and older is 

 to nearly double over the next 40 years, reaching 80 million in 2040. As the U.S. population ages, so too does 

the prevalence of medically complex patients

, limit activities of daily living or both. Prominent among the conditions that will balloon with this demographic trend are Alzheimer’s Disease and Related Dementias (ADRD); it is 

 that 14 million Americans will be diagnosed with ADRD in 2060 (up from 5.8 million today).

, the single-most costly disease in the U.S., totaling more than 

 in annual Medicare/Medicaid costs and growing. Claims analyses show that 50% of hospitalizations for those with ADRD are due to causes that are potentially preventable (e.g., falls and infections). The high rate of potentially preventable hospitalizations (PPH) among those with ADRD puts 

 on families, caregivers, healthcare providers and health insurance companies alike.

For most families, the burdens of caregiving are assumed by family members who are inexperienced and stressed. Caregivers frequently use words such as “frustrating,” “hard” and “stressful” when asked to describe their caregiving experience, typically due to a lack of personalized information to assist them.

 states that the stress of caregiving leads to a “26% greater impact of health conditions” on caregivers. Furthermore, 

 that in 2020, more family caregivers (26%) have difficulty coordinating care compared to 2015 (19%). High-quality resources to support caregivers exist, but more can be done to provide personalized support for caregivers.

Integrated care and support programs provide an enormous opportunity to enhance the quality of life for ADRD patients and their caregivers. More knowledgeable, skilled and confident family caregivers can identify emerging medical issues, thus reducing preventable healthcare utilization and costs. Telehealth provides a cost-effective platform for caregivers to receive personalized education, access to services (e.g., transportation), remote coaching and support that has been optimized for ADRD.

Catalyzed by the COVID-19 pandemic and the rapid 

 of telehealth, it is now possible to remotely support the family caregivers of vulnerable and expensive patients. 

 examined persons with dementia and their caregivers supported by telephone-based collaborative care by a trained care team navigator. The intervention improved patient quality of life, reduced emergency department visits and decreased caregiver depression and burden.

Along with developing a more robust strategy to support all caregivers, one Medicare health plan provides a six-month caregiver support telehealth program as a no-cost supplemental benefit for family caregivers of loved ones with dementia or other cognitive impairments. Caregivers receive a tablet device that enables access to personalized educational and other content that addresses the unexpected challenges often faced by a spouse, child or other relative who has taken on increasing caregiving responsibilities. 

 includes videos, tutorials and access to support by remote human coaches.

Caregivers who participated in this program engaged with the digital platform for an average of 40 minutes per week and completed an average of three daily assessments per week while demonstrating high user satisfaction rates. Consistently high engagement — a pre-requisite for cost savings — and high caregiver satisfaction ratings suggest that telehealth programs that provide personalized education, resources and support for family caregivers can improve the experience of living with dementia for both the health plan’s beneficiaries and their family caregivers.

The COVID-19 public health emergency has increased the demands placed on family caregivers of loved ones with ADRD. It has been well documented that COVID-19 has increased self-reported stress, isolation and loneliness, threatening caregivers’ quality of life. This circumstance underscores the importance of supporting family caregivers.

Integrated care and support programs, when aimed at family caregivers, can increase the quality of care for patients with ADRD while improving the quality of life of both patients and caregivers. Telehealth is a promising means of cost-effectively supporting family caregivers with personalized education, resources and remote coaching. Medicare Advantage and Managed Long-Term Services and Supports (MLTSS) plans, as well as Accountable Care Organizations and other providers incented to manage ADRD successfully, have new opportunities to leverage telehealth to empower and support caregivers to improve outcomes and lower costs for people with ADRD.

Michael Adelberg is the leader of Faegre Drinker Consulting’s healthcare strategy practice. 

 is a board-certified internist and a Senior Medical Director with Blue Cross and Blue Shield of Minnesota. 

, MS, MBA, is the Co-Founder and CEO of Ceresti Health, a digital health company that specializes in virtual care for persons living with Alzheimer’s disease and related dementias. 

The number of aging Americans 65 years and older is projected to nearly double over the next 40 years, reaching 80 million in 2040. As the U.S. population ages, so too does the prevalence of medically complex patients with conditions that require ongoing medical attention, limit activities of daily living or both. 

Michael Adelberg

Articles

Considering the Ideal Role for Non-Emergency Medical Transportation in Addressing SDoH in Medicaid and Medicare Populations

Improving Outcomes for Alzheimer’s Disease Patients by Supporting Their Caregivers Via Telehealth