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WASHINGTON -- Non-emergency medical transportation (NEMT) continues to be necessary for many Medicaid patients, but it has issues that need to be resolved, speakers said at a meeting of the Medicaid and CHIP Payment and Access Commission (MACPAC).

"The best investment in health isn't always in healthcare," said MACPAC Commissioner Kisha Davis, MD, MPH, regional medical director at Aledade, a company in Rockville, Maryland, that helps physicians start up and run accountable care organizations. "How are we shoring up the transportation system so that we are helping people to access care in ways that are validating and keep them independent? ... Investing in transportation networks and Uber and Lyft and taxis -- all those things really support their independence."

Report Requested by the Senate

Commission members were responding to presented at a January MACPAC meeting in response to a request from the Senate Appropriations Committee. In its fiscal year 2020 report, the committee asked MACPAC to "examine ... the benefits of NEMT from state Medicaid programs on Medicaid beneficiaries, including beneficiaries with chronic diseases including ESRD [end-stage renal disease], substance abuse disorders, pregnant mothers, and patients living in remote, rural areas, and to examine the benefits of improving local coordination of NEMT with public transportation and other Federally-assisted transportation services." The request didn't have a due date or require specific recommendations.

The MACPAC analysis noted that states are required to provide Medicaid beneficiaries with NEMT using the "most appropriate form of transportation." Transport services are delivered either through a fee-for-service system, Medicaid managed care, or through a third-party broker. Report authors Kacey Buderi and Aaron Pervin looked at every state's NEMT policies and interviewed Medicaid directors in six states, as well as officials at the Centers for Medicare & Medicaid Services and the Federal Transit Administration. They also analyzed NEMT utilization and spending.

The authors found that in fiscal year 2018, Medicaid spent $2.6 billion on NEMT, providing 61.5 million "ride days" to 3.2 million beneficiaries -- a small fraction of Medicaid's 74 million enrollees that year. Ride days were defined as days that an NEMT procedure code was used for a particular enrollee. Beneficiaries living in urban areas used an average of 19.8 ride days for the year compared with 15.8 for those in rural areas, although some rides couldn't be classified by ZIP code alone as being urban or rural.

Large Variance by Diagnosis

The number of ride days also varied greatly depending on the user's diagnosis, with chronic kidney disease patients who had ESRD showing an average of 70.1 ride days in 2018, compared with 20.1 for those with serious mental illness. Patients with developmental or intellectual disabilities averaged 34.5 ride days, while those with opioid use disorder averaged 25.0 ride days.

Nearly half of NEMT ride days (46.0%) involved the use of vans, with taxis the next most common at 36.7%; ride-sharing apps like Uber and Lyft were included in those classifications. Only 5.0% involved public transportation (one ride day can involve multiple modes of transportation, so the percentages don't add up to 100). About 41% of rides were to the beneficiary's residence, with another 20.3% ending at the physician's office and 16.9% at a diagnosis or therapy site, the authors reported.

MACPAC also contracted with research firm PerryUndem to convene focus groups of Medicaid NEMT users in six states to discuss their feelings about NEMT. Each focus group, which lasted 90 minutes, involved groups of four to seven participants who participated by either phone or video. The groups included a total of 34 patients who had chronic conditions such as hypertension, cancer, ESRD, bipolar disorder, substance use disorder, depression, and seven participants who were caregivers of such patients. Some participants used wheelchairs, and most had been using NEMT for a year or more.

Participants reported a variety of transportation barriers before they started using NEMT. Many didn't have a car or driver's license, and couldn't rely on friends or family to transport them to appointments. Public transportation often took too long, or was not available at all, especially in rural areas. Many said they couldn't afford transportation on their own.

"Many participants, particularly those with serious conditions like ESRD, felt that their continued and regular access to treatments and medical services was saving their lives," the report noted. "Many also remarked that NEMT added greatly to their quality of life because it helped them maintain their health, improve their mobility, or just enabled them to function and get through the day."

Issues With Drivers, Scheduling

Although participants were pleased with NEMT overall, they also reported specific issues with it, including drivers who arrived too early, too late, or not at all; rude and unprofessional drivers or call center representatives; and no way to hold transportation companies accountable for problems. They also flagged policies that required them to share rides or use public transportation even when doing so was not practical; policies that required rides to be scheduled 3 days in advance; and policies that precluded parents from bringing their children along in rides.

Maybe other solutions are possible for parents caring for multiple children, said Davis. "There are some of these services we can bring to patients. I'm a doctor that did house calls up until last year... For a doctor to come into the home is often much less invasive for mom and the family."

Commissioners also raised the issue of telehealth possibly eliminating the need for some of these trips. "It's hard for me to think about the balance in using NEMT and what I might recommend without telehealth," especially since telehealth use has increased during the pandemic, said Sheldon Retchin, MD, of Ohio State University in Columbus. "Finding that balance when NEMT is necessary and expedient in medical care versus telehealth would be a really important contribution."

Buderi said that a few beneficiaries reported trying telehealth visits, "but I think for the most part they're still wary of it because of bandwidth issues or just because they're not used to it," she said. "It doesn't seem that telehealth has completely replaced NEMT rides for beneficiaries, even in the pandemic."

In any case, transportation is likely to remain a problem, said Christopher "Kit" Gorton, MD, of Germantown, Maryland. "In the years I ran Medicaid MCOs [managed care organizations] in various states, the number one cause of complaints among beneficiaries was about transportation; it was not only an irritant to members and providers, but the plans spent a whole lot of time on it. It's hard and there are no easy fixes."

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