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6 CHAPTER TWO LITERATURE REVIEW INTRODUCTION Transportation-Disadvantaged Populations: Some Coordination Efforts Among Programs Providing Transportation Services, But The first step in the discussion of barriers and potential bar- Obstacles Persist, GAO-03-697, U.S. General Accounting Office, Washington, D.C., June 2003 riers to NEMT and public transportation coordination was the literature review. The search included a broad review of documents related to coordination of human service trans- This report examined the extent to which government agencies portation in general, coordination of NEMT specifically, any are providing and coordinating transportation service to the publications that discussed NEMT, best practices guides, and transportation disadvantaged. The report addressed the federal other related information. A number of relevant documents programs that provide transportation services for the trans- were identified. Of those documents, 11 selected publications portation disadvantaged and the types of service provided; fed- are reviewed here in detail. eral, state, and local spending; the extent of coordination at the federal, state, and local levels; and any obstacles that may impede coordination. SELECTED PUBLICATIONS The report discussed the benefits of coordination through During the literature review process, it became clear that vehicle sharing, consolidating services, and sharing informa- some of the documents were more pertinent for the purposes tion. Efforts to improve service and achieve cost savings vary, of this study than others. The following is an overview of the however. In other areas, the researchers saw positive results. most appropriate reports and studies. The report noted that coordination can lead to improvements, whereas lack of coordination can result in overlap and dupli- Bradley, D., et al., Designing and Operating Cost-Effective cation of services. Medicaid Non-Emergency Transportation Programs--A Guide- book for State Medicaid Programs, Health Care Financing Administration and National Association of State Medicaid There were numerous obstacles cited in the report, which Directors' Non-Emergency Transportation Technical Advisory were categorized as follows: (1) sharing vehicles and the Group, Washington, D.C., Aug. 1998 low priority given to funding coordination activities; (2) pro- grammatic differences; and (3) limited state, federal, and local This guidebook was written by the Non-Emergency Trans- leadership and commitment. Three options were recom- portation Technical Advisory Group (TAG) of the National mended to mitigate these difficulties: (1) harmonize standards Association of State Medicaid Directors, which is composed and requirements among federal programs with transporta- of Medicaid transportation managers from around the coun- tion, (2) provide and disseminate additional guidance and try. It addresses some of the issues of note including coor- information, and (3) provide financial incentives or mandates dinating NEMT with public transportation, meeting needs in to coordinate. rural areas, provider qualifications and standards, brokerage operations, managed care, and data collection. The use of Raphael, D., Medicaid Transportation: Assuring Access to fixed-route bus passes is also discussed as a method of Health Care--A Primer for States, Health Plans, Providers and reducing operating and administrative expenses. Advocates, Community Transportation Association of America, Washington, D.C., Jan. 2001 The report recommended that Medicaid agencies work with the state DOTs and local transit agencies to become an This report briefly describes the NEMT program in general integral part of "the local system." The report stated that these terms. It provides a description of the program, federal reim- agencies should set a higher level of provider qualifications bursements, the various components, and some of the mod- and standards that level the playing field, such areas as driver els used, with an emphasis on brokerage and managed care. training, vehicle standards, insurance, and safety. It suggested There are a number of examples of different structures. Mod- that the monitoring of service is critical, particularly that of els that use fixed routes such as those in Connecticut and brokers and operators. The report identified a number of effi- Portland, Oregon, are highlighted. The second half of the cient local brokers such as in the states of Florida, Oregon, report summarizes the state programs and includes the use of and Washington. The report also indicated that freedom of public transit (although it does not compare fixed-route ver- choice makes coordination problematic. sus paratransit costs).

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7 Borders, S., J. Dyer, and C. Blakely, Texas Medicaid Trans- Medicaid Non-Emergency Transportation National Survey portation Program: A Study of Demand Response Services in 200203, National Consortium on the Coordination of Human Texas, Public Policy Research Institute, Prepared for Texas Services Transportation, Washington, D.C., Dec. 2003 A&M University, Austin, July 2003 This survey was constructed to review the state of NEMT. This study sought to determine the reasonableness of the For the purposes of this study, there is a review of coordina- demand-response transportation rates for rural public transit tion activities between state Medicaid agencies and state across Texas. The study was commissioned by the Texas transit agencies. This report provides an overview of state Department of Health, which at the time was the Medicaid Medicaid programs including review of match-rate issues, transportation agency [subsequently it changed to the Texas service designs, coordination with state transit agencies, and Department of Transportation (TxDOT)]. The Department of description of each state program. Health believed that they were paying too much for NEMT, especially in rural areas. One of the significant findings was that more than half of the states (and the District of Columbia) have some type of fixed- The research found no evidence to conclude that the state route bus pass program for at least some of their cities. The was overpaying for this service. Costs were commensurate agreements are between the state Medicaid agency (or its bro- with other programs and states with comparable trip dis- ker) and the participating transit agencies. The review of each tances. The study did find that the Department of Health did state indicated that some states do not take advantage of fixed- not take full advantage of fixed-route services, citing a rate route service, opting instead for more expensive paratransit. of 10% fixed-route transit usage in the largest urban areas of the state. The report cited a number of examples of urban KFH Group, Maryland Transportation Coordination Manual, areas with more than 50% fixed-route usage, resulting in Prepared for the Mass Transit Administration, Maryland Depart- significant savings. ment of Transportation, Baltimore, Jan. 1998 This "how to guide" is intended for the local level coordina- Medicaid Non-Emergency Transportation: Three Case Studies, National Consortium on the Coordination of Human Services tors. It focuses on actual steps that can be taken to facilitate Transportation, Washington, D.C., 2003 and enhance coordination. It takes a realistic look at coordi- nation, including step-by-step sections on planning for coor- This consortium of nonprofit human service and transportation dination, developing a service model, overcoming barriers, programs conducted three case studies: Delaware, capitated implementation, and marketing. It is based on real-world broker; Utah, broker/operator; and New York, county-by- experiences and is applicable for NEMT. county. Key discussion items included the use of bus passes, freedom of choice waivers, brokerage, tracking, and reporting Westat and Nelson/Nygaard Consulting Associates, TCRP data. The conclusion recognizes that transportation services Report 91: Economic Benefits of Coordinating Human Service Transportation and Transit Services, Transportation Research are different from medical services and, as a result, different Board, National Research Council, Washington, D.C., 2003 approaches are used. There is little discussion of coordinating service with public transit, other than the purchase of bus This report points out that significant economic benefits can tickets. accrue when human service transportation is coordinated. It cites many examples of coordination from across the coun- Sundeen, M., J. Reed, and M. Savage, Coordinated Human Ser- try. First, it reviews and defines coordination. The report vice Transportation--State Legislative Approaches, National notes that under any coordination strategy there are two pre- Conference of State Legislatures, Washington, D.C., Jan. 2005 conditions that must be met: shared objectives and shared respect. After these preconditions are met, sharing of respon- This study reviewed the effectiveness of state legislatively sibility, management, and funding can take place. mandated human service coordination. It reported on a vari- ety of approaches used by the states; 34 states have statutes The report further suggests a variety of strategies from requiring or authorizing coordination, 21 require specific examples of other systems and describes the aggregate coordination, and 2 are consolidated (human service and potential benefits to human service and transit agencies. The public transit administered together). benefits include additional revenue generated by transit, sav- ings generated by using fixed-route service--identified as the The report discusses approaches to legislating coordina- single highest potential savings ($90$300 million), savings tion, barriers and benefits to coordination, federal coordination associated with human service transportation coordination of guidance, state coordination approaches, and coordination pro- their own services, and the benefits to other areas as transit is files of each state. expanded. The report suggests that each state should look carefully Medical Transportation Toolkit and Best Practices, 3rd ed., Com- at legislatively coordinating transportation and that it may munity Transportation Association of America, Washington, not be a solution to many of the specialized concerns. D.C., 2005