National Academies Press: OpenBook

Transit Agency Participation in Medicaid Transportation Programs (2006)

Chapter: Chapter Two - Literature Review

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Suggested Citation:"Chapter Two - Literature Review." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Two - Literature Review." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Two - Literature Review." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
×
Page 8
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Suggested Citation:"Chapter Two - Literature Review." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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INTRODUCTION The first step in the discussion of barriers and potential bar- 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- portation in general, coordination of NEMT specifically, any publications that discussed NEMT, best practices guides, and other related information. A number of relevant documents were identified. Of those documents, 11 selected publications are reviewed here in detail. SELECTED PUBLICATIONS During the literature review process, it became clear that some of the documents were more pertinent for the purposes of this study than others. The following is an overview of the most appropriate reports and studies. Bradley, D., et al., Designing and Operating Cost-Effective Medicaid Non-Emergency Transportation Programs—A Guide- book for State Medicaid Programs, Health Care Financing Administration and National Association of State Medicaid Directors’ Non-Emergency Transportation Technical Advisory Group, Washington, D.C., Aug. 1998 This guidebook was written by the Non-Emergency Trans- portation Technical Advisory Group (TAG) of the National Association of State Medicaid Directors, which is composed of Medicaid transportation managers from around the coun- try. It addresses some of the issues of note including coor- dinating NEMT with public transportation, meeting needs in rural areas, provider qualifications and standards, brokerage operations, managed care, and data collection. The use of fixed-route bus passes is also discussed as a method of reducing operating and administrative expenses. The report recommended that Medicaid agencies work with the state DOTs and local transit agencies to become an integral part of “the local system.” The report stated that these agencies should set a higher level of provider qualifications and standards that level the playing field, such areas as driver training, vehicle standards, insurance, and safety. It suggested that the monitoring of service is critical, particularly that of brokers and operators. The report identified a number of effi- cient local brokers such as in the states of Florida, Oregon, and Washington. The report also indicated that freedom of choice makes coordination problematic. 6 Transportation-Disadvantaged Populations: Some Coordination Efforts Among Programs Providing Transportation Services, But Obstacles Persist, GAO-03-697, U.S. General Accounting Office, Washington, D.C., June 2003 This report examined the extent to which government agencies are providing and coordinating transportation service to the transportation disadvantaged. The report addressed the federal programs that provide transportation services for the trans- portation disadvantaged and the types of service provided; fed- eral, state, and local spending; the extent of coordination at the federal, state, and local levels; and any obstacles that may impede coordination. The report discussed the benefits of coordination through vehicle sharing, consolidating services, and sharing informa- tion. Efforts to improve service and achieve cost savings vary, however. In other areas, the researchers saw positive results. The report noted that coordination can lead to improvements, whereas lack of coordination can result in overlap and dupli- cation of services. There were numerous obstacles cited in the report, which were categorized as follows: (1) sharing vehicles and the low priority given to funding coordination activities; (2) pro- grammatic differences; and (3) limited state, federal, and local leadership and commitment. Three options were recom- mended to mitigate these difficulties: (1) harmonize standards and requirements among federal programs with transporta- tion, (2) provide and disseminate additional guidance and information, and (3) provide financial incentives or mandates to coordinate. Raphael, D., Medicaid Transportation: Assuring Access to Health Care—A Primer for States, Health Plans, Providers and Advocates, Community Transportation Association of America, Washington, D.C., Jan. 2001 This report briefly describes the NEMT program in general terms. It provides a description of the program, federal reim- bursements, the various components, and some of the mod- els used, with an emphasis on brokerage and managed care. There are a number of examples of different structures. Mod- els that use fixed routes such as those in Connecticut and Portland, Oregon, are highlighted. The second half of the report summarizes the state programs and includes the use of public transit (although it does not compare fixed-route ver- sus paratransit costs). CHAPTER TWO LITERATURE REVIEW

7Borders, S., J. Dyer, and C. Blakely, Texas Medicaid Trans- portation Program: A Study of Demand Response Services in Texas, Public Policy Research Institute, Prepared for Texas A&M University, Austin, July 2003 This study sought to determine the reasonableness of the demand-response transportation rates for rural public transit across Texas. The study was commissioned by the Texas Department of Health, which at the time was the Medicaid transportation agency [subsequently it changed to the Texas Department of Transportation (TxDOT)]. The Department of Health believed that they were paying too much for NEMT, especially in rural areas. The research found no evidence to conclude that the state was overpaying for this service. Costs were commensurate with other programs and states with comparable trip dis- tances. The study did find that the Department of Health did not take full advantage of fixed-route services, citing a rate of 10% fixed-route transit usage in the largest urban areas of the state. The report cited a number of examples of urban areas with more than 50% fixed-route usage, resulting in significant savings. Medicaid Non-Emergency Transportation: Three Case Studies, National Consortium on the Coordination of Human Services Transportation, Washington, D.C., 2003 This consortium of nonprofit human service and transportation programs conducted three case studies: Delaware, capitated broker; Utah, broker/operator; and New York, county-by- county. Key discussion items included the use of bus passes, freedom of choice waivers, brokerage, tracking, and reporting data. The conclusion recognizes that transportation services are different from medical services and, as a result, different approaches are used. There is little discussion of coordinating service with public transit, other than the purchase of bus tickets. Sundeen, M., J. Reed, and M. Savage, Coordinated Human Ser- vice Transportation—State Legislative Approaches, National Conference of State Legislatures, Washington, D.C., Jan. 2005 This study reviewed the effectiveness of state legislatively mandated human service coordination. It reported on a vari- ety of approaches used by the states; 34 states have statutes requiring or authorizing coordination, 21 require specific coordination, and 2 are consolidated (human service and public transit administered together). The report discusses approaches to legislating coordina- tion, barriers and benefits to coordination, federal coordination guidance, state coordination approaches, and coordination pro- files of each state. The report suggests that each state should look carefully at legislatively coordinating transportation and that it may not be a solution to many of the specialized concerns. Medicaid Non-Emergency Transportation National Survey 2002–03, National Consortium on the Coordination of Human Services Transportation, Washington, D.C., Dec. 2003 This survey was constructed to review the state of NEMT. For the purposes of this study, there is a review of coordina- tion activities between state Medicaid agencies and state transit agencies. This report provides an overview of state Medicaid programs including review of match-rate issues, service designs, coordination with state transit agencies, and description of each state program. One of the significant findings was that more than half of the states (and the District of Columbia) have some type of fixed- route bus pass program for at least some of their cities. The agreements are between the state Medicaid agency (or its bro- ker) and the participating transit agencies. The review of each state indicated that some states do not take advantage of fixed- route service, opting instead for more expensive paratransit. KFH Group, Maryland Transportation Coordination Manual, Prepared for the Mass Transit Administration, Maryland Depart- ment of Transportation, Baltimore, Jan. 1998 This “how to guide” is intended for the local level coordina- tors. It focuses on actual steps that can be taken to facilitate and enhance coordination. It takes a realistic look at coordi- nation, including step-by-step sections on planning for coor- dination, developing a service model, overcoming barriers, implementation, and marketing. It is based on real-world experiences and is applicable for NEMT. Westat and Nelson/Nygaard Consulting Associates, TCRP Report 91: Economic Benefits of Coordinating Human Service Transportation and Transit Services, Transportation Research Board, National Research Council, Washington, D.C., 2003 This report points out that significant economic benefits can accrue when human service transportation is coordinated. It cites many examples of coordination from across the coun- try. First, it reviews and defines coordination. The report notes that under any coordination strategy there are two pre- conditions that must be met: shared objectives and shared respect. After these preconditions are met, sharing of respon- sibility, management, and funding can take place. The report further suggests a variety of strategies from examples of other systems and describes the aggregate potential benefits to human service and transit agencies. The benefits include additional revenue generated by transit, sav- ings generated by using fixed-route service—identified as the single highest potential savings ($90–$300 million), savings associated with human service transportation coordination of their own services, and the benefits to other areas as transit is expanded. Medical Transportation Toolkit and Best Practices, 3rd ed., Com- munity Transportation Association of America, Washington, D.C., 2005

The toolkit is designed to assist medical institutions and organizations to better serve their clients needs. It is not specifically geared to NEMT programs, but does include chapters on coordination and Medicaid transportation. This document was updated in 2005 and includes a reference guide and glossary. Burkhardt, J.E., C.A. Nelson, G. Murray, and D. Koffman, TCRP Report 101: Toolkit for Rural Community Coordinated Trans- portation Services, Transportation Research Board, National Research Council, Washington, D.C., 2004 This report documents a wide range of coordination efforts and provides a step-by-step guide to the coordination of rural transit services with human service transportation. It is intended for transit agency and human service transportation managers at the state and local levels. The report also has many examples of coordination and a set of resources for managers. Advantages and disadvantages of coordination are highlighted. The authors concluded that there are no true pro- hibitions or barriers to coordination, there are just obstacles and challenges. In summary, the various publications reviewed different barriers and needs to coordination. Most of the reports focused on general coordination issues, with some literature related to public transit and NEMT specifically. These pub- lications and reports suggest a variety of ways to coordinate and improve coordination through administrative and orga- nizational, operational, and legislative approaches. KEY ISSUES Administrative and Organizational Issues The CTAA document had considerable information regarding administrative issues such as rate setting and waivers. The Texas Medicaid review of rates found that the cost models used by transit agencies in rural areas were appropriate and reasonable, whereas coordination and use of urban fixed-route services was not being fully utilized. Operational Issues The NEMT TAG report, the TCRP report on economic ben- efits, and the Maryland Coordination Manual included some sound operating and contract management recommendations that can be used by Medicaid transportation managers to assist in coordination efforts. There were a number of stud- ies initiated by Florida concluding that the expanded use of fixed-route public transit and the use of the waiver to elimi- nate the so-called freedom of choice have saved considerable sums while meeting needs in an appropriate manner. In addi- tion, a number of other studies, including reports by the Texas Public Policy Research Institute and Florida’s Center for Urban Transportation, and the CTAA Medical Trans- portation Toolkit, identified the use of fixed-route service as 8 a practical way to coordinate and lower cost and advocate maximizing the use of fixed-route services. These studies cite fixed-route usage at 50% of NEMT trips in some urban areas. Economic Benefits and Legislative Issues One study focused on legislative approaches to coordination, reporting that legislative mandates may help. The GAO report on transportation-disadvantaged populations cited some of the coordination barriers as leveling the playing field; educating federal, state, and local officials; and sharing of resources. The TCRP report on economic benefits (TCRP Report 91) quantified the economic benefits by type and cited conditions required for coordination. Summary of Key Issues The following summarizes the key issues from the literature review relating to the coordination of NEMT and public transportation: • Fixed-route bus—An essential component to any coor- dination effort (where available). The use of fixed-route passes or tickets is extremely advantageous. The Med- icaid agency gets an extremely low-cost trip (typically $1 or less), the transit agency boosts ridership for no significant cost, and the customer gains access for more than just medical transportation. Many studies cited the clear benefits of this approach. • Close working relationship with transit—State and local (where appropriate) Medicaid agencies and the state DOTs and transit agencies should have a good working relationship. The Maryland Transportation Coordination Manual (KFH Group 1998) cites the clear benefits to building an atmosphere of trust. The TAG report (Bradley et al. 1998) emphasized the need for a close working relationship. Coordination requires that all participating organizations benefit from the effort. • Level playing field—Identification of the need for a level playing field operationally is important to any coordination effort. The research (and discussions with operators) indicated that this is a concern. The TAG report (Bradley et al. 1998) firmly grasped the issue. Often, the standards for operating Medicaid transporta- tion service are less stringent than those for public tran- sit operators. This poses challenges to transit agencies in competing with an operator who is willing to conduct less training, have non-ADA-compliant vehicles, and accept operators with less experience. • Use the waiver—Freedom of choice does not work as effectively in the context of transportation as it does in the medical profession, which is a much more heavily licensed and credentialed profession (see level playing

9field). The Florida example cites many benefits to elim- inating the choice requirement. • Legislative mandates—It is not clear to researchers that legislating coordination is effective. One report sug- gested that each state should look carefully at legisla- tively coordinating transportation and that it may not be a solution to many of the specialized concerns. • Cost transferring—One report (TAG) stated that NEMT programs should not “shed” clients onto the ADA para- transit agency, because it would place an undue burden on the local transit agency. The report indicated that a number of Medicaid officials have stated that it is per- missible for NEMT managers to negotiate a rate that is higher than the general public fare.

Next: Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies »
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TRB's Transit Cooperative Research Program (TCRP) Synthesis 65: Transit Agency Participation in Medicaid Transportation Programs explores the tasks that may help develop successful public transit-non-emergency medical transportation (NEMT) partnerships. The report examines real and perceived barriers to NEMT and public transit coordination and includes case studies of Medicaid transportation program participation by transit agencies.

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