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8 The toolkit is designed to assist medical institutions and a practical way to coordinate and lower cost and advocate organizations to better serve their clients needs. It is not maximizing the use of fixed-route services. These studies specifically geared to NEMT programs, but does include cite fixed-route usage at 50% of NEMT trips in some urban chapters on coordination and Medicaid transportation. This areas. document was updated in 2005 and includes a reference guide and glossary. Economic Benefits and Legislative Issues Burkhardt, J.E., C.A. Nelson, G. Murray, and D. Koffman, TCRP Report 101: Toolkit for Rural Community Coordinated Trans- One study focused on legislative approaches to coordination, portation Services, Transportation Research Board, National Research Council, Washington, D.C., 2004 reporting that legislative mandates may help. The GAO report on transportation-disadvantaged populations cited This report documents a wide range of coordination efforts some of the coordination barriers as leveling the playing and provides a step-by-step guide to the coordination of rural field; educating federal, state, and local officials; and sharing transit services with human service transportation. It is of resources. The TCRP report on economic benefits (TCRP intended for transit agency and human service transportation Report 91) quantified the economic benefits by type and cited managers at the state and local levels. The report also has conditions required for coordination. 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- Summary of Key Issues hibitions or barriers to coordination, there are just obstacles and challenges. The following summarizes the key issues from the literature review relating to the coordination of NEMT and public In summary, the various publications reviewed different transportation: barriers and needs to coordination. Most of the reports focused on general coordination issues, with some literature Fixed-route bus--An essential component to any coor- related to public transit and NEMT specifically. These pub- dination effort (where available). The use of fixed-route lications and reports suggest a variety of ways to coordinate passes or tickets is extremely advantageous. The Med- and improve coordination through administrative and orga- icaid agency gets an extremely low-cost trip (typically nizational, operational, and legislative approaches. $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 KEY ISSUES clear benefits of this approach. Close working relationship with transit--State and Administrative and Organizational Issues local (where appropriate) Medicaid agencies and the state DOTs and transit agencies should have a good The CTAA document had considerable information regarding working relationship. The Maryland Transportation administrative issues such as rate setting and waivers. The Coordination Manual (KFH Group 1998) cites the Texas Medicaid review of rates found that the cost models clear benefits to building an atmosphere of trust. The used by transit agencies in rural areas were appropriate and TAG report (Bradley et al. 1998) emphasized the need reasonable, whereas coordination and use of urban fixed-route for a close working relationship. Coordination requires services was not being fully utilized. that all participating organizations benefit from the effort. Operational Issues Level playing field--Identification of the need for a level playing field operationally is important to any The NEMT TAG report, the TCRP report on economic ben- coordination effort. The research (and discussions with efits, and the Maryland Coordination Manual included some operators) indicated that this is a concern. The TAG sound operating and contract management recommendations report (Bradley et al. 1998) firmly grasped the issue. that can be used by Medicaid transportation managers to Often, the standards for operating Medicaid transporta- assist in coordination efforts. There were a number of stud- tion service are less stringent than those for public tran- ies initiated by Florida concluding that the expanded use of sit operators. This poses challenges to transit agencies fixed-route public transit and the use of the waiver to elimi- in competing with an operator who is willing to conduct nate the so-called freedom of choice have saved considerable less training, have non-ADA-compliant vehicles, and sums while meeting needs in an appropriate manner. In addi- accept operators with less experience. tion, a number of other studies, including reports by the Use the waiver--Freedom of choice does not work as Texas Public Policy Research Institute and Florida's Center effectively in the context of transportation as it does in for Urban Transportation, and the CTAA Medical Trans- the medical profession, which is a much more heavily portation Toolkit, identified the use of fixed-route service as licensed and credentialed profession (see level playing

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