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ACKNOWLEDGMENT This work was sponsored by the Federal Transit Administration (FTA) in cooperation with the Transit Development Corporation. It was conducted through the Transit Cooperative Research Program (TCRP), which is administered by the Transportation Research Board (TRB) of the National Academies. DISCLAIMER The opinions and conclusions expressed or implied in the report are those of the research agency. They are not necessarily those of the TRB, the National Research Council, the FTA, the Transit Development Corporation, or the U.S. Government. This report has not been edited by TRB.
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Table of Contents Executive Summary ............................................................................................................................. 1 Chapter 1: Introduction....................................................................................................................... 7 Chapter 2: Literature Review ........................................................................................................... 10 2.1 Identification of the Transportation-Disadvantaged Population ....................................... 10 2.2 Evidence of Unmet Need for NEMT ................................................................................ 11 2.3 Consequences of Unmet NEMT Needs ............................................................................ 12 2.4 Estimates of Costs and Benefits of Meeting Unmet NEMT Needs .................................. 14 2.5 Additional Use of Literature in This Report ..................................................................... 15 Chapter 3: The Transportation-Disadvantaged Population and Access to Healthcare............... 16 3.1 Estimating the Size of the Transportation-Disadvantaged Population That Lacks Access to NEMT............................................................................................................... 18 3.1.1 NHIS Perspective on the Transportation-Disadvantaged Population .................. 18 3.1.2 MEPS Perspective on the Transportation-Disadvantaged Population ................. 19 3.1.3 Conclusions Regarding NHIS, MEPS, and This Study ....................................... 20 3.2 Additional Estimates of the Size of the Transportation-Disadvantaged Population That Lacks Access to NEMT............................................................................................ 21 Chapter 4: Description of the Transportation-Disadvantaged Population That Misses Medical Care Due to a Lack of Access to Non-Emergency Medical Transportation ....................... 24 4.1 Demographic and Socio-economic Characteristics of the Population That Lacks Access to NEMT............................................................................................................... 24 4.2 Urban-Rural Split of the Target Population That Lacks Access to NEMT ...................... 25 4.3 Identification of Medical Conditions Faced by Those Lacking NEMT ........................... 26 4.3.1 Adult Disease Conditions .................................................................................... 26 4.3.2 Child Disease Conditions..................................................................................... 28 4.3.3 Discussion and Conclusions from Analysis of Medical Conditions.................... 30 4.3.4 The Prevalence of Multiple Medical Conditions Experienced by the Target Population ............................................................................................................ 31 4.4 Utilization of Health Resources by the Target Population ............................................... 32 4.4.1 Disease Prevalence and Co-Morbidities .............................................................. 33 Chapter 5: Cost of Providing Non-Emergency Medical Transportation ...................................... 35 5.1 Paratransit Cost Estimates ................................................................................................ 36 Final Report iii
5.2 Fixed-Route Cost Estimates.............................................................................................. 37 5.3 Linking Medical Conditions to Transportation Service Type .......................................... 38 5.4 Discussion of NEMT Cost Estimates ............................................................................... 40 Chapter 6: Method for Estimating Healthcare Costs and Outcomes............................................ 41 6.1 Review of Health Costs and Outcomes Evaluation .......................................................... 41 6.1.1 Healthcare Costs .................................................................................................. 41 6.1.2 Health Outcomes.................................................................................................. 42 6.2 Estimating Missed Trips from a Disease Perspective ....................................................... 43 6.2.1 Identifying and Aggregating Missed Trips .......................................................... 43 6.2.2 Comparison of Costs for Well and Poorly Managed Individuals ........................ 43 6.2.3 Cost Benefit Analysis Issues................................................................................ 44 6.3 Review of Cost-Effectiveness Analysis in Healthcare ..................................................... 45 6.4 Using the MEPS for Cost-Effectiveness Analysis............................................................ 46 6.4.1 QALY Information in the MEPS......................................................................... 46 6.4.2 Using the Richness of the MEPS for Cost and Benefit Analysis......................... 47 6.5 Establishing the Benefits of Well-Managed Care............................................................. 50 6.6 Benefits and Costs of Providing Transportation for Chronic Medical Conditions: Analytical Steps ................................................................................................................ 51 6.7 Benefits and Costs of Providing Transportation for Preventive Health............................ 53 6.8 Summary and Discussion of Healthcare Cost Methods.................................................... 53 Chapter 7: Condition-Based Cost-Effectiveness Analysis of NEMT and Health ......................... 55 7.1 Cost-Effectiveness of Increased Access to Healthcare for Preventive Care..................... 55 7.1.1 Influenza Vaccinations ........................................................................................ 55 7.1.2 Prenatal Care........................................................................................................ 56 7.1.3 Cancer Screening: Breast Cancer........................................................................ 58 7.1.4 Cancer Screening: Colorectal Cancer .................................................................. 59 7.1.5 Dental Care .......................................................................................................... 60 7.2 Cost-Effectiveness of Increased Access to Healthcare for Chronic Conditions ............... 61 7.2.1 Asthma................................................................................................................. 62 7.2.2 Heart Disease ....................................................................................................... 65 7.2.3 Chronic Obstructive Pulmonary Disease (COPD)............................................... 68 7.2.4 Hypertension........................................................................................................ 70 7.2.5 Diabetes ............................................................................................................... 73 7.2.6 Depression/Mental Health ................................................................................... 75 7.2.7 End-Stage Renal Disease ..................................................................................... 79 7.3 Summary and Discussion.................................................................................................. 82 7.3.1 Summary of Condition Analyses ......................................................................... 82 Final Report iv
7.3.2 Discussion............................................................................................................ 82 Chapter 8: A Spreadsheet Tool for Regional and Local Analysis.................................................. 84 8.1 Regional and Local Analysis ............................................................................................ 84 8.2 Use of Local Knowledge and Data with Spreadsheet Tool .............................................. 85 8.3 Sensitivity Analysis with Spreadsheet Tool ..................................................................... 86 8.4 Use and Application of Spreadsheet Tool ........................................................................ 87 Chapter 9: Conclusions...................................................................................................................... 89 9.1 Principal Findings ............................................................................................................. 89 9.1.1 The Transportation-Disadvantaged Population and Access to Healthcare .......... 90 9.1.2 Characteristics of the Target Population.............................................................. 91 9.1.3 Cost of Non-Emergency Medical Transportation................................................ 91 9.1.4 Optimal Method for an Economic Evaluation of Healthcare Costs, Outcomes, and Offsetting Transportation Costs .................................................................... 92 9.1.5 Value of a User-Based Spreadsheet Tool ............................................................ 92 9.2 Discussion and Suggestions for Further Research............................................................ 92 References ........................................................................................................................................... 95 Appendix A: Glossary of Technical Terms ....................................................................................A-1 Appendix B: Annotated Bibliography ............................................................................................ B-1 Appendix C: Cost-Effectiveness Analysis and QALYs .................................................................C-1 Final Report v
List of Figures Figure ES-1: Transportation-Disadvantaged Population at Risk of Missing Non-Emergency Care...... 4 Figure 3-1: Identification of Target Population for This Study ......................................................... 16 Figure 3-2: Transportation-Disadvantaged Population at Risk of Missing Non-Emergency Care.... 23 List of Tables Table ES-1: Summary of Condition-Specific Cost-Effectiveness......................................................... 2 Table ES-2: Critical Medical Conditions Affecting Transportation-Disadvantaged Persons ............... 5 Table ES-3: NEMT Costs for Paratransit Services in Urban and Rural Areas ..................................... 6 Table 3-1: Adults Reporting Lack of Transportation to Medical Care from 2002 NHIS................. 19 Table 3-2: Children Reported to Lack Transportation to Medical Care from 2002 NHIS ............... 19 Table 4-1: Number of Persons Missing NEMT Trips per Year in Urban and Rural Areas.............. 26 Table 4-2: Medical Conditions Experienced by Adults in the Target Population ............................ 26 Table 4-3: Prevalent Conditions in Adults from 2002 NHIS............................................................ 28 Table 4-4: Medical Conditions Faced by Children Who Lack NEMT............................................. 29 Table 4-5: Critical Medical Conditions Affecting Transportation-Disadvantaged Persons Who Lack Access to NEMT ............................................................................................................. 30 Table 4-6: Prevalence of Co-Morbidities in the Target Population Compared to Everyone Else .... 31 Table 4-7: Aggregate Utilization Means for the Target Population and Non-Target Population (Prior 12 Months) ............................................................................................................ 32 Table 4-8: Condition-Based Visits from the 2001 MEPS ................................................................ 33 Table 4-9: Condition Prevalence and Utilization Means at the Condition Level â Target Population33 Table 5-1: Estimated One-Way Trips Costs for NEMT by Paratransit Service Category (2004) .... 37 Table 5-2: Cost Estimates for Fixed-Route Service Based on APTA Web Site (and NTD Data).... 38 Table 5-3: Average per NEMT One-Way Trip Cost by Condition .................................................. 39 Table 6-1: EuroQol 5 D Results from the MEPS ............................................................................. 47 Table 6-2: Demographic Review of the Target Population and Rest of the U.S. ............................. 48 Table 6-3: Insurance Status of the Target Population....................................................................... 49 Table 6-4: Utilization of Services ..................................................................................................... 49 Table 6-5: Weighted Median Per Capita Healthcare Costs by Category.......................................... 49 Table 6-6: Medicare Fee Schedule Evaluation & Management Visits for Established Patients ...... 52 Table 7-1: Cost-Effectiveness Results for Flu Vaccine.................................................................... 56 Table 7-2: Prenatal Care Trip Costs ................................................................................................. 57 Table 7-3: Cost-Effectiveness Results for Prenatal Care.................................................................. 58 Table 7-4: Cost-Effectiveness Results for Breast Cancer Screening................................................ 59 Table 7-5: Cost-Effectiveness Results for Colon Cancer Screening ................................................ 60 Final Report vi
Table 7-6: Cost-Effectiveness Results for Preventive Dental Care .................................................. 61 Table 7-7: Cost Comparison of Asthma Patients in MEPS (2001)................................................... 63 Table 7-8: Calculation of NEMT Cost for Asthma .......................................................................... 64 Table 7-9: Cost-Effectiveness Results for Asthma NEMT............................................................... 65 Table 7-10: Cost Comparison of CHF Patients in MEPS (2001) ....................................................... 66 Table 7-11: Calculation of NEMT Cost for CHF ............................................................................... 67 Table 7-12: Cost-Effectiveness Results for CHF NEMT ................................................................... 67 Table 7-13: Cost Comparison of COPD Patients in MEPS (2001) .................................................... 68 Table 7-14: Calculation of NEMT Cost for COPD ............................................................................ 69 Table 7-15: Cost-Effectiveness Results for COPD NEMT ................................................................ 69 Table 7-16: Drug and Visit Screen Cost Comparison of HTN in MEPS (2001)................................ 70 Table 7-17: Drug Screen Only HTN and TOTAL Cost Comparisons in MEPS (2001) .................... 71 Table 7-18: Calculation of NEMT Cost for HTN............................................................................... 72 Table 7-19: Cost-Effectiveness Results for HTN NEMT................................................................... 72 Table 7-20: Cost Comparison of Diabetes Patients in MEPS (2001) ................................................. 73 Table 7-21: Calculation of NEMT Cost for Diabetes ......................................................................... 74 Table 7-22: Cost-Effectiveness Results for Diabetes NEMT ............................................................. 75 Table 7-23: Depression Only Cost Comparison for Depression Patients in MEPS (2001)................ 76 Table 7-24: Total Healthcare Cost Comparison for Depression Patients in MEPS (2001) ................ 77 Table 7-25: Calculation of NEMT Cost for Depression..................................................................... 78 Table 7-26: Cost-Effectiveness Results for Depression NEMT ......................................................... 79 Table 7-27: Cost of ESRD in MEPS (2001)....................................................................................... 80 Table 7-28: Calculation of NEMT Cost for ESRD............................................................................. 81 Table 7-29: Cost-Effectiveness Results for ESRD NEMT................................................................. 81 Table 7-30: Summary of Condition-Specific Cost-Effectiveness Results .......................................... 82 Table 9-1: Summary of Condition-Specific Cost-Effectiveness Results ............................................ 89 Table 9-2: Racial Composition of Target Population and All-Others................................................. 91 Final Report vii
