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Chapter 1: Introduction Millions of Americans are considered to be âtransportation disadvantaged,â because they cannot provide or purchase their own transportation. Members of this population, due to low income, physical or mental disability, inability to drive, geographic isolation, or some other reason, cannot transport themselves or are unable to purchase available transportation services, such as those provided by buses or taxis. As a result, this populationâwhich is disproportionately elderly, poor, disabled, or some combination of theseâdepends on others to access employment, education, shopping, and healthcare. This dependency, in turn, reduces access to essential healthcare services. Although disease progression can be complicated, for some people this reduced access clearly leads to decreases in health status or lost opportunities for detecting diseases early. People who are particularly affected include those with chronic conditions (e.g., heart failure, asthma, diabetes), especially those with multiple conditions (i.e., co-morbidities), and those who stand to benefit from prompt screening and disease prevention. Because transportation-disadvantaged persons are associated with a critical lack of healthcare access, routine conditions can lead to a need for emergency care. Poor monitoring and preventive activities result in unnecessary hospitalizations. For example, poorly managed asthmaâa problem among children in the inner city who are also more likely to be transportation disadvantaged than the general population isâcan cause a major attack. This study investigates the hypothesis that improving access to healthcare for the transportation-disadvantaged population will lead to improved quality of life, potential enhancements in life expectancy, and an overall decrease in healthcare costs nationally. Furthermore, this study examines whether or not this decrease in healthcare costs exceeds the incremental increase in transportation costs required to provide additional non-emergency medical transportation (NEMT) to the transportation-disadvantaged population. Billions of dollars are already being spent on transportation services for transportation-disadvantaged persons nationally. Because these dollars come from so many different sources, identifying and totaling these dollars is not easy. Indeed, according to a report prepared by the General Accounting Office (U.S. GAO, 2003), the multitude of programs makes it difficult to even measure the amount of federal funding spent to serve the transportation disadvantaged, though GAO found that 29 of the 62 federal programs that provide transportation services spent a combined total of nearly $2.4 billion per year, and the states together spend hundreds of millions of dollars per year. (In July 2004, the General Accounting Office was renamed the Government Accountability Office.) These estimates do not include the cost of time off from work and other costs borne by private individuals who transport disadvantaged family members and friends; thus, the real total is much higher than the sum of these federal, state, and local estimates. For those Americans who are unable to purchase their own transportation or to obtain needed transportation from relatives, friends, and acquaintances, various forms of paratransit (such as demand-responsive buses, taxis, van services, etc.) are a primary mode by which they achieve mobility. This service, including that associated with non-emergency medical transportation, is provided by both public transportation Final Report 7
agencies and other (generally private or not-for-profit) entities. On the public side, paratransit serves a number of trip purposes (medical, shopping, employment) for older adults, people with disabilities, and other members of the transportation- disadvantaged population, much of this through Section 5310 of the transportation bill. In a study of public paratransit in southeastern Michigan, however, Wallace (1997) found that medical-related trips were the dominant trip purpose in the three- county area around Detroit, Michigan. To access public paratransit, prospective riders generally must schedule their trip two days in advance. Furthermore, the demand may exceed the supply of trips, resulting in denied trip requests. Again for the service in southeastern Michigan, Wallace (1997) found that roughly 15 percent of trip requests could not be accommodated. While those eligible under the Americans with Disabilities Act (ADA) cannot be denied service in many situations, the average older adult without other access to transportation must compete with other users of the system for available service. Thus, denied trip requests can also lead to missed or delayed medical care. A substantial investment is already being made to provide transportation to help transportation-disadvantaged people obtain medical services. Much of this is part of the Medicaid program and is provided by a patchwork of van services, taxis, ambulance services, and the like. Unlike Medicaid, however, Medicare does not offer a non-emergency transportation benefit, meaning that NEMT needs for this class of medical care must be funded from other sources. In many regions, brokers have been established to match riders with available services. In other places, state or local agencies manage such services. In all cases, operators face the challenge of making maximum use of available transportation to meet a growing trip demand. Studies from Kentucky (OâConnell et al., 2002), Georgia (Logisticare, 2003a), Connecticut (Logisticare, 2003b), and North Carolina (Olason, 2001) have shown that such factors as computer-aided scheduling and dispatching and tight controls on eligibility can increase the capacity of available service by reducing average trip length, carrying more than one passenger at a time, and reducing the number of ineligible trips. In this way, average trip cost is reduced and more trips can be provided with no change in available resources. In response to the importance of examining unmet needs for non-emergency medical transportation nationally, the Transportation Research Board (TRB) launched the project, Cost Benefit Analysis of Providing Non-Emergency Medical Transportation (TCRP B-27). The primary goal of this study is to determine if the costs of providing NEMT to those transportation-disadvantaged persons who currently lack access to NEMT are outweighed by the benefits of providing this service. To achieve this goal, the objectives of this study are to: ⢠Identify the transportation-disadvantaged population that misses non- emergency medical care due to a lack of available transportation ⢠Determine the medical conditions that this target population suffers from and describe other important characteristics of these individuals, such as their distribution across urban and rural areas Final Report 8
⢠Estimate the cost of providing the transportation that this target population would need to obtain non-emergency medical transportation according to various transportation service needs and trip modes ⢠Estimate the healthcare costs and benefits that would result if these individuals obtained transportation to non-emergency medical care for a set of key healthcare conditions prevalent for this population ⢠Compare the relative costs (from transportation and routine healthcare) and benefits (such as improved quality of life and better managed care, leading to less emergency care) to determine the cost-effectiveness of providing NEMT for the target population for the selected conditions This final report presents the results, conclusions, and supporting documentation from the Altarum Instituteâs study of this complex issue. The following chapters describe this work, including methods and findings, in detail. In addition, there are three appendices to facilitate use of this report: A. A brief glossary of technical terms B. A comprehensive, annotated bibliography for most of the literature reviewed for this study (Articles obtained in the latter stages of completing the cost- effectiveness case studies, mostly found in Chapter 7, are not included in the Annotated Bibliography, but are cited in the References section.) C. A technical appendix presenting an overview of cost-effectiveness analysis and the use of quality-adjusted life years in healthcare studies (QALYs) Final Report 9
