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Research Results Digest 75 January 2006 This digest contains information on the relative costs and benefits of providing transportation to non-emergency medical care for individuals who miss or delay healthcare appointments because of trans- portation issues. Paratransit operators and other transportation providers, legislative policy makers, and healthcare providers responsible for cost-effective transporta- tion and healthcare decisions will find this digest of interest. INTRODUCTION Millions of Americans are considered to be âtransportation disadvantaged,â because they cannot provide or purchase their own transportation. As a result, this populationâ which is disproportionately elderly, poor, mobility-impaired, minority, or some com- bination of theseâdepends on others to ac- cess employment, education, shopping, and healthcare. Because they depend on others for transportation, the persons in this popu- lation have reduced access to healthcare services, and this places them at risk for poor health outcomes. Lacking available or affordable transportation, they miss or post- pone routine care or preventive services, which can lead to a need for emergency care and preventable hospitalizations. For example, poorly managed asthma, a prob- lem among children in the inner city with unique transportation barriers, can cause a major asthma episode (or attack). Access to non-emergency medical transportation (NEMT) can reduce emergency room and hospital expenditures for members of the transportation-disadvantaged population. In response to the importance of ex- amining the need for improved access to NEMT nationally, TCRP launched Project B-27, âCost Benefit Analysis of Providing Non-Emergency Medical Transportation.â The goal of this study was to compare the costs and benefits, including potentially large net health benefits, of providing NEMT to those who lack access to it. To achieve this goal, the objectives of this study were to â¢ Identify the transportation-disadvan- taged population that misses non- emergency medical care because of a lack of available transportation (the target population); â¢ Determine the medical conditions that this target population suffers from and describe other important charac- teristics of these individuals, such as their distribution across urban and rural areas; EXECUTIVE SUMMARY: COST BENEFIT ANALYSIS OF PROVIDING NON-EMERGENCY MEDICAL TRANSPORTATION This digest summarizes the final report of TCRP Project B-27, âCost Benefit Analysis of Providing Non-Emergency Medical Transportation.â The final report is available as TCRP Web-Only Document 29. This digest was written by P. Hughes-Cromwick and R. Wallace of Altarum Institute. Subject Area: IA Planning and Administration VI Public Transit Responsible Senior Program Officer: Dianne S. Schwager TRANSIT COOPERATIVE RESEARCH PROGRAM Sponsored by the Federal Transit Administration
â¢ Estimate the cost of providing the transporta- tion that this population would need to obtain medical transportation according to various transportation service needs and trip modes; â¢ Estimate the healthcare costs and benefits that would result if these individuals obtained trans- portation to non-emergency medical care for key healthcare conditions prevalent for this population; and â¢ Compare the relative costs (from transporta- tion and routine healthcare) and benefits (such as improved quality of life and better man- aged care, leading to less emergency care) to determine the cost-effectiveness of providing transportation for selected conditions. This study investigated the hypothesis that im- proving access to healthcare for the transportation- disadvantaged population will lead to improved quality of life and an overall decrease in healthcare costs. Furthermore, this study examined whether this hypothesized net decrease in healthcare costs exceeds the incremental increase in transportation costs. TCRP Web-Only Document 29 (www4.trb.org/ trb/onlinepubs.nsf/) explains the methods used in the Altarum Instituteâs study of this novel and complex issue and presents the findings, along with supporting documentation. SUMMARY OF RESULTS An analysis of nationally representative health- care datasets revealed that about 3.6 million Amer- icans miss or delay non-emergency medical care each year because of transportation issues. This target population of 3.6 million persons was found to have a higher prevalence of chronic diseases and a higher rate of multiple chronic conditions. The reasons for this higher prevalence and rate are described in TCRP Web-Only Document 29, as are the reasons chronic conditions and preventive care conditions were selected for the economic evaluation of pro- viding transportation. The researchers determined that the most appro- priate method of evaluating the benefits of improved access to medical care is cost-effectiveness analysis (CEA). For all 12 medical conditions analyzed, the researchers found that providing additional NEMT is cost-effective; for four of these conditions, the re- searchers found that providing additional NEMT is actually cost savingâadditional investment in trans- portation leads to a net decrease in total costs when both transportation and healthcare are examined. Table 1 summarizes the condition-specific results highlighting the most likely estimates. The CEA method measures the effectiveness- per-unit cost, as opposed to a cost-to-cost comparison. As described in the final report, healthcare improve- ments are worth the amount invested when the cost is reasonable in light of improvements in mortality (en- hanced life expectancy) and morbidity (health-related quality of life). Thus, while cost savings are the best possible outcome, cost increases may nevertheless be seen as worthwhileâi.e., cost-effective if they pro- vide sufficient improvement in quality of life, life ex- pectancy, or both. This standard is met for the eight conditions that are not estimated to be cost saving. 2 Table 1 Summary of Condition-Specific Cost-Effectiveness Condition Type Result Influenza Vaccinations Preventive Highly Cost-Effective Prenatal Care Preventive Cost Saving Breast Cancer Screening Preventive Moderately Cost-Effective Colorectal Cancer Screening Preventive Moderately Cost-Effective Dental Care Preventive Highly Cost-Effective Asthma Chronic Cost Saving Heart Disease (Congestive Heart Failure, CHF) Chronic Cost Saving Chronic Obstructive Pulmonary Disease (COPD) Chronic Highly Cost-Effective Hypertension (HTN) Chronic Highly Cost-Effective Diabetes Chronic Cost Saving Depression / Mental Health Chronic Highly Cost-Effective End-Stage Renal Disease (ESRD) Chronic Highly Cost-Effective
Based on the convention frequently cited in health economics literature, investments that provide one additional Quality Adjusted Life-Year (QALY) are valued at $50,000 (see Appendix C in TCRP Web- Only Document 29). Interventions that provide one QALY and cost less than $50,000, therefore, are deemed to be cost-effectiveâworth the investment. Each of the analyses yielded either a cost saving or a net cost increase of less than $50,000 per QALY. Due to variations in cost per QALY, the researchers la- beled NEMT for specific conditions as either highly or moderately cost-effective, with the former refer- ring to costs far less than $50,000 per QALY and the latter referring to costs closer to $50,000 per QALY. Using two approachesâone for chronic condi- tions amenable to disease management and one for conditions amenable to preventive careâthe re- searchers were able to determine reasonable health- care cost differences between well and poorly man- aged care. These differences were applied to the target population, which is assumed to have poorly managed care due to its transportation barriers. For chronic conditions, the researchers used the Medical Expenditure Panel Study data to determine these cost differences and, for preventive care, used values derived from the literature. The net healthcare benefits of increased access to medical care for the transportation- disadvantaged exceed the additional costs of transportation for all of these conditions. These benefits include both ac- tual decreases in healthcare costs for some condi- tions (e.g., emergency care replaced by routine care) and improved quality of life for those who receive access. For three of the chronic conditions (asthma, heart disease, and diabetes), results show net cost savings; for the other four (depression, hyperten- sion, chronic obstructive pulmonary disease, and end- stage renal disease), improvements in life expectancy or quality of life are sufficient to justify the added expense. These results evince a major finding and theme of this project: adding relatively small transportation costs does not make a disease-specific, otherwise cost-effective environment non-cost-effective. For example, a congestive heart failure monitoring pro- gram, already evaluated as highly cost-effective, will not become cost-ineffective by only adding incre- mental transportation costs. In other words, in todayâs economy, transportation is relatively inexpensive compared with the high and rapidly growing cost of healthcare. WHO MISSES NON-EMERGENCY MEDICAL TREATMENT BECAUSE OF LACK OF TRANSPORTATION: DEFINING THE TARGET POPULATION The estimate of 3.6 million Americans who miss or delay medical care because of a lack of access to NEMT each year, derived from analysis of the National Health Interview Survey (NHIS) and the Medical Expenditures Panel Survey (MEPS), is conservative and should be seen as a lower bound estimate. Response bias inherent in these studies, e.g., their difficulty in surveying the homeless and other truly disadvantaged individuals, lowers the esti- mate, and some populations may be totally ignored in the data. This bias will tend to make the estimate lower than if the studies truly represented the entire U.S. population. Furthermore, because people can fall into and out of transportation-disadvantaged status over time, as well as change healthcare status (e.g., healthy or not, have insurance or not), results suggest that only some of the Americans who are at risk of miss- ing non-emergency care because of a lack of trans- portation actually do miss medical treatment in a given year. This phenomenon is shown in Figure 1. Finally, several factors and trendsâdisproportionate population growth of groups in the current target population; the aging of the U.S. population; more expensive, less affordable healthcare; rising disease prevalenceâwill conspire to dramatically increase the future projection of transportation-disadvantaged individuals at risk of missing health care, i.e., this studyâs target population. Those who fall into the target population of 3.6 million for this study have characteristics that clearly distinguish them from the rest of the U.S. pop- ulation. Demographically and socio-economically, the findings show that, compared to the rest of the U.S. population, this target population â¢ Has relatively low income (54.6 percent have household incomes less than $20,000 per year compared with only 17.7 percent for the re- mainder of the U.S. population); â¢ Is disproportionately female (62.8 percent female versus 51.9 percent) and non-white (19.1 percent non-white versus 17.7 percent); â¢ Has a higher minority representation (13.5 per- cent African American versus 12.6 percent; 16.7 percent Hispanic versus 13.2 percent); â¢ Is roughly one-half as likely to possess a four-year college degree; 3
â¢ Is older (16.3 percent are 70 or older compared with 11.5 percent); and â¢ Is distributed across urban and rural America much the same as the U.S. population as a whole, although children are slightly more concentrated in urban areas. In terms of health status, the target population suf- fers from critical diseases at a higher rate than does the rest of the U.S. population, and it generally accesses more medical care than does the rest of the U.S. pop- ulation, despite its transportation barriers, almost cer- tainly because it is much more ill on average. SELECTION OF HEALTH CONDITIONS FOR THE ANALYSIS The examined diseases were drawn from the prevalence data in NHIS and MEPS. While there is clear value in a condition-by-condition approach for evaluating the costs and benefits of providing trans- portation to transportation-disadvantaged individu- als, there is an obvious trade-off between the num- ber of conditions that are evaluated and the quality of these analyses. For this study, a limited number of health conditions, both chronic and preventive, were analyzed. These conditions were selected pri- marily because of their prevalence in the target pop- ulation. The final list was reviewed and approved by the panel convened by TCRP to oversee the project. The conditions are listed in Table 2. Members of the target population are extremely high healthcare users, despite the barriers they face getting to appointments, because they have high dis- ease prevalence, multiple simultaneous diseases, and high disease severity. Based on their demo- graphic, socio-economic, and health characteristics, members of the target population also appear to be more likely than others are to live in less healthy en- vironments, exacerbating their need for healthcare visits. Recent research shows that a significant por- tion of overall healthcare cost inflation derives from a small set of healthcare conditionsâon the order of 30 percent of cost growth is accounted for by five conditions (heart disease, pulmonary disease, men- tal health, cancer, and hypertension). These findings strongly argue for a condition-specific method, in which a selective set of conditions is intensively studied. THE COST OF NEMT To determine the costs associated with providing additional transportation, the researchers analyzed trip cost data for the year 2004 obtained from trans- portation providers located throughout the United 4 Transportation- Disadvantaged Persons Transportation- disadvantaged persons who missed non- emergency medical care Transportation-disadvantaged persons who found transportation from a source that is not always available â a friend, acquaintance, family member, etc. Transportation-disadvantaged persons who should be in a disease-management program or should be receiving preventive care. Those Who Miss Non-Emergency Medical Care Primary reasons for missing care include lack of insurance or funds to pay for care, time conflicts with appointment, refusal to seek care, etc. Approximately 3.6 million Americans per year Figure 1 Transportation-Disadvantaged Population at Risk of Missing Non-Emergency Care
States. The ambulatory, wheelchair, and stretcher costs of various trip types were determined in both urban and rural locations. Although persons who are ambulatory could, in theory, access fixed-route trans- portation, the research suggests that those who actu- ally have such access are or could be using it to obtain medical care. Thus, paratransit service was the focus for these three service types in urban and rural areas, resulting in six transportation cost categories. These categories and costs are listed in Table 3. A small portion of missed trips could be provided by fixed-route public transportation. Using data from the National Transit Database (NTD), the researchers also determined that the average cost of providing a one-way, fixed-route trip is $2.86 (using 2002 data). Using these average costsâparatransit and fixed- route public transportationâfor providing the unmet NEMT needs of the target population, the researchers were able to determine whether the net healthcare cost savings exceed the costs, by medical condition. MISSING LINKS: SHORTCOMINGS IN AVAILABLE DATA Addressing the studyâs objectives was difficult using the available datasets from the healthcare and transportation fields. Simply put, healthcare data lack sufficient information on transportation and access to care, while transportation data contain little on health- care utilization and nothing on utilization by medical condition. To allow more detailed study of the nation- ally important questions and hypotheses addressed in this study, both transportation and healthcare pro- fessionals and researchers need better data. PROMISING AVENUES FOR FUTURE RESEARCH The current study was not able to investigate two important dimensions of the problem associated with the transportation-disadvantaged and access to non- emergency medical care. First, the researchers were not able to examine the target population over time (longitudinally), meaning that the cumulative health benefits derived from improved access to transporta- tion were not captured. Second, the researchers were not able to investigate the effects of disease severity on cost-effectiveness and to identify the individuals most likely to benefit from improved access to NEMT. Both of these limitations are in line with the conser- vative nature of the research and, when studied in more detail, should contribute to even more signifi- cant findings than this study obtained. 5 Table 3 NEMT Costs for Paratransit Services in Urban and Rural Areas Average Cost per Service Type Region One-Way Trip ($) Ambulatory Urban 19.95 Rural 20.95 Wheelchair Urban 28.52 Rural 33.02 Stretcher Urban 89.68 Rural 86.20 Source: Proprietary cost data (from 2004) based on 800,000 trips provided by services located in 20 locales across the United States. Table 2 Critical Medical Conditions Affecting Transportation-Disadvantaged Persons Type of Care Medical Condition Prevalence in the Target Population (%) Chronic Depression or Other Mental Health Problem 50 Hypertension 37 Heart Disease 26 Asthma 20 Chronic Obstructive Pulmonary Disease (COPD) 19 Diabetes 15 End-stage Renal Disease (ESRD) 7 Preventive Dental Problems 28 Cancer 12 Prenatal Care 2 Vaccinations N/A Source: National Center for Health Statistics, Centers for Disease Control and Prevention, NHIS (2002).