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60 A key to successful collaboration is defining and articulating common desired outcomes across agencies. The meaningful results that all stakeholders for NEMT seek to achieveâtransportation to improve access to medical services for individuals and families with low incomesârequire the efforts of state officials, regional and local transportation providers, and, in a growing number of states, statewide or regional brokers and MCOs. Other stakeholders include human services pro- gram managers and mobility managers who help Medicaid beneficiaries arrange NEMT or find transportation to non-medical services. With so many stakeholders, a wide variety of perspec- tives exists about the goals and objectives for NEMT. Designing and operating NEMT programs that create benefits for all parties can be challenging. A focus on common desired outcomes can lessen these challenges and lead to successful program outcomes. As the number of Medicaid beneficiaries continues to grow, stakeholders find it is increasingly important to consider how improved coordination and collaboration can help to provide NEMT to meet the need for transportation assistance but with limited resources. GAO has reported that a key component to successful collaboration is the importance of defining and articulating common desired outcomes across agencies. In a collaborative process, the participants may not have the same overall interestsâin fact, participants may have conflicting interests. However, by establishing goals based on what stakeholders share in common, rather than on where there is disagreement among specific objectives, collaboration can be successful (57). The purpose of this chapter is to summarize different stakeholder perspectives based on a review of literature and previous studies, original research for this project, and informa- tion gathered during the case studies in seven states. This chapter also highlights the common expected outcomes for NEMT that are agreed upon by all stakeholders. What Are the Stakeholder Perspectives About NEMT? The following summarizes the different stakeholder perspectives about NEMT: ⢠State Medicaid agencies fund NEMT to ensure Medicaid beneficiaries who have no other means of transportation can get to and from authorized medical services in a safe, efficient, and reliable manner. State Medicaid agencies consider different models to deliver NEMT at the lowest cost for eligible individuals while preventing fraud and abuse. Most state Medicaid agencies look to recover a higher rate of federal reimbursement by providing NEMT as a medical service at the federal matching assistance percentage or through a brokerage. ⢠State DOTs and recipients of federal transit funds in urbanized areas are responsible for coordinating public transportation and human services transportation, including NEMT, to improve general mobility. The objectives for coordinated transportation services are to avoid duplicative and overlapping services, reduce service gaps, and achieve cost savings through improved efficiency and effectiveness. C H A P T E R 6 Common Desired Outcomes
Common Desired Outcomes 61 ⢠Regional and local transportation providers, including human services transportation pro- viders and public transit agencies, are interested in providing NEMT for low-income pas- sengers as a complement to other transportation services. Regional and local transportation providers hope to improve efficiency and increase ridership by coordinating NEMT with other transportation. By contracting to provide NEMT with state Medicaid agencies, brokers, or MCOs, public transportation providers want to recover the cost of providing the transportation service and use the contract revenues as local share to match federal transit grants. ⢠For-profit and not-for-profit brokers qualify and authorize Medicaid beneficiaries for transportation and then contract with transportation providers to perform the NEMT service according to a broker contract with the state Medicaid agency or MCO. For-profit brokers look to generate profits by effectively managing the cost of providing NEMT. Accordingly, for-profit brokers want to purchase NEMT from human services transportation providers, public transit agencies, or private transportation companies at the lowest cost while meeting the requirements of the state Medicaid agency. ⢠MCOs responsible for an organized health care delivery system that includes transportation services (carved-in NEMT) try to purchase NEMT services from transportation providers that are cost effective, safe, on time, and dependable. MCOs focus on three critical objectives known as the triple aim: improve health, enhance the patient care experience (including reliable transportation to medical services), and reduce, or at least control, cost. ⢠Human services program managers provide a range of services to Medicaid beneficiaries including sometimes serving as an NEMT broker. Human services program managers seek to ensure each program client has transportation to medical and non-medical services. Coordinated transportation helps clients arrange linked trips or multiple trips with one call/ one click. ⢠Mobility managers coordinate transportation resources in a community to assist individuals to arrange travel for various purposes, including for medical services. Mobility managers seek to improve transportation services for individuals with disabilities, older adults, and indi- viduals with lower incomes by ensuring that communities coordinate transportation resources through multiple programs. What Are the Common Desired Outcomes for NEMT? Although stakeholders have different perspectives about NEMT, they also share common desired outcomes for providing NEMT services. Common desired outcomes for NEMT emerged from the literature and conversations with stakeholders during case study research. Identifying shared outcomes sets a framework for collaboration to achieve better results. Figure 9 illustrates the common desired outcomes. Desired Outcome: Improved Health Stakeholders agree that NEMT is an important benefit for Medicaid beneficiaries who need to get to and from medical services but have no other means of transportation. Without NEMT, individuals who most need medical care might not be able to access critical services. Identifying shared outcomes sets a framework for collaboration to achieve better results. Figure 9. Common desired outcomes for NEMT.
62 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Interviews with stakeholders confirm that the lack of transportation for Medicaid recipients can impede their ability to access medical services, particularly for individuals living in rural or underserved areas as well as those with chronic health conditions. Lack of transportation can restrict access to medical care, affecting health outcomes for individuals and higher costs for medical services. The case study research confirmed that missed medical appointments due to transportation issues lead to costly subsequent medical care, such as hospitalization and the use of an ambulance for emergency transportation. All stakeholders agree that providing reliable NEMT will contribute to improved health outcomes for Medicaid beneficiaries. Desired Outcome: Better Quality of Service Stakeholders agree that better quality of NEMT service is a desired outcome: ⢠Medical service providers emphasize the importance of on-time NEMT service for drop-offs and pickups for patients. Dependable NEMT will contribute to increased access to preventive and primary medical care, leading to better health outcomes and eventually to reduced costs for medical services. ⢠CMS emphasizes state Medicaid agency responsibility to provide oversight for the quality of NEMT service. Under DRA, the state Medicaid agency is responsible for establishing standards for quality of service and the NEMT broker is required to monitor beneficiary access and complaints, and to ensure transportation is timely and transportation providers are licensed, qualified, competent, safe, and courteous. ⢠Human services and public transportation providers seek to enhance the economic and social well-being of all passengers by creating and maintaining a reliable, integrated, and accessible transportation system. Public transportation is intended to enhance choices for all riders by providing access to educational and employment opportunities, health care, and other destinations. Public transportation providers that are recipients of federal funds are required to comply with FTA regulations for safety, qualifications of drivers, and state of good repair for transit vehicles. Most public transit agencies set performance standards for safety, on-time service, and passenger satisfaction and monitor performance metrics on a monthly, quarterly, or annual basis. ⢠Human services program managers and mobility managers assist individuals that need transportation to arrange travel for various purposes, including for medical services. These stakeholders use the ability to arrange linked trips or multiple trips for any purpose conveniently as a measure of the quality of service. During case study research, stakeholders agreed that providing dependable NEMT service that is safe and on time will improve Medicaid beneficiary access to medical services, contribute to improved health outcomes, and lead to a better quality of life. Desired Outcome: Maximize Services Delivered Within Available Resources Stakeholders know that delivering efficient transportation can maximize service delivered within available resources. Medicaid funds may be used only to provide NEMT for eligible beneficiaries to authorized medical services. NEMT must be the lowest cost for the most appropriate transportation to meet the clientâs transportation need. More efficient NEMT is a priority for CMS and state Medicaid agencies.
Common Desired Outcomes 63 Through FTA, U.S. DOT encourages public transportation providers to coordinate trans- portation services with human services agencies, including NEMT, to improve the efficiency of transportation services. Economies of scale can be realized by reducing unnecessary redundancies in service and more efficiently using existing transportation resources (e.g., vehicles, drivers, and administrative staff). CCAM was established to promote interagency cooperation, to minimize duplication and overlap of federal programs and services, and to maximize access to more transportation services. Agency representatives participating in CCAM recognize the importance of maximizing service delivery within limited resources and seek ways to achieve the highest return on investment by enhancing efficiencies and simplifying access for consumers. Summary Defining and articulating common desired outcomes across agencies are a key component to successful collaboration. Common desired outcomes for Medicaid NEMT emerged from the literature review and case study research. The common desired outcomes are improved health for Medicaid beneficiaries who need transportation assistance, better quality of NEMT service, and the ability to maximize transportation services delivered within available resources. The challenge is to find ways human services transportation, public transportation, and Medicaid NEMT programs can work together to recognize shared desired outcomes and achieve better results through coordination and collaboration. The next chapter identifies strategies that can help to achieve common desired outcomes.
