Transportation:
A barrier to ensuring that kids have a medical home?
Jeff Muschell, ME, MPHDirector of Health Systems InitiativesThe Children’s Health Fund
Health insurance coverage: a major financial barrier to ensuring that kids have a medical home
• 9 million children (11.2%) in the U.S. are uninsured
• The majority (88%) live in a household with at least one working parent
• 71% live in low-income families
• More than three-fourths are eligible for public health insurance (Medicaid or SCHIP)
– Sources: Families USA, American Academy of Pediatrics
Other “non-economic” barriers
• Inequitable distribution of health care resources– Rural communities have persistent problems of
availability of health professionals (HPSAs)
• Language and cultural considerations– Particularly affects children and families for whom
English is a second language
• Family issues– Family functioning and health-literacy
• Transportation– Kids must be able to physically access health services
Evidence of transportation as a barrier to health care access
• In a Boston-based study, Hispanic parents cited transportation barriers as the most significant reason why they did not bring their child for treatment and well-child care
– Archives of Pediatrics and Adolescent Medicine. 1998; 152:1119-1125
• In a study of migrant agricultural workers, 80% cited transportation as a barrier to bringing their child for healthcare
– Pediatrics. 2004; 113:e276-e282
• Transportation barriers also affect urban children, even when public transportation is available
– Journal of Healthcare for the Poor & Underserved. 2006; 17:928-943;
– Advances in Pediatrics. 2005, Chapter 2
CHF-commissioned national survey on health care and transportation
• 9% of children uninsured
• 21% publicly insured (Medicaid or SCHIP)
• 16% of parents reported that transportation was a covered benefit in their child’s health plan
• 39% have no access to public transportation in community
• 75% in rural areas do not have access to public transport
• 9% who have public transportation use it “regularly”
Households without public transport to health care in their community
46%
20%
28%
38%
0% 10% 20% 30% 40% 50%
Region
West
South
Central
East
Households without public transport to health care in their community
4%
27%
28%
44%
77%
0% 20% 40% 60% 80% 100%
Type ofcommunity
Rural
Small town
Suburban
Small city
Big city
Distance from home to usual source of pediatric care
38%
27%
24%
11%
0% 10% 20% 30% 40%
Miles
20 or more
10 to 19
5 to 9
<5
Fortunately, someone in government recognized that transportation can be a significant barrier to health care access:
• Each state Medicaid agency specify in its state plan that it will “ensure necessary transportation for clients to and from providers” and “describe the methods that the agency will use to meet this requirement” (42 CFR 431.53).
• Each state Medicaid agency is further directed to offer and provide clients of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services with “necessary assistance with transportation,” if requested (42 CFR 441.62).
Medicaid non-emergency medical transportation benefit (NEMT)
Okay, but NEMT is expensive, right?
$ Trips Per trip NEMT
Estimated spending on Medicaid transportation
216,246,928 9,391,392 23
192,459,766
Medicaid transportation spending for children 1,319,156 51,720 26 1,174,049
Percent 0.61%
New York City Medicaid expenditures – 2007 estimates
Source: Department of Health quarterly Medicaid statistics
Right…NEMT is kinda sorta expensive. But is it worth it?
Source: Cost Benefit Analysis of Providing Non-emergency Medical Transportation, Altarum Institute, 2005
Summary of condition-specific cost-effectiveness
Condition Type Result
Influenza vaccinationsPreventive Highly Cost-Effective
Prenatal carePreventive Cost Saving
Breast cancer screeningPreventive
Moderately Cost-Effective
Colorectal cancer screeningPreventive
Moderately Cost-Effective
Dental carePreventive Highly Cost-Effective
Asthma Chronic Cost Saving
Heart disease (congestive heart failure) Chronic Cost Saving
Chronic obstructive pulmonary disease Chronic Highly Cost-Effective
Hypertension Chronic Highly Cost-Effective
Diabetes Chronic Cost Saving
Depression / Mental health Chronic Highly Cost-Effective
End-stage renal disease Chronic Highly Cost-Effective
2.64
3.53
0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00
No
Yes
Use
of
MT
P S
ervi
ces
Number of EPSDT VisitsDifferences significant at p<.05
Average number of EPSDT visits in Texas, 2003:NEMT users and non-users
More from the CHF/Marist national survey
• Missed appointments due to transport affect 4% of US kids regardless of income, insurance status or region
43%
25%
11%16%
0%
20%
40%
60%
Well child Chroniccondition
Acuteillness
Other
• 63% of those who missed an appointment missed two or more appointments in past year
• 31% of parents reported that ER care was needed later on as a result of the missed appointment
• 3 million kids, 750K chronic conditions
• 1 million preventable ER visits
Drilling down into the CHF/Marist national survey results
Savings from preventable ER visits
New York City Medicaid expenditures – 2007 estimates
Estimated USA population 299,398,484
Estimated NYC population 8,085,742
Estimated number of preventable emergency room visits 27,007
Estimated cost of preventable ER visits 20,254,967
Estimated cost of providing 27,007 trips 702,182
Sources: 1) Department of Health quarterly Medicaid statistics
2) Back of envelope
Essentially, transportation is relatively cheap
New York City Medicaid expenditures – 2007 estimates
$ TripsUnit cost NEMT
Estimated spending on Medicaid transportation
216,246,928 9,391,392 23
192,459,766
Medicaid transportation spending for children 1,319,156 51,720 26 1,174,049
Percent 0.61%
Visits, claims,
daysUnit cost
Estimated spending on Free Standing Clinics - children
139,798,968 1,198,080 117
Estimated spending on Hospital Inpatient days - children
812,825,688 433,532 1875
Other potential areas of cost savings with increased investments in transportation for health care access
• Reductions in missed opportunities for immunizations and routine well-child care
• Reductions in use of emergency transportation
• Decreased incidence of untreated chronic illnesses
• Reductions in preventable hospitalizations
Federal effort to coordinate transportation resources
• Executive Order 13330 of Feb 04
– Coordinating Committee on Access and Mobility (CCAM), an interagency group charged with integrating 62 separate human services transportation funding streams
• United We Ride initiative, working with states to develop coordinated transportation plans (usually working through state DOTs)
Summary of NEMT in SCHIP Programs
Comparison of Medicaid and SCHIP Eligibility for Children Ages 6-19: Washington and Texas
Child Health Transportation Initiative (CHTI)
• Three-year project of research, pilot project development and public education & advocacy
• Goal: to address deficiencies in public and private transportation systems that preclude millions of lower-income children from accessing primary and specialty health care services
• Supported by the Kellogg Foundation and the Federal Transit Administration (FTA)
CHTI working philosophy
• We accept that additional investments in NEMT are likely to be cost-beneficial or cost-effective
• Much of our effort in pilot project development is thus focused on efficiency and cost-effectiveness
• Cost-effectiveness: what combination of resources works best in a given set of circumstances
• Allocative efficiency: doing the right things
• Technical efficiency: doing things right
Specific objectives at first group of pilot sites
Arkansas• 1) Strengthen management of clinic’s transportation “wing”
(technical efficiency)• 2) Shift Medicaid riders over to Medicaid transportation
broker (allocative efficiency)
Mississippi Gulf Coast• Establish new transit service for moving people from
remote location to the city and associated public services (cost-effectiveness)
Mississippi Delta• Research reasons why people with non-emergency
conditions show up at the ER (allocative efficiency)