NEMT Past, Present and Future

Transcription

1 NEMT Past, Present and Future Stephen Borders, PhD, MSHP School of Public and Nonprofit Administration Grand Valley State University

2 Big Picture for This Session Need for Non-Emergency Medical Transportation Think Like a Doctor in the Post ACA World Results of Poor Transportation and Healthcare Coordination Health Service Delivery in a Post ACA World

3 Access Barriers to Healthcare Services Affordability, accommodation, availability, accessibility, and acceptability (Penchansky and Thomas 1981) Missed opportunities for immunizations and routine well-child care/annual visits Increased incidence of untreated chronic illnesses Increased use of emergency rooms (and ambulances) for non-emergency care Increase in preventable hospitalizations

4 Transportation Barriers in Texas Texas Medicaid (17 years) remains under a Corrective Action Order to improve services and access to care. Medicaid covered Children in Texas About 25% or 475,000 have unmet transportation needs. About 30% or 600,000 missed routine health and dental appointments because of transportation barriers (Borders, Chaudhuri, & Dyer, 2010). In Houston As household size increased, the likelihood of the child to miss his or her appointment also increased. Among children that missed an appointment, their family was less likely to own a car as compared to families that did own a car (Yang, Zarr, Kass-Hout, & Kourosh, 2006).

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6 Relationship B/w Automobiles and ACSCs

7 Measuring Health and Transportation Barriers

8 IMUTD - Alaska Index of Medical Underservice & Transportation Disadvantaged Fewer Health and Transportation Barriers Greater Health and Transportation Barriers

9 Broad to Narrow Focus

10 Often Working with Population-Based Data

11 Why We Don t Necessarily Need Health Data To Identify Health Disparities Gapminder Income and Life Expectancy Infant Mortality and Educational Attainment What does this analysis tell us?

12 Working with Population-Based Data

13 Why You Have to Think Like a Doctor Post ACA World there really isn t a lot of new $ in the healthcare system Rebalance/refocus where it is spent Fee-for-service

14 Diabetes In 2008, nearly one in five hospitalizations were related to patients with diabetes, totaling over 7.7 million stays and $83 billion in hospital costs. Hospital stays for patients with diabetes were longer, more costly, and more likely to originate in the emergency department than stays for patients without diabetes.

15 Diabetes The rates of hospital stays for patients with diabetes increases as the income level of the patient ZIP Code decreases 3,232 diabetes-related stays out of every 100,000 persons from the lowest income quartile 1,762 stays out of every 100,000 persons from the highest income quartile.

16 Diabetes The South had the highest rate of hospital stays for patients with diabetes 2,829 stays per 100,000 persons The West has the best rate of hospital stays for patients with diabetes 1,866 stays per 100,000 persons in the Source: Healthcare Cost and Utilization Project, Statistical Brief#93

17 Issue American Medical Response had contracted with the State of South Carolina to provide Non-Emergency Medical Transportation for the state s Medicaid beneficiaries States must use the least expensive mode of transportation available that is appropriate for the recipient and transport the recipient to the nearest qualified provider

18 Network Analysis

19 Dialysis Trip Analysis Sept/Oct 2011 Dialysis Trips Averge Cost per Trip Average Distance per Trip Total Costs Total Miles Analysis Actual Claims Data 26,784 $ $ 593, ,889 If Using the Near Facility 26,784 $ $ 327, ,959 Difference - $ $ 265, ,930 Extrapolate to 1 Year, Potential Savings = $1,594,598 Formula = $265,766 X 6 = $1,594,598 Assumes cost per mile of $1.86

20 Quality of the Dialysis Facility Was the dialysis facility related to consumer choice about quality? User Type Facility Hospitalization Ratio of 1.25 or more Utlized Nearest Facility 728 (38%) Did Not Utilize Nearest Facility 1,205 (62%)

21 Quality of the Dialysis Facility Medical costs related to facility choice? 119 patients had dialysis at a facility with a hospitalization rate in excess of 25% higher than average Typical person receiving hemodialysis 1.88 inpatient admissions per year (unadjusted) $10,937 per admission (2008)

22 What if Dialysis Patients Move to a Facility with an Average Hospitalization Ratio? Facility Expected Number of Expected Costs Admissions Above Average = 1.31 Hospital Admission Rate 2.46 $ 26,905 Average = 1.0 Hospital Admission Rate 1.88 $ 20,562 Difference 0.58 $ 6,343 For 119 patients receiving hemodialysis, we would expect to have 69 additional admissions at a cost of $754,872 Assumptions = $10,937/Admission * 2.46 (Expected Admissions)

23 What if Dialysis Patients Move to a Facility with A Better Than Ave Hospitalization Ratio? Facility Expected Number of Expected Costs Admissions Above Average = 1.31 Hospital Admission Rate 2.46 $ 26,905 Lowest Quartile =.76 Hospital Admission Rate 1.43 $ 15,627 Difference 1.03 $ 11,278 For 119 patients receiving hemodialysis, we would expect to have 123 fewer admissions at a savings of $1,342,110 Assumptions = $10,937/Admission * 2.46 (Expected Admissions)

24 Why a Dinosaur? How do you solve this problem? Change the economics Shift the risk in the system to the healthcare providers How will that happen? Accountable Care Organizations (Medicare) Coordinated Care Organizations (Medicaid)

25 NEMT Broker Model Moving from fee-for-service to capitation Shifting the risk Potential problem for a community transportation provider How do you take on risk (capitation)? Potential contracting models

26 NEMT Broker Model Get involved with your state legislature and your Medicaid agency You need data to identify needs You want to influence the RFP You want to influence the contract Proactive in working with potential broker Status quo is probably not an effective position from which to argue

27 Strategies for NEMT Broker Models Significant Traditional Medicaid Providers (Texas) The Legislature directed Texas Medicaid program to ensure that significant traditional providers (STPs) of Medicaid services be included in managed care networks

28 Strategies for NEMT Broker Models Critical Access Hospitals (CAHs) isolated areas, making them the only option for local residents. Medicare repays them their cost plus 1 percent, more than it pays other hospitals, to ensure they do not close.

29 Strategies for NEMT Broker Models Federally Qualified Health Center FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors.

30 Strategies for NEMT Broker Models As part of our study, we re putting together a single source of NEMTrelated documents on the web State Contracts RFP documents related to contracting Federal data NEMT evaluations/reports

31 Contact Information for Questions Stephen Borders, PhD, MSHP