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)