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Non-emergency medical transportation (NEMT) continues to be necessary for many Medicaid patients, but it has issues that need to be resolved, speakers said at a meeting of the Medicaid and CHIP Payment and Access Commission (MACPAC).

“The best investment in health isn’t always in healthcare,” said MACPAC Commissioner Kisha Davis, MD, MPH, regional medical director at Aledade, a company in Rockville, Maryland, that helps physicians start up and run accountable care organizations. “How are we shoring up the transportation system so that we are helping people to access care in ways that are validating and keep them independent? … Investing in transportation networks and Uber and Lyft and taxis — all those things really support their independence.”

Report Requested by the Senate

Commission members were responding to a report on NEMT presented at a January MACPAC meeting in response to a request from the Senate Appropriations Committee. In its fiscal year 2020 report, the committee asked MACPAC to “examine … the benefits of NEMT from state Medicaid programs on Medicaid beneficiaries, including beneficiaries with chronic diseases including ESRD [end-stage renal disease], substance abuse disorders, pregnant mothers, and patients living in remote, rural areas, and to examine the benefits of improving local coordination of NEMT with public transportation and other Federally-assisted transportation services.” The request didn’t have a due date or require specific recommendations.

The MACPAC analysis noted that states are required to provide Medicaid beneficiaries with NEMT using the “most appropriate form of transportation.” Transport services are delivered either through a fee-for-service system, Medicaid managed care, or through a third-party broker. Report authors Kacey Buderi and Aaron Pervin looked at every state’s NEMT policies and interviewed Medicaid directors in six states, as well as officials at the Centers for Medicare & Medicaid Services and the Federal Transit Administration. They also analyzed NEMT utilization and spending.

The authors found that in fiscal year 2018, Medicaid spent $2.6 billion on NEMT, providing 61.5 million “ride days” to 3.2 million beneficiaries — a small fraction of Medicaid’s 74 million enrollees that year. Ride days were defined as days that an NEMT procedure code was used for a particular enrollee. Beneficiaries living in urban areas used an average of 19.8 ride days for the year compared with 15.8 for those in rural areas, although some rides couldn’t be classified by ZIP code alone as being urban or rural.

Large Variance by Diagnosis

The number of ride days also varied greatly depending on the user’s diagnosis, with chronic kidney disease patients who had ESRD showing an average of 70.1 ride days in 2018, compared with 20.1 for those with serious mental illness. Patients with developmental or intellectual disabilities averaged 34.5 ride days, while those with opioid use disorder averaged 25.0 ride days.

Nearly half of NEMT ride days (46.0%) involved the use of vans, with taxis the next most common at 36.7%; ride-sharing apps like Uber and Lyft were included in those classifications. Only 5.0% involved public transportation (one ride day can involve multiple modes of transportation, so the percentages don’t add up to 100). About 41% of rides were to the beneficiary’s residence, with another 20.3% ending at the physician’s office and 16.9% at a diagnosis or therapy site, the authors reported.

MACPAC also contracted with research firm PerryUndem to convene focus groups of Medicaid NEMT users in six states to discuss their feelings about NEMT. Each focus group, which lasted 90 minutes, involved groups of four to seven participants who participated by either phone or video. The groups included a total of 34 patients who had chronic conditions such as hypertension, cancer, ESRD, bipolar disorder, substance use disorder, depression, and seven participants who were caregivers of such patients. Some participants used wheelchairs, and most had been using NEMT for a year or more.

Participants reported a variety of transportation barriers before they started using NEMT. Many didn’t have a car or driver’s license, and couldn’t rely on friends or family to transport them to appointments. Public transportation often took too long, or was not available at all, especially in rural areas. Many said they couldn’t afford transportation on their own.