Patients Deserve Better: Gaps in NEMT Coordination and Delivery

“Issues such as late or missed pickups, stranded patients — many of them children or the elderly — long hold times at the call center, unpaid claims submitted by the taxi and van companies, and poor quality control.” – Hartford Courant, 3/5/16 (1)
“[Late or missed rides] led to backups in dialysis units, missed chemotherapy sessions and diagnostic tests. That created systemic problems, with more patients ending up in expensive hospital emergency departments for care they should have received elsewhere.” – Cherry Hill Courier Post, 1/25/16 (2)
“She quit her job at LogistiCare because, she says, she couldn't take the feeling she got at 5 p.m. every day. She said the phones at the company were turned off everyday at 5 p.m. and employees went home knowing sick and elderly people were left stranded by the company at doctor's appointments with no one coming to pick them up.” ClickOn Detroit, 1/15/16 (3)

These kinds of articles have been appearing in local newspapers around the country for years, as patients and their providers struggle to make sense of why the transportation they rely on doesn’t show up on time – if at all. The consequences for patients, many of whom have multiple chronic conditions and are low-income, elderly or contend with disabilities, are unacceptable.

What has led to this? First, there are 42 programs across six federal departments, alongside 50 different state programs that have direct oversight within their jurisdictions, that fund NEMT as part of their broader operations. Not surprisingly, administrative inefficiencies and a lack of effective leadership can result from this complex web of distributed responsibility.

Second, state-contracted transportation brokers sub-contract rides out to dozens or hundreds of local transportation companies that use inconsistent technology. Most NEMT providers do not have digitally-enabled dispatch systems that any driver with a smartphone and ride sharing app would have. Earlier this year, advocates in one state celebrated the addition of GPS requirements in the state’s request-for-proposal for an NEMT broker to be a momentous victory. GPS has been standard in cars for well over 10 years, but the fact that many NEMT providers do not have such basic systems is indicative of the current state of affairs.

Third, those in positions of power have precious little information upon which to act. There is no reliable ride-level data capture to facilitate continuous program evaluation and improvement. The systems are black boxes of accountability, where complaint rates often run at less than 1 percent because patients either cannot navigate the byzantine phone lines or do not feel empowered to speak up about their experiences.

There is good news however. Awareness of the problems with NEMT is growing, as coverage makes its way from local media sources into higher-profile news outlets. There is a widespread consensus that patients deserve better. Furthermore, we have all the ingredients we need in order to reimagine and pursue a better way:

  • Knowledge among engaged community advocates, civic-minded government officials, enlightened health system leaders, front-line care coordinators and social workers, and patients themselves who understand best their own lived experiences;
  • Technology in the form of efficient route optimization systems, direct patient messaging, instant eligibility verification protocols, streamlined billing and reimbursement systems, and emerging opportunities in predictive analytics and machine learning;
  • Resources as evidenced by the more than $3 billion spent through Medicaid, $2 billion spent through Medicare, and an estimated $1 billion spent through contract research organizations (CROs) on non-emergency medical transportation each year.

The challenge, then, is about connecting the dots between these hubs of knowledge, technology and resources. This network orchestration – no single entity is positioned to solve the problem, so it will indeed take a village of partnerships across geographies, industries and sectors – will take shape through strong leadership from public policy makers, an opportunity for patients and medical providers to have a role in decision-making, and the incorporation of insights from other fields such as design, energy and operations research.

But all of the expert knowledge, all of the financial resources, and all of the technology we can bring to the table will fall short if we lose sight of the human factors. These are patients we are helping; not widgets built in a factory that need to reach distributors within a certain timeframe. Approaching the challenges of healthcare transportation with just a traditional logistics mindset, instead of a patient-centered one, is a recipe to perpetuate the current failing system. That is a system in which patients can feel dehumanized and left out of an equation that prioritizes ever-narrower time frames and ever-thinner margins.

Do we need optimized routes and real-time status updates? Yes. Ride-level data capture for continuous improvement? Yes. Predictive analytics to pinpoint which patients will need help before problems arise? Yes, and much more. All of this can be achieved without sacrificing service quality, applying the same approach to each geographic area in spite of meaningful variation in local contexts, or forgetting the importance of the patient experience. That is the careful balance that Ride Health and other organizations need to strike.

Problems that have persisted for almost 50 years will never be solved overnight. But with an approach based on intellectual humility, patient-centered decision making, and with knowledge integrated from across stakeholders and sectors, we can make real progress and help build a better NEMT system that does not let patients down in their times of need.