Home | Business News | Browse by Publication | H | Health Services Research

Transportation brokerage services and Medicaid beneficiaries' access to care.

Article Excerpt
Transportation can be a major access barrier to timely health care for low-income populations. The literature shows two distinct health effects of poor transportation: less use of preventive and primary care, and more use of the emergency department (Wilson and Jonathan 2000; Johnson and Rimsza 2004; Arcury et al. 2005). These associations are particularly significant for those people who live in rural areas, and are also found for medical care services such as prescription drugs and pediatric dental care (Saunders 1987; Mofidi, Rozier, and King 2002). The provision of and access to reliable transportation increases the likelihood of primary care physician visits in the pediatric population (Johnson and Rimsza 2004), HIV-positive adults (Messeri et al. 2002), and frequent emergency room users (Nemet and Bailey 2000; Baren et al. 2001). Overall, these studies suggest that provision of reliable transportation services is important to enable patients to have access regular and preventive care.

Transportation is a particularly important issue for Medicaid, both because Medicaid beneficiaries represent a vulnerable population and because states are concerned with controlling costs. By 2001, 10 percent of the Medicaid population (about four million beneficiaries nationwide) relied primarily on Medicaid to pay for transportation services to get to medical appointments (Rafael 2001). Nonemergency medical transportation (NEMT) services are federally mandated Medicaid services to meet the transportation needs of vulnerable populations. However, many states found that transportation costs were high under fee-for-service arrangements, in which transportation providers typically billed Medicaid based on reported trips and miles. Anecdotal reports indicate that to get higher reimbursement, some providers generated phantom trips, inflated mileage, and misclassified eligible clients. Absence of oversight further exacerbated the possibility of transportation-related fraud and abuse. Finally, inefficient and limited provision of NEMT services could potentially increase total Medicaid expenditures via delayed and expensive care.

By 2001, 21 states contracted with brokers (i.e., profit or nonprofit organizations) to manage nonemergency transportation services on a capitated basis for Medicaid beneficiaries (Rafael 2001). The goal of transportation brokerage services is to provide reliable transportation for Medicaid beneficiaries at minimum cost. Before transportation brokerage services, Medicaid funding for NEMT services was strictly cost based. Under transportation brokerage services, all nonemergency transportation services are included in capitated rates that are adjusted by beneficiaries' health status and by geographic area (e.g., urban or rural). The brokers are responsible for negotiating payment rates with transportation providers, beneficiaries' service eligibility verification, timely transportation reservation, and monitoring quality of services (Kulkarni 2000; Rafael 2001). The success of transportation brokerage services also depends on the expanded availability of transportation in underserved areas. Brokers therefore reach out to eligible beneficiaries by giving out public transportation schedules, providing user-friendly trip reminders, and educating beneficiaries about the available transportation options.

A review of the brief literature suggests that states that contracted with transportation brokerage services improved cost savings and quality (O'Connell et al. 2002; Dai 2005). One study using Florida data suggests that transportation brokerage services are associated with substantially decreased unit cost per trip and more accountability (Dai 2005). A study of the effect of prior-approval requirement for Medicaid transportation services in Indiana found a decrease in primary care visits and prescription refills, but did not find any measurable short-term effects on health outcomes (Tierney et al. 2000). However, the relatively short study period in the latter study to assess health outcomes--6 months each in the pre- and postperiods--and the limited study sample (from just one large hospital) may hinder the determination of the true effect of the changes in the system.

This study examines how transportation brokerage services affect beneficiaries' access to care, expenditures, and health services use using a longitudinal panel data set over 4 years in two states. We address three research questions. First, do transportation brokerage services directly affect transportation expenditures? Second, do transportation brokerage services have spillover effects, leading to changes in other Medicaid expenditures? Third, do transportation brokerage services lead to changes in health services use? With various types of expenditures and selected medical conditions, we assess the comprehensive effects of transportation brokerage services.

The staggered implementation of transportation brokerage services in Georgia and Kentucky provide a natural experiment. We compare how measures of access to care and health services use changed after the implementation of transportation brokerage services for two groups of patients with chronic conditions. The results provide new insights into how Medicaid beneficiaries gain access to care under a system of capitated rates for nonemergency transportation services.

METHODS

Georgia and Kentucky were chosen to study the effects of transportation brokerage services for four reasons. These states implemented transportation brokerage services at different times, allowing each state to be a control for the other. They had similar fee-for-service payments for NEMT during the preperiod. They had a similar percentage of NEMT spending to total Medicaid costs during the preperiod. Both states had similar concerns in the preperiod about overpayment by Medicaid, and about lack of coordination leading to lack of access to health care. They had the same type of NEMT payment in the postperiod. In sum, the study design is strong because these two states were similar in the preperiod, and implemented similar programs at different times.

The study period is from 1996 through 1999. Georgia implemented transportation brokerage services statewide in 1997, while Kentucky implemented gradually by county starting in 1998. The staggered implementation times across the two states allows us to estimate difference-in-differences models. This...

View this article FREE - Now for a Limited Time, try Goliath Business News
Free for 3 Days!