Free or low-cost transport to medical appointments for those who need it has been a mandatory Medicaid benefit since the program’s inception in 1966. It’s specified in federal regulation. Scattered cases of fraud have marred the administration of Medicaid transportation and the desire to rein in Medicaid spending has led some policy-makers to consider ways to limit this benefit, formally called non-emergency medical transportation (NEMT).
Our new research examines the value of non-emergency medical transportation for people with three relatively common and expensive diseases. We demonstrate that such transportation provides a healthy return on investment (ROI) for two of the three conditions. Trimming non-emergency medical transportation in Medicaid runs contrary to trends in other health insurance markets and is likely penny-wise and pound-foolish for Medicaid’s coffers.
To date, a few states have limited transportation through federal waivers. Iowa and Indiana generally don’t generally offer it to their Medicaid expansion populations. Kentucky and Massachusetts are seeking to follow. In its budget proposal for 2019, the Trump Administration wants to let states limit the transportation benefit without seeking a waiver, a move that could increase the number of states that curtail non-emergency medical transportation.
Skepticism about non-emergency medical transportation in Medicaid runs counter to its expansion in other health insurance markets, where it is seen as a valuable care management asset that helps beneficiaries stick with their care plans, thereby driving down emergency department visits, hospitalizations, and other expensive services. The Centers for Medicare and Medicaid Services recently promoted non-emergency medical transportation as a supplemental benefit in a national presentation to Medicare Advantage plans and broadened the benefit to cover trips to pharmacies.
The National Association of Accountable Care Organizations recently requested that non-emergency medical transportation be added to its Medicare accountable care organization models. Responding to the market trend, national rideshare services Lyft and Uber have made headlines with non-emergency medical transportation deals with major insurers and health systems. Even Ford Motors has moved to adopt it.
We have just completed a first-of-its-kind study on behalf of the Medical Transportation Access Coalition. It uses Medicaid claims data and a survey of nearly 1,000 Medicaid beneficiaries to determine the ROI in non-emergency medical transportation for three common conditions and their corresponding treatments: dialysis for kidney disease, wound care for diabetes, and substance use disorder treatment.
We found a positive ROI for patients receiving dialysis and wound care treatments, with savings of more than $40 million per month for Medicaid beneficiaries (10,000 in each condition) affected by either end-stage kidney disease or diabetes-related wounds. A detailed explanation of the study and its methodology is posted on the Medical Transportation Access Coalition’s website.
Dialysis for kidney disease. The study identified significant cost avoidance for Medicaid-covered patients with kidney failure who rely on non-emergency medical transportation to attend their dialysis treatments. Consistent with clinical guidelines, survey respondents reported attending an average of 12.0 dialysis treatments a month using non-emergency medical transportation and said they would expect to attend only 4.1 treatments a month without it. That reduction would likely lead to expensive emergency dialysis treatments and hospitalizations. We calculated that non-emergency medical transportation saves Medicaid $3,423 per month for each individual with kidney failure receiving dialysis, or $41,076 per year.
Diabetes wound care. Non-emergency medical transportation for Medicaid patients with diabetes-related wounds was also associated with avoiding significant costs. Survey respondents reported attending an average of 5.5 wound care treatments a month using non-emergency medical transportation but expected to attend only 1.3 treatments a month without it. We calculated that Medicaid would avoid spending $792 per member per month, or $9,504 per year, by keeping patients on a path to receive all necessary wound-care treatments.
Substance use disorder. Non-emergency medical transportation did not appear to save Medicaid money for patients with substance use disorder, in part because our methods did not identify the full range of costs avoided. It is possible that different study parameters, such as a longer claims analysis period, consideration of relapse rates, and quantification of social costs (increased employment and productivity; lower costs related to encounters with law enforcement and the judicial system; and a reduction in social services) would likely lead to positive ROI. It’s also important to note that the study did not consider whether non-emergency medical transport as an adjunct to substance use disorder treatment improves Medicaid as a “ladder out of poverty,” a key policy goal of Republican leaders.
For 30,000 individuals covered by Medicaid (10,000 with each of the three conditions we evaluated), the total monthly ROI for non-emergency medical transportation would be $40,040,304. Unfortunately, we were not able to make a national extrapolation of these savings because national statistics do not exist for the number of Medicaid beneficiaries who use non-emergency medical transportation.
The significant positive ROI associated with transportation to dialysis and wound treatment demonstrates that curtailing non-emergency medical transportation for these conditions — and potentially other conditions such as asthma and heart disease — is not in the best interest of patients or for Medicaid’s bottom line. While our analysis does not yield a positive ROI for the treatment of substance use disorder, we believe that is attributable to study limitations.
Our study results affirm — and we think particularly strongly — previous studies from researchers at Florida State and Texas A&M suggesting that non-emergency medical transportation more than pays for itself as part of a care management strategy for people with chronic diseases within Medicaid, and probably beyond it.
We hope policymakers at all levels will take these findings into account as they consider any changes to this benefit.
Michael Adelberg is a principal at Faegre Baker Daniels Consulting who previously held senior policy-making positions in the Centers for Medicare and Medicaid Services. Patricia Salber, M.D., is a physician consultant who previously held senior physician executive positions with health plans and large employers. Michael Cohen, Ph.D., is a policy consultant at Wakely Consulting who previously held a senior advisor position in the Center for Medicare and Medicaid Services. The Medical Transportation Access Coalition supported the research described in this article.