Mandated Report On Non-Emergency Medical Transportation Further Findings
Mandated Report on NonEmergency Medical Transportation: Further Findings Medicaid and CHIP Payment and Access Commission Kacey Buderi and Aaron Pervin January 29, 2021 www.macpac.gov
Overview Congressional request Recent changes to non-emergency medical transportation (NEMT) requirements NEMT overview MACPAC study components Findings from analysis of administrative data Findings from beneficiary focus groups January 29, 2021 2
Congressional Request The Senate Appropriations Committee report language for fiscal year (FY) 2020 directs MACPAC to “.examine, to the extent data are available, the benefits of NEMT from State Medicaid programs on Medicaid beneficiaries, including beneficiaries with chronic diseases including ESRD, 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.” Request has no due date and does not require recommendations January 29, 2021 3
Recent Changes to NEMT Requirements The Consolidated Appropriations Act, 2021 (P.L. 116-260) codified NEMT requirements into Section 1902(a)(4) of the Social Security Act – Prior to this action, NEMT was required by regulation, not statute It is no longer possible to make NEMT an optional benefit via administrative action (as proposed by the Trump Administration) January 29, 2021 4
NEMT Overview States are required to provide NEMT and use the most appropriate form of transportation Scope of benefit varies by state but generally covers a broad range of transportation services States deliver NEMT through one or more approaches: – Fee for service (FFS) – Third party broker – Medicaid managed care January 29, 2021 5
MACPAC Study Components Environmental scan and semi-structured interviews – Scan of state NEMT policies (all 50 states and D.C.) – Interviews with Medicaid officials in six states (AZ, CT, GA, IN, MA, and TX), federal officials from the Centers for Medicare & Medicaid Services (CMS) and the Federal Transit Administration (FTA), and other stakeholders Focus groups with beneficiaries who have used NEMT – Eight virtual focus groups with beneficiaries in the six study states Analysis of administrative data on NEMT utilization and spending – Fiscal year (FY) 2018 Transformed Medicaid Statistical Information System (T-MSIS) data – Goal of providing data on NEMT utilization and spending by various factors (e.g., destination, transportation type, basis of eligibility, dually eligible status, urban versus rural, and diagnosis) January 29, 2021 6
Findings from Analysis of Administrative Data January 29, 2021 7
T-MSIS Methodology Rides were identified using NEMT codes within the Healthcare Common Procedure Coding System Population was limited to full-benefit Medicaid enrollees in FY 2018 Findings are presented as ride-days, number of door-to-door rides are much higher – Adjusts for state variation in NEMT billing practices January 29, 2021 8
National Utilization and Spending T-MSIS data yielded 61.5 million ride-days and 3.2 million NEMT users – Use varied by eligibility group, mode of transportation, and different diagnostic categories Total Medicaid spending on NEMT was 2.6 billion – Does not include spending by managed care plans on NEMT January 29, 2021 9
NEMT Ride-Days by Basis of Eligibility, FY 2018 30.0 24.4 25.0 20.5 Childr en 20.0 16.6 Aged 14.7 15.0 Disabled Pregnant Women 9.1 10.0 7.2 5.0 - 2.8 0.1 New Adult Group Other Adults 3.7 0.3 Ride-days per FYE 0.5 0.5 Ride-days per NEMT user Notes: NEMT is non-emergency medical transportation. FYE is full-year equivalent. Ride-days are defined as days with an NEMT procedure code. MACPAC uses the terms pregnant and postpartum women as these are the terms used in Medicaid statute and regulations. However, the terms birthing people or pregnant individuals are being used increasingly, as they are more inclusive and recognize that not all individuals who become pregnant and give birth identify as women. Source: MACPAC analysis of Transformed Medicaid Statistical Information System Data. January 29, 2021 10
NEMT Ride-Days by Dually Eligible Status, FY 2018 30.0 24.1 25.0 20.0 15.9 Dually Eligible 15.0 Medicaid Only 10.0 5.0 3.6 0.5 Ride-days per FYE Ride-days per NEMT user Notes: NEMT is non-emergency medical transportation. FYE is full-year equivalent. Ride-days are defined as days with an NEMT procedure code. Source: MACPAC analysis of Transformed Medicaid Statistical Information System Data. January 29, 2021 11
NEMT Ride-Days by Urban or Rural Status, FY 2018 25.0 19.8 20.0 15.8 15.0 Urban Rural 10.0 5.0 0.9 0.9 Ride-days per FYE Ride-days per NEMT user Notes: NEMT is non-emergency medical transportation. FYE is full-year equivalent. Ride-days are defined as days with an NEMT procedure code. Some rides could not be classified as urban or rural based on the beneficiary’s ZIP code, and therefore total urban and rural rides are smaller compared to overall rides. Source: MACPAC analysis of Transformed Medicaid Statistical Information System Data. January 29, 2021 12
NEMT Ride-Days per Enrollee among Selected Diagnoses, FY 2018 80.0 70.1 70.0 60.0 Chronic kidney disease with ESRD 50.0 40.0 Chronic kidney disease without ESRD 30.0 Opioid use disorder 25.0 20.0 10.0 Intellectual or developmental disorders 34.5 32.6 15.5 2.6 7.0 4.1 3.9 0.0 Rides per enrollee Serious mental illnesses 20.5 12.8 None of these conditions 0.4 Rides per NEMT user Notes: NEMT is non-emergency medical transportation. FY is fiscal year. ESRD is end-stage renal disease. Ride-days are defined as days with an NEMT procedure code. Diagnoses are defined based on Centers for Medicare & Medicaid Services’ chronic conditions warehouse algorithm (CCW), which is a combination of billing codes, such as International Classification of Diseases versions 9 and 10, National Drug Codes, and Healthcare Common Procedure Coding System (HCPCS). Opioid use disorder’s CCW algorithm does not include codes for methadone treatment. Source: MACPAC Analysis of Transformed Medicaid Statistical Information System Data. January 29, 2021 13
Share of Ride-Days with Each Mode of Transportation, FY 2018 50.0% 46.0% 40.0% 36.7% 30.0% 22.5% 20.0% 10.0% 6.9% 5.0% 0.2% 0.0 % Van Taxi NEMT other Personal vehicle Public transportation Airplane Notes: NEMT is non-emergency medical transportation. FYE is full-year equivalent. Ride-days are defined as days with an NEMT procedure code. A ride-day can have multiple modes of transportation, and percentages do not add to 100. Source: MACPAC analysis of Transformed Medicaid Statistical Information System Data. January 29, 2021 14
Share of Ride-Days with Each Destination within Six States, FY 2018 50.0% 40.9% 40.0% 30.0% 20.3% 20.0% 16.9% 10.0% 7.3% 3.3% 1.8% 0.9% 0.5% Hospital Other Nursing home 0.0 % Beneficiary's residence Physician office Diagnosis or therapeutic site Residential facility Dialysis facility Notes: NEMT is non-emergency medical transportation. FY is fiscal year. Ride-days are defined as days with an NEMT procedure code. Percentages shows the share of ride-days on which each destination type was specified. Multiple destinations may be specified for the same ride-day. Percentages will not add up to 100. Only the six states with over 95 percent of identifiable destinations are included in the sample. “Other” destinations may include sites of an NEMT transfer, scene of accident or other acute event, or an intermediate stop at a physician office on the way to a hospital. Source: MACPAC analysis of Transformed Medicaid Statistical Information System Data. January 29, 2021 15
Key Takeaways NEMT is used extensively by a small number of beneficiaries Aged and disabled persons are the most frequent users when compared to other eligibility groups Beneficiaries diagnosed with end-stage renal disease (ESRD) use NEMT most frequently – Those with intellectual or developmental disabilities and serious mental illnesses also use NEMT more frequently than those with none of these conditions NEMT users primarily ride in a van or taxi—which includes Uber and Lyft The most common NEMT destinations are to the home or a physician’s office January 29, 2021 16
Insights from Online Focus Groups with Medicaid Beneficiaries Understanding the Value of the Medicaid Non-Emergency Medical Transportation (NEMT) Benefit CONDUCTED FOR THE MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION (MACPAC) PREPARED BY PERRYUNDEM JANUARY 29, 2021
MACPAC commissioned eight online video focus groups with Medicaid enrollees (or a caregiver representative) who are enrolled in the NonEmergency Medical Transportation (NEMT) benefit and have experience using these services. 2 § The eight online focus groups were conducted September – November 2020 by PerryUndem. § Participants live in six states: Arizona, Connecticut, Georgia, Indiana, Massachusetts, and Texas. § Each group lasted 90 minutes and included between four and seven participants. § Some participated by phone while others participated by video from laptops or mobile phones. § The groups included a mix of participants by race/ethnicity and gender. One group was held among Spanish speakers.
The research participants have chronic conditions that require monthly to daily mental or physical health care visits. While some have been using NEMT services for a short time, most have been using NEMT services for a year or more. 3 § Focus group participants have (or are caring for someone who has): ! end-stage renal disease ! cancer ! high blood pressure ! back problems ! hip and knee problems ! neuropathy ! cirrhosis of the liver ! vision issues ! asthma and other breathing issues ! autoimmune disorders ! heart disease ! PTSD ! bipolar ! anxiety ! depression ! substance use disorder § Some participants also use wheelchairs, including two participants with quadriplegia and paraplegia due to spinal injuries.
§ We had 41 total participants in the focus groups across the six states. This included: ! 31 women and 10 men More details about research participants: ! 24 participants were 45 years or older while 17 participants were 44 years or younger ! 27 Medicaid enrollees and 14 dual-eligible Medicaid and Medicare enrollees ! 14 residents of urban areas, 7 suburban residents, 14 in small towns, and 6 who lived in rural areas ! 14 White participants, 13 Black participants, 9 Latinx participants, 2 APPI participants, 1 Indigenous participant, and 2 who identified as mixed race ! 34 participants use NEMT themselves, 6 were caregivers for others, and 1 had a child who uses NEMT 4
Before NEMT: Prior to enrolling, research participants reported a variety of different transportation barriers to accessing the care they needed. 6 § Many did not have a car or a driver’s license. § Some were unable to drive or use public transportation because of their medical conditions. § A few required a specialty vehicle such as a wheelchair van. § Many said they could not afford the cost of transportation. This was a particular issue for those living in rural areas and for those in need of frequent transportation to reoccurring appointments (e.g., dialysis, etc.). § Public transportation was not available or took too long for some. § Participants did not have, or could not rely on, friends or family to drive them to appointments, or they felt the burden was too great on their loved ones.
§ A Georgia woman with quadriplegia used NEMT to go to a spinal care center three days a week. This therapy was critical to maintaining her strength and mental health. § An Arizona man, who was left with a broken femur and hip, among other injuries, following a car accident used NEMT for physical and occupational therapy to help his mobility recover. § An Indiana woman who has cirrhosis of the liver, neuropathy, and degenerative discs – which has reduced her walking ability – went to physical therapy two to three times a week and other specialists a few times a year. § A Massachusetts woman with ESRD signed up for NEMT when she broke her hip and couldn’t drive herself to dialysis anymore. § A Massachusetts man with SUD used NEMT to go to a methadone clinic seven days a week to assist his ongoing recovery from addiction. § An Arizona mother of a child with autism used NEMT regularly to take her daughter to see developmental specialists. Her daughter also participated in a respite and living skills program that arranged transportation funded by NEMT. Using NEMT: Examples of how participants used transportation services 7
The value of NEMT: It helped them manage their physical health and chronic conditions. 8 § Many participants, particularly those with serious conditions like ESRD, felt that their continued and regular access to treatments and medical services was saving their lives. § Having access to NEMT was critical for managing ongoing health conditions, and without these services, participants worried whether they could make appointments and continue their care. § Prior to NEMT, some told stories of missing appointments or being unable to receive necessary treatment. Many felt their health was worse before NEMT because conditions were unchecked and not managed. § Many also remarked that NEMT added greatly to their quality of life because it helped them maintain their health, improve their mobility, or just enabled them to function and get through the day.
The value of NEMT: It improved the emotional health of those with disabilities or physical limitations. 9 § NEMT helped those who might otherwise feel isolated or trapped in their homes. § Some talked about the emotional toll of being confined to their homes and how NEMT helped give them agency to get around again. § NEMT allowed some to access mental health or substance use disorder services that were vital for their daily lives. § A few with mental health needs also faced barriers to using public transportation prior to NEMT. One participant shared that when she was more depressed and anxious, just leaving her home and getting on public transportation was too much.
The value of NEMT: It gave more independence to participants, lessening their reliance on family members. 10 § Just as important to many participants was the freedom the NEMT services provided them. No longer reliant on family members to get them to and from appointments, they felt a sense of independence and being able to control their own lives, which mattered to them. § For some, particularly those with mobility challenges, they appreciated NEMT simply because it enabled them to “get out of the house” and continue with some normalcy to their lives. § Others said having NEMT had a positive effect on their families and gave them freedom too. One participant explained that without NEMT, her mother would have to quit her fulltime job in order to transport her to and from her appointments. § Some said just trying to coordinate and navigate public transportation, Uber/Lyft, and getting rides from family and friend members would just be too much for them to handle.
§ Drivers arrived too early, too late, or not at all. Some blamed drivers, others blamed dispatch. § Customer service deficiencies, including rude or unprofessional drivers or call center representatives. § Feeling there was little recourse to hold drivers or transportation companies accountable when there were problems. § Some felt NEMT policies were not practical or fair. Specifically: NEMT challenges: While overall positive about NEMT, there was a lot of variation of experiences with using these services and a number of beneficiaries had run into challenges. 11 ! Policies that required them to share rides or use public transportation even when doing so was not practical; ! Policies that required them to schedule rides three days in advance; ! Policies that precluded parents from bringing their children along in rides.
Improvement ideas: Beneficiaries offered ways to improve NEMT. 12 § Improve dispatching processes. § Prevent overcrowding on shared vehicles. § Reducing excessive wait times. § Implementing stronger background checks for drivers. § More flexibility in rules so beneficiaries can use NEMT for nonmedical purposes, such as trips to the grocery store. § More flexibility around some of the policies mentioned on the previous slide (e.g., such as parents being able to bring children). § Some beneficiaries mentioned wanting to be able to use Lyft and Uber for NEMT services because the drivers are accountable for their ratings, are timely, and have better-maintained vehicles. § They like the idea of introducing new technologies into NEMT, such as an app to help schedule appointments and track their rides.
Closing: Beneficiaries explained what it would mean to them if they lost NEMT. 13 § Many got anxious in the focus groups when we asked what would happen if they could no longer receive NEMT services. They had an emotional response to the question. § The biggest fear was that they would regress, and their health would deteriorate. Some felt they might die. § Others said there would be mental health consequences. The peace of mind NEMT services provided, the sense of independence, and the ability just to leave their house would be lost. § Many also said there would be intense financial consequences from losing NEMT services. They said they could not afford to pay for services on their own, buy a car, or afford public transportation on a regular basis. This was particularly a concern for those living in rural areas.
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Mandated Report on NonEmergency Medical Transportation: Further Findings Medicaid and CHIP Payment and Access Commission Kacey Buderi and Aaron Pervin January 29, 2021 www.macpac.gov
Van Taxi NEMT other Personal vehicle Public transportation Airplane Notes:NEMT is non-emergency medical transportation. FYE is full-year equivalent. Ride-days are defined as days with an NEMT procedure code. A ride-day can have multiple modes of transportation, and percentages do not add to 100.
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