The dialogue around providing accessible health care includes such big issues as high-priced prescriptions, overuse of emergency rooms and a burgeoning need for long-term care. One topic that gets relatively little attention, but could have a big impact on accessibility, is transportation. It represents a tiny fraction of the total spent on health care, but it has been a big challenge for states to manage.

This piece of the health-care puzzle affects 7.1 million people, according to the nonprofit Altarum Institute, which provides health-care research and consulting. A chunk of this group are Medicaid patients. The federal government requires transportation reimbursement for all Medicaid recipients. 

A report to the 2015 National Conference of State Legislatures described the extent of the overall problem. “Services can overlap in some areas and be entirely absent in others,” it said, noting that funding shortfalls, policy and implementation failures, and lack of coordination leave many who need transportation with few or no options. 

Often the service shortfalls are as mundane as cars that show up late -- sometimes 15 minutes, sometimes hours. Or worse, they don’t arrive at all. This is more than an inconvenience. It can be devastating, particularly when the patients involved are frail or disabled and trying to get home from an appointment. Nathalie Molliet-Ribet, senior associate director of Virginia’s Joint Legislative Audit and Review Commission notes, for instance, how traumatic it would be for, say, an intellectually disabled child to be left alone for hours while waiting for a ride home.

Poor service isn’t the only issue states have to deal with. There have been a host of instances in which states wind up overpaying for transportation or paying for transportation that wasn’t necessary in the first place.  

Massachusetts, for example, audited a company that had contracted to provide wheelchair van services based on a fee-for-service model. When Massachusetts examined the books, the state auditor’s office found that:

More than $17 million in questionable payments were made to the provider for wheelchair van transportation. Hundreds of claims were made for members who were inpatients at hospitals at the time the alleged transportation was proffered. 16 percent of transportation services to methadone clinics occurred with members who were not receiving any medical services. In a model of understatement, State Auditor Suzanne Bump says that “the administration of the program has not been its strong suit.” The provider’s failure to comply with the terms of the program was so blatant, she adds, “it blew the auditors and me away.” 

How did the provider respond to the publication of these problems? They said that they were acting under the direction of MassHealth, the state’s Medicaid and children’s health insurance program. MassHealth denies that was the case. The provider has been suspended, and the attorney general’s office is investigating. Meanwhile, Medicaid recipients, with the help of MassHealth, have been scrambling to find other ways to get to their medical appointments.

The problems with nonemergency medical transportation in Virginia have been somewhat different. As many states do, Virginia uses a single broker to match transportation providers with Medicaid recipients. Under the contract, the broker is paid a fixed rate per enrollee. But the broker has claimed to be unable to cover its costs, arguing that the service rate set in its contract is too low. There is no demonstrated cause and effect between the reimbursement rate and the quality of service, but there would appear to be a link. The state has experienced an increased rate of complaints from patients about unfulfilled trips.

One of the challenges in fixing the problem was a lack of data. “Medicaid didn’t have any information on whether the broker was losing money, and why,” says Molliet-Ribet. A year ago, the state did a study and found enough justification to provide an increase in reimbursement.

But the broker continues to claim not to have enough money, and the state doesn’t appear willing to raise its rates again since “the broker has been unwilling or unable to provide [necessary] information,” says Molliet-Ribet. In the meantime, the auditor’s office has been pushing for greater transparency in order to deal fairly with its broker and optimize quality of service.

It’s not all failure out there. One state that has run a particularly efficient nonemergency medical transportation program is Vermont. The state is largely rural, and a lot of citizens live far away from medical facilities. As a result, many Medicaid recipients do not have easy access to health care. What’s more, the number of transportation-needy Medicaid recipients has been growing as a result of Medicaid expansion and an increase in the number of patients with addiction-related problems. 

Vermont has taken a multiprovider approach to managing the transportation challenge. It gives 12 separate providers wide latitude to provide rides. “It’s their responsibility to develop their own transportation plans,” says Suellen Bottiggi, who heads up Medicaid provider relations. But that’s only the first part of their approach. The second is to practice oversight -- each of the 12 is audited once or even twice a year. “Ongoing monitoring is so important,” says Bottiggi. 

Regardless of the public-sector service, we can’t repeat that sentiment often enough. There’s nothing like a focused look at the books to keep providers on their toes.