Transportation Insecurity as Part of a Medical Diagnosis

Imagine going to a doctor and getting a prescription for transportation insecurity. Thanks to the work of the Gravity Project, this can happen now.

The Gravity Project, convened in 2019, is a national, public, consensus-based community charged with developing data elements, and data standards for the social determinants of health by leveraging the insights of subject matter experts and key stakeholders across the medical and social care community (patients, providers, payers, community-based organizations, vendors, and government). Data standards are the foundation for every health care diagnosis and reimbursement procedure.

Let’s look at this a bit further.  Health care professionals rely on a dense volume of diagnostic codes, called the International Classification of Diseases, created by the World Health Organization; we are now in version 10, so it’s called ICD-10. In this volume is a catalog of all known health conditions, grouped by similar disease categories and then detailed with more specific conditions. These codes feed into how health conditions are reported and reimbursed. Note that both are equally important: reporting (and thus tracking) disease conditions throughout the world and getting reimbursed for procedures that address the ICD-10–identified health condition.

Over the last several years, the health care industry has come to recognize the impact social determinants of health (SDOH) have on their ability to make progress in improving health conditions. SDOH are the conditions in which people are born, grow, live, work, and age. The CDC groups them into five categories: 1) economic stability, 2) education access and quality, 3) health care access and quality, 4) neighborhood and built environment, and 5) social and community context. Transportation would fit into most of these categories: transportation to education, leading to more job opportunity; transportation to health care and other life-sustaining destinations, such as food sources; transportation to safe housing sites; and transportation to social and community activities.

Although percentages may vary, it has been said that a person’s health outcomes are determined only 10% by the actual medical care they receive, 40% by their genetics, and 50% by SDOH. So, it stands to reason, that if the medical community wants to make an impact on people’s health outcomes, they need to at least figure out how to integrate SDOH-related factors.

This is why the work of the Gravity Project to—for the first time—create the data standards that will allow SDOH factors to be codified and applied to health care, is so important. To date, the Gravity Project has submitted, and had approved, the following ICD-10 codes, grouped under the general category of Z codes, defined as “factors influencing health status and contact with health services” (i.e., SDOH):

• Z59.82 Transportation insecurity
• Z59.86 Financial insecurity
• Z59.87 Material hardship
• Z71.88 Encounter for counseling for socioeconomic factors
• Z911.10 Patient’s noncompliance with dietary regimen due to financial hardship
• Z911.90 Patient’s noncompliance with other medical treatment and regimen due to financial hardship

The subheadings under Transportation Insecurity, Z59.82, are:

• Excessive transportation time
• Inaccessible transportation
• Inadequate transportation
• Lack of transportation
• Unaffordable transportation
• Unreliable transportation
• Unsafe transportation

As noted by the Gravity Project, the Centers for Medicaid and Medicare Services (CMS) have now determined that these new Z codes, including transportation insecurity, must be integrated into in-patient and long-term care plans, Medicare Advantage “special need plans,” the CMS Physician Fee Schedule, and Medicaid and CHIP programs.

At first, these integrations are for diagnostic and reporting purposes only. However, in August 2024, CMS determined that certain services related to housing insecurity can be reimbursed. It is hoped that reimbursement related to transportation, since it impacts so many of the SDOH categories defined by CDC, is not far behind.

So, what can transportation professionals do? First and foremost, work with your community partners to ensure health care providers are coding for transportation insecurity. Talk to staff in the health care facilities where your transportation agency delivers patients each day. The point person within hospitals would be utilization review nurses or case managers or specialists within health care offices who manage health information/medical records.

The more data that are formally gathered to document transportation insecurity, the quicker the impact of transportation access or the lack thereof can be tied to health outcomes, and the stronger the case for reimbursing for transportation-related services. You now have your mission!