Transportation's Role in Saving Health Care Dollars
The United States has initiated sustained efforts to contain health care costs over the last several decades. In understanding what is driving those costs, researchers have identified two activities that make up 58% of health care costs nationwide: hospital-based care (33%) and office-based care (25%). Making an impact in these two cost categories can help drive down health care costs as a whole.
While a complex set of factors play into the cost of hospital- and office-based medical services, three scenarios can be isolated that have a transportation component:
- Patients who miss health care appointments because of a lack of transportation
- Patients being re-hospitalized because they did not have transportation to their post-hospitalization appointments, during which health care issues could be addressed before they reach the level of requring readmission to the hospital.
- Patients using more expensive emergency services (ambulances, emergency departments) for non-emergency conditions because they did not have transportation to less costly primary/preventive care provided in an office setting
Reducing the number of missed appointments
Missing screening, regular, and follow-up medical appointments can lead to many consequences for patients, such as the worsening of one’s illness or condition, the missed opportunity to communicate new symptoms to a health care provider, and limiting options for learning strategies to promote better health. In fact, one study found that missing appointments in the past is a predictor for also missing appointments in the future.
When health care providers do not regularly see patients, especially those with chronic illnesses, they are prevented from gaining a full picture of their patient’s health. In addition, it inhibits them from making an early diagnosis of any new, emerging illnesses or the onset of complications related to the existing illness.
There are financial consequences for the health care provider and the health care system as a whole as well: missed appointments and the consequent worsening of a patient’s condition may lead to the need for more costly interventions that might have been avoided.
Although several studies have reported no-show rates from 3 to 80%, they vary broadly among providers and even within an institution’s own departments.
Health care providers lose revenue for every missed appointment because they are no longer able to provide what would be a billable service to that patient. While it is difficult to determine the economic repercussions, one estimate suggests that no-shows or last-minute cancellations result in an industry loss of $150 billion per year, compounding at an average rate of $200 per unused timeslot. In short, if patients are unable to see their health care providers, it creates a domino effect which can create short- and long-term impacts on their health, and health care professionals’ ability to provide care.
Lowering the rate of re-hospitalizations
In 2011, 3.3 million hospital readmissions cost the U.S. health care system $41.3 billion. The Hospital Readmissions Reduction Program (HRRP), established by the Affordable Care Act, was designed to combat excessive and costly readmissions. As part of the HRRP, the Centers for Medicare and Medicaid bean imposing penalties on hospitals for re-hospitalizations of Medicare patients discharged less than 30 days prior for the same condition. This strategy seemed to show some results from 2010 to 2017, as the readmission rate decreased 7 percent for Medicare patients, from 16.7% in 2010 to 15.7% in 2017. Based on 2020 readmission rates, 2,545 — or 83% — will face penalties under HRRP in FY 2021 payment penalties, costing hospitals $553 million. [The Advisory Board annually updates the hospital readmission penalties, listed by state and then by hospital system. Kaiser Health News also tracks readmission rates, and has a look-up feature for hospitals.]
The following strategies have been identified as impacting readmission rates; nos. 2 and 4 below have a clear transportation component:
- Coaching patients on discharge instructions and self-management
- Providing care coordination and care setting transition planning with inpatient and outpatient providers, family members, follow-up appointments, and transportation to appointments.
- Performing medication reconciliation
- Tackling the social determinants of health, working with community partners who can provide social, emotional, financial, nutritional, and logistical/transportation support to low-income and socially isolated patients.
- Leveraging data identifying higher-risk patients to effectively allocate resources by using demographic, psychographic, and geographic data along with hospital and payer data to detect and manage social, behavioral, and location-based risk factors.
Hopelink Care Mobility Concierge. This video, from a NCMM Health Care Access Grantee, shows how ideas such as a concierge can make a system run more smoothly.
Transportation Navigators Supporting Patients Post-Hospitalization. This short video from another NCMM Grantee shows how navigator programs can help reduce missed visits.
Decreasing usage of emergency services for non-emergent conditions
Unnecessary emergency department (ED) visits are costly and consume resources that other individuals with more acute needs may need. In 2017, an estimated $8.3 billion was spent on ED care that could be provided in another location, a significant increase from the $4.4 billion annual cost of such care as identified in a 2010 study. A more recent study correlated patients who miss primary care appointments with increase usage of ED services and hospitalizations.
Unnecessary ED visits generally include visits that could have been handled in a different setting as well as visits that could have been avoided through more appropriate preventive or chronic care. The most common reasons patients may go to the ED relate to access: lack of a relationship with a primary care provider or care team, lack of after-hours or timely access to a provider, or barriers to access such as transportation. Other reasons may be more complex, including inadequate chronic care management or gaps in care coordination among multiple locations of care.
For further investigation . . .
Transportation to Healthcare Destinations
This NCMM white paper outlines the connections between transportation and healthcare, providing context and suggestions that will enable transportation providers to engage in conversations with healthcare agencies and make the case for more collaboration between the two sectors.
Reducing Preventable Emergency Department Utilization and Costs by Using Community Health Workers as Patient Navigators
This study found that the patient navigation intervention was associated with decreased odds of returning to the ED among less frequent PCR-ED users. The savings associated with reduced PCR-ED visits were greater than the cost to implement the navigation program.
Needham Community Council – Needham, MA
In 2017, the Needham Community Council began supplementing its volunteer driver medical transportation program with trips provided through the ridehailing company, Lyft. Lyft rides were funded through the Needham Community Council operating budget and a donation from Beth Israel Deaconess Hospital – Needham.
Brookline Council on Aging – Brookline, MA
Transportation Resources Information Planning and Partnership for Seniors (TRIPPS) is an initiative of the Brookline Council on Aging. TRIPPS launched in 2015 with initial funding through a grant from the Massachusetts Department of Transportation using federal 5310 funding. We provide information, resources, and support to older adults in Brookline who are looking for transportation options. Our focus has been on older adults who are either not driving or are transitioning from driving to other modes. About 70 percent of our older adults who we work with do not own a vehicle.
Gloucester Health Department – Gloucester, MA
Cape Ann Seniors on the GO launched in October 2019 across the communities of Gloucester, Rockport, Essex and Manchester by-the-Sea to meet an identified need of improving access to healthy food and opportunities for physical activity among low income older adults through increased transportation access. This pilot grew out of the work of the Cape Ann Mass in Motion coalition, a part of the Massachusetts Department of Public Health’s Municipal Wellness & Leadership Program. The need for food and physical activity access was identified through root cause analysis and examining high rates of chronic disease among older adults in our Cape Ann communities. Over half of older adults who reside in Gloucester have four or more comorbidities.
Dakota County Community Services, “The Rapid” – Dakota County, MN
RideLink is a network of five area transportation providers that together provide older adults (age 60+) with door-to-door transportation as a complement to the fixed route bus. RideLink can be utilized for medical appointments, shopping trips, and recreational trips, which sets it apart from other options in the area that limit rides for older adults for specific purposes. RideLink’s providers have multiple types of vehicles that provide service to those who use a wheelchair accessible, and also accommodate service animals and caregivers.
Franklin Regional Transit Authority – Greenfield, MA
In 2019, FRTA launched the FRTA Access microtransit program. In contrast to many microtransit programs that are contracted out to a third-party company, FRTA operates its microtransit in house: FRTA upgraded its scheduling software to allow riders to book on-demand rides, and uses its existing demand-response vehicles to make the trips. Eligible demand-response riders have priority when they reserve in advance, and then any remaining capacity is open to the general public through the FRTA Access app. Initially, riders could only summon rides through the app, but over time FRTA also added an online reservation as some parts of the region lack good cell coverage.
Franklin Regional Transit Authority – Greenfield, MA
In April 2021, the Franklin Regional Transit Authority (FRTA), which provides transportation in 41 communities in rural Western Massachusetts and fixed-route services in the small city of Greenfield, added a new pilot to expand mobility for workers needing to commute to late night and early morning shifts. In partnership with the local Workforce Board, FRTA received a grant to fund taxi rides for workers needing to get to second and third shift jobs during hours when public transit was not operating. In addition to getting a ride to work, participants could also stop at a childcare facility if they needed to drop off or pick up their children on the way.
SeniorCare Inc. – Gloucester, MA
Recognizing that they would not be able to fill all trip requests with just their volunteer driver program, they also set out to become knowledgeable about other transportation options in the region, and to share that information with their riders. SeniorCare began by reaching out to area Councils on Aging and the local transit authority to learn about their transportation services. They compiled a town-by-town listing of transportation resources, posted on the SeniorCare website. To keep the information up to date, SeniorCare does regular outreach. When a new caller requests a ride, SeniorCare’s Transportation Coordinator discusses all transportation options appropriate for them and mails them a welcome packet with that information.
Franklin Regional Transit Authority – Franklin County, MA
In November 2021, Franklin Regional Council of Governments (FRCOG) a new program, entitled the Franklin County Access Pilot for Nonprofits. It was created for a coalition of local health and social service agencies. FRCOG had funding from a state legislative earmark that they originally planned to use to subsidize Lyft rides. The Lyft pilot was delayed due to lack of Lyft drivers in the rural area, and in the meantime, FRTA’s in-house ride-hailing program, Access, launched. , so FRCOG pivoted to subsidize microtransit rides instead of Lyft rides. FRTA’s Advisory Board met in May 2022 to discuss the future of these initiatives and voted to make the FRTA Access a permanent program.
OCCK Public Transportation – Salina, KS
On the Go: Enticing Seniors to Try Salina’s Public Transportation program began in 2022 as a partnership between the Salina Senior Center, OCCK Transportation and the Mobility Manager for North Central Kansas. The goal of the program is to increase the number of senior citizens using Salina’s public transportation system.
Cape Cod Regional Transit Authority – Hyannis, MA
To promote access for Cape Cod residents to specialty medical appointments in Boston, the Cape Cod Regional Transit Authority (CCRTA) has run a Boston Hospital shuttle since 2001. The shuttle starts on the Outer Cape and picks passengers up at seven stops in different Cape towns, and then drives into Boston and drops passengers off at their appointments. In the early afternoon, the shuttle picks riders back up for the return trip to the Cape. Prior to the pandemic, service ran one daily round trip five days a week; since the pandemic, the shuttle runs Monday through Thursday. In order to serve as many residents as possible, the shuttle is open to the general public.