Should we help poor, sick people in Indiana get to the doctor? Discuss.

I rewrote the title to this post eight times before I gave up. I’m too tired, frustrated, and annoyed with this week and this issue. Nonetheless, let’s dive in.

As part of Medicaid, beneficiaries are eligible for a non-emergency medical transportation (NEMT) benefit. They get a ride to the doctor. They get this because people generally understand that if we don’t poor provide people, especially sick people, a way to get to the doctor, they can’t go.

But in 2007, as part of their negotiation for the Healthy Indiana Plan (HIP), Indiana got a waiver for this benefit. The waiver was approved again in 2013, 2014, and 2015. As part of their negotiation to accept the Medicaid expansion in 2015, they got a waiver for HIP 2.0 for all beneficiaries except pregnant women, the medically frail, and certain smaller categories.

But this waiver depended on them studying a “demonstration year”. They had to conduct an independent evaluation of the NEMT to see that the impact was. They hired the Lewin Group, and that report has now been published. The conclusion:

In sum, the member survey shows a relatively small number of HIP 2.0 members missed appointments due to transportation-related issues. Also, members without NEMT benefits did not appear to be substantially more likely to report transportation problems relative to those with [managed care entitiy] MCE-provided or state-provided NEMT benefits. However, due largely to the limitations of the analysis, particularly the lack of comparable comparison groups, the picture is less clear regarding the extent to which the provision of NEMT coverage affects this issue. Future research could explore the use of a control group. In particular, if the NEMT benefits are similarly operationalized by the MCE and the state, it may be possible to conduct more robust comparisons of members within the population of members without state-provided NEMT based on whether their MCE provided NEMT or not.

In other words, it seems fine not to cover transportation. This is the state-sponsored report, though. Others, including Marsha Simon, beg to differ:

The evaluation found a significant number of individuals on Medicaid are missing appointments because they lack transportation.  According to survey results, 6 percent of Medicaid recipients under the waiver missed an appointment because they lacked the transportation benefit states are required to provide to Medicaid beneficiaries throughout the country. Even though this accounts for a relatively small proportion of enrollees, this figure nonetheless suggests there is unmet need for transportation to care among a portion of enrollees in the Healthy Indiana Program. Addressing this unmet need is the very rational[e] of the federal NEMT policy, a feature of the Medicaid program for the poor since it’s beginning in 1965. An entitlement to medical services is meaningless with no way to access the services.

Further, the question of whether an appointment was missed is too narrow a measure of access to care, as it fails to identify Medicaid enrollees that do not schedule an appointment because they know they cannot get to the doctor’s office. With this in mind, those evaluating Iowa’s NEMT waiver asked beneficiaries whether they had an “unmet need for transportation to or from a health care visit.”  There, researchers found that 15 percent of those with incomes under 100% of poverty had an unmet need for transportation.

One of the state’s managed care plans, Anthem, is continuing to provide this benefit even though the state refuses to reimburse the cost. I imagine they recognize that this probably improves outcomes. Maybe they even see that it is cost-saving because people who can get to the doctor in a cab might be less likely to call an ambulance (MUCH MORE EXPENSIVE) to go the emergency room (MUCH MORE EXPENSIVE) later. Other states agree:

When considering a similar waiver, Arkansas hired The Stephen Group (TSG) to offer a recommendation on waiving NEMT benefits.  Their recommendation warned against dropping the benefit. Far from being an additional expense, TSG argued that NEMT benefits were a good investment for the state, citing a Florida State University study showing a return on investment factor of 11:1 for as well as a Transportation Research Board study finding a 10:1 return on investment. Providing Medicaid enrollees with transportation benefits allows them to access preventative care that forestalls more costly interventions down the road. After this recommendation, Arkansas quickly dropped their proposal to waive NEMT.

Indiana’s waiver is set to expire in November. It’s up to the Obama administration whether to allow it to continue. We’ll see, I guess.


P.S. As this focuses on Indiana, I feel the need to direct you to my always-true-disclaimer: The views in Aaron’s posts represent his views only.  They do not represent the views of Indiana University, any funding agencies or foundations,  any organizations, or especially any of his friends or family.

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