The new report, Transportation and Health Access: Rides to Wellness Community Scan Project, conducted by Health Outreach Partners, describes the scope of the problem of transportation barriers to health care and its financial impact due to missed appointments. Based on a national survey with community health centers, findings show no-show rates ranging from 11-30%, but that the reasons for missed appointments are not being tracked. By addressing transportation barriers, there is greater potential for financial benefits for health centers that are also likely transferable to other health care providers. The Missouri Rural Health Association and Community Asset Builders were contributors to the report, which includes six profiles of communities – one of which is Missouri’s HealthTran initiative – who are taking action to address barriers and decrease loss of revenue.
Our Missouri pilot project showed that free trips to the doctor pay off for everyone
In 2014, Leo Haralson’s big toe turned black, a casualty of his battle with diabetes. A veteran and a former software developer for the U.S. Navy, he had insurance through both Medicare and the Veterans Affairs Department, so getting good health care shouldn’t have been a problem. But after the toe was amputated, he developed an infection that spread to his bones. Haralson needed daily oxygen treatments at a hospital to halt the infection.
Haralson and his wife, 65, motorcycle enthusiasts originally from Wisconsin, had retired to southern Missouri, seeking a warmer climate and a home in the middle of the country so they could drive off in any direction. They built their dream home on the outskirts of the town of Mountain View, named for its commanding view of the Ozarks. But his wife could no longer drive, and with his foot in bandages, Leo couldn’t either. The hospital was 30 miles down Highway 60 from his home, and the local transit provider has bus service only on Wednesdays. Without a way to get to the hospital every day for a month, Haralson faced losing his leg—and his ability to live independently.
Transportation comes up in virtually every conversation about rural health care, particularly in the past few years as hospital closures have increased the distances many patients need to travel. Missouri has closed three hospitals since 2010, victims of cutbacks in reimbursement from insurers and the government. Distances patients must travel are increasing.
As policymakers look at ways to improve the health of rural Americans, it’s becoming increasingly clear that transportation is a critical missing link between patients and providers.
The problem isn’t necessarily a lack of rides; many places, like Missouri, have a variety of transportation options for people who can’t drive. Medicaid provides some non-emergency transportation for eligible patients. Some local communities run van services, particularly for seniors. The Southern Missouri Transportation System and OATS, a nonprofit transit company, provide van services, as well. And there are medical transportation services including emergency ambulances.
But all of those systems have problems and gaps. For Medicaid, rides must be ordered five days in advance, and cannot include secondary stops, even just to visit a pharmacy to fill a prescription after the doctor visit, without prior approval. Van and bus services run once or twice a week on fixed schedules and routes that may not match a patient’s appointment times. And ambulances are expensive.
There’s a bigger problem, too: The current system puts the burden of navigating those options and schedules on patients, even as they are struggling with illness and symptoms like pain, confusion and fatigue. In Missouri, we have found that when getting a ride isn’t simple and affordable, patients will forgo care. And that means that their conditions can worsen until they become acute and result in an ambulance ride to the ER instead—the most expensive option of all.
Clearly, the existing system doesn’t work well for anybody. Patients are overwhelmed and often give up. Doctors and hospitals lose time and revenues because of “no-shows.” And ambulance companies are transporting patients who didn’t know whom else to call—and then don’t get paid if an insurance company or Medicaid decides it wasn’t an actual emergency.
As a health care consultant and the executive director of the Missouri Rural Health Association, I helped develop a program to test whether there was a better way. We got seed money to hire a “mobility coordinator” who could arrange rides for patients who needed them. Our program, called HealthTran, trained clinic and hospital staff to ask patients at the time they made appointments whether they needed a ride. And if they did, they alerted the HealthTran coordinator who would contact them, assess their transportation needs and figure out a cost-effective solution.
Leo Haralson was one of HealthTran’s first patients. In his case, the coordinator determined that because of his infection, he needed private rides from his home in Mountain View to Ozarks Medical Center in West Plains, 30 miles away. She arranged 70 rides for him at a cost of $6,000. That wasn’t cheap, but it paid off. The hospital benefited by being able to bill Medicare $13,000 for the oxygen treatments and avoiding penalties for a hospital readmission. Medicare saved the cost of a leg amputation and possible transfer to a nursing home.
Here was how it played out at one hospital system: In just 17 months, HealthTran provided 2,470 rides for patients receiving services, at a cost of just over $66,000. Including staffing, the total cost of coordinating and paying for transportation was approximately $95,000, an average of $33 per ride. These patients resulted in over $730,000 in payments to the hospital and its clinics. In short, for every $1 invested in transportation, the hospital earned $7.68 in reimbursement.
The return on investment in transportation is so strong that it can pay off even for individual doctors. A missed appointment means missed revenue, loss of provider productivity, patient rescheduling and most likely a sicker patient. If 20 percent of scheduled appointments are missed on a weekly basis, and the average charge for that primary care visit is $150, a provider who typically sees 20 patients per day will miss out on $3,000 each week (or 1 entire day’s worth of revenue), while staffing costs remain constant. At $225 per visit for specialty care, the provider misses out on $4,500. Over the course of a year, the health care provider is missing out on $156,000 to $234,000. Considering the average cost of a ride for these patients at $33, the annual cost of paying for transportation and mobility coordination would be about $45,000. This is a $3.46 to $5.20 return for every $1 invested in transportation.
And that doesn’t even consider the improved patient outcomes and those long-term savings to the health care system.
Perhaps the biggest payoff is that it helps senior citizens like Haralson and people with disabilities to live successfully in homes of their own rather than move to nursing homes or assisted-living facilities, placements that can erode their health and cost the government and other insurers much more money in the long run. If Haralson had required a leg amputation, that would not only have cost Medicare and Medicaid upward of $1 million, but left him disabled and likely forced to move to a nursing home. Instead, Haralson was able to continue to live at home and fend for himself. These days, he’s spending his retirement helping deliver meals to homebound seniors in his community.
So, why aren’t more hospitals offering no-cost transportation to their patients? One reason is that well-intentioned federal regulations have created unnecessary hurdles. In an effort to avoid a practice known as “self-dealing,” hospitals are not allowed to directly provide transportation to patients. While there were a few instances in the past of hospitals unfairly profiting by providing transportation between nursing homes and hospitals, the practice was not widespread. Still, the rules designed to eliminate that practice now make it difficult for providers to take on the transportation problem directly. That’s why the HeathTran model offers a solution: By using an outside coordinator to make the arrangements, HealthTran helps hospitals maintain an arms-length relationship from transportation services.
In theory, driverless cars could someday address some of the need for medical transportation. But I’m skeptical that will solve the problem for most patients because a key factor in health care is human interaction. Many patients who need transportation are seniors, or have a disability that can make it hard to get to and from their front door and the vehicle without assistance. At least in Missouri, and I would venture to say in many other areas of rural America, people need a human connection—a person in the community, familiar with the community—to connect the health, transportation and payer systems in a way that makes good, common sense. And besides, we can’t wait for a driverless future. Patients in rural America need a solution now.
Missouri’s HealthTran was designed to bridge the transportation gap between patients and providers in a way that works for all sides. Rural America needs more of these solutions. If we can’t make it easier for rural patients to get to and from their homes and their doctors, the whole country will pay for it down the road in greater medical costs and poorer health outcomes.
Suzanne Alewine is a health care consultant and executive director of the Missouri Rural Health Association.
Community Asset Builders, LLC reached a significant milestone in July 2016, celebrating 15 years of business. The company has grown from the dreams of co-founders Doris Boeckman and Suzanne Alewine, to a company that has supported more than 150 organizations through project-specific and retainer contracts, and generated more than $235 million in grant revenue for customers. As part of our celebration, we are excited to share, “15 Years of Taking Clients Beyond Their Potential,” a document that captures our journey throughout the years and summarizes the wonderful relationships that have been established to improve the health and well-being of individuals in Missouri and throughout the United States.
“It gives me great pride in joining Suzanne and our employees, clients and business partners in celebrating our company’s 15th anniversary. We have come a long way since the business first started in 2001 and we are very excited about our future as we continue to seek innovative solutions and services to meet the needs of our customers,” said Boeckman.
Community Asset Builders readied itself for growth by focusing on its core tenets:
- Serving as a voice on community development and asset building for the communities and organizations it serves with state and national organizations;
- Increasing access to financial resources through grant writing and fund development;
- Providing technical assistance and planning services so clients can more effectively utilize their resources;
- Strengthening peer networks among clients to increase opportunities for collaboration and shared learning; and
- Challenging public and private funding sources to invest more robustly in communities where clients are serving vulnerable populations.
Our ability to engineer solutions based on the specific needs of customers has helped the company to continually grow over the past 15 years, and offers promise for future growth.
Joe Lopez, Director of Strategic Growth and Development for Community Asset Builders, LLC (CAB), will be the lead team member for all three new accounts. Joining the network of peer organizations being served by CAB are Helias Catholic High School and The Helias Foundation (Jefferson City, Missouri), and Concord Christian School of New Hope International Church (Concord, California). Each of these organizations will receive professional assistance with planning and fund development in 2016 to develop new and augment existing resources.
Helias Catholic High School is a co-educational high school of the Diocese of Jefferson City which seeks to educate and strengthen the whole student – mind, body, and soul – within the strong tradition of Catholic secondary education. Welcoming Catholic and non-Catholic students alike, Helias seeks to provide a strong education in a safe environment for students who will further their education in college, trade school, the armed forces, or the workforce. The Helias Foundation, Inc. supports Helias Catholic High School to enable Helias to offer a quality, affordable Catholic education to the students of Central Missouri.
New Hope International Church ministers to people from every imaginable ethnic background. The membership includes Hispanics, African Americans, Asians, Europeans, Caucasians, and many other ethnic groups who freely worship together. Concord Christian Schools aid children in their academic, spiritual, and character development. Concord Christian Schools was started in 1972. All of the classrooms are designed and supplied with a wide variety of learning essentials and educational resource materials, each unique and creating a learning environment for each child to succeed and excel.
Welcome to the CAB network!
Community Asset Builders, LLC (CAB) is always looking at funding sources that may be of benefit to community based organizations. The following are a few postings that may be of interest.
MINORITY HEALTH. SAMHSA is accepting applications for more than $33 million in available funds to support the Targeted Capacity Expansion HIV: Minority Women grant program. These grants aim to expand substance use disorder treatment and HIV services for racial and ethnic minority women. Learn more and apply by April 29. http://www.samhsa.gov/newsroom/press-announcements/201603081100
CHILDREN. HRSA is accepting applications for more than $2.5 million in available funds to support the Innovation in Care Integration for Children and Youth with Autism Spectrum Disorders and Other Developmental Disabilities Program. These funds support the implementation of innovative, evidence-informed strategies to integrate care at a system-level within states. Learn more and apply by May 10. https://grants.hrsa.gov/2010/Web2External/Interface/FundingCycle/ExternalView.aspx?fCycleID=7e770aa8-93a7-4ff5-b515-7cb534d05021
JUSTICE. The U.S. Department of Justice is accepting applications for $9 million in available funds to support the Justice and Mental Health Collaboration Program. This program aims to increase public safety through innovative cross-system collaboration for individuals with mental illness who come into contact with the criminal justice system. Learn more and apply by May 17. https://www.bja.gov/Funding/JMHCP16.pdf
HIV/AIDS. SAMHSA is accepting applications for more than $1.6 million in available supplement grant funds to support the Minority AIDS Initiative Continuum of Care (MAI-CoC) program. The MAI-CoC supplemental grants will allow organizations to expand and enhance current grant activities related to behavioral health treatment services, prevention and HIV and hepatitis medical services. Learn more and apply by June 8. http://www.samhsa.gov/grants/grant-announcements/sp-16-008
TRAUMA. The Substance Abuse and Mental Health Services Administration, Center for Mental Health Services is accepting applications for fiscal year (FY) 2016 Resiliency in Communities After Stress and Trauma (Short Title: ReCAST Program) grants. The purpose of this program is to assist high-risk youth and families and promote resilience and equity in communities that have recently faced civil unrest through implementation of evidence-based, violence prevention, and community youth engagement programs, as well as linkages to trauma-informed behavioral health services. The goal of the ReCAST program is for local community entities to work together in ways that lead to improved behavioral health, empowered community residents, and reductions in trauma and sustained community change. Application Due Date: Tuesday, June 7, 2016 http://www.samhsa.gov/grants/grant-announcements/sm-16-012
TELEHEALTH. Universal Service Administrative Company. The Healthcare Connect Fund provides funding to healthcare providers for telecommunications and internet access services, as well as network equipment, at a flat discounted rate of 65%. Participants can apply as a member of the consortium or a stand-alone entity. Rural public or nonprofit healthcare providers (HCPs) are eligible. Consortia may be comprised of both rural and non-rural HCPs. All consortia must consist of more than 50% rural participation within three years of receipt of the first funding commitment obtained through the HCF Program. Connections to, and equipment located at, eligible off-site data centers and administrative offices are eligible for support. Application Deadline: Jun 1, 2016
Eligible entities include:
- A post-secondary educational institution offering healthcare instruction, such as teaching hospitals or medical schools,
- A community health center or health center providing healthcare to migrants
- A local health department or agency
- A community mental health center
- A nonprofit hospital
- A rural health clinic, including mobile clinics
- A dedicated emergency room of a rural for-profit hospital
DENTAL. DentaQuest Foundation. The Oral Health 2020 Initiative will provide funding to organizations working to eliminate oral disease in children and increase oral health across the lifespan. Funding will be awarded to create networks, establish partnerships and analyze policy.
Proposals should focus on one of the following goals:
- Mandatory inclusion of an adult dental benefit in publicly funded health insurance
- Incorporate oral health into the primary education system
- Comprehensive national oral health measurement system
- Eradicate dental disease in children
The Foundation is especially interested in promoting health equity outcomes. Proposals that address one or more of the multiple factors affecting health equity (race, ethnicity, geography, etc.) are encouraged. Applications accepted on an ongoing basis http://dentaquestfoundation.org/oh2020/submitconcept
DENTAL. American Dental Association. The Semi-Annual Grant Program: Access to Care will award funding to projects that improve access to oral healthcare. Application Deadline: Jul 29, 2016.
Examples of eligible projects include:
- Oral health care
- Clinic supplies, instruments, and equipment
- Salary-specific to work on this grant project
- Outreach to recruit dentist participation in program activities
RESEARCH. The AHRQ Small Research Grant Program (R03) supports different types of health services research projects, including:
- Pilot and feasibility studies
- Secondary analysis of existing data
- Small, self-contained research projects
- Development of research methodology
- Development of new research technology
Rural and frontier areas are considered a priority population, along with inner city, low-income groups, minority populations, and individuals with special healthcare needs. Application Deadline: Jul 16, 2018.
Research projects should be organized around a set of priority conditions of importance to the Medicare, Medicaid, and SCHIP programs. The current list of conditions includes:
- Arthritis and non-traumatic joint disorders
- Cardiovascular disease, including stroke and hypertension
- Dementia, including Alzheimer’s Disease
- Depression and other mental health disorders
- Developmental delays, attention-deficit hyperactivity disorder and autism
- Diabetes Mellitus
- Functional limitations and disability
- Infectious diseases including HIV/AIDS
- Peptic ulcer disease and dyspepsia
- Pregnancy including pre-term birth
- Pulmonary disease/Asthma
- Substance abuse
Have I mentioned that the crew a CAB knows how to have a good time while supporting a great cause? If not, well then I guess you need some proof!
If you haven’t checked out the good work being done by the HALO Foundation you should! They do great things in our community and they use all their donations very effectively and efficiently. That pleases me greatly.
We’ve made the move to using WordPress as our web platform and even our resident ‘html curmudgeon’ Christina is starting to enjoy the ease with which we can now manage our web presence. We are excited about the new ways we can use this platform to foster communications with our clients and the public. Please stay tuned as we should have our updates done within a few weeks.