When patients do not have reliable transportation, the effects ripple through the entire healthcare system. Here's a look at the fallout as well as innovative solutions.
According to the American Hospital Association (AHA), transportation challenges prevent a staggering 3.6 million Americans from receiving medical care each year. A 2019 survey by Kaiser Permanente found that one-third of Americans frequently or occasionally experience stress over their families' transportation needs.
While access to a reliable personal vehicle or public transit system can affect virtually any patient at any point in time, it can be persistently problematic for the roughly one-in-five patients residing in rural areas who experience commutes 17 minutes longer and 10.5 miles farther than their urban and suburban counterparts. Associated travel expenses pose additional barriers, especially for those with mobility-limiting conditions requiring specialized vehicles or with chronic conditions requiring repeated visits.
When lack of transportation leads to missed, canceled, or delayed appointments, the impact on patients and providers is significant, interrupting continuity of care and compromising patient outcomes as well as the successful management of complex comorbidities. The rise in such scenarios has prompted the creation and implementation of targeted solutions. "Addressing social needs [like transportation] is the next frontier in healthcare," says Edward Lee, MD, executive vice president of information technology and chief information officer at the Permanente Federation in Oakland, Calif. "An individual's social needs can have a huge impact on their health; physicians are often the first professionals working in a community to identify those needs."
Social determinants of health (SDOH)-where patients are born, live, learn, and work-are increasingly being studied as a way to stymie existing health inequities, improve access to both acute and preventive care, and address modifiable risk factors. According to the Centers for Disease Control and Prevention (CDC), genetic, biologic, and personal behaviors account for just 25 per cent of an individual's wellness. The remaining 75 per cent is attributed to SDOH factors like housing, safe neighborhoods, food insecurity, and access to transportation and healthcare services.
The true cost of missed appointments
When patients cannot attend appointments, regardless of the reason, it creates a cascade of consequences for all involved. An interruption in the continuity of care and access to critical support services can leave patients struggling to independently maintain treatment regimens and make healthful decisions that advance their care plans.
According to a 2018 Journal of Primary Care and Community Health study, patients with a history of missed appointments are nearly five times more likely to miss subsequent appointments. Another study determined that patients with higher rates of no-shows are significantly more likely to have incomplete preventive cancer screenings, worse chronic disease control, and increased rates of acute care utilization for hospitalization and emergency department visits, adding to healthcare costs in an already overburdened system. Missed appointments are a risk factor for all-cause mortality, according to a 2019 BMC Medicine study, with mental health patients experiencing an eightfold increase in risk.
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Healthcare organizations and providers feel the strain too. In the current healthcare environment where physician shortages are rampant, last-minute scheduling changes may result in unfilled timeslots, underutilization of valuable finite resources, and increased wait times for other patients. A secondary effect is the potential loss of revenues. 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. When patient visits are infrequent or sporadic, quality metrics can suffer, resulting in financial penalties under emerging value-based reimbursement models.
Although several studies have reported no-show rates from three per cent up to 80 per cent, they vary broadly among providers and even within an institution's own departments. "No-show rates average 15 percent for appointments across our system and around 50 per cent for behavioral health appointments," says Lisa Brandt, MBA, BS, RDH, vice president of population health for Indiana University Health Physicians group in Indianapolis, Ind.
When care managers contacted emergency room patients post-discharge to ensure care plan adherence, a common theme quickly became evident. "We would often find out they had no social support to bring them to their appointments," says Brandt. When patients inevitably became ill or required further treatment, they would resort to visiting the emergency room instead.
Missed appointments due to a lack of transportation also tend to point to a patient's overall socioeconomic status. Patients residing in communities with poor SDOH factors tend to face more barriers to care including less social support, fewer financial resources, and greater travel distances. "Lack of transportation is a significant barrier when accessing care, especially for patients that are low-income, disabled and/or suffer from a chronic condition," says Liz Helms, president and CEO of the California Chronic Care Coalition in Sacramento.
Although Medicaid frequently covers non-emergency medical transportation (NEMT) services, prior authorization requirements and varying coverage from state to state can undermine the program's reach. If patients are forced to pay out-of-pocket for NEMT services, the expense may simply be too great. "These added costs are especially significant for patients who need to receive treatment at a certified clinic only a couple of minutes away from their home, but are [sometimes sent] to [centers in] other states their insurance will cover," says Helms. "Costs include time away from work, accommodations, paying for a professional caregiver or having a family member provide transportation."
A 2013 Journal of Community Health study found that transportation challenges disproportionately affect the elderly, children, minorities, and veterans, as well as patients who are low income, less educated, or chronically ill. To bridge the gap for the most vulnerable populations, Indiana University Health recently formed new ride-sharing partnerships to provide transportation to eligible patients. The initial focus is on the elderly, those with chronic diseases such as heart failure and diabetes, and Medicare Advantage and ACO health plan participants. High utilizers of emergency services and patients without social support or who have SDOH needs are also included.
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"To avoid patients paying out of pocket, we are paying for transportation services if they meet our regulatory criteria and have financial need, based on information provided to our care managers and social workers," says Brandt. While the program is still in its early stages, feedback has been positive and promising for reducing total no-shows. At an average per ride cost of less than $30, it's significantly less than an emergency room visit and may likely prove more sustainable.
K.C. Kanaan, cofounder and CEO of Envoy America, a senior transportation provider headquartered in Tempe, AZ, has seen a shift in client demographics and needs. "Even though most of our marketing is focused on serving the elderly, we have clients as young as 20 years old," says Kanaan, who estimates the organization has provided more than 100,000 NEMT rides through its network of medical partners which includes the Mayo Clinic as well as dentists, rehabilitation facilities, and kidney dialysis centers. His employees have also assisted parents traveling with young children, who may have otherwise struggled to find a way to easily and safely commute as a family.
Although formal data isn't yet available for Envoy America's program, demand has grown. "We estimate that our services are making a difference, because we are seeing our business grow," says Kanaan. "Anecdotally, we have heard from some of our partners that our services help them in their overall goal to lower readmission rates."
Once the impact of ride-sharing programs can be more fully measured, it's possible the scope could be expanded into a modern version of the house call. "In the future, it could be used to send a healthcare provider to the patient's home if that is a more efficient and cost-effective option," says Brandt.
Telehealth and integrated solutions
When physical commutes prove challenging, mobile may be the answer, especially now that cellphone ownership has reached an all-time high. According to Pew Research Center, 96 per cent of Americans own a cellphone and 81 per cent own a smartphone. Tapping into that technology can keep providers and patients connected for follow-ups, and perhaps even more importantly, create opportunities to access first-line care.
"Because many people have time and transportation barriers to their initial visit with a medical provider, virtual healthcare options speed time to initial evaluation," says Blake McKinney, MD, cofounder and chief medical officer at CirrusMD, a text-based virtual care platform located in Denver, Colo. "[CirrusMD is] instantly available from any mobile or web device."
Through partnerships with employers, payers, and integrated delivery networks, the service is offered at no cost to most patients, completely bypassing three of the most commonly cited barriers to care – transportation, distance, and money. Users of the platform, including more than 200,000 veterans, connect with a physician in less than 60 seconds. Avoidable emergency room visits have been reduced by as much as 40 per cent and utilization rates are three times that of national telehealth averages.
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"Management of chronic diseases, such as heart failure, require a high touch clinical workflow. Currently, most hospitals and medical groups have programs staffed by highly trained nurse practitioners following evidence-based protocols who stay in touch and manage patients over the telephone – which these days means voicemail and can lead to many lost conversations," says McKinney. "We live in a world where everyone texts, so it makes sense to use medical-grade texting capabilities for the management of chronic disease."
Other telehealth services like patient portals and secure messaging partially circumvent the transportation gap and have slowly gained traction alongside EHRs. Unfortunately, rollouts are often clunky and interfaces not particularly intuitive, essentially trading one barrier for another. The key, experts say, is to offer patients accessible resources at every turn.
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That's exactly what Kaiser Permanente hopes to accomplish through their Thrive Local initiative, a comprehensive social health network designed to connect patients with SDOH needs to appropriate services. "A network of community resources will be integrated into Kaiser Permanente's electronic health record. By doing so, our members with unmet social needs will be more efficiently connected to community services by our clinicians and staff," says Lee.
Ultimately, the most effective solutions must focus on ease of use and streamlined access to providers. "Some believe that doctors need a bunch of information inputted before they can talk to you – that's the paradigm of the office clipboard, right?" says McKinney. "What I prefer, and what I believe patients prefer, is to just let us connect and communicate as quickly and as personally as possible. A doctor you can communicate with is more relevant to your care than a doctor you have to wait weeks to see."