Arizona
Medicaid Director Jami Snyder heard many complaints about enrollees missing
medical appointments because the transportation provided by the state didn’t
show or came too late.
So this
summer she hatched a solution familiar to millions of Americans looking for an
efficient ride: She turned to Uber and Lyft.
Arizona
became the first state to revamp its Medicaid regulations to make it easier for
ride-sharing companies to participate in its nonemergency transportation benefit.
Under the changes, Arizona eliminated several safety rules such as requiring
all drivers to undergo drug testing and first aid training.
The
strategy has added thousands of vehicles to the fleet serving Arizonans on
Medicaid, nearly 24% of the state’s 7 million residents.
“It
seemed like an obvious solution,” Snyder said. “So far, our anecdotal reports
have been very positive.”
As they
seek to lower costs and improve care, Medicaid and other insurers have begun to
examine the transportation needs of patients — along with other so-called
social determinants of health such as adequate food and housing. Whether states
save money remains to be seen.
In
2017, more than 2 million Medicaid enrollees under age 65 ― about 4% of the
program’s members — delayed care because they lacked transportation, according
to a federal survey.
Lyft is
working with about 35 state Medicaid programs or Medicaid managed care
organizations, according to LogistiCare, one of the nation’s largest Medicaid
transportation brokers. Uber works with Medicaid only in Arizona.
Lawmakers
in Florida and Texas this year also relaxed state regulations to make it easier
for Uber and Lyft to provide services for appropriate Medicaid patients. That
service is expected to begin early next year.
Uber
and Lyft can’t handle all Medicaid transportation demands because they
generally don’t have enough drivers with cars fit to ferry people with serious
disabilities, such as those who use a wheelchair. But Arizona’s Snyder said
many Medicaid enrollees are healthy enough to use a typical ride-sharing
service.
Van
Means, executive director of a company that Arizona pays to arrange
transportation for Medicaid enrollees, said the expanded options help even some
patients who can’t use them.
“It
gives us way more supply, it’s faster and frees up space [in specialized
transportation] for people who need more substantial help such as those in
wheelchairs,” he said.
In most
traditional Medicaid transportation programs, patients need to reserve rides
days ahead and then often must share a van. In contrast, the ride-sharing
companies need little advance notice and can easily take solo passengers.
To ease
the use of Uber and Lyft, states generally waive safety requirements that are
standard for more traditional transportation. Those include mandates that
drivers undergo drug testing and learn first aid and CPR. State officials said
such mandates are not necessary since Uber and Lyft serve ambulatory enrollees
who likely are in better health than those needing specialized transportation.
The
ride-sharing companies already work with hospitals and health systems across
the country, but participating in Medicaid could bring them millions of more
riders.
Unlike
typical Uber or Lyft riders, Medicaid enrollees don’t order rides on their
smartphones. Instead, these patients will continue to request transportation
services by phone or computer through their health plan or a Medicaid
transportation broker.
The
Medical Transportation Brokerage of Arizona said about 15% of rides taken by
Medicaid recipients this summer relied on Uber and Lyft.
So far,
though, Means said the brokerage hasn’t found the service substantially cheaper
in most areas of the state.
Arizona
officials did not have an estimate of cost savings.
Officials
at Atlanta-based LogistiCare said working with Lyft in dozens of cities has added vehicles and
helped speed service.
“The
ride-sharing companies are cost-effective and for curb-to-curb, urban or
suburban short-distance trips,” said Effie Carlson, a LogistiCare executive
vice president.
But she
cautioned that the companies are not the ideal option for enrollees who need
extra time getting in and out of their house because drivers typically leave
within five minutes of arriving.
Uber
and Lyft are often cheaper than using taxis or other private transportation
companies, but not always. She noted that when companies raise prices during
peak-traffic hours, alternatives may be less expensive.
Carlson
said her company decides whether ride-sharing services or more traditional
transportation is most appropriate based on the health information provided
about each Medicaid enrollee.
The Medicaid
transportation benefit varies by state but typically includes rides by taxi
services, wheelchair vans, private vehicles and public transportation.
Enrollees are eligible for the services if they do not have another means of
transport.
Despite
states’ growing interest in expanding transportation options, a University of
Pennsylvania study, published last year in JAMA Internal Medicine, found providing
ride-sharing services did not improve the no-show rate for primary care
appointments among Medicaid patients in West Philadelphia. The no-show rate
among patients offered free rides was 36.5%, compared with 36.7% for those who
weren’t offered free rides.
Krisda
Chaiyachati, co-author of the study and a University of Pennsylvania associate
professor of medicine, said reliability of transportation is not the only
factor determining whether Medicaid enrollees show for medical appointments.
“People on Medicaid tend to live more chaotic lives, so they may be more OK
with missing primary care appointments,” he said, referring to how low-income
people often fear missing work, or have difficulties arranging child care and
other necessities.
Still,
Chaiyachati envisions Uber and Lyft playing larger roles for Medicaid.
“Their
cars can be everywhere, and having a dispatcher draw upon that network is a
no-brainer,” he said. “It may not solve the transportation needs for everybody,
but it’s certainly an answer for many.”
Megan
Callahan, vice president of health care at Lyft, said she expects more states
to adopt ride-sharing.
“I
think what we are seeing is the beginning of a domino effect,” she said. “Our
overall driver availability and speed are the big advantages that will have an
impact on Medicaid members’ satisfaction.”
Uber
officials said in about dozen cities they are developing a fleet of drivers
trained to work with patients who must travel with fold-up wheelchairs, walkers
and scooters.
“From a
cost standpoint, we can save states significant dollars,” said Dan Trigub, head
of Uber Health.
[Correction:
This story was updated at 5 p.m. ET on Sept. 27 to correct the number of state
Medicaid plans using ride-sharing services.]
Phil
Galewitz: pgalewitz@kff.org,
@philgalewitz
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