1. Transportation: A barrier to ensuring that kids have a medical home? Jeff Muschell, ME, MPH Director of Health Systems Initiatives The Children’s Health Fund

2. Health insurance coverage: a major financial barrier to ensuring that kids have a medical home 9 million children (11.2%) in the U.S. are uninsured The majority (88%) live in a household with at least one working parent 71% live in low-income families More than three-fourths are eligible for public health insurance (Medicaid or SCHIP) –Sources: Families USA, American Academy of Pediatrics

3. Other “non-economic” barriers Inequitable distribution of health care resources –Rural communities have persistent problems of availability of health professionals (HPSAs) Language and cultural considerations –Particularly affects children and families for whom English is a second language Family issues –Family functioning and health-literacy Transportation –Kids must be able to physically access health services

4. Evidence of transportation as a barrier to health care access In a Boston-based study, Hispanic parents cited transportation barriers as the most significant reason why they did not bring their child for treatment and well-child care –Archives of Pediatrics and Adolescent Medicine. 1998; 152:1119-1125 In a study of migrant agricultural workers, 80% cited transportation as a barrier to bringing their child for healthcare –Pediatrics. 2004; 113:e276-e282 Transportation barriers also affect urban children, even when public transportation is available –Journal of Healthcare for the Poor & Underserved. 2006; 17:928-943; –Advances in Pediatrics. 2005, Chapter 2

5. CHF-commissioned national survey on health care and transportation 9% of children uninsured 21% publicly insured (Medicaid or SCHIP) 16% of parents reported that transportation was a covered benefit in their child’s health plan 39% have no access to public transportation in community 75% in rural areas do not have access to public transport 9% who have public transportation use it “regularly”

6. Households without public transport to health care in their community

8. Distance from home to usual source of pediatric care

9. Fortunately, someone in government recognized that transportation can be a significant barrier to health care access: Each state Medicaid agency specify in its state plan that it will “ensure necessary transportation for clients to and from providers” and “describe the methods that the agency will use to meet this requirement” (42 CFR 431.53). Each state Medicaid agency is further directed to offer and provide clients of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services with “necessary assistance with transportation,” if requested (42 CFR 441.62). Medicaid non-emergency medical transportation benefit (NEMT)

10. Okay, but NEMT is expensive, right? $TripsPer tripNEMT Estimated spending on Medicaid transportation 216,246,9289,391,39223192,459,766 Medicaid transportation spending for children 1,319,15651,720261,174,049 Percent0.61% New York City Medicaid expenditures – 2007 estimates Source: Department of Health quarterly Medicaid statistics

11. Right…NEMT is kinda sorta expensive. But is it worth it? Source: Cost Benefit Analysis of Providing Non-emergency Medical Transportation, Altarum Institute, 2005 Summary of condition-specific cost-effectiveness ConditionTypeResult Influenza vaccinationsPreventiveHighly Cost-Effective Prenatal carePreventiveCost Saving Breast cancer screeningPreventiveModerately Cost-Effective Colorectal cancer screeningPreventiveModerately Cost-Effective Dental carePreventiveHighly Cost-Effective AsthmaChronicCost Saving Heart disease (congestive heart failure)ChronicCost Saving Chronic obstructive pulmonary diseaseChronicHighly Cost-Effective HypertensionChronicHighly Cost-Effective DiabetesChronicCost Saving Depression / Mental healthChronicHighly Cost-Effective End-stage renal diseaseChronicHighly Cost-Effective

12. Average number of EPSDT visits in Texas, 2003: NEMT users and non-users

13. More from the CHF/Marist national survey Missed appointments due to transport affect 4% of US kids regardless of income, insurance status or region

14. 63% of those who missed an appointment missed two or more appointments in past year 31% of parents reported that ER care was needed later on as a result of the missed appointment 3 million kids, 750K chronic conditions 1 million preventable ER visits Drilling down into the CHF/Marist national survey results

15. Savings from preventable ER visits New York City Medicaid expenditures – 2007 estimates Estimated USA population299,398,484 Estimated NYC population8,085,742 Estimated number of preventable emergency room visits27,007 Estimated cost of preventable ER visits20,254,967 Estimated cost of providing 27,007 trips702,182 Sources:1) Department of Health quarterly Medicaid statistics 2) Back of envelope

16. Essentially, transportation is relatively cheap New York City Medicaid expenditures – 2007 estimates $Trips Unit costNEMT Estimated spending on Medicaid transportation216,246,9289,391,39223192,459,766 Medicaid transportation spending for children1,319,15651,720261,174,049 Percent0.61% Visits, claims, days Unit cost Estimated spending on Free Standing Clinics - children139,798,9681,198,080117 Estimated spending on Hospital Inpatient days - children812,825,688433,5321875

17. Other potential areas of cost savings with increased investments in transportation for health care access Reductions in missed opportunities for immunizations and routine well-child care Reductions in use of emergency transportation Decreased incidence of untreated chronic illnesses Reductions in preventable hospitalizations

18. Federal effort to coordinate transportation resources Executive Order 13330 of Feb 04 –Coordinating Committee on Access and Mobility (CCAM), an interagency group charged with integrating 62 separate human services transportation funding streams United We Ride initiative, working with states to develop coordinated transportation plans (usually working through state DOTs)

19. Summary of NEMT in SCHIP Programs

20. Comparison of Medicaid and SCHIP Eligibility for Children Ages 6-19: Washington and Texas

21. Child Health Transportation Initiative (CHTI) Three-year project of research, pilot project development and public education & advocacy Goal: to address deficiencies in public and private transportation systems that preclude millions of lower-income children from accessing primary and specialty health care services Supported by the Kellogg Foundation and the Federal Transit Administration (FTA)

22. CHTI working philosophy We accept that additional investments in NEMT are likely to be cost-beneficial or cost-effective Much of our effort in pilot project development is thus focused on efficiency and cost-effectiveness Cost-effectiveness: what combination of resources works best in a given set of circumstances Allocative efficiency: doing the right things Technical efficiency: doing things right

23. Specific objectives at first group of pilot sites Arkansas 1) Strengthen management of clinic’s transportation “wing” (technical efficiency) 2) Shift Medicaid riders over to Medicaid transportation broker (allocative efficiency) Mississippi Gulf Coast Establish new transit service for moving people from remote location to the city and associated public services (cost-effectiveness) Mississippi Delta Research reasons why people with non-emergency conditions show up at the ER (allocative efficiency)