Seniors' medical transportation needs must be addressed
In all the talk around healthcare reform, the issue of meeting medical transportation needs of the burgeoning senior population hasn't received a lot of press, but as the healthcare system grapples with how it will manage an estimated 70 million Americans who will be age 65 and older by 2030, industry insiders say it's imperative the issue be addressed.
"There is a need for transportation for our aging communities," said Ronald Pirrallo, MD, president of the National Association of EMS Physicians. "I guess the dilemma is, what is their healthcare need or healthcare intervention requirement either prior to or during that transport, because that's what defines the true use or need for an ambulance."
Hospitals often find themselves scrambling to find transportation for elderly patients who have arrived at their emergency rooms but are not admitted and who need transportation back home, Pirrallo said. He cites as an example of this problem an 87-year-old woman who arrives at the ER by ambulance having fallen in her bathroom. An evaluation finds that she has a knee laceration but no fractures. She'll need assistance ambulating but doesn't need to be admitted to the hospital. "The dilemma is how do I get (her) back home? It's clearly not an ambulance transport that is required. There's no medical care needed in route or medical monitoring," Pirrallo said. If the patient has no one who can return her home, the hospital is at a loss. "We'd look to the community, either if there's a community service or for-profit transport service, that can provide this role, but there are not that many."
Communities providing transportation services for the elderly are subject to budget restrictions on both the local and federal levels. In the National Association of Area Agencies on Aging's Maturing of America report released at the beginning of June, transportation ranked second among the top three challenges local governments said they faced in meeting the needs of or planning for older adults. Transportation did not make the top three challenges from the 2005 survey.
"When you look at the exposure of the federal budget to either Medicare and Medicaid expenditures for residential services versus allowing people to age in place at home, it is really stark how much money we save with just a little bit of investment in seeing to it that aging in place at home can happen and be a viable option," said Federal Transit Administration administrator Peter Rogoff, at a press conference about the study.
Rogoff's solution to the issue of providing transportation for the elderly is to ensure more money is available in the federal budget for transportation but others within the healthcare system say appropriate fixes would come through realignment of healthcare priorities.
"(Healthcare reformers) need to align the financial incentives with the optimal patient care incentives," said Richard Keller, a partner at consulting firm Fitch and Associates in Missouri who has expertise in emergency medical services operations. "In other words, they need to make sure that the reimbursement is based on getting the patient to the right place at the right time to receive the right service rather than artificially say we're not going to cover or provide reimbursement any place but . . .. Open up some flexibility to the system."
Currently, Medicaid may pay for some transportation services, but reimbursement is usually small, and Medicare only provides reimbursement for ambulance service. In some states, ambulances are required to transport patients only to hospitals.
If an ambulance arrives at a patient's home and the ambulance technicians find the patient has a legitimate need for transportation to medical services, but doesn't need to go to an emergency room, the technicians are faced with a difficult decision, said Jay Fitch, founding partner at Fitch and Associates. "Their choice is to leave (the patient) there, to abandon (the patient) to find (his or her) own way to get to the right level of care, or to take (the patient) to the wrong place of care, the most expensive place of care."
"I think we're going to see, as we move through this change in the realignment of priorities within the healthcare system, a readjustment of how ambulance services are viewed because the transportation component really is the connective material that helps the whole system function and function well," Fitch said.
The accountable care organization model may contain a solution industry experts say, because ACOs will receive a fixed payment to cover the total costs of a patient's care, which would include medical transportation.
