There is a fun opinion piece in the September 6, 2016 issue of JAMA. It is from our friends at CareMore Health, Sachin Jain, MD, MBA and colleagues. They write about a pilot project to use Lyft to transport patients to their medical appointments instead of using traditional non-emergency medical transportation services. What I love about this story is it is really an Uberization or Lyfting of medical care (whichever version of the term you prefer), not just a fantasy of healthcare futurists (like myself).

 

Why was the pilot important?

It was my experience as Chief Medical Officer of a Medicare Advantage plan—and it has been confirmed by a 2016 Government Accountability Office report—that traditional nonemergency medical transportation services have long wait times and, even worse, frequent no-shows. At the Medicare Advantage plan that I worked at in Houston, we also used to get reports of unprofessional, if not downright rude, behavior. This causes patients to miss appointments or sometimes not to bother to even schedule them.

The JAMA paper authors quote a paper from the Journal of the American Society of Nephrology (2014;25(11):2642-2648) that found:

“…an analysis of 182,536 patients receiving dialysis, those who relied on car services, were at an increased risk of missing hemodialysis treatments (odds ratio, 1.21; 95% CI, 1.16-1.25).”

Clearly, an alternative is desirable. So, it is noteworthy that CareMore Health System conducted a pilot project with Lyft and their partner, National MedTrans (NMT), a non-emergency medical transportation benefit manager. Patients call in their request for transportation to CareMore so that their request and benefits can be verified. The request is then transferred to NMT which uses Lyft’s new web-based product, Concierge, to dispatch a Lyft driver to pick up the patient. Having NMT enter the details of the transportation request into the Lyft platform obviates the need for the patient to have and be facile at using a smartphone. Good move, CareMore!

The very early results look good. Using data from May and June 2016 on 479 rides, average wait times fell from 12.52 minutes to 8.77 minutes—a 30% decrease. Per-ride costs also decreased by a bit more than 32% from $31.54 to $21.32. The patient satisfaction rate was 81%. The main problem reported in this article was that some beneficiaries were confused that the Lyft vehicles were not branded with CareMore or some other recognizable healthcare logo. This seems to me a problem that could be easily be fixed.

 

Potential concerns

Lyft and other digital transportation companies tend to have more drivers in urban areas compared with rural areas. Even in the suburban county where I live, only a half hour from downtown San Francisco, it can occasionally be a hit or miss to schedule a pickup during non-commute hours of the day.

And, although nonemergency medical transportation drivers don’t have medical training, they may gain competence in helping sick, disabled, or frail patients over time. Because Lyft and Uber drivers mostly transport nonmedical passengers, they might not acquire those skills as readily. Uber and Lyft are addressing that with communications or training programs.

The authors also question whether decreasing barriers to access could increase the use of medical services. At first glance, you may think that is a callous concern. But, we do know that completely unfettered access to care can lead to unnecessary use and costs of care. Here are some examples from my early days at Kaiser when copays were in the $2 to $5 range. Care was so cheap that patients thought nothing of coming in because they discovered their uvula (that thing that hangs down in the back of your throat) or their radial artery. They would make multiple visits for simple colds or common, uncomplicated rashes. I used to think those patients were substituting a doctor for the care that Grandma used to give. Now, we would say they’re using a doctor instead of google search. However you frame it, it was wasteful and fueled, in part, by absence of financial barriers to unnecessary care.

On the other hand, we do know that getting people to the care that they really need can save money. The CareMore authors cite a report from the National Academy of Sciences that found that

“…nonemergency medical transportation was cost-effective for most chronic conditions, and even saves costs for conditions such as congestive heart failure and diabetes.”

 

Going forward

The beauty of doing a pilot is that you find problems that have to be addressed before rolling a program out widely. Currently, the CareMore pilot is limited to their Medicaid enrollees in New York city and Medicare Advantage beneficiaries in California. Hopefully, if the costs and benefits of using Lyft or another digital transportation company hold up, we will see continued improvements that allow this type of service to be offered to much more widely.

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