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Paying attention to the access gap: tackling both the digital divide and transport to improve outcomes

Driven by concerns that some in-person care was too dangerous during the COVID-19 pandemic of 2020, the U.S. healthcare industry has accelerated the expansion of telehealth. While telehealth has improved access to many outpatient services, marginalized patients (rural, poor, elderly and minority) may not have benefited in the same way from the expansion of telehealth. This stems, in part, from the ‘digital divide’, i.e. differential access to personal technology or broadband connectivity that results from historical disparities in economics or educational attainment. .

Uncertainties assimilated to telehealth

If the digital divide is not bridged, the continued and broader implementation of telehealth could exacerbate inequalities in health and health care outcomes. Naturally, policymakers and health systems have focused on equity initiatives to bridge the digital divide: expanding broadband access, distributing digital devices, and deploying digital health browsers or community health workers. .

While laudable, initiatives designed to address the digital divide may focus on an increasingly unpredictable and shrinking slice of care in the United States. In May 2021, telehealth’s share of all ambulatory care requests was less than 5% from its pandemic peak of 13%. The reasons for this downward trend are likely multifactorial: providers and patients may prefer face-to-face interactions, and there may be clinical indications for in-person examination, testing, or vaccinations. In addition, telehealth regulation and payments reforms have been widely enacted using emergency clearances with expiration dates slated for late 2021, which has led to uncertainty as to the timing. future of telehealth regulation and payments.

Telehealth is arguably here to stay, but its future is still in motion. This period of uncertainty, however, should not cause health care providers, payers and policy makers to lose sight of the underlying potential of telehealth to improve access to care. Indeed, as the pendulum swings back to face-to-face in-office care, marginalized patients are squarely stuck in a gap: they lose the potential gains of telehealth access while again encountering pre-existing barriers. -pandemic to in-person care. During this transitional time, the healthcare industry should invest in post-COVID-19 infrastructure that better meets the access needs of all patients than the pre-pandemic system; the digital divide must be tackled, but also the “transport divide”.

Non-urgent medical transport as an alternative to telehealth

Transportation is an analogue of telehealth, a way to connect patients with providers. Despite the existence of non-emergency medical transport (NEMT) programs, transport barriers have been overlooked and under-studied. For example, even though Medicaid has provided an NEMT benefit since 1965 and Congress in 2020 required state programs to provide an NEMT, about 5% of Medicaid registrants consistently report that they have delayed care due to transportation issues. Outside of Medicaid, surveys of underserved populations show how much of a barrier transportation was 10-50% of the time, correlated with geography, disability, insurance status or clinical condition. Yet beyond the Medicare Advantage program where transportation has grown rapidly as an optional and additional benefit, the healthcare industry has not applied the same degree of energy or innovation to reduce the burden. transportation divide that he applied to reduce the digital divide.

Strategies to improve how the health care sector is bridging the transport gap

Ignoring the transport divide could prove perilous for marginalized populations. We offer four solutions to guide the way forward. First, we need to change our view of NEMT from a regulatory mandate to be fulfilled to a potential tool to achieve a desired end – better health and well-being for patients. Otherwise, debates over NEMT will continue to revolve closely around program administration: poor service delivery, limited travel availability, and documentation issues that have led to bad patient experiences, inefficiency and poor use rate. Likewise, research has focused on the isolated benefits of providing transport services, such as reducing missed office appointments or facilitating efficient discharge from inpatient services.

While it is important to measure NEMT performance in these areas, just focusing on these metrics misses the point. NEMT should be viewed more broadly, designed and evaluated as a health care intervention with potential gains in health outcomes. If it does not meet these goals, it should be rethought.

With this in mind, NEMT should not simply benefit the Medicaid or Medicare population, but should be extended to those in need within all insurance programs, public or private, and arguably the uninsured. We should focus on identifying the clinical conditions under which face-to-face care provides the best possible results compared to virtual care modalities such as telehealth. For example, the Biden administration’s partnership with Uber and Lyft to provide discounted rides for people who used them to get to and from a COVID-19 vaccination site could motivate more than 12% of unvaccinated people to receive the vaccine. Transport could be a friction reduction intervention that connects patients to care of high public health or population health value, such as vaccinations, preventive care, or behavioral health care.

Second, the federal government, states and other payers should modernize their NEMT services to facilitate future improvements in productivity, costs and services so that patients see it as a useful and desired benefit; otherwise, we will not be able to fully understand its full potential to improve results. Localities and private insurers already have key data on enrolled beneficiaries needed to develop a system to provide patients with a vehicle that meets their accessibility needs at the right time and in a convenient location. More than 10 states have turned to transportation network companies that are enhancing traditional NEMT services with ride-sharing networks.

Going further, public programs and private insurers should team up to share resources, using GPS, trip tracking, driver reviews and other technologies to improve customer satisfaction and ensure compliance. rules of public accountability. The federal government can help with up-front investments or reconfiguration of program rules to facilitate such partnerships, as start-up costs are barriers to entry for new suppliers and potential innovators.

Third, greater cross-sectoral collaborations could occur or, at a minimum, stakeholders could align their efforts. The Federal Communications Commission worked with the Department of Health and Social Services to bridge the digital divide. Similar collaborations within the transport sector can be strengthened. Already, many local transportation providers, in states such as Iowa and Vermont, depend on Medicaid NEMT dollars to help support more general transportation services. It’s important to remember that many of the most vulnerable people have disabilities or communication barriers, or live in rural areas outside of the Lyft and Uber service areas. Investing in pre-existing transport networks to deepen links with people with disabilities, non-English speakers and underserved areas would reduce duplication of effort and help support more robust local transport networks and infrastructure.

Finally, those engaged in defending the digital divide and those engaged in defending the transportation divide should find ways to work together. The goal of both groups is to improve access to care, and both will be judged on their ability to improve health outcomes. If we can bridge the digital divide for marginalized patients while reducing barriers to transport, the stubborn social risk factors of marginalized patients can be removed, allowing patients and their providers to focus on improving care, and not on whether patients can access it in the first place.

In closing

Many of the innovations of the past year – telehealth expansion, licensing liberalization, payments reform and equity initiatives – show us that access-related reforms are possible. As the nation finally emerges from the COVID-19 pandemic and the telehealth revolution balances out, we should have the foresight to use transportation as a complementary tool to improve access to healthcare and not let patients stuck between two divisions.

Author’s Note

Michael Adelberg leads research for the Medical Transportation Access Coalition. Dr Krisda Chaiyachati reported receiving a grant from the National Institutes of Health (K08AG065444), the Patient-Centered Outcomes Research Institute, the RAND Corporation and Roundtrip, Inc .; personal expenses of the Villanova School of Business; consulting fees from Verily, Inc .; member of the board of directors of Primary Care Progress, Inc .; and in-kind support from Independence Blue Cross, Inc., which is outside of the submitted work.


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