The Doctor May Be In…But Some Low-Income Patients Are Left Waiting for a Ride

Andrew Kitchenman | August 7, 2014 | Health Care
Health advocates cite long waits for medical-transport vans, seek changes in what Medicaid requires of contractors

For patients with chronic conditions, working closely with healthcare professionals takes time and dedication. Some low-income patients face an additional worry – trying to get a ride to the doctor’s office.

While the federally and state-funded Medicaid program provides transportation for needed medical visits, residents in Camden, Trenton and elsewhere in the state say these rides are too often delayed or nonexistent, adding to the physical and financial costs of untreated illnesses.

But both patients and their advocates say there’s an opportunity to change that, starting with the state’s Medicaid transportation contract.

Dr. Jeffrey Brenner, executive director of the Camden Coalition of Healthcare Providers, said the state should realign the incentives to ensure that transportation payments are tied more closely to the quality of service. He said there should also be more community input into how the system is designed and better monitoring to make sure rides are on schedule and that patients are satisfied.

Brenner recalled the case of an elderly, disabled patient who had to walk four miles home from getting blood tests – including walking part of the way along busy Admiral Wilson Boulevard — when the transport company refused to give her a ride home because of a paperwork mix-up.

Similar incidents contribute to 20 percent to 40 percent of patients failing to arrive for medical appointments in Camden, said Brenner, who’s received national recognition for his efforts to improve how healthcare is targeted and coordinated for the patients with the greatest health needs.

“We wonder why people miss their appointments, why they don’t get their labs drawn,” Brenner said, referring to the blood work. “And then you hear stories like this and it becomes very clear that when you’re old or disabled, or you’re poor, it’s very hard to get around, and getting to the doctor’s office — getting to the lab — can be a real challenge.”

Atlanta-based LogistiCare has held a five-year, $350 million contract to handle non-emergency transportation for Medicaid in the state since 2009. It serves as a broker, arranging for local companies to transport patients to and from medical appointments.

With the contract coming to an end, the state has solicited public comments for the first time on its draft request for new contract proposals.

Department of Human Services spokeswoman Nicole Brossoie said comments submitted by Brenner and others will be considered by the state as part of an effort to improve the contract and associated transportation services.

Company defends quality of service

A LogistiCare spokeswoman defended its handling of the contract, saying that the company has fulfilled its contract obligations, has a successful track record in more than 40 states, and has launched a pilot program in Camden and Trenton that has earned praise from residents.

Beneficiaries of this pilot program – which allows designated local transportation companies to meet the needs of residents who live in specific housing complexes – say it should be incorporated into the statewide contract.

Jackie Fitzgerald, a 72-year-old resident of the Kingsbury Towers senior housing complex in Trenton, recalled multiple occasions when she waited three hours for a van to arrive before the pilot program was in place. She has faced many serious medical situations including two battles with cancer, multiple cardiac stents, and a knee replacement last year.

“I kept calling, (and was repeatedly told) ‘They’re coming, they’re around the corner,’ ” Fitzgerald recalled in describing of one of her lengthy waits. “OK, OK, OK. If you’re not going to come and get me, tell me. I’m mad; I had nothing to eat; it’s hot; and I’m sitting out in the sun.”

But Fitzgerald said that the work she and other volunteers have done with Faith in New Jersey and the Camden Churches Organized for People group has already made a difference, and is hopeful that will have an impact on the statewide contract.

“A lot of people use their families but under the circumstances, my son, who has a car, lives in Philly — he can’t come up from Philly every time I need transportation,” she said.

Brenner said the primary problems are how the contract is designed and how the state has overseen it, adding that neither the state nor LogistiCare is a “bad guy.”

He’d like to see the state consider including Medicaid transportation in the managed care contracts overseen by insurance companies. Doing that would more closely align the incentives for the companies overseeing transportation with the interests of the patients.

The contract currently pays a vendor based on the overall number of Medicaid patients served, rather than paying for each individual ride. Therefore, it can actually be profitable for a vendor to miss a ride, since it will be paid regardless of an individual appointment is kept.

“Bifurcating transportation out from how you pay for and structure medical services is really a fundamental flaw and failure,” Brenner said. “It should be such that if you do a great job getting people access and there’s an outbreak of health and well-being, that everyone benefits.”

Under the current contract structure, Brenner added: “People benefit from failure, they don’t benefit from success,”

LogistiCare spokeswoman Melissa Speir wrote in an emailed response to questions that the state adopted the broker model of providing transportation “to meet federal standards, provide increased services, and to eliminate fraud, waste and abuse in the transportation system.”

She said the company continually measures and improves performance “based on daily operations.

“We embrace the responsibility of providing all qualified Medicaid members with access to healthcare providers while reducing costs to taxpayers,” Speir wrote, adding that these are goals are not mutually exclusive, as the company’s model has demonstrated in more than 40 states.

Recommended changes

Brenner would also like to see the state Department of Human Services’ Medicaid office emphasize more experience and training in contract procurement among its own employees. He said the combination of losing veteran state workers to retirement and having a history of providing services rather than procuring contracts has left the state ill-prepared to oversee the transportation contract.

Brenner would like to see the contract include a company separate from the primary vendor that would monitor whether the vendor is providing on-time service and meeting the needs of patients.

Speir noted that state officials make on-site visits to the company’s call center under the contract, and that the state conducts audits of local transportation services.

“LogistiCare provides the state with detailed monthly reports on service metrics, including every complaint,” she wrote. “While we strive to have no service deficiencies, we are not perfect. When things don’t go according to plan, we take immediate action to fix the problem and put in procedures that prevent them from recurring.”

She added that the company actively solicits concerns from riders, asking them to call the company’s general manager of New Jersey operations, Lori Bonderowitz.

Brenner added that seeking more input from patients and healthcare providers could lead to more locally tailored transportation solutions, such as having separate local companies devoted to each hospital or community health center.

He likened the current system to an airport in which there are no shuttles devoted to taking travelers to individual car-rental offices, but instead a hodgepodge of separate companies providing overlapping and inefficient services.

Speir countered: “The broker system actually allows for greater efficiency and removes reliance on single providers that often lack capacity and the administrative processes to provide adequate coverage.”

She also said that the company has been providing more rides than ever in Camden and Trenton, and the company makes monthly calls to riders, leaders and social workers to monitor progress.

Brenner, despite his critique of the current contract, credits state Medicaid officials with being responsive to concerns raised by residents.

Another advocate impressed with the state response is Angeline Dean, statewide transportation coordinator for Faith in New Jersey, a nonprofit formerly known as PICO New Jersey. But she would like to see the state exert its influence to make more improvements.

Considering the amount the state pays for the service, “It’s just not working properly or as efficiently as it could be,” according to Dean. She wants to see records of whether medical trips are on time, as well as all patient complaints, shared directly with state Medicaid officials.

“Cars are not showing to get our patients and part of the most vulnerable population is being left for up to three hours,” Dean said. “Their doctor’s offices have closed and they’re setting by themselves in areas that are not safe. That’s a big concern for us.”

Dean credited residents with volunteering to gather testimony submitted to the state in response to the request for proposal.

“They talked to the residents, they did surveying, they went door to door,” Dean said, adding that this work led to LogistiCare’s pilot project, in which residents are able to request rides with specific local transportation companies.

The most heart-rending experiences involve elderly patients who are left alone in poorly lit, potentially dangerous areas, according to Anthony Phoenix, a resident of the Northgate II affordable housing complex in Camden, who works as a volunteer advocate with Camden Churches Organized for People.

“It’s just respect for us as patients and as clients,” Phoenix said when asked what he would like to see built into the new contract.

Tomorrow is the last day to submit public comments on the draft request for proposal.

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