When the Oregon legislature passed laws to transform the state's healthcare system three years ago, stakeholders had high hopes that the new model would help providers and public health agencies improve Medicaid patients' access to basic care.
But making sure patients who need medical transportation can get to appointments seems to have slipped through the cracks in the initial transformation effort. Now medical transportation brokerages and coordinated care organizations around the state are putting the pieces together.
“Where things are at is we don't have any solid agreement with any of the CCOs for the seven counties that we provide services to,” said Julie Brown, general manager of the Rogue Valley Transportation District, which operates a call center for a variety of community transportation services, including paratransit, veterans transit and programs for people with developmental disabilities.
Funding comes from different pockets, with funding for the program coming from a state contract with transportation brokerages in the area Rogue Valley serves. If that contract goes away, the call center will reduce staff, Brown said, but she's less concerned about that than about the fragmentation of a 10-year-old system where every brokerage followed the same rules and worked roughly the same way.
“We are actually breaking a system that has been consistent and has worked for almost 10 years. All of a sudden the clients that have relied on this that have worked. That's my biggest concern, is the clients are going to be the ones that are going to suffer,” Brown said.
In other areas of the state, non-emergency transportation coordinators are beginning to work with CCOs, though those relationships are in their beginning stages.
“We started telling [the state] a long time they needed to get us involved,” said Kris Lyon, human services transportation coordinator for the Lane Transit District.
Now that the Lane Transit District is working with Trillium Community Health Plan to provide transit services to its members, Lyon said the relationship is going exceptionally well, and that the agency has even been able to expand its services. For instance, Lyon said, Lane Transit now gives CCO members rides to health-related educational classes and has more flexibility on which pharmacies people can use.
Previously, Lyon said, dispatchers would screen callers who requested urgent care visits to see if they really needed to go to urgent care or if they were a better fit for primary care – but now the CCO has authorized them to skip that step.
“Due to a shortage of primary care providers, which is a whole other issue, they have asked us to go ahead and not screen and do the trip,” Lyon said.
Phil Warnock, transportation brokerage manager of the Oregon West Cascades Council of Governments, said his agency started coordinating with InterCommunity Health Network, the CCO that serves Linn, Benton and Lincoln counties early in its formation, and the transition has been nearly seamless.
“I guess from our perspective it went pretty well. It was pretty smooth,” Warnock said. “I feel for the folks that have multiple brokers to work with, multiple CCOs to work with, so many different things at the same time.”
“It almost goes without saying that I think Medicaid transportation gets neglected often. It's often thought of as an afterthought, a service the feds impose on the states,” said David Raphael, the founder and former executive director of the Community Transportation Association of America who now works as a transportation consultant.
Earlier this year, Raphael wrote an op-ed for the Statesman-Journal (WILL LINK) expressing concern that state transformation efforts had not really included discussion about non-emergency medical transportation, which in most states is a major part of Medicaid funding – and Raphael is quick to point out that access to transportation is a key determinant of health.
Since last spring, Raphael's been encouraged by what he's heard about coordination efforts in some parts of the state, but is still concerned about how coordination efforts will play out in rural areas where access to services may have been more fragmented to begin with.
“It's almost a nightmare situation to think how that one small organization can work out arrangements,” said Raphael in reference to the challenges in southern Oregon. “It's not like Lane where everyone is focused on the same objective and the same people and the same communities.”
Oregon Health Authority spokesperson Karynn Fish said initial transformation efforts were focused not on the benefits provided to Medicaid members, but the larger framework in which they'd be delivered.
“Non-emergent medical transport is a benefit. But the transformation plans did not address benefits; they addressed plans for the transformation of the local health delivery systems. Some transformation plans may address particular benefits, but this was not a requirement. The requirement was to present an comprehensive plan for the whole system,” Fish told the Lund Report.
In addition to IHN and Trillium, she estimates the 14 other CCOs in Oregon will have their non-emergency medical transportation systems online by July.
“It is one of the many issues the CCOs and their community partners are taking on amidst the transformation of their local health care delivery systems and as they prepare to serve tens of thousands of new members coming into the Oregon Health Plan in 2014,” she added.”
Brown said coordinating medical transportation is a big, logistically complex job with a huge economy of scale – and it's outside the area of expertise of insurance and medical providers.
“I think it's so inconsistent [throughout the state], because you're asking medical providers to provide a service that they've never had to do before,” Brown said.
Christen can be reached at [email protected].
