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GUEST EDITORIAL |
1 Division of Geriatric Medicine, Saint Louis University Medical Center, and Geriatric Research Education and Clinical Center, St. Louis VA Medical Center, Missouri.
2 Office of Aging Policy and Information, Texas Department on Aging, Austin.
3 Geriatric Research Education and Clinical Center, Greater Los Angeles VA Medical Center & Multicampus Geriatrics Program, University of California–Los Angeles, Sepulveda.
TRANSPORTATION is an essential part of our community infrastructure, which helps people gain access to goods, services, and social contacts that support their daily activities and quality of life. Our reliance on transportation systems has grown over the years as populations have shifted from the city to more remote suburban areas, and remains vital for populations in rural areas. Absence of transportation among any population impairs quality of life by decreasing personal independence, access, choice, and opportunities, which can lead to social isolation. Older adults, for whom quality of life and health are intimately connected (1–3), are one of the populations who often lack transportation. This is particularly true for the large emerging population of frail elderly adults (4,5). As our health care system continues to struggle to find ways to keep older persons healthy and functional (6,7), the link between transportation services and health care becomes increasingly critical.
Driving Remains an Important "Resource"
Before jumping to the assumption that medical transportation is the only solution, let us not forget the importance of driving. Older adults are the fastest-growing segment of the U.S. driving population, both in total number of drivers and total number of miles driven per year (8). Estimates indicate that, by the year 2024, 1 in 4 drivers will be over the age of 65 years (9). Driving is important for the mobility of older adults, with almost 90% of those older than 65 years of age relying on private automobiles for their transportation needs (10). The majority of older Americans are still able to drive safely. However, some experience age-related declines in performance that may hinder their ability to safely operate a vehicle (11,12). Driving requires the ability to visually process one's environment, the cognitive capacity to formulate an appropriate response, and the physical ability to execute the necessary actions (13). Some older adults with substantial visual problems, cognitive limitations, medication side effects, and/or other physical limitations that can compromise driving ability still retain their licenses (14,15). Many others recognize their functional limitations and seek rehabilitation options (e.g., visual correction, vehicle modification), or responsibly regulate or discontinue their driving in visually or cognitively challenging situations such as heavy traffic, bad weather, or at night (16). Education can be effective in helping older adults assess their own driving skills and modify their driving behavior to stay on the road as long as it is safe (17). Driving cessation, however, may be the only realistic option for the small proportion of older drivers who have severe, irreversible functional impairments.
Without education, rehabilitation, or cessation, age-related declines in driving ability can increase the risk for negative outcomes such as crashes. Older adults have the highest rate of crash involvement per mile driven of all drivers, except for those under age 25 (18). An even greater concern is that, in similar crash situations, older drivers are more likely than the young to be killed or injured (19). The fatality rate among older drivers is a significant traffic safety and public health concern. Some system planners have tried to reduce crash risk by adapting driving environments to accommodate age-related changes in physical function. For example, research by the Transportation Research Board indicates that increasing the size and reflectivity of road signs can make driving safer for older adults (20). These changes to the roadway help people more quickly recognize and respond to visual cues (21). Vehicle modifications (e.g., seatbelts, airbags) have also served to increase the safety of the driver who is involved in a crash.
Older Nondrivers: The Transportation Disadvantaged
Although nearly 90% of those older than 65 years of age drive, this percent declines with age (10). Only 75% of community-dwelling persons older than 75 years of age drive (22). Thus, older adults are among the population at risk of becoming transportation disadvantaged: those who do not have access to or cannot operate a vehicle and must rely on alternative means of transportation (23). The transportation disadvantaged also include people with disabilities and those with low incomes.
Transportation is a critical issue for nondrivers in rural areas. In the year 2000, almost three quarters of people aged 65 years and older nationwide lived in suburban or rural areas where there are few alternatives to driving (24). According to the Community Transportation Association of America (CTAA), 66% of rural residents either have no access to public transit service (38%) or have access to limited services (28%) (25). Suburban sprawl, coupled with limited transit capacity in rural areas, creates a mismatch between demand for transportation and the services provided.
Link Between Transportation and Health
Our definition of health continues to broaden. For robust older persons, health conjures up discussions about physical activity, proper nutrition, and other healthy lifestyle behaviors that can prevent or reduce the need for healthcare services (26). For some of the oldest-old and frail elderly adults, optimal physical and mental health is inherently dependent on physicians and other components of the healthcare system, which include nursing facilities, outpatient treatment centers, private homes, senior centers, adult day care centers, pharmacies, exercise and rehabilitation programs, and support groups (27,28). In order for the health care delivery system to work effectively, services must be available, accessible, and affordable to those in need. Transportation services are a critical component of health care access.
When Medicare was established in the 1960s, the largest part of the budget was for costs of hospitalization, and since medical technology in the past three or four decades has focused primarily on acute care, this remains the case today. Although counterintuitive, the health care system is beginning to realize that focusing only on sick people is not optimal. The impact that implementing preventive-type measures [i.e., preventing hospitalization (29), long-term care placement (30), and functional decline (31)] has on the individual's ability to live longer and remain functional is gaining attention.
At a recent hearing of the Senate Special Committee on Aging, Medicare policy makers were recently briefed on how disease management programs cannot only empower individuals to improve health status and reduce the complications often associated with chronic disease, but may also reduce overall health care costs (32). For example, research demonstrates that $1 spent on diabetes outpatient education can save $2 to $3 in hospitalization costs (33). Similarly, for patients with arthritis, who account for an estimated 36.5 million ambulatory care visits (34), participation in an arthritis self-help course can reduce pain an average of 18% and save an average of $267 in health care system costs per person over a 4-year period (35).
Coordinated health care delivery programs such as the Programs of All-inclusive Care for the Elderly (PACE), adult-day care programs, and certain home health care interventions can also impact health status and reduce costs (36,37). One of the commonalities among all types of successful programs is the importance of necessity for transportation services in facilitating access to these services.
The Need for Consensus
Given that transportation is an essential part of our society's infrastructure and that an increasing number of older persons will become transportation disadvantaged, especially those who require unique health care, the prevailing question is whether health care systems for older persons should provide for nonemergent medical transportation (NEMT). If so, what should a NEMT system designed for older adults look like?
The following discussion includes a description of America's first medical transportation model, the Medicaid transportation system. Using the Medicaid system as a framework, a consensus statement related to NEMT for older persons, utilizing a Delphi process was developed.
The Medicaid Transportation System
Medicaid is an entitlement program established in 1968 as a health insurance plan for individuals and families who meet certain low-income eligibility requirements. Medicaid began funding NEMT in the 1970s. Although each state may provide NEMT differently, they must all follow certain federal guidelines. Each state must develop and submit a Medicaid state plan to the Center for Medicare and Medicaid Services (CMS), outlining the state's program and how the state is choosing to address the federal guidelines (38). The transportation sections for all federal Medicaid State Plans are available on the CTAA website (39).
Approximately 1% of the Medicaid budget, or $1.75 billion, is spent on NEMT annually. Based on a 2000 survey done by the CTAA, approximately 10% of the nearly 40 million Medicaid recipients nationwide use NEMT services (38) (Table 1). State per capita annual expenditures range from over $100 in Alaska and New Jersey to just $2 per recipient in Wyoming, with the average nationally around $45 per recipient per year. The average cost of the more than 100 million Medicaid trips was $16 per trip.
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Second, the data presented here on the Medicaid NEMT system helps allay fears that there would be an overuse (or abuse) of the system by Medicare recipients who do not need the service. Overuse has not been the case for Medicaid, which has been funding NEMT since the 1970s, and it would not be expected to be the case for Medicare. Only 10% of the Medicaid population utilizes NEMT and, as noted above, approximately 10% of those aged 65 years and older do not drive and would potentially use this service.
Third, the data on Medicaid NEMT provides an estimate of the budget necessary for a Medicare NEMT system. Both Medicaid and Medicare have approximately the same number of recipients, 39 million. However, for Medicare, $1.7 billion might actually be an overestimate because of the savings afforded by a new NEMT system (Table 2).
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Further savings would be realized by reducing emergency room visits, of which there are over 100 million each year. If just half of the GAO-estimated 14% inappropriate emergency room visits could be prevented, this would save Medicare $1.4 billion (.07 x 100 million visits x $200 differential between outpatient and emergency room visits).
Achieving Consensus: The Delphi Process
One of the major problems related to NEMT is lack of scientific studies that specifically evaluate utilization rates among older adults and the full range of potential cost savings associated with NEMT services. As in other areas of health care, consensus methods can be useful to assist those for whom the issue affects (patients, providers, policy makers) and serves as a bridge to determine future research agendas (i.e., if, how, and what research should be done). There is more than one type of consensus method, but most have the following in common: (a) the use of anonymity to avoid dominance by anyone in the group, (b) the use of iteration, which usually involves "rounds" to allow individuals to modify their opinions, and (c) the use of feedback, which involves showing the distribution of the group's response and one's own response (42).
The type of consensus method used here was the Delphi process, which takes its name from the Greek Delphic oracle's skills of interpretation and foresight. The primary principles of the Delphi process are feedback and iteration (42). The details of the process were the following. Relevant persons [i.e., experts (43)] came together as a team and were given the charge: Develop a consensus statement for NEMT for older persons, utilizing the Medicaid NEMT system as a framework. There were 10 members with the following backgrounds: Social Services [1], Internal Medicine and Pediatrics [1], Internal Medicine and Geriatrics [4], Rural Family Medicine [1], Medical Transportation Consulting and Management [2], and Aging Policy and Services [1].
First, each member of the team was asked to list 5 issues or areas on index cards that they believed would be important to NEMT for older persons, based on what they knew about the Medicaid NEMT systems. Then 2 of the panel members, who had expertise on the Medicaid NEMT system, presented updated information and data. Then the group reviewed, defined, and clarified the issues they had identified on the index cards. The index cards were categorized into 10 areas identified as being of key importance related to NEMT. Statements were developed for each of these areas (Table 3). Within a few weeks, the experts were asked via questionnaire to rank the previously developed statements for agreement on a scale of 1 (total disagreement) to 7 (total agreement). The statements are listed in decreasing order of consensus. The means and standard deviations of these rankings are seen in Table 3. Typically, the rankings would be summarized and sent back to the same experts for another round of ranking, but an acceptable degree of consensus was obtained on the first round (i.e., rankings were very high), so no further rounds were necessary (42).
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While the benefits to the recipient seem obvious, service providers may be challenged by the realities of paying for these services. However, costs may be offset by substantial savings through reduced use of emergency services (e.g., ambulance trips, emergency department visits). There is consensus that more research is needed to evaluate the effects of these services on outcomes such as improved health status, cost effectiveness, and prevention of hospitalization and long-term care placement.
Summary
Older adults comprise 13% of the total population, yet account for 49% of all days of hospital care and 50% of all physician hours (44). They will continue to place disproportionate demands on our health care system as the size of the older adult population grows to 15% of the total U.S. population by the year 2015 (45). Yet, the ability of older adults to access needed health services is dependent on transportation options. Many older adults retain the desire and ability to drive safely; however, a subset of the older population in need of health services are disadvantaged due to lack of transportation.
Currently, the only formal transportation program dedicated to medical services is the NEMT under the Medicaid program. Unfortunately, this service is accessed by few older adults. Beneficiaries of programs who do not provide NEMT services (i.e., Medicare) must often rely on emergency transportation and crisis acute care, which can be costly. Thus, the ensuing question is: If an NEMT program were implemented through Medicare, could health care costs be reduced? Evidence from the Medicaid NEMT program indicates that transportation to health care services can be provided at significantly lower rates than emergency transportation. Moreover, there are potential cost savings as the expense is shifted from crisis care to preventive care.
Progress towards implementing a NEMT for older persons who are transportation disadvantaged will likely require a shift in focus regarding how medical transportation services are delivered. New policies, new legislation, and broad-based system change may be required.
Acknowledgments
The NEMT panel members were: Barbara Beckermann, MSW, St. Louis Public School System, Kirkwood, Missouri; Marilyn Billingsly, MD, Saint Louis University Health Sciences Center, St. Louis, Missouri; Joseph H. Flaherty, MD, Saint Louis University/VA Med Center, St. Louis, Missouri; Jennifer Hetrick, MD, Family Medicine, Fulton, Missouri; John E. Morley, MB, BCh, Saint Louis University/VA Medical Center, St. Louis, Missouri; David Raphael, Medical Transportation Consulting, Portland, Oregon; Laurence Rubenstein, MD, University of California/VAMC, Los Angeles, California; Jim Sebben, PhD, Medical Transportation Management, Inc., Lake St. Louis, Missouri; Beth Stalvey, MPH, PhD, Texas Department on Aging, Austin, Texas; David R. Thomas, MD, Saint Louis University Health Sciences Center, St. Louis, Missouri.
Address correspondence and reprint requests to Joseph H. Flaherty, MD, Division of Geriatric Medicine, Saint Louis University Medical Center, 1402 S. Grand, St. Louis, MO 63104. E-mail: flaherty{at}slu.edu
Received March 31, 2003
Accepted April 24, 2003
References
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