Transportation  to  Healthcare  Destinations  How A Lifeline for Patients Impacts
the Bottom Line for Healthcare Providers
This document outlines the connections between transportation and healthcare, providing context
and suggestions that will enable transportation providers to engage in conversations withhealthcare agencies and make the case for more collaboration between the two sectors. For thisdocument, two fundamental questions were posed: To what degree is a lack of transportation
associated with missed medical appointments? and What do those missed appointments actually
cost health systems? In addition to gathering information from literature linking healthcare andtransportation, insight was gained directly from providers and by reviewing information frominstitutions like the Robert Graham Center, which is in the process of gathering non-medical data,(i.e. social, economic, and housing information) from patients for the creation of morecomprehensive electronic medical records. The reflections section includes connections made by
the literature and some thoughts on ways to weave commentary about social factors that impact
health into discussions partners from different sectors might have as they look to positively impact
the health of the communities they serve. The document has a companion resource guidetransportation providers can use to begin conversations with the healthcare community.

Even in areas where access to healthcare services is relatively easy, achieving and maintaining
good health outcomes is a complicated undertaking because of the many factors that contribute toindividuals’ health. Improving the frequency and quality of the interaction patients have with thehealthcare provider team can positively impact health. This is especially true for individuals withlimited income who are particularly vulnerable to the negative impacts of poor housing,inadequate education, lack of access to healthy food, challenging physical environments, and highrates of unemployment. As health systems pay closer attention to the costs associated with caring
for populations of patients, they have had to focus on the nonmedical factors that impact healthoutcomes. Factors like housing, education, employment, and economic development all play amajor part. Also on that list is transportation. The focus of this document is to explore the roletransportation plays in connecting patients to their healthcare providers, medications, and other
health-related services.

The Role of Transportation in Poor Health Outcomes
In any population, missed medical appointments (treatment non-adherence) results in poor healthoutcomes. There are many reasons cited by patients for missing appointments, including not being
able to leave work, inability to find child care, and lack of health insurance, but transportationrelated challenges are one of the most often mentioned.
This connection between transportation challenges and the ability to keep medical appointments
has been discussed in several studies; and, although anecdotal evidence abounds, we still do nothave comprehensive data to determine the ultimate impact that transportation barriers have on
health outcomes. However, one report by Syed and colleagues looked at the results of 61 studies
that in one way or another explored the issue of transportation barriers; in those 61 studies,
researchers reported that anywhere from 3% to 67% of the population sampled reported a lack oftransportation as a barrier to healthcare.1
Among the findings from those 61 studies are the following:

	
  

•

A survey of 183 caregivers of children in urban Texas who had at least one medical
appointment over a 9-week period found an overall no-show rate of 26%. For those with ahistory of missed appointments, 50% cited transportation problems, and for those who kept
appointments, 30% cited transportation issues. Factors associated with missed
appointments included not owning a car and not having access to a car.2•

Cancer patients who were significantly less likely to receive first-line chemotherapy were
those who lived in neighborhoods that had a higher percentage of households without any
vehicle.3•

In one study of 200 children with a history of missed appointments, 51% of parents
identified transportation barriers as the primary reason for missing clinic appointments.4•

A study of almost 47,000 Medicaid patients demonstrated that when patients wererequired to receive prior approval for Medicaid-funded transportation, there was an
associated reduction in visits for primary care visits at hospital-affiliated healthcare clinics
and reduced refilling of prescriptions. Neighborhood-located health centers partiallyameliorated the decline in primary care visits.5•

In rural North Carolina, patients who had a driver's license or a friend or family member
with access to a vehicle, attended anywhere from 1.5 to 2.3 times as many healthcare
visits for chronic care as those who did not.6•

In a study of an urban population in Dayton, Ohio, 30% of respondents indicated that alack of transportation was one of the barriers to their seeking heathcare.7•

One study looked at access to healthcare for those who used public transit to get there.
They found that accessibility to a hospital, defined as getting to a hospital or clinic in 30

2	
  min or less by public transit, or being within walking distance (less than a half-mile way),varied from 0 to 28%. Additionally, 55% of missed appointments or late arrivals were due
to transportation problems.8

Benefit of Accessing Consistent Healthcare
Improving the access patients have to providers is an opportunity to improve health outcomes
immediately and in the long-term. Patients who spend more time with their healthcare team havebetter rapport with their providers, greater understanding of their medical conditions, and arelikely to be more satisfied with their experience with the provider, making it a relationship theywant to maintain.
As more and more healthcare systems establish “medical homes” for patients, transportation will
be a key factor in how well that approach is implemented. In this model, the primary care medical
home is accountable for meeting the large majority of each patient’s physical and mental
healthcare needs, including prevention and wellness, acute care, and chronic care. This model is
implemented with a team of care providers, and is focused on delivering comprehensive,
coordinated care to patients. Patients who receive the needed, regular primary and preventive carethrough such a coordinated system will be less likely to rely on emergency departments for care.

The Cost of Missed Appointments
Many factors contribute to the high cost of healthcare. When patients miss appointments—
whether for primary/preventive care or as follow-up to a recent hospitalization or other acute care(e.g., surgical procedure)—the cascade of events can all lead to higher costs. For example,
not following a healthcare provider’s recommended treatment regimen can lead to

	
  

•

poorer health outcomes, especially for those with chronic conditions, which in turn canlead to a more acute complication needing immediate attention and potentially leading toan emergency department visit or a premature hospital readmission, both more costly thanif the patient had followed through with outpatient or clinic-based appointments.

•

diminished ability to closely follow a patient’s condition. During appointments, not only dohealthcare providers treat symptoms of chronic or acute conditions, they also perform
necessary diagnostic and screening tests, prescribe or adjust medications, and refer patientsto other medical services.

•lost opportunity for patient education. Healthcare providers use appointments to build
rapport with the patient and educate them on different aspects of their healthcare
diagnoses or conditions. It is also the time when providers can ask patients about othernon-medical aspects of their life that may be impacting their health and refer them to othersupportive services, in essence treating the whole person and not just their disease.

3	
  

•

financial implications for the healthcare provider, related to staff time and resources alreadydedicated to providing a service to the patient which, once the patient doesn’t show,
cannot be billed, thus resulting in lost revenue for the provider.

The literature shows a wide variance in the cost of missed medical appointments, with healthsystems reporting a range of $150 to %274 in lost revenue per missed appointment. Across ahealthcare system, this adds up quickly. For example, in a health system that has 1,000 patient
visits each year, if 100 (or 10%) of those patients missed appointments each year, this would resultin annual revenue losses ranging from $15,000 to $27,400. Using the same missed appointment
rate, a system that sees 45,000 patients each year would see annual revenue losses of $675,000 to$1.2 million each year. Of course, if the no-show rate is higher than 10%, these costs would gocorrespondingly higher.
In addition, it should be noted that these cost estimates only consider the cost of running theclinical unit, and do not take into account the additional cost associated with patients needing to
use the emergency department for follow-up (estimated in one study to be 15 times more
expensive than a regular clinic appointment), premature hospital admissions, inadequate
management of pain, or missed opportunities to provide education, perform further assessment,
and prescribe medication. These indirect costs were highlighted in a 2012 study of primary carevisits for diabetic patients in which a correlation was found between “no-shows” (patients who
missed appointments) and a greater risk of hospitalization.9
Another cost driver that came to light in conversation with practitioners was the issue of the cost of
not being able to discharge patients from hospital beds. A night in a hospital can cost much as$1,500, without factoring in the cost of ambulance transport, major procedures, or diagnostic
testing, so having discharge-ready patients stay beyond their course of treatment is costly.
Hospitals need beds for sick patients; further, they wish to avoid spending hospital resources forpatients who no longer need hospital-based care and want to decrease the chance of those“discharge-ready” patients getting sick from an infection acquired while in the hospital. In
addition, when hospitals do not have available beds for new patients, they must divert thesepatients—and the potential revenue they would bring to the hospital—to another facility. These
potential consequences of not being able to discharge patients home has led to hospitals providing
taxi fare or some other transportation option just to get them home.

How Addressing Transportation Can Help
Understanding the needs of patients and how factors like transportation impact their healthrequires good data. Some of this can be achieved by interviewing patients directly, or by reviewing
large volumes of medical records and charts.
Given the range of methods, questions, and settings in which this research is done, it is no surprisethat there is a lot of variability in what the research shows. The literature reviewed describedtransportation as one of many factors impacting a patient’s access to care. The literature alsosuggested that improving transportation options would likely serve to decrease missed medical

	
  

4	
  

appointments and the many undesirable outcomes that go along with that. Fixing this not only
benefits patients, but also benefits health systems who annually lose millions of dollars because of
missed appointments, high emergency department or urgent care utilization, and premature
hospital readmissions accompanied by heavy fines and reimbursement penalties.
The incentive to address transportation gaps is also driven by the desire of health systems toprovide patients with a quality healthcare experience. Moving patients to and from visits is
facilitating care, and increases the likelihood of appointments being kept and of patients being
satisfied, more compliant, better informed about their condition(s), and healthier. With thecompetition created in markets where patients have the ability to choose their provider or payer,
the advantage will go to those that can rise above the competition by providing an attractive suiteof services designed to make it easier for patients to access care, medication, and other related
services. Healthcare providers might look at the option of covering transportation costs (see next
section), coordinating appointment scheduling with available transportation options, partner withshared-ride providers, or even providing transportation services for clients.

New OIG Opinion: Provision of Medical Transportation and “Safe Harbor” Protection
from Penalties
The U.S. Department of Health and Human Services, Office of Inspector General (OIG), issued a
new ruling on December 7, 2016, covering financial contributions to and provision of nonemergency medical transportation (NEMT) by healthcare providers. The rule effectively creates a
new safe harbor for two types of local transportation: transportation that is provided for individual
patients and shuttle services for patients or others – along a fixed route with a set schedule. The
rule makes clear that healthcare providers are allowed to contribute to or provide transportation
services within certain parameters without being in violation of regulations against unfair businesspractices. In essence, the new rule permits healthcare providers—including hospitals, clinics,
physician’s offices, dialysis clinics, medical laboratories, physical therapists, and the like—tochoose to fund by themselves, or in combination with others, local NEMT or shuttle services that
may go way beyond NEMT.10

Reflection
It is clear that transportation barriers have an impact on health outcomes, although the literatureshows such variance in how that connection is made that it is hard to be say with certainty that
simply improving transportation options will improve health outcomes. It is however indisputablethat missed medical appointments carry with them significant cost. Combine this with the fact that
hospitals are being heavily penalized for premature readmissions and primary care providers may
not be reimbursed if they are unable to show improvements in their patient’s medical conditions,and the “missed appointment puzzle” becomes more pressing.
At the root of the best response to this problem is the availability of data collected from patients asthey interact with health systems and healthcare providers. Being able to make the case fortransportation as a primary determinant of health outcomes requires more robust data, specifically

	
  

5	
  

the kind reflecting the social, economic, and environmental realities of the low-income, minority,
and rural communities most impacted by health challenges. Reliable data from patients captured
in electronic medical records is already used for research and to help understand patient
populations. It is hoped that over time, more providers bolster their patient’s electronic medical
records with inputs related to the broader socioeconomic and environmental factors that directly
and indirectly impact health.
Filling out a patient’s profile with relevant socioeconomic factors, including transportation, can
•
•
•
•
•

lead to a more robust understanding of the patient and what the most impactfulinterventions are for that patient
tells the healthcare system more about patient experiences, bolstering their ability toenhance the care provided to patients
puts funding where resources are needed
informs policy-making, andsets a standard for a comprehensive approach to health and healthcare.

This mindset underpins the patient-centered approach to managing patients’ health and the cost of
their care. It is a mindset that places a premium on spending more time with patients and getting
to know them in a very comprehensive way. This methodology understands the complexity of thefactors that impact health, and recognizes that health is more than healthcare. The data systems
that support such ventures should be similarly detailed and broad in the data they are capable ofgathering. Health systems seeking to work in this way need to ensure that they have payers willingto support the non-medical (i.e. transportation) opportunities to improve health outcomes that the“new data” present.
What kind of data would need to be collected? The data could run the gamut, such as:
•
•
•
•
•

determining a patient’s primary language and literacy level
understanding the environment in which the patient lives
understanding the patient’s family responsibilities and dependents
knowing about a patient’s employment status, work environment, and work activities
exploring the patient’s mobility options (e.g., driver’s license, ownership of motor vehicle,
current insurance, access to rides by others, access to public transportation)

Combining these data with the medical information in patients’ medical records, when added toin-depth focused interviews, will help piece together the many aspects of patients’ lives that
influence their health. It will enable clinical operations to better understand patient healthbehaviors based on information coming directly from clients, and could open the door fordesigning health-impacting programs with clients in which they will be more likely to participate.

	
  

6	
  

Notes1

Syed ST, Gerber BS, Sharp LK. (2013). Traveling towards disease: transportation barriers to healthcare access. J Community Health. Vol. 38(5), pp 976–993.
2

Yang S, Zarr RL, Kass-Hout TA, Kourosh A, Kelly NR (2016). Transportation barriers to accessing
healthcare for urban children. J Health Care Poor Underserved. Vol. 17(4), pp 928–943.
3

Salloum RG, Smith TJ, Jensen GA, Lafata JE (2012). Factors associated with adherence tochemotherapy guidelines in patients with non-small cell lung cancer. Lung Cancer. Vol. 75(2), pp
255–260.
4

Silver D, Blustein J, Weitzman BC (2012). Transportation to clinic: findings from a pilot clinicbased survey of low-income suburbanites. J Immigr Minor Health. Vol. 14(2), pp 350–355.
5

Tierney WM, Harris LE, Gaskins DL, et al. (2000). Restricting Medicaid payments fortransportation: effects on inner-city patients' healthcare. Am J Med Sci .Vol. 319(5), pp 326-33.
www.ncbi.nlm.nih.gov/pubmed/10830557
6

Arcury TA, Preisser JS, Gesler WM, et al. (2005). Access to transportation and healthcare
utilization in a rural region. J Rural Health Vol. 21(1), pp 31-38.
www.ncbi.nlm.nih.gov/pubmed/15667007.
7

Ahmed SM, Lemkau JP, Nealeigh N, et al. (2001). Barriers to healthcare access in a non-elderly
urban poor American population. Health Soc Care Community. Vol 9(6), pp 445–453.
8

Roadblocks to health: Transportation barriers to healthy communities. Center for Third World
Organizing (CTWO), People United for a Better Oakland (PUEBLO), Transportation and Land Use
Coalition (TALC) 2002.
9

Chan, KE, Thadhani RI, Maddux FW (2014). Adherence barriers to chronic dialysis in the UnitedStates. J Am Soc Nephrol. Vol. 25(11), pp 2642-2648.
10

Read the full OIG opinion at https://www.federalregister.gov/documents/2016/12/07/201628297/medicare-and-state-health-care-programs-fraud-and-abuse-revisions-to-the-safe-harborsunder-the; also, listen to the archived February 21, 2017 webinar in which a legal expert helps theaudience understand the ramifications of this ruling: “Safe Harbor Regulation and NEMT” at
nc4mm.org/ncmm-webinars.

Additional Resources
Agency for Healthcare Research and Quality, Department of Health and Human Resources.
“Defining the Patient-Center Medical Home.” https://pcmh.ahrq.gov/page/defining-pcmh
Bellamy, G. R., Stone, K., Richardson, S. K., & Goldsteen, R. L. (2003). Getting from here to there:
Evaluating West Virginia's rural nonemergency medical transportation program. J Rural Health.
Vol. 19, pp 397-406.

	
  

7	
  

Boccuti C, Casillas G (2015). Aiming for Fewer Hospital U-turns : The Medicare Hospital
Readmission Reduction Program. Policy Brief., 1–10. http://bit.ly/1KWsOkd
Centers for Disease Control and Prevention (2014). National Chronic Kidney Disease Fact Sheet.
CKD Surveillance Project, 1–4. https://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf
Champlin L (2016). Improved Community Health Depends on Knowing the Extent of Social
Deprivation. www.graham-center.org/rgc/press-events/press/all-releases/111016-socialdeprivation.html
Cheung PT, Wiler JL, Lowe RA, et al (2012). National study of barriers to timely primary care andemergency department utilization among Medicaid beneficiaries. Ann Emerg Med. Vol. 60(1), p 4.
Cronk I (2015). The transportation barrier. The Atlantic.
http://www.theatlantic.com/health/archive/2015/08/the-transportation-barrier/399728/
Deen TL, Bridges AJ, McGahan TC, et al (2012). Cognitive appraisals of specialty mental healthservices and their relation to mental health service utilization in the rural population. J Rural
Health. Vol. 28(2), pp 142-151.
Frueh BC (2015). Solving mental healthcare access problems in the twenty-first century. Aust
Psychol. Vol. 50(4), pp 304-306.
Godavarthy R, Mattson J, Ndembe E (2014). Cost-benefit analysis of rural and small urban transit.
National Center for Transit Research. https://www.nctr.usf.edu/2014/07/cost-benefit-analysis-ofrural-and-small-urban-transit-2/
Green-Hernandez C (2006). Transportation challenges in rural healthcare. Nurse Practitioner. Vol.
31(12), p 10.
James P, Ito K, Buonocore JJ, et al (2014). A health impact assessment of proposed public
transportation service cuts and fare increases in Boston, Massachusetts (U.S.A.). Int J Environ Res
Public Health. Vol. 11(8), pp 8010-8024.
Cronin J, Hagerich J, Horton, J, et al (2008). Florida Transportation Disadvantaged Programs:
Return On Investment Study. http://tmi.cob.fsu.edu/roi_final_report_0308.pdf
Kheirkhah P, Feng Q, Travis LM, et al (2016). Prevalence, predictors and economic consequencesof no-shows. BMC Health Serv Res. Vol. 16(1), p. 13.
MSJ & Co, Marsico D (2014). Medicaid Expansion and Premium Assistance: The Importance of
Non-Emergency Medical Transportation (NEMT ) To Coordinated Care for Chronically Ill Patients.
http://web1.ctaa.org/webmodules/webarticles/articlefiles/MedCT14chronic.pdf
Nuti LA, Lawley M, Turcan A, et al (2012). No-shows to primary care appointments: subsequent
acute care utilization among diabetic patients. BMC Health Serv Res. Vol 12, p 304.

	
  

8	
  

Pellowski JA (2013). Barriers to care for rural people living with HIV: a review of domestic
research and healthcare models. J Assoc Nurses AIDS Care. Vol. 24(5), pp 422–437.
Phillips RL, Liaw W, Crampton P, et al (2016). How other countries use deprivation indices--andwhy the United States desperately needs one. Health Aff. Vol. 35(11), pp 1991-1998.
Salanitro AH, Safford MM, Houston TK, et al (2011). Patient complexity and diabetes quality ofcare in rural settings.” J Natl Med Assoc. Vol. 103(3), pp 234–240
Siegel CE, Wanderling J, Haugland G, et al (2013). Access to and use of non-inpatient services in
New York state among racial-ethnic groups. Psychiatr Serv. Vol. 64(2), pp 156-164.
Sorkin DH, Murphy M, Nguyen H, et al (2016). Barriers to mental healthcare for an ethnically andracially diverse sample of older adults. J Am Geriatr Soc. Vol 64(10), pp 2138-2143.
Syed ST, Gerber BS, Sharp LK (2013). Traveling towards disease: Transportation barriers tohealthcare access. J Commun Health. Vol 38(5), pp 976–993.
Wallace R, Hughes-Cromwick P, Mull H (2006). Cost-effectiveness of access to nonemergency
medical transportation comparison of transportation and healthcare costs and benefits.
Transportation Research Record. Vol. 1956, pp 86–93.

	
  

9