Edith Stowe, 83, waited patiently on a recent afternoon at the bus stop outside MedStar Washington Hospital Center in the District of Columbia. It’s become routine for her, but that doesn’t make it any easier.
Stowe, who lives about five miles from the hospital, comes into the medical center twice every three months to get checkups for chronic kidney failure. She doesn’t own a car and relies on buses. During rush hour, buses are more frequent, and she can keep the commute to about 30 minutes. But when she has to come in the middle of the day, it takes her at least an hour to get in and another hour to get home.
“It’s pretty good except for waiting during non-rush hours,” she said. “When that happens I don’t plan anything else for the day.”
For people without access to private transportation, getting to medical appointments can be a challenge, especially if they have chronic conditions that require frequent appointments.
Some hospitals and medical providers think that the hot-new technology in town — ride-hailing services such as Uber and Lyft — can address this problem by making the trips easier and, in some cases, it is even covered by Medicaid and other insurance plans. Partnerships between ride-hailing companies and hospitals are emerging around the country. While the efforts are still small, some hospitals and medical transportation providers think the potential for growth is large.This KHN story also ran in The Atlantic. It can be republished for free (details).
MedStar Health, a nonprofit health care system with hospitals in Maryland and the district began a partnership with Uber in January that allows its patients who use Uber to access the ride service while on the hospital’s website and set up reminders for appointments. Medicaid patients who may not have access to the Uber app can also arrange the ride by calling the hospital’s patient advocates.
National MedTrans Network, a transportation system that provides non-emergency medical rides for patients and medical providers in a number of states, expanded its services through a partnership with Lyft last year in New York, California and Nevada.
Hackensack UMC, a hospital in New Jersey, the Sarasota Memorial Hospital in Florida, and Relatient, a health care communication company have also announced partnerships with Uber in the past year. Veyo, a San Diego startup, says it is offering a ride-hail-like technology for health care appointments in Idaho, Arizona, Texas, Colorado and California.
“We probably had 50 different systems across the country reach out to us and ask us ‘How did you do it?’” said Michael Ruiz, chief digital officer for MedStar. “I would say that it has been a seismic shift for the people who have used the service and the places we’ve provided it.”
Patients’ costs for the services vary. For Medicaid patients, transportation for non-emergency medical visits are covered, although the extent of reimbursement depends on state rules. Traditional Medicare does not cover non-emergency medical transportation, although some private Medicare Advantage plans may offer some benefits.
Getting To Your Doctor
When going to a medical appointment becomes a hassle, patients are likely to miss the visit, and that can help lead to untreated symptoms or worsening health.
“Transportation can make it difficult for people to see health care providers on a regular basis,” said Ben Gerber, an associate professor of medicine at the University of Illinois at Chicago who has studied patient transportation issues. “It is important to see health care professionals regularly, especially for patients with diabetes or asthma.”
In a 2013 analysis of 25 studies, Gerber and colleagues found that 10 to 51 percent of patients reported that lack of transportation is a barrier to health care access. One of those studies showed that 82 percent of those who kept their appointments had access to cars, while 58 percent of those who did not keep appointments had that access. Another study reported bus users were twice as likely to skip on appointments compared to car users.
In addition to concerns about patients’ health, those absences can also be expensive for medical institutions, which lose revenue from the missed appointment.
Hospitals and managed care organizations do offer a variety of options to assist with transportation for non-emergency medical appointments. Health centers often work with volunteer drivers to pick up and drop off patients.
Patients can call them ahead of time to arrange a ride, but these services generally require advance planning, which becomes a problem when the patient needs to go in for an unscheduled appointment or if the patient forgets to book ahead.
Some patients also end up calling 911 for non-emergency situations, potentially diverting resources that could be used for others with more pressing needs.
The National Medtrans Network partnership with Lyft began after an incident in February 2015. One of its clients, an elderly woman, was left waiting for a ride to a hospital in New York in freezing weather for 30 minutes. The contracted provider failed to show up.
“It was almost a dangerous situation,” said CEO Andrew Winakor. When his company was notified of the situation, officials immediately called a ride-hail service. The ride arrived within six minutes. Winakor said Medtrans officials realized they had to find a transportation option that could respond immediately to canceled rides.
But ride-hailing services do have some disadvantages. Wheel-chair friendly rides are still limited to a few cities. They also depend on the availability of drivers, which might be scarce in rural areas and low-income communities.
MedStar in Washington, dealt with the problem in one of its hospitals in rural Maryland, where there was a lack of Uber drivers, when a patient there had to travel to the flagship hospital in D.C. for an outpatient surgery at 6 a.m.
“Our social workers worked with the folks at Uber to be able to coordinate the ride to pick this patient up at 4:30 am, and coordinate the ride back,” Ruiz said.
Buses, vans and local public transportation for people in wheelchairs come and go frequently in MedStar Washington Hospital Center’s bus center. Stowe is satisfied with the transport options available. While she hasn’t used Uber before, she said it is something she wouldn’t mind trying especially when it gets cold outside.
“There are times when you come out and you really don’t feel that well. If Uber is here, it’d be really nice to have it,” said Stowe.
BIRMINGHAM, Ala. — Thelma Atkins ended up in the University of Alabama at Birmingham (UAB) Hospital-Highlands after a neighbor in her senior living center ran over her feet with a motorized scooter.
Terri Middlebrooks, a nurse at the hospital, tried to figure out how active the 92-year-old Atkins was before the incident. “Are you up and moving at home?” she asked.
“I can manage, but I have to have help sometimes,” Atkins replied.
Atkins said she uses a walker to visit friends and to get to the communal dining room. But she’s also fallen a few times in recent years.
“Don’t quit walking here,” Middlebrooks told her. “It’s the most important thing you can do. … This bed is not your friend.”This KHN story also ran in Modern Healthcare. It can be republished for free (details).
Middlebrooks is the coordinator of a unit designed to address the challenges specific to caring for the elderly. She told her new patient that throughout her stay, one of the main goals would be to keep her active.
The medical center’s effort to get older patients up and moving while they are in the hospital is far from typical. Despite a growing body of research that shows staying in bed can be harmful to seniors, many hospitals still don’t put a high priority on making them walk.
At UAB Hospital-Highlands’ 26-bed geriatric unit, known as the Acute Care for Elders unit, or ACE, patients are encouraged to start moving as soon as they arrive. The unit is one of a few hundred around the U.S. that is attempting to provide better and more tailored care to geriatric patients.
The hospital opened the unit in 2008 with the recognition that the elderly population was growing and that many older patients didn’t fare well in the hospital. ACE units are based on the idea that if the unique needs of seniors are met, they will have better outcomes and their care will be less costly.
Research has shown that the units shorten patients’ stays in the hospital, reduce their likelihood of returning too soon after discharge and make it less likely they will be sent to a nursing home.
In addition to employing specially trained staff who work together as a team, the Alabama unit has special handrails attached to the walls, low-glare lighting and non-skid floors. Every room has a walker and plenty of space to move around. Volunteers walk with patients, and therapists work with them on maintaining their strength.
Staff members try to disabuse patients of the idea that they are there to rest. “People walk in the door of a hospital and think it’s OK to stay in a bed. It’s not,” said Middlebrooks.
Andres Viles, a nurse coordinator, said nurses at other hospitals are often so busy administering medications and tending to wounds that they don’t make time to walk with their charges. The emphasis on patient mobility is “a culture change” for most hospitals, he said.
At UAB Hospital-Highlands, that shift took a lot of education. Staff members in the new unit attended workshops that included role playing and sensitivity training. The hospital also trained “geriatric scholars,” who became advocates for addressing the particular physical and cognitive needs of seniors.
The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don’t fall, often leave them in their beds.
“We are doing an awful lot to prevent falls, but there is a cost,” said Heidi Wald, an associate professor at the University of Colorado School of Medicine. “The cost is decreased mobility.”
Researchers said there are other explanations for the failure of hospitals to get elderly patients moving. They may not have enough staff, for example, or they may fear lawsuits.
Families won’t sue if their mom gets weaker in the hospital, but they may if she falls, said Cynthia Brown, director of the Division of Gerontology, Geriatrics and Palliative Care at the UAB School of Medicine.
“Why would the hospital want to put themselves at risk for litigation or the CMS [Centers for Medicare and Medicaid Services] coming back and biting them?” she said.
Brown added that hospital staffers around the country generally do not consider walking with patients to be as important as their other duties. “It is just one more thing on a list of a whole lot of things,” she said. “Often times, walking falls to the bottom.”
It’s also harder for patients to walk around if they are attached to IV lines or oxygen tanks, or if they take drugs that make them sleepy. Such medication or equipment is not always necessary.
The very layout of hospitals and the way they operate makes it too easy for patients to remain stationary. They can control their televisions by raising a finger, and they typically get their food in bed.
On average, hospitalized older patients spend just 43 minutes a day standing or walking, according to a study by Brown published in the Journal of the American Geriatrics Society. They are in bed more than 80 percent of their hospital stay, she found.
The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion.
Immobility can also reduce patients’ ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of readmission to the hospital, according to research.
Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.Click to view slideshow.
Instead of returning home to their normal lives, patients who can’t walk when they leave the hospital are more likely to go into nursing homes, said Seth Landefeld, chairman of the Department of Medicine at the UAB School of Medicine.
“They don’t bounce back,” Landefeld said. “The pneumonia is better, but Aunt Mary is not walking and talking the same as before.”
Landefeld said hospitals frequently take the “smart bomb” approach to illness. “We blow away the disease, but we leave a lot of collateral damage,” he said.
Making sure hospitalized patients spend sufficient time out of their beds can save money, keep them mobile after they return home and improve their overall health. Researchers in Texas found that increasing the number of steps elderly patients took on their first and last days in the hospital reduced their risk of dying over the following two years. A study of pneumonia patients of all ages showed that walking early in their hospital stay shortened its duration, saving an average of $1,000 per patient.
The hospital hosts a twice-weekly session called “Move and Groove,” designed to get older patients dancing. At a recent session, a music therapist played the piano as the patients held tambourines or bells and moved their feet to the beat. All of the patients used walkers. A few had oxygen tanks and most wore bracelets indicating they were at risk of falling.
Occupational therapist Linda Pilkerton said she doesn’t give patients a choice of whether to participate.
“We don’t ask them if they want to do an x-ray or if they want a CT scan,” she said. “This is ordered by the doctor. If they don’t get up and move, they start the death spiral.”
After Atkins was admitted to the unit following the scooter mishap, Middlebrooks told her it would only take two days of lying in bed to lose muscle mass. “And if you lose muscle mass, you get weaker and you’re more apt to fall,” the nurse explained, adding that Atkins had done enough of that.
Atkins, who has a pacemaker and has had hip and hernia surgeries, said she has lived alone a long time and doesn’t want to end up in a nursing home. As she pushed her walker down the hospital corridor, she acknowledged that she’s gotten weaker as she’s gotten older and that her arthritis makes it more difficult to shower and dress by herself.
But she said she’s determined to keep walking — at home and in the hospital.
“I don’t want to lose more independence,” she said. “I’ve already lost a lot of it.”
But even if patients spend a lot of time out of bed while they are in the hospital, it does not guarantee they will recover.
Willie Mae Rich, 86, came to the Alabama hospital this spring because her doctor was concerned about her heart. Rich knew her bones wouldn’t withstand a fall, so she worried about walking around too much.
“I’ll break up like peppermint candy,” she said.
But the hospital staff didn’t give her a choice. They urged her to eat meals while sitting in a chair, get herself dressed and get up as often as possible.
“The more time you spend out of this bed, the healthier you’ll be,” Viles told her.
Despite staying active in the hospital, Rich, a great-grandmother, became more sedentary over the next several weeks. Her daughter, Debra Rich-Horn, said her mother continued to walk when she first came home, but soon she could barely get out of bed.
In May, she passed away.
“Her heart was already at a bad stage,” Rich-Horn said. “By the time [the hospital] got her, it was too late.”
This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.
Buried in the fine print of many marketplace health plan documents is language that allows them to refuse to cover a range of services, many of which disproportionately affect women, a recent study found.
It’s unclear the extent to which these coverage “exclusions” have prevented patients from getting needed treatments. An insurance industry representative said patients are generally able to get the care they need if it’s appropriate for them. Yet, some women with hereditary breast and ovarian cancer, advocates say, may have gaps in care because of the exclusions.
More broadly, experts said that the report provides a useful roadmap to potential coverage issues that may still need to be addressed, despite significant improvements following passage of the federal health law.
The study, by researchers at the National Women’s Law Center, an advocacy group based in Washington, D.C., examined health coverage exclusions in marketplace plans offered by 109 insurers in 16 states in 2014 and 2015.More from this series
The health law requires insurers to provide a general summary of benefits and coverage for every plan that states whether the plan excludes coverage of 13 specific services, including acupuncture, bariatric surgery and infertility treatment. These coverage summaries, which are no longer than eight pages, are easy to read and available online or in paper form. But other services that aren’t in the summary documents may be excluded as well, although they may be hard for consumers to find because they appear in the detailed plan coverage materials. Health plans must provide a link from the online summary to those documents, which can be quite technical and run dozens of pages.
Reviewing these detailed documents, researchers identified six types of excluded services that could have a disproportionate impact on women’s health care, although many of them also apply to men. The excluded services included:
- Treatment for conditions that result from non-covered services, for example, if you get an infection following cosmetic surgery (42 percent of plans).
- Maintenance therapy for a chronic disease or other care that prevents regression of a stable condition (27 percent of plans).
- Genetic testing, except as required by law (15 percent).
- Fetal reduction surgery, which is sometimes recommended when a woman is carrying multiple fetuses, to protect the woman’s health or improve the odds a pregnancy will be successful (14 percent).
- Treatment for self-inflicted conditions, such as a suicide attempt or eating disorder (11 percent).
- Preventive services not required by law (10 percent).
“We wanted to highlight issues that would have a particular impact on women as well as show how broad some of the exclusions are,” said Dania Palanker, who co-authored the study and is now an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.
It’s not uncommon for women who have a family history of breast or ovarian cancer to run into this type of roadblock when they need genetic testing or preventive services, said Lisa Schlager, vice president of community affairs and public policy at Force, an advocacy group for people affected by hereditary breast, ovarian and related cancers.
The health law requires insurers to cover services that are recommended by the U.S. Preventive Services Task Force, an independent panel of medical experts, without requiring consumers to pay anything out of pocket. The task force recommends that women with a family history of breast or ovarian cancers receive genetic counseling and, if necessary, testing for a mutation in the BRCA1 or BRCA2 genes that are known to increase the risk of developing those cancers.
However, insurers aren’t required to cover testing for the 40 or so other genetic mutations that are also recognized as increasing women’s risk of breast or ovarian cancer, Schlager said, and many don’t do so.
If a woman does test positive for a BRCA mutation, insurers may not cover earlier or more frequent screening or other preventive care she may need, Schlager said.
“We are in this strange scenario where insurers are paying for the testing and then not paying for the breast MRIs or prophylactic mastectomies,” she added.
Clare Krusing, a spokesperson for America’s Health Insurance Plans, a trade group, called the report “overblown.” She said it fails to address important issues such as whether treatments are safe and effective for all patients, whether there are alternative treatments that are covered and the processes in place to enable patients to get access to treatments if for whatever reason a plan doesn’t provide coverage.
“If a patient has a medically necessary reason for this care, it will likely be covered,” Krusing said.
Kirsten Sloan, senior policy director at the American Cancer Society Cancer Action Network, said people who use the society’s call center aren’t generally complaining about plan coverage exclusions. Still, coverage distinctions may be confusing for patients, Sloan said, and highlight the need for better transparency in communicating coverage information.
More research is needed to understand how these exclusions affect patient care, said Gwen Darien, executive vice president for patient advocacy at the National Patient Advocate Foundation.
“What the study does and calls for is further uncovering where the exclusions are and to make sure plans cover them as part of the essential health benefits,” she said.
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