Transportation remains a major barrier to health care

Can a reliable trip to the hospital improve your health? In the world of healthcare, where every moment counts, missing out on essential medical care just because of transportation can be life-threatening. That’s the reality for the 3.6 million Americans who live with health-related transportation insecurity, according to the American Hospital Association’s “Transportation and the Role of Hospitals” guide.

LDI Senior Research Fellow Marina Surper, working with Harvard Medical School Assistant Professor Neka Ufere and colleagues, studied how transportation affects the lives of the 4.5 million Americans with chronic liver disease (CLD) in the United States. In their research in Hepatology Communicationsthe authors examine the relationship between care-related transportation uncertainty and financial security, health status, work productivity, ambulatory and urgent care use, and mortality.

About 6% of the 152,836 adults with CLD surveyed reported experiencing care-related transportation uncertainty. These individuals face a cascade of challenges, from financial hardship to compromised health outcomes.

The study found some intriguing correlations. Transportation insecurity was associated with increased odds of cost-related medication nonadherence, food insecurity, and self-reported health deterioration. The authors also found an association between transportation-related anxiety and increased health care utilization and mortality.

According to the authors, transportation uncertainty is a critical risk factor that should be investigated. They also propose expanding insurance benefits to include medical transportation to appointments, along with maintaining broadband Internet to improve access to telemedicine.

To learn more about the study, we asked Dr. Serper and Ufer ask a series of questions.

What are the strategies to support patients with transportation needs?

Top: When we encounter patients with transportation issues, we ask our social workers to look into whether there is extended social support they can use to get a ride and help them arrange medical transportation. For patients being evaluated or on the waiting list for a liver transplant, this is especially important because they have urgent appointments they cannot miss. However, many patients are not part of the transplant pathway and lack sufficient support. These cases are more difficult. We supplement with telemedicine visits and home care in situations where people are forced to live at home, but this still leaves us with a vulnerable population.

Another Penn study offering rides with Lyft showed low uptake among vulnerable populations. This suggests that patients may have other more pressing social needs; addressing transport barriers alone may not be enough.

Can you explain more about how related factors, such as food and financial insecurity, affect a patient’s ability to receive care?

Ufere: As part of the conceptual framework of our study, we believe that there are links between transport insecurity and other social risk factors such as food and financial insecurity, as well as self-reported health and work productivity (due to lack of access to transport in general). . We found that CLD populations experiencing transportation insecurity are particularly socially vulnerable due to concomitant financial and food insecurity. Patients with social risk factors, especially those with financial insecurity, often have to make difficult decisions about how best to use their limited household income, which can lead to trade-offs as they make decisions to pay for their basic needs (food , housing) against health care (transportation costs there, payment of medicines, etc.).

Who is most affected by these transport barriers?

Top: The study shows that people living in poverty, with functional limitations, and those who are underinsured or uninsured have a higher healthcare-related transportation burden.

Are there innovative programs you see that excite you?

Chief: I am working on home exercise and nutrition programs for cirrhosis and liver transplant patients. The aim is to further extend home care and provide remote monitoring. This study of a home physical activity program that increased steps with an incentive payment is an example.

How do you envision future research building on this study?

Ufer: Future research can extend this study by using fully validated instruments to assess the multifaceted factors contributing to healthcare-related transportation uncertainty. This research may focus on prospective studies involving well-characterized cohorts of patients with chronic diseases, particularly those undergoing evaluations such as liver transplantation for cirrhosis. By examining the relationship between transportation uncertainty and health outcomes both before and after transplant, additional insight into the impact of transportation barriers on health care utilization and overall health outcomes in individuals with chronic conditions may be gained.

What do you think the policy implications of your research findings are for addressing healthcare-related transportation uncertainty?

Chief: Insurance providers could provide medical transportation to appointments, expand the use of telemedicine, and strengthen broadband Internet access so that the Internet can reach populations without Internet access. However, it is important to note that telehealth may exacerbate health care disparities among patients with low digital literacy and low access to technology.

National organizations have their role. For example, the American Association for the Study of Liver Diseases (AASLD) recently published quality measures to improve the quality of liver transplantation, including access. Dr. Ufere and I are the authors of this guide along with a team of doctors from around the country. Efforts such as these can help medical practices and transplant programs measure barriers to accessing care, some of which may be related to transportation.

Ufer: Similar to what Dr. Surper mentioned, policymakers should consider including non-emergency medical transport (NEMT) as an insurance benefit for all Medicare enrollees (currently only available as an additional benefit for those with eligible Medicare Advantage [MA] plans) and removing restrictions that limit the use of NEMT services (ie, prior authorization) for Medicaid and Medicare enrollees. In addition, national paid leave policies would greatly benefit both working CLD patients and their family caregivers, on whom they often rely for support with and from medical care.

The study, “Health-related transportation uncertainty is associated with adverse health outcomes among adults with chronic liver disease,” was published in January 2024 in Hepatology Communications. Authors include Tiana Walker, Kimberly Schoener, Emily Bethea, Siddharth Singh, Lauren Nephew, Patricia Jones.