Transportation Disadvantaged Populations:
Nonemergency Medical Transportation Not Well Coordinated, and Additional Federal Leadership Needed
GAO-15-110: Published: Dec 10, 2014. Publicly Released: Jan 9, 2015.
What GAO Found
Forty-two programs across six federal departments—Agriculture, Education, Health and Human Services (HHS), Housing and Urban Development, Transportation (DOT), and Veterans Affairs (VA)—can provide funding for nonemergency medical transportation (NEMT) service, although NEMT is not their primary mission. Twenty-one of these programs, including Medicaid, are administered or overseen by HHS. The type of funding provided by these programs varies, but includes capital investments (such as bus purchases) and reimbursements of transportation costs (e.g., bus passes). Total federal spending on NEMT is unknown because federal departments do not separately track spending for these services. In some cases data were not available or NEMT was incidental to a program's mission. However, one of the six departments (HHS) was able to provide estimates indicating that its spending totaled at least $1.3 billion in fiscal year 2012—most of this attributable to Medicaid.
Coordination of NEMT programs at the federal level is limited, and there is fragmentation, overlap, and potential for duplication across NEMT programs. The federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council)—chaired by the Secretary of DOT and tasked with promoting interagency cooperation and establishing mechanisms to minimize duplication and overlap of programs for the transportation disadvantaged—has taken some actions to improve coordination, such as developing a strategic plan. The strategic plan identified the council's goal, priorities, and objectives for 2011 to 2013. However, the council has provided limited leadership and has not issued key guidance documents that could promote coordination. For example, the council has not met since 2008 and has not finalized a cost-sharing policy that would allow agencies to identify and allocate costs among programs. GAO has previously found that agencies providing similar transportation services to similar client groups may lead to duplication and overlap when coordination does not occur. This review found instances of fragmentation, overlap, and the potential for duplication, although the extent could not be quantified.
State and local officials in the selected states GAO visited identified a variety of ways they facilitate coordination of NEMT. These include state coordinating bodies (two states GAO visited), regional coordinating bodies (two states GAO visited), local metropolitan planning organizations, and local transit agencies. Cost and ride sharing and one-call/one-click information centers were also used to coordinate NEMT services. However, GAO found two programs—Medicaid and VA NEMT programs—largely do not participate in coordination activities. Requirements to serve only eligible individuals and ensuring proper controls are in place to prevent improper payments and fraud are among the challenges to coordination for these programs. These important NEMT programs provide services to potentially over 90 million individuals and coordination without the Medicaid and VA programs increases the risk for potential overlap and duplication of services.
Why GAO Did This Study
Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. NEMT is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. GAO was asked to review the coordination of NEMT services. This report addresses (1) the federal programs that provide funding for NEMT services, (2) how federal agencies are coordinating NEMT services, and (3) how NEMT services are coordinated at the state and local levels and the challenges to coordination.
GAO analyzed a compendium of federal programs that provide assistance to the public; reviewed program information from the six departments that fund NEMT; interviewed officials of DOT, HHS, and VA; and interviewed state and local officials in five states, chosen based on a variety of considerations, including geographic diversity and existence of a coordinating body.
What GAO Recommends
GAO recommends that the Secretary of Transportation, as chair of the Coordinating Council, should publish a new strategic plan, issue a cost-sharing policy, and address the challenges associated with coordinating Medicaid and VA NEMT programs with other federal NEMT programs. DOT concurred in part with developing a new strategic plan and issuing a cost-sharing policy, and it concurred with identifying challenges of coordinating NEMT, particularly with HHS agencies.
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Recommendations for Executive Action
Comments: The Federal Transit Administration (FTA) concurred with this recommendation. Although, as the report notes, staff level activities have been very active since the last Executive Council meeting and, although staff continues to follow the expired strategic plan, FTA is working to develop a new two year strategy for the Coordinating Council by September 30, 2015. With this updated strategy, FTA will determine what strategic governing framework is most effective and what, if any, updates are needed to the strategic plan. FTA expects the new two year strategy to contain a comprehensive health and transportation focus.
Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and complete and publish a new or updated strategic plan that, among other things, clearly outlines a strategy for addressing NEMT and how it can be coordinated across federal agencies that fund NEMT service.
Agency Affected: Department of Transportation
Comments: FTA concurred with this recommendation. The agency said expanding upon past efforts and building upon the findings of the Transportation Research Board 2011 cost-sharing study noted in the GAO report, FTA plans to develop and propose a cost-sharing model with Coordinating Council members by May 30, 2016.
Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and finalize and issue a cost-sharing policy and clearly identify how it can be applied to programs under the purview of member agencies of the Coordinating Council that provide funding for NEMT.
Agency Affected: Department of Transportation
Comments: FTA said they concurred in part with this recommendation. Through its new "Rides to Wellness" initiative, FTA will be able to specifically identify and address challenges related to coordinating the areas of health and transportation, including Medicaid and other NEMT programs. The initiative has a three pronged strategy: to build commitment; stimulate investment; and to identify challenges and solutions for greater health access and health outcomes for people by ensuring they can get a ride. FTA, with other key Coordinating Council partners, will develop recommendations for how these challenges can be addressed. Additionally, small community planning grants will be used to identify challenges and suggest promising practices for NEMT coordination and community health associated transportation needs. Once the various activities of "Rides to Wellness" are completed and recommendations are formed by December 31, 2015, FTA will seek support from Coordinating Council members to implement those recommendations within each entity's legal authority. FTA will report to Congress on progress through the regular updates it provides Congressional Committees and through the FTA Administrator's testimony that covers these areas.
Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and using the on-going work of the Health, Wellness, and Transportation working group and other appropriate resources, (1) identify the challenges associated with coordinating Medicaid and VA NEMT programs with other federal programs that fund NEMT, (2) develop recommendations for how these challenges can be addressed while still maintaining program integrity and fraud prevention, and (3) report these recommendations to appropriate committees of Congress. To the extent feasible, the Coordinating Council should implement those recommendations that are within its legal authority.
Agency Affected: Department of Transportation