Written by Stephen UmunnaLet's face it. Going to the doctor is an inconvenience for
most of us. Sometimes, it takes an entire workday to go to the doctor because
of long wait times or because the doctor's office is closer to our home than
our workplace. If we cannot take the day off, then we must do a bit of planning
to go to work, run to the doctor's office, run back to work, and make it home
at a reasonable time. It's no wonder most Americans choose to drive to the
doctor if they can. Unfortunately, many Americans don't have access to reliable
transportation, which is costing the American healthcare system medically and
financially.
We will explore the financial burden of missing a doctor's
appointment, who is more likely to miss a doctor's appointment because of
access to vehicles, and what solutions are being done to improve patient
outcomes and financial relief for both patients and the healthcare system.
How Many Patients Miss Their Doctor Appointments?
Every year, 3.6 million patients miss their medical
appointments because of transportation barriers, according to a study published
in The
Gerontologist. Patients missing medical appointments can have a
compounding effect on the healthcare system. For example, atenahealth
looked at more than 3.5 million visits by 1.2 million patients at 1,626 primary
care practices in a two-and-a-half period. Each "visit" included
no-shows, cancellations, rescheduled, and kept appointments. They found that
patients who failed to stay just one appointment with their primary care doctor
were 70% more likely not to return within 18 months.
How Do Missed Appointments Cost Americans?
Missing one medical appointment can be the difference
between diagnosing dangerous cancer early versus finding cancer too late. It's
the difference between maintaining control of your diabetes versus losing
control of diabetes.
On the financial end, late diagnoses are expensive. The World
Health Organization (WHO) released figures suggesting that "studies in
high-income countries have shown that treatment for cancer patients who have
been diagnosed early are 2 to 4 times less expensive compared to treating
people diagnosed with cancer at more advanced stages." This is because
early-stage cancer treatments are prone to be more effective, less complicated,
and thus less expensive.
Just like restaurants lose money by people missing
reservations, hospitals and clinics miss out on opportunities to treat more
patients when one patient misses an appointment. One
study found that no-shows cost the United States healthcare system more
than $150 billion annually. Individual physicians lose about an average of $196 per
unused time slot. Treatments are cheaper and more effective on the patient, the
hospital, and insurance companies when the patient and doctor have frequent and
reliable access to each other.
Socioeconomic Status and Vehicular Access
In general, people of lower socioeconomic status are less
likely to have vehicle access than those of higher socioeconomic status. A literature review
by Samina Syed et al., published in the Journal of Community Health,
reviewed nine studies investigating the relationship between vehicular access
and access to healthcare. They defined vehicular access as the patient owning a
vehicle themselves or having access to a car through a family member or friend.
All the studies suggested that increased access to a car was positively
correlated with increased access to healthcare.
Urban vs. Rural Vehicular Access
One
study published in The Journal of Rural Health analyzed the
relationship between access to transportation and the frequency of healthcare
checkups in rural western North Carolina counties. The study found that
patients with a driver's license had 2.3 times more health care visits for
chronic care and 1.9 times more visits for regular checkup care than those
without. Also, the study investigated what happens when patients have family or
friends who could provide transportation. Those patients had 1.58 times more
healthcare visits for chronic illnesses than those who did not. Those with a
vehicle were more likely to visit medical care than those using public
transportation. Those who used public transportation to seek medical care were likelier
to see a doctor than those without public transport and vehicular access.
In urban areas like Atlanta, a study published by Rask
et al. surveyed 3,897 urban patients of low socioeconomic status, suggesting
that walking or using public transportation to seek regular medical attention
was an independent predictor for patients not seeking care. Also, the study
found that patients with no vehicular access were more likely to wait more than
two days before attempting medical care.
Racial and Ethnic Disparities on Vehicular Access
We can see racial and ethnic disparities in access to
vehicles. According to the National Equity
Atlas, minorities are less likely to have access to a car, especially in
highly urbanized cities like New York, Newark, and Jersey City, compared to
smaller towns out West and South like Henderson City, Nevada, and Plano, Texas.
Guidry et al. reviewed
593 survey responses of patients who had been clinically diagnosed with breast,
colon, cervical, or prostate cancer, or lymphoma between 1989 and 1993. The
research found that 38% of whites, 55% of African Americans, and 60% of
Hispanics stated that reduced access to a vehicle was a significant barrier to
cancer treatment. Black and Hispanic patients reported that barriers such as
distance and access to a car were the most prominent barriers despite white
patients having to travel farther to the facilities.
What about the Elderly?
One of the biggest and often forgotten groups that have
consistent vehicular access barriers is older adults. These patients face an
eclectic combination of transportation barriers because of their increased need
for frequent doctor visits because of compounding health issues relative to
other age populations. A report in The
Atlantic discussed how 83-year-old patient Edith Stowe relies on buses
to get regular checkups for chronic kidney failure twice every three months
despite living only five miles from the hospital. If her appointment was
scheduled in the middle of the day, it would take her at least an hour to get
to the hospital and an hour to get home using the bus. This resonates with many
other studies suggesting that 3% to 21% of the elderly report that
transportation barriers prevent them from accessing healthcare.
Do Ridesharing Companies Like Uber and Lyft Improve Vehicular Access?
Ridesharing companies like Uber and Lyft have sought to help
address this $150 billion problem. Uber created Uber Health which is
currently being used by more than 100 healthcare organizations in the United
States and has become part of the beta program from centers like Adams
Clinical, Blood Centers of the Pacific, Georgetown Home Care, LifeBridge
Health, MedStar Health, Manhattan Women's Health, NYU Perlmutter Cancer
Center, Pro
Staff Physical Therapy, ProActive Work Health Services, Project Open Hand, Renown Health,
Thundermist Health Center and Yale-New Haven Health. Healthcare technology
companies like Bracket Global and Collective
Health are also exploring ways Uber Health can work with their
offerings.
Since 2016, Lyft has expanded its network to broaden access
to non-emergency medical transportation (NEMT). As of April 2020, Lyft
works with three Medicaid agencies in Florida, Indiana, and South Carolina.
Also, they provide access to rides for eligible Medicaid patients in 10 states
plus Washington D.C., giving access to potentially 22 million patients.
Currently, the results are mixed on whether ridesharing
companies help improve vehicular access. A 2018 Penn Medicine study
published in JAMA
Internal Medicine conducted a clinical trial of ridesharing
interventions between October 2016 and April 2017. The study suggested offering
free Lyft rides to Medicaid patients for upcoming medical appointments was less
than promising. They found that the missed appointment rate for patients
offered a free Lyft ride and those not offered a ride was practically the same:
36.5% vs. 36.7%.
On the other hand, Hennepin
Healthcare in Minneapolis used Lyft rides to patients in need. Their pilot
program reduced no-shows by 27% and increased the clinic's revenue by an
estimated $270,000 (ROI of 297%). Boston Medical Center used Uber
Health to move their outpatients. They reported having greater patient
satisfaction while saving $500,000 by replacing shuttle buses between main
campuses and clinics.
Are There Other Supplemental Programs That Hospitals Provide?
Some medical centers and clinics try to bring doctors and
resources to the patients at the most risk of no vehicular access via mobile
health clinics. A mobile health clinic is a regular doctor's office or
examination room inside a large van or vehicle. CalvertHealth Medical Center
has a Mobile
Health Center providing primary and preventive care services to patients
with transportation barriers. A 2017 literature
review published in the International Journal for Equity in
Health suggested that mobile health clinics helped patients in underserved
areas access a doctor while clinics profited. The operational cost of the 2,000
mobile health clinics is $429,000 annually. While serving 6.5 million mobile
health clinic visits annually, the return on investment is approximately $12
per patient.
Hospital van programs in rural areas have helped increase
access to medical care via transportation. For example, Taylor Regional
Hospital operates a hospitality van service for patients in Taylor County and
three neighboring counties. The hospital serves approximately 110,000 people in
the rural community of Campbellsville, Kentucky, and surrounding regions. Jane
Wheatley, CEO of Taylor Regional Hospital, discusses the van services and says,
"With 25,000 people using this service, we've never received a negative
comment or complaint about it. Patients themselves and their loved ones have
expressed how helpful this service has been in receiving treatment."
In Summary
Implementing new strategies to help decrease the number of
no-show medical appointments can increase revenue and positive patient
outcomes. Although physicians are more likely to live and work in areas of higher
affluence, companies are working to help patients at risk of not accessing
a doctor due to transportation access.