Non-Emergency Medical Transportation in the Time of COVID-19


May 5, 2020

A rideshare driver wears gloves and a mask while driving following the outbreak of COVID-19, in New York City, March 15, 2020, photo by Jeenah Moon/Reuters

A rideshare driver wears gloves and a mask while driving following the outbreak of COVID-19, in New York City, March 15, 2020

Photo by Jeenah Moon/Reuters

During normal times, over 3.6 million Americans miss or delay medical care due to transportation barriers. Non-Emergency Medical Transportation (NEMT), transportation to medical appointments, pharmacies, lab visits, and other types of routine care for the transportation-disadvantaged, aims to reduce this barrier.

During the current pandemic, movement has slowed as people shelter in place. Traditional NEMT options have narrowed or disappeared as public transportation and paratransit stop or operate at reduced schedules, and family and neighbors become less willing to provide transit (lest the infection spread, as occurred in New Rochelle, New York, where an ill individual infected the neighbor providing transportation to the hospital). Still, people have to obtain non-emergency but necessary medical care, including kidney dialysis, chemotherapy, and prenatal care visits.

Transportation problems are often cited as a barrier to receiving care and medical compliance. NEMT, covered by Medicaid and certain Medicare Advantage plans, is associated with greater use of preventive and primary health care, lower use of emergency services and inpatient services, and timely medical care among certain health conditions. These services continue to be needed during a pandemic, especially among the chronically ill, a group which may already face greater transportation barriers than the general public.

Reduced transportation options create almost impossible dilemmas. For highly vulnerable populations, like older adults living independently, using public transportation-NEMT involves either risking potential infection to travel to the places they need to go, or possibly risking other adverse health outcomes by not traveling to necessary medical care. Other NEMT options, such as family or friends driving, ambulances or “handivans” picking up individuals, become difficult in a pandemic as resources become scarce and people isolate themselves by necessity.

Transportation Network Companies (TNCs) like Lyft and Uber have been providing NEMT, since 2016 and 2018 respectively, through a ride-share model. Generally, the service has yielded positive results; studies found patients using rideshare-based NEMT had fewer missed primary care appointments, a lower average wait time, a higher rate of on-time pickup compared to those using other types of NEMT, and lower costs.

While other forms of transportation become increasingly unavailable due to quarantine, lack of access to public transit, or reserving transit for emergencies such as ambulances reserved for transferring COVID-19 patients, TNCs may be uniquely suited to current needs. With high scalability and an existing service model available, rideshare could address transportation needs.

TNCs can do more than just provide NEMT during the current crisis. They can deliver (and as of April 15th are delivering) food to individuals in medical quarantine or who are unable to safely shop for themselves, supplementing existing grocery delivery services who are currently overwhelmed. They can also deliver goods from open stores, such as pharmacy items, including sanitizing materials, non-prescription drugs, and personal care products.

With government cooperation, the range of services rideshare drivers could provide and the number of drivers available are limited only by what is safe for the driver and logistically feasible.

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Making ridesharing a workable option in the current crisis requires local and state government cooperation, TNC capacity, clarity around the rideshare driver's role, and protection for the driver.

First, TNCs must be able to provide NEMT within the state. Some states were unable to allow TNCs to provide NEMT because of historical barriers, driver requirements, or other obstacles. Currently, at least 10 states include rideshare as a NEMT provider. If the ranks of Medicaid swell due to an economic downturn, there may be greater need for NEMT. With state and local government cooperation, the range of services rideshare drivers could provide and the number of drivers available are limited only by what is safe for the driver and logistically feasible. This could include an expanded service into remote, rural areas.

Second, the TNC must have the logistical capabilities to provide NEMT to transportation-vulnerable Medicare and Medicaid recipients. The TNC must be able to work within the state statutes on NEMT, and within the state dictated operating model, such as working with health plans, transportation brokers, and/or state agencies to coordinate service. Beyond current services, TNCs deliver customer-purchased groceries and goods. Delivering goods rather than people has the additional benefit of not exposing drivers to potentially infectious but asymptomatic customers.

Third, drivers must be protected during the current pandemic. If rideshare drivers are going to continue to work, everyone, from the TNCs to the customers, must ensure this remains a safe occupation. Lyft and Uber have issued guidance to their drivers around safe operations, including disinfecting the in-vehicle environment and not driving when ill. Both are working to distribute cleaning supplies to drivers. Some drivers have erected a do-it-yourself, see-through barrier between the rear and front seats. Both TNCs have suspended pooled rides. Both offer financial assistance to drivers self-quarantining with a doctor's note. Such efforts could be necessary if rideshare drivers and TNCs are going to be depended upon to provide essential services at this time. If PPE supplies were sufficient to satisfy the needs of medical providers, rideshare drivers, as public-facing essential personnel, may be appropriate recipients of masks.

Finally, making rideshare-based NEMT a workable option requires a firm understanding of what rideshare drivers and TNCs can and cannot do. Although drivers for TNCs could be asked to deliver goods to and between medical facilities, they cannot move medical samples or soiled supplies between medical facilities. Similarly, drivers cannot be used to transport patients with suspected or confirmed COVID-19, based on CDC guidance. Patients need to be advised that if they have confirmed or suspected COVID-19 and are seeking help or are experiencing a medical emergency, rideshares are not the right transportation option. Although drivers can bring a transportation-vulnerable individual to a pharmacy anywhere across the country, they don't have scaled capabilities to pick up the prescription and deliver it to the individual's home. Drivers receive no formal medical training. Rideshare-based NEMT currently works best for those who are physically and cognitively healthy enough to use curb-to-curb rather than door-to-door service.

Changes are already occurring in isolated circumstances. At least three states removed regulatory barriers to allow rideshares to provide NEMT in the last few weeks, some using the 1135 waivers (PDF) under the Stafford Act to exercise greater flexibility. Pilot programs allowing medication pickup by rideshares are underway, supplementing existing efforts by Doordash, Postmates, and Deliv. Door-to-door service involving light assistance from the driver is being explored under other new pilots. Lyft is delivering meals to students who normally received subsidized school meals, and to senior citizens. They also recently started delivering groceries, medical supplies, and necessary goods to medically vulnerable or transportation-disadvantaged recipients on behalf of nonprofits, government agencies, and health care organizations. Uber has pledged free rides and free meals for health care providers internationally.

More widespread availability of rideshare for NEMT may save lives, reserve emergency resources for those who need them, and provide safe pathways to primary care for the chronically ill. It may also save livelihoods, providing employment in a time of economic hardship. Rideshares cannot offer everything, but there are things that could be done to support rideshare in doing the one thing their drivers do very well: move people and things to where they need to be.

Laura Fraade-Blanar is an associate policy researcher at the nonprofit, nonpartisan RAND Corporation. Christopher Whaley is a policy researcher at RAND and a professor at the Pardee RAND Graduate School. This perspective was supported through an ongoing project on NEMT sponsored by Lyft.