On March 11, 2020 the World Health Organization (WHO) categorized COVID-19 as a pandemic. Initially this seemed to be a virus that affected China, Europe and large metropolitan areas in the United States. Over the next few days, however, the situation changed. It has spread to all 50 states and significantly altered how people live and interact with each other. “Sheltering in place” is recommended as necessary to slow the spread of the virus and avoid overwhelming our healthcare system.
Amid this, transportation to healthcare has become even more important. Questions about providing service, sanitation, and other precautionary measures to keep drivers and members safe is critical for NEMT transportation providers and brokers.
What is COVID-19?
According to the Centers for Disease Control (CDC), COVID-19 is a novel coronavirus.
A novel coronavirus is a new coronavirus that has not been previously identified. The virus causing coronavirus disease 2019 (COVID-19), is not the same as the coronaviruses that commonly circulate among humans and cause mild illness, like the common cold. (https://www.cdc.gov/coronavirus/2019-ncov/faq.html)
The symptoms of COVID-19 include dry cough, shortness of breath, and fever. It does not discriminate between age, race, or socio-economic status. At risk groups include individuals with compromised immune systems, older adults, and those with chronic disease including diabetes, and heart or lung conditions. The recommended way to prevent the spread of the virus is to wash hands with soapy water for at least 20 seconds, use hand sanitizer when soap and water are not available, and practice social distancing.
Persons typically show symptoms between two and 14 days from the time of exposure, which is why people have been asked to self-quarantine for 14 days following travel to known outbreak areas. With the spread of the virus to the U.S., the probability of exposure in transportation has increased.
Providing good customer service is the goal of anyone operating an NEMT business. In order to meet demand, drivers must be available to operate vehicles in order to get individuals to and from medical appointments. Three concerns for a transportation provider to manage in a pandemic environment are fear, combatting driver shortages, and anticipating a loss of revenue.
Fear, real or perceived, impacts an individual’s ability to function in the work environment. Drivers and direct service providers risk coming into contact with an infected individual and not be aware of it. Fear of COVID-19 exposure could result in an increase in distracted driving, refusing to transport anyone who appears to have a cold or seasonal allergies, or even refusing to come in to work.
Drivers play a critical role in the healthcare of the individuals they transport. A rule of thumb, as suggested to healthcare professionals, also applies to NEMT drivers. Make sure to have the most current information available. Use the CDC website (cdc.gov) or reach out to the local Public Health Agency for information that can be distributed. Make sure to have supplies available for drivers to ensure proper cleaning between transports. This means using antiseptic products to wipe down seats, handles, windows, doors, and seatbelts in each vehicle prior to arriving for the next pickup. Practicing social distancing may mean passengers sit in the back seat of the vehicle and not next to the driver to minimize the transmission of the virus.
Driver shortages may become a new reality as the need to be quarantined due to self or family exposure or illness increases. This is a concern in all areas of transportation, but may specifically impact the health outcomes of the NEMT population. As more companies are laying off workers in “non-essential” roles, this may be an untapped resource for companies to reach out to and bring them onboard as current drivers are no longer able to provide services. Training, especially on universal precautions and infection control (consistent cleaning and hand washing) will become particularly important to emphasize with any new employee.
Declining revenue is another concern for providers. In some areas providers are already experiencing a significant decline in trips due to the increase in alternative healthcare delivery systems, such as the increased use of Telemedicine. Through telephone or video exchange, people can now interact with their healthcare professionals from home. This decreases the number of trips needed to go to and from healthcare offices. While this is beneficial in the current pandemic environment, it results in a loss of income for providers and drivers. Recently, the U.S. Small Business Administration (SBA) has begun offering low interest federal disaster loans for working capital in areas significantly affected by COVID-19. Information about these loans and areas eligible is located on the SBA website. https://disasterloan.sba.gov/ela/Declarations/Index.
Non-emergency medical transportation brokers are used to arranging transportation to and from medical appointments for people with various medical conditions. However, COVID-19 presents some unique concerns for NEMT operations which differ from other medical conditions. Communications with health plans, clients, and staff all become unique challenges. HIPAA compliance concerns arise when different operating procedures, such as working from home, come into play. Further service risks may also include provider capacity, staff availability, technology, and finances.
Communication during a public health pandemic is critical to ensure needed services continue. As with transportation providers, it is important to ensure that the information sent to staff and clients is current and factual. Communicating with clients is key to ensuring that vehicles are not dispatched to homes when in-person appointments are cancelled. Telephone systems that have messages regarding available services are important, as well as systems that can send out information updates and process trip cancellations. Keeping the lines open with health plans is important to ensure the broker is providing services as expected, including the kind of transportation needed and not needed. Most brokers and healthcare providers are authorizing only essential services, to include treatments like dialysis and chemotherapy. Other trips for general medical checkups are being postponed until the pandemic has passed.
Ensuring compliance with HIPAA protocols remains essential as more individuals work from home. Home networks are typically not as robust as office networks, most of which have VPN (virtual private networks). Operations software that is web-based is more easily available in a work-from-home environment than application-based software. These are concerns that must be addressed to ensure that patient confidentiality is maintained.
It is possible that some HIPAA concerns may be relaxed as the push for social distancing increases and call centers are not be able to have staff working 2 to 3 feet from each other. Be sure to check the CMS website for the latest guidance. https://www.hhs.gov/sites/default/files/hipaa-and-covid-19-limited-hipaa-waiver-bulletin-508.pdf
Brokers also have risks in ensuring proper service delivery. This includes provider capacity, call center staffing and keeping tracking of locations that are open or closed. The declining driver pool experienced by transportation providers also directly affects the ability of the broker to provide needed service to their clientele. If call center staff are not available to answer phones, the software platform does not allow on-line trip booking and cancellations, or the telephone system does not have the ability to have staff work from home, call times increase, frustrating those who still need service.
Brokers also need to pay attention to business closures. In most areas, medical offices and pharmacies are still open. But medical offices may only be providing telemedicine services, meaning that if a patient arrives to see a physician in-person, they may be turned away. Other types of offices may be completely closed. The broker will need to keep this information updated on a daily basis.
Financially, those brokers that are reimbursed on a FFS (fee-for-service) basis may see a reduction in revenue as trip volume decreases, similar to that for NEMT providers. However, those brokers that are reimbursed on a capitated rate basis may not be affected, as long as their contracted capitated rate remains steady. Capitated payments are based on the number of eligible individuals and payment is not tied to numbers of trips.
In this new and uncharted public health crisis, medical transportation will be impacted in ways that we can only speculate about today. In the weeks and months to come, a change in the delivery of medical care will impact both transportation providers and brokers. We can best prepare ourselves by staying up-to-date with current public health directives, maintaining open, accurate and frequent communication, and being prepared to pivot to delivery of whatever new model of service comes our way. Stay safe and wash your hands.