An Enterprise Risk Management Perspective on Non-Emergency Medical Transport

The second in a series on transportation-related risks for healthcare businesses.

October 26, 2018

There is little doubt that the healthcare industry is in a cycle of rapid change. From technology, to merger and acquisitions, expanding roles for mid-level providers and the shift to increasing rates of ambulatory care, there is array of emerging risks impacting the healthcare enterprise.

The Context for Change in Patient Transportation

One area of change involves the delivery of non-emergency medical transport. For years patients were reliant on family and friends to provide transportation when they could not drive themselves. Additionally, some patients found taxi service was cost-prohibitive or bus transport inaccessible.

Use of non-emergency transport ambulances also raised challenges. Either such services were not available, or the needs of the patient did not meet the criteria for non-urgent medical transport. Even when such service criteria were met, the cost was prohibitive for patients due to steep co-pays or the lack of coverage in whole or in part by insurance, Medicare or Medicaid.

Today, in many ways there are changes in the patient population. Coupled with a growing emphasis on ambulatory care, healthcare leaders have been compelled to develop an innovative response to the transportation issue.

The justification for innovative transportation reflects a blend of economic factors. For patients, costs are a key consideration. Even when practical approaches such as a "rideshare" service is made available, the transport schedule may be incongruent with patient clinical tests or treatment visits. Lack of convenient transport hours for tests or treatment can lead to missed appointments that in turn "cost" the healthcare entity and providers in terms of decreased revenue. For patients and care providers alike being a "no show" appointment can adversely disrupt continuity of clinical services. The result can be patient safety issues, injury or death.

An Evolving Solution: Private Vehicle Owners for Hire

Healthcare has taken a page from innovators in transportation: Uber and Lyft for example for healthcare entities. Although there are several other programs available in the marketplace, in these examples there are specific programs available called Lyft Healthcare and uberASSIST. Essentially, the service relies on individuals using their own vehicles to transport customers who "book" their rides through these rideshare or ride hailing programs. For their part, Uber and Lyft screen the drivers and provide the billing infrastructure for charging the ridership. Using "apps" that can be downloaded from the likes of Apple, prospective clients can set location and time for pick-up, the number of passengers and the costs of the service. To know that they have the correct vehicle, details are provided through the app that includes a photograph of the driver.

The private vehicle model is different from traditional taxicab or transport services. Uber and Lyft drivers and services are not regulated like the taxicab and transport services. The overhead costs are less than for traditional taxicab and transport services, enabling Uber and Lyft to charge less for customer service.

How does this transportation innovation work in the healthcare field? In essence, there are two approaches. One is a private transaction between a patient and Uber or Lyft. The patient makes arrangement for transport to a clinic, lab, ambulatory care facility or physician office. The patient uses an app interface for this purpose.

In the second approach, there is a contractual arrangement between the healthcare entity and Uber or Lyft. It is the healthcare facility that books the transport for the patient. Further, many healthcare entities pay for the transport service.

Whether arranged by the patient or the healthcare entity, the innovative model touts a predictable, cost-effective, efficient means of transportation. It addresses the need for timely transport, serves to promote continuity of care and the reduction in missed appointments. However, it is not without risk.

For healthcare entities, services like Uber and Lyft provide innovative approaches to non-emergency medical transport. Identifying potential risks prior to embarking on such a program provides healthcare entities with a well-rounded picture of such innovative transport.   It means that an informed healthcare entity can weigh the benefits and risks and decide if this innovative transport model is consistent with its strategic plan, mission and vision in providing quality, safe, patient care.

Enterprise Risk Management Concerns with Private Vehicle Owners for Hire

An enterprise risk management approach can help healthcare leaders identify and analyze the risks associated with private vehicles being used for non-emergency medical transport. This identification-analysis approach can be used across the continuum of care, from acute care and critical access hospitals, to ambulatory care centers, clinics, physician practices and assisted living. With the results in hand, informed business decisions can be made about using services such as Uber or Lyft.

To look at the potential impact of the transport innovation for all aspects of the healthcare entity, it is helpful to put the identified risks into certain categories or "risk domains" as the term is used in enterprise risk management. There is no set number of categories for this purpose, but in many instances these risk "buckets" include: 

  • Human capital
  • Operations
  • Hazards
  • Technology/Equipment
  • Legal/Regulatory
  • Financial
  • Strategy

Once categorized, the risks can be analyzed, and choices can be made based on the total cost of risks or TCOR. Such information can then be evaluated in the broader context of potential benefits, especially if measures can be applied to mitigate or eliminate a risk. For example, an identified risk may be a lack of sufficient transport vehicles due to rush hour traffic congestion. Such a risk can impact operations. To address the risks, steps can be taken to work with scheduling for patient appointments or to use more than one service to meet transport needs. Additionally, patient/client expectation can be adjusted for what to expect in terms of transport service wait times.

An Enterprise Risk Identification List for Private Vehicle Transport for Non-Emergency Medical Purposes

It is useful to obtain input from the content experts in the healthcare organization. With regard to patient transport services, the content experts would include case managers, billing and coding staff, receptionists, and schedulers in addition to clinical personnel.

The following list can be used as the base for an enterprise risk management identification process. Additional items can be added to the list to get a comprehensive picture of risks associated with innovative private vehicle transport for non-emergency medical purposes.

  • Lack of well-crafted contract terms between healthcare organizations/entities and ride services
  • Insurance coverages for the healthcare entity: including auto (owned and non-owned), umbrella, errors and omissions, property, property and casualty, cyber risk/privacy breach and insurance coverages for drivers injured in the course of serving patients/clients under the Uber or Lyft transportation program
  • Proof of auto insurance for private vehicles used in the Uber and Lyft patient transport program
  • Excess coverage for private vehicles used in the Uber ad Lyft patient transport program
  • Absence of credentialing for Uber and Lyft drivers for healthcare services
  • Will this meet the need for a "responsible adult" to accompany a patient home (e.g. post procedure, on discharge from an inpatient stay, etc.?
  • Driver is unable to assist customer (e.g. getting in or out of vehicle)
  • Driver is unable to assist special needs customers, including:
    • Legally blind
    • Hearing impaired
    • Physically impaired (walker, cane, crutches, partial amputee)
    • Oxygen dependent
    • Large clients (cannot fit comfortably in the vehicle)
    • Service animals (capacity to and requirement to transport)
  • Driver not certified in CPR, BLS
  • Lack of emergency plans for common exigencies, including:
    • Inclement weather
    • Traffic jams
    • Vehicle breakdowns en route
    • Motor vehicle accidents
    • Response for customer medical emergency
  • Videotaping or audiotaping healthcare customers in the vehicle without consent but built into contract between Uber or Lyft and healthcare organizations/entities
  • Vehicle capacity is inadequate for transporting healthcare customers
  • Absence of a Customer Privacy Policy and Procedure
  • Absence of a Customer Confidentiality Policy and Procedure
  • Absence of appropriate Business Associate Agreements (BAAs)
  • Absence of a corporate compliance plan for contractual arrangements with Uber or Lyft
  • Absence of a terms of use agreement between the healthcare entity and patients/clients for the use of contracted Uber or Lyft transport services
  • Inadequate legal/regulatory review of proposed contracted Uber or Lyft transport services with respect to such laws as federal and state anti-kickback provisions, the Americans with Disability Act, the Rehabilitation Act of 1973, HIPAA , and the False Claims Act (FCA)
  • Absence of expectation setting for patients/clients on wait time for Uber or Lyft transport services.
  • No show (driver and customer) protocol
  • Understanding by patient/client on appropriate use of rideshare transport (e.g. non-urgent only)
  • Drivers substituting others to transport patients
  • Drivers accompanied by friends while driving patient/client, a practice not authorized under contract
  • Retention of patient transport information in the electronic medical record
  • Transport records retention, release

Conclusion

Patient transportation services have emerged as an area of concern for all types of healthcare entities. From missed appointments, discontinuity in patient care, lost revenue and patient safety, innovation is needed to provide non-emergency medical transport services. The prospect exists for the expansion of reliance on "commercialized" private vehicle services such as Uber and Lyft. Using an enterprise risk management approach, healthcare entities can identify, analyze and potentially mitigate or eliminate risks associated with this transportation innovation as a mechanism for providing quality, safe, and effective patient care.

Prepared for OneBeacon Healthcare Group by Fay Rozovsky, President, The Rozovsky Group, Inc.

Do you have an experience with using a rideshare or other type of transportation company for non-emergent patient transport? Patty Hughes, SVP, Risk Management would love to hear from you! 

 

Information is provided for general informational purposes only and does not constitute legal, risk management, or other advice. Viewers should consult their own counsel or other advisors for such advice. OneBeacon Insurance Group, and its parents and affiliates ("OneBeacon"), and consultants, contractors, and vendors of OneBeacon assume no responsibility or liability for the discovery or elimination of risk that possibly could cause accidents, injuries, or damages. Compliance with any strategies or opportunities for improvement provided does not assure elimination of risk or the satisfaction of requirements of applicable law. Copyright OneBeacon Insurance Group. All Rights Reserved. Information may not be redistributed to non-OneBeacon insured policyholders without OneBeacon's permission.