By JOE MKHITARYAN
We spend a lot of time talking about who has health insurance. I think we need to spend more time asking who can actually use it.
You can approve an appointment, find a specialist and cover the treatment. But if the patient cannot get out of the house and into the right vehicle, none of that gets them to the doctor.
I have been in the medical transportation business since 2010. I built my businesses in Southern California, where a few miles on a map can turn into a long trip in traffic. Running these operations has taught me to ask questions that are easy to miss when you are looking at a transportation budget.
Can the patient walk? Can they sit upright? Are there stairs outside the home? Do they need a wheelchair vehicle or a gurney? Who is bringing them back?
Those answers determine whether the ride will work. They need to be settled before a vehicle arrives.
Non-emergency medical transportation, or NEMT, is how many patients reach appointments when they cannot get there on their own. It is easy to describe it as a ride. Providing it is more involved.
Take a gurney trip. In our operation, that means sending two staff members. They have to help the patient safely, load and secure the gurney, make the trip and complete the handoff. Then there is the return. That crew is working well before the vehicle starts moving and after it stops.
If you price that trip mainly by the miles driven, you leave a lot of the work out of the calculation.
I pay attention to this because I am the one paying wages, insurance and vehicle expenses. I have a business interest in the rates. But anyone responsible for patient access should care whether those rates can support the service they expect. You cannot keep asking for trained staff and dependable vehicles without considering what it costs to provide them.
Of course, paying more does not automatically produce better service. Providers should have to show that they are safe, reliable and doing the work they bill for. The question is whether the payment and the expectations make sense together.
The need is real.
In 2022, CDC data found that 14.4 percent of adults with disabilities lacked reliable transportation for daily living, compared with 4.9 percent of adults without disabilities. That includes needs beyond healthcare, so it is not a measure of missed appointments. It does tell us that assuming everyone can find a ride is a mistake.
Medicaid recognizes the problem. CMS explains that states must ensure access to necessary transportation for beneficiaries who have no other way to reach covered care. The state remains responsible for meeting transportation requirements even when other organizations run the program.
I want us to judge that responsibility by what happens to the patient. A ride can be booked and still go wrong. The wrong vehicle can arrive. The pickup can be too late for the appointment. The patient can reach the clinic and have no clear way to get home.
That last part deserves more attention. We usually know when an appointment starts. We do not always know when it will end. A return trip needs a process that accounts for that uncertainty.
Who tells dispatch the patient is ready? Who confirms the pickup? If there is a delay, who explains it to the patient and works on getting them home? Those are basic questions. Leaving them unanswered puts the burden on someone who may already be tired, uncomfortable or unable to make the calls themselves.
For patients receiving recurring care, keeping a familiar crew can also help. The crew learns where to park, how to enter the property and what assistance the patient needs. When that arrangement is working safely, I think there should be a good reason to disrupt it.
Complaints still need to be taken seriously. If a driver is unsafe or a provider repeatedly fails patients, investigate and act. Providers deserve a fair review, and patients deserve a service they can trust.
We could learn a lot by measuring a few things consistently: whether the patient reached the appointment on time, whether the vehicle met their needs and how long they waited for the ride home.
When a trip fails, find out why. Was the authorization missing? Did the provider arrive late? Did the facility change the time? Did the patient cancel? You cannot fix all four problems with the same response.
This is where I see a useful role for technology. Software can flag missing information before dispatch sends a crew. It can let a facility know a vehicle is approaching and give staff a simple way to request the return. Those improvements would help with the actual work.
But the schedule has to allow time to assist the patient. An app cannot make two people load a gurney instantly, and an arrival estimate does not help much if no suitable vehicle is available. The people building these tools should spend time with dispatchers and crews before deciding how the system ought to work.
I would like health plans and policymakers to spend that time with us too. Watch a pickup. Follow the calls needed to arrange a return. Ask what happens when an appointment runs late. Then use that information when setting rates and service requirements.
We do not need to guess whether better transportation saves money or improves health. We can study it. Start by connecting trip information with appointment records and checking whether patients actually received the care they were scheduled for.
After years in this business, that is the question I keep coming back to. Did the patient get there?
If the answer is no, having insurance was only part of the solution. We still have work to do.
Joe Mkhitaryan is the founder of General Medical, a non-emergency medical transportation, home health and therapy services provider in Southern California and host of the Social Venture Podcast.
