How Uber and Lyft Became Major Players in the Healthcare Space

In my post on the MBTA’s On-Demand Paratransit Pilot Program, I made reference to the rise of partnerships with Uber and Lyft for non-emergency medical transportation (NEMT) services. I wanted to go into more detail into this especially with the recent IPOing of Lyft and Uber.

What is NEMT?

So what is NEMT? NEMT is crucial for facilitating access to care for low income beneficiaries who do not have reliable affordable means of getting to health care appointments, people with disabilities who have frequent medical appointments, and anyone who has limited public transit options and long travel times to health care providers. Organizations conducting clinical trials also usually provide NEMT to participants.

NEMT services have been provided since the inception of Medicaid in 1966, which requires that transportation is provided to beneficiaries to and from medical services. This requirement shows real foresight on the part of those involved in creating Medicaid and it’s clear that NEMT is just as important as ever before. It’s estimated that NEMT coverage through Medicaid provided 104 million trips in 2013. And a number of studies continue to support this need for NEMT. One study found that around 3.6 million people miss or delay medical care because they lack available or affordable transportation. A 2014 CMS survey of Medicaid also found that lack of transportation was the third highest barrier to care for adults with disabilities with 12.2% of these patients reporting they couldn’t get a ride to a doctors office. Another study found that adults who lack transportation to medical care are more likely to have chronic health conditions that can escalate to a need for emergency care. A 2010 post in the Harvard Business Review found that missed appointments likely costs the healthcare system over $150 billion annually.

Do Uber and Lyft Have a Place in NEMT?

In the last couple of years, we’ve begun to see Lyft and Uber take an interest in the NEMT space and for good reason. The NEMT transportation market is estimated to be worth over $3 billion.

CareMore and Lyft

In January 2016, Lyft announced their partnership with National Medtrans Network through which they would pilot Lyft Concierge, a web-based product allowing organizations to request Lyft rides for Medicaid enrollees in New York and Medicare Advantage beneficiaries in California. The California pilot program involved CareMore, a network model health maintenance organization operating Medicare Advantage plans. In an article in the Journal of the American Medical Association, Sachin Jain, the CEO of CareMore, and his colleagues discussed the early success of the pilot. Based on 479 rides given from from May 2016 to June 2016, average wait times fell by 30%, average per-ride costs fell by 32.4%, composite patient measures yielded an 80.8% satisfaction rate. CareMore also saved $1 million by switching to Lyft.

Based on the success of this partnership, in August 2016, CareMore expanded this program to all of their Medicare Advantage markets, which included 75,000 members across 18 counties in California, Nevada, Arizona, and Virgina. CareMore partnered American Logistics Corporation (ALC) to offer these Lyft-based rides.

CareMore made several changes to the program based on feedback from the pilot program. Patients could still call a CareMore associate who would take down the information and would relay this to ALC, which used software incorporating the Lyft Concierge API to schedule the Lyft pickups. CareMore however would emphasize that Lyft would be picking up the patients, not the care services they were used to. CareMore and ALC also released a smart phone app-MyRide Manager, which would allow patients, caregivers and the care team members to track and manage rides via an interface resembling Lyft.

By the end of 2017, CareMore was providing 91% of curb-to-curb (C2C) rides through Lyft, accounting for up to 7,000 rides per month and 68,993 rides over the course of 2017. CareMore was able to accomplish similar results to those in the pilot. On time performance for Lyft based rides was 92% compared to 74% for non-Lyft rides, wait times for Lyft based rides were 9.2 minutes compared to 16.6 minutes for non-Lyft rides, patient satisfaction results were also quite high with 96% of riders feeling “Safe” or “Very Safe” during their ride and 98% reported being “Satisfied” or “Very Satisfied”. Ride costs were 39% lower than non-Lyft rides, which allowed CareMore to provide an additional 28,000 rides (12% increase) at no additional costs.

The CareMore pilot is not alone in showing the benefits of complimentary ride sharing services for patients. At Hennepin Healthcare in Minneapolis, Hitch Health’s automated SMS technology was used to offer Lyft rides to patients in need. This pilot was shown to reduce no-shows by 27%, increase the clinic’s revenue by an estimated $270,000 and a estimated ROI of 297%. The Boston Medical Center reported greater patient satisfaction and $500,000 in transportation savings by using Uber Health.

Complimentary Ridesharing Doesn’t Work?

While this CareMore pilot seemed to be quite successful, other studies have found that offering complimentary ridesharing services to Medicaid patients did not reduce rates of missed primary appointments. Researchers at UPenn conducted a clinical trial of ridesharing interventions between October 2016 and April 2017 in two academic internal medicine clinics in West Philadelphia. 786 existing patients with Medicaid were randomized into a control and intervention arm. Both sets of patients received two types of phone call reminders for their appointments, one from an automated system and one from research staff with a maximum of 3 attempts to make verbal contact. The research staff arranged Lyft rides for the patients in the intervention group that both answered the phone and expressed an interest. The patients communicated with the driver via text message and they were also given a number to call to arrange a ride home. These patients did not require a smartphone for this. For each group, the study authors measured the number of missed appointments (# of no-shows + same day cancellations/total number of patients). Additionally, they analyzed rates of emergency department visits to Penn Medicine facilities. The study ultimately found that the rate of missed appointments did not differ between the groups. It was 36.5% in the intervention group and 36.7% in the control group. Even when the analyses only included patients who could be reached by phone, the rate of missed appointments for the intervention group was 30.6% compared to 34.8%.

The researchers did however mention several limitations that are important for understanding this study.

• First, they suggested that transportation may not have as much of an impact in this geographic region because the furthest point in West Philadelphia was less than 5 miles from the clinics and the public transportation network was quite extensive. However, that isn’t to say that transportation is still not a barrier even within short geographic distance.
• Transportation might be 1 of many other social risk factors such as home environment stability, which could limit patient ability to attend appointments.
• Their recruitment strategy of making phone calls might not have been the best way to offer the new service.
• They did not measure comfort with using text communication, which was required to dispatch ridesharing services.
• There may have been something bigger than their intervention that caused an overall change in the health system and a fewer overall missed appointments.
• The study population might not have been interested in ridesharing with less than half of patients stating an interested in ridesharing and less than half of those using the ridesharing.

This study cannot be used to rule out offering complimentary ridesharing. The study authors suggest that more qualitative research on the causes of missed appointments is required before initiating large-scale transportation support.

An Uber/Lyft Ambulance?

On a side note, some studies have shown that the entrance of Uber in a given city also resulted in a decrease in the use of ambulance services. Economists at the University of Kansas found that there was at least a 7% decrease in the rate of ambulance use based on data from the National Emergency Medical Services Information System and Uber. In many cases, there is in fact no real need for an ambulance. Overuse of ambulances result in longer wait times and ambulance costs add up (in 2011, the U.S. spent around $14 billion on these services). As Anupam Jena, an economist and physician with Harvard Medical School (and one of my favorite professors) puts it, “Don’t reflexively call an ambulance. Ambulances are for emergencies. If you’re not having one, it’s reasonable to consider another form of transportation.” Jena sees ambulance rides as an typical example of Americans using higher-intensity care than necessary.

A Timeline of Uber and Lyft’s Entry into the NEMT Space

In April 2016, we saw Uber announce a partnership with Circulation, a digital transportation platform to provide 3rd party, healthcare related ride requests. Circulation noted only 8% of its patients reported no-shows with Uber, compared to 25–50% of no-shows seen in the NEMT industry as a whole. Circulation touts that they ensure that 95% of patients arrive to their appointments on time and that they save participating health plans and providers up to 50% on rides. Then, in September 2016, Lyft announced a partnership with Aging2.0, an organization that seeks to accelerate innovation in the senior care space, to provide an affordable transportation to older adults and senior care providers. In this announcement, Lyft also discussed many of its existing partnerships. These include partnerships with GreatCall in San Diego, through which seniors can request Lyft rides through Jitterbug, a simplified cell phone, various senior care communities, nonprofit groups, and home care providers as well as with senior transportation providers like Common Courtesy and Ride N Care.

In 2017, we continued to see the growth of NEMT partnerships with Lyft/Uber. LogistiCare, the nation’s largest non-emergency medical transportation (NEMT) manager, and Lyft announced a 3 year partnership in February 2017 to offer select Medicaid and Medicare Advantage beneficiaries in 31 states with transportation services. The American Medical Response (AMR), the nation’s largest provider of medical transportation, and Lyft announced a NEMT partnership in March 2017, through which AMR hospitals, health systems and health plan clients could utilize “One Call” services that allows them to request and pay for rides for patients. In May 2017, Lyft announced another partnership with Blue Cross Blue Shield (BCBS) to provide rides for BCBS members. Circulation also announced a partnership with Lyft in December 2017.

The Launch of Uber Health and Lyft Concierge

Then in March 2018, Uber introduced Uber Health, a dashboard enabling healthcare providers to coordinate rides on behalf of patients that would available in 250 cities. And it made a lot of sense for Uber to develop this product.

Before Uber began piloting Uber Health, many healthcare providers (around 100) were already using Uber to transport their patients. Patients could be notified of pick-ups via text message and given a link to track the driver. Healthcare administrators can also provide paper printouts with pick-up location, license plate number, and car model. Uber also launched an Uber Health API for software developers to integrate these ride-hailing capabilities into their own healthcare tools. A few days after the launch of Uber Health, Lyft publicly announced their Lyft Concierge API enabling organizations to incorporate Lyft Concierge into their own systems.

Some of the organizations that have made use of the Lyft Concierge API include: Circulation, the American Medical Response, the American Logistics Company, which used the API to create custom pickup and drop-locations, CareLinx, which incorporated the API into their app so that clients could arrange and pay for caregiver rides, GoGo Grandparent, which used the API to allow seniors to request rides without a smartphone, One Call, and AllScripts. Through the AllScripts partnership, Lyft touts that their platform can be integrated into the routines of 2,500 hospitals and 45,000 physician practices-reaching 180,000 physicians and 7.2 million patients. Lyft also partnered with Partners HealthCare also announced a partnership with Circulation where Lyft would provide the rides.

Then in April 2018, CMS actually announced that it was “reinterpreting the standards for health-related supplemental benefits in the Medicare Advantage program to include additional services that increase health and improve quality of life.”

These additional services can include NEMT and therefore a great opportunity for Uber and Lyft. Lyft in February 2019 announced that it would be expanding its NEMT services through BCBS and Humana Medicare Advantage (MA) plans. (They also piloted a 6 month MA pilot in 2017 with Cigna-Health Spring, where they offered 14,500 free rides with 92% of members preferring this service).

Lyft is Now Leading the Charge

As of 2019, it looks like Lyft has now taken the lead in the healthcare space compared to Uber. Lyft says that it has partnerships with 9 health care systems including the 141-hospital system Ascension and Denver Health. Lyft also announced a new web-based Concierge feature that would allow members without smartphones. In addition, Solve.Care, a blockchain startup, announced a new partnership with Lyft. Users can use the Solve.Care wallet to schedule a Lyft ride for healthcare services and can pay for them through the Solve.Care wallet. Lyft is hoping this partnership could increase coordination between all parties involved in healthcare. Patients will be able to share details with insurance providers and family members. Uber is of course still a major force to be reckoned with. They have mentioned having partnerships with over 100 healthcare organizations including MedStar Health, LifeBridge Health, NYU Perlmutter Cancer Center and Yale New Haven Health.

Wheelchair Accessible Transportation

Uber is also much further along when it comes to wheelchair accessible transportation. Uber offers both uberASSIST and Uber WAV, having recently partnered with MV Transportation to provide significantly more wheelchair accessible vehicles (check of my article on wheelchair accessible vehicles and Uber/Lyft). Lyft is quite behind when it comes to providing the same services. Hopefully, both Uber and Lyft will continue to make positive strides in this area. Uber and Lyft cannot leave out these patients and if anything, transportation is an even bigger barrier for patients that are wheelchair users. If these patients cannot use public transit, they often must use paratransit, which has a whole host of other problems. Now one solution is what we have the MBTA’s paratransit program, where paratransit users (who are also often Medicaid recipients) can use ridesharing services (check out my previous article in which I go into depth with this program). In any case, a lot of work still has to be done in this aspect.

HIPAA

One major concern for both Uber and Lyft is the issue of HIPAA compliance. Uber and Lyft claim that their platforms are HIPAA compliant. However, the drivers are classified as independent contractors and don’t have to undergo HIPAA-training. Uber and Lyft could face major penalties if these drivers leaked patient names and transportation records. In Lyft’s recent IPO filing, they estimated that a data breach would make them vulnerable to approximately $1.5 million in civil penalties.

My Thoughts

Dan Trigub, the head of Uber Health recently said “we think every rideshare company should provide a way for the healthcare industry to utilize their product. It’s good for Uber, it’s good for the industry.” I don’t think anyone thought that someone at Uber, let alone a head of Uber Health, would be saying that when Uber and Lyft first began, Who would have thought they would be big players in the healthcare space?

I am excited to see what is next when it comes to their role in the NEMT space. Do Uber and Lyft only have this opportunity in the U.S? Will Uber and Lyft actually be able to increase the number of wheelchair accessible vehicles and make it easier for patients that are wheelchair users? And where will self driving technology fit into all of this? These are some of questions that I still have. As Megan Callahan, the VP of Lyft Healthcare puts it, “I think we are just seeing the beginning of the possibilities here.”