Why JAMA’s new study won’t put the brakes on ridesharing in healthcare

A Conversation with Dr. John Brownstein, co-founder of Circulation

A new study in the Journal of the American Medical Association is making the rounds around the health innovation watercooler.

Researchers from UPenn tried to gauge the effectiveness of ridesharing as a way to reduce primary care no-shows among patients enrolled in Medicaid. The study found a virtually identical no-show rate among patients who were offered free transportation and those who weren’t.

This was unexpected news to everyone but the most ardent skeptics of digital health innovation. Even the study authors expressed surprise in an e-mail to Reuters: “We think this is likely because we didn’t have a high percent of people who agreed to use the service or ultimately used it after agreeing. We think this may be the result of the way we delivered the service or lack of familiarity.”

A closer look at the details brings up several more yellow lights, from the seeming lack of any sort patient-centered study design, to the odd way the final results were calculated.

We’re not experts in academic study design, but we do know our way around the real world market dynamics of digital health, and one question rose above all the others: If it’s true that rideshare doesn’t work, then why have *dozens* of health systems invested in it over the last two years?

Onboard Health put us in touch with one of digital health’s foremost experts to help the industry understand these issues a little more closely.

A Chat with Dr. John Brownstein

John Brownstein, PhD

The word “pioneer” is bandied about these days, so suffice to say Dr. John Brownstein was testing and deploying digital health tools long before there was even a hashtag in front of the term. He’s a professor, researcher, data geek, and advisor to businesses like Google and Uber. And as co-founder of the country’s leading NEMT startup, Circulation, he knows more about translating the impact potential of ridesharing into public health and business outcomes than just about anyone out there.

The following conversation has been condensed and edited for clarity.

Patchwise Labs (PL): Can you talk a little bit about this study? What did you think when you read it? What does it mean for the industry?

Dr. John Brownstein (JB): Sure. Well it’s definitely struck a chord, and there are many different stakeholders out there talking about these issues. And there’s still a group of people out there somewhere who don’t consider transportation as a barrier to care. But if you look at the bigger movement in healthcare towards social determinants, we’re reaching a consensus that addressing some of these non-clinical issues can lower cost, and improve the patient experience.

As far as this study goes — Overall, I want to start off by saying I think it’s great that there’s an effort to do formal evaluations of digital health tools. There’s this emerging field of social determinants entering the mainstream, and we absolutely have to hold ourselves to be accountable in evaluating these new tools. I mean even a few year ago, [ridesharing] is not an area where we saw this sort of [academic evaluation] activity.

But even the authors acknowledged some of the challenges with this one. The issue isn’t really about the technology of ridesharing itself, it’s how it’s delivered and how the study is run. If you look at how many patients were actually eligible to receive a ride, it’s a small portion of the group in the study.

Excerpted from the study abstract (emphasis added)
All individuals receiving a phone call reminder were included in the study sample, regardless of whether they answered their phone…Within the intervention arm, 85 among 288 (26.0%) participants who answered the phone call used ridesharing. The missed appointment rate was 36.5% (144 of 394) for the intervention arm and 36.7% (144 of 392) for the control arm (P = .96).”

JB: So, it speaks to how much work goes into understanding the right population for an intervention, in this case, a rideshare. Another key issue that comes up is about education, how people were being offered the ride. Are we making sure we’re offering them the right tools?

Without addressing those considerations, the end result is that the outreach was very broad, and in the intervention arm only a very small portion were offered a ride…when you evaluate something like that, it’s going to sort of drown out any impact.

PL: Can you talk about the tension between academic studies and real-world business considerations in an area like ridesharing?

JB: I’m an academic and I still have an academic view of this, for sure, in how we approach this as a business. We’re very meticulous about tracking how transportation is working. We want to provide our health systems with analytics and good data on questions like, “how does it change their costs, what does it mean for their care programs” — there’s 100% transparency to that.

Circulation’s Outcomes (source: Circulation.com)

If you look at how Circulation is integrating into health systems, it’s helping patients who are already accessing transportation, but face challenges with wait times, or bad experiences. We’ve been able to produce amazing changes, lower costs, higher percentages of time visits, fewer missed appointments, we’re seeing it across the board.

I mean, we’re in over 70 health systems now. And it’s not just us — if you look at what Caremore’s doing, they’ve got some great data to support ridesharing as well. So yeah, I think it’s great to study these new tools, and it’s a very important discussion that we’re having because of this study, but also in a way we’re also learning a lot in the real world, from all of the business activity around the country.

A special thanks to Onboard Health and to Dr. Brownstein for sharing his insights on short notice.

Are you interested in SDOH-related innovation? Let us know! Share any thoughts, ideas, examples, or other resources with us in the comments, or get at us on Twitter! @patchwiselabs @onboardhealth

Naveen Rao is Managing Partner of Patchwise Labs.