Offering Free Patient Services Can Be Rewarding and Compliant

The COVID-19 pandemic was instrumental in further revealing the health inequities that have existed in the United States for decades. It exposed long-standing structural drivers of those inequities and exacerbated existing vulnerable infrastructures and scarce resources.

In cancer care, we are no strangers to the fact that some patients have more means and opportunities than others. Through a mixture of fragmented—but good-willed—programs, we have tried to close gaps and increase opportunities for people to live as healthy as possible.

Although we know that 80 percent of what makes up a person’s health status happens outside the four walls of our care institutions, we continue to focus more on quality clinical care than address social determinants of health and close existing gaps in care. As healthcare providers, we still have much work to do. But a shift is happening, and there is now more widespread acceptance, adoption, and proactive effort to incorporate social care into clinical care. Nowhere is the importance of that more evident than in chronic disease management such as cancer care.

Navigating the volume of appointments necessary for cancer treatment poses challenges for all patients—let alone those with limited resources. Recognizing these challenges, cancer care providers have come to expect and even accept a certain level of treatment non-compliance. But accepting what many providers now consider to be inevitable gaps in care related to socioeconomic realities has allowed health inequities and disparities to flourish.

But cancer programs are beginning to change their approach, putting mechanisms in place to understand social barriers before they complicate or disrupt treatment. Screening patients for social determinants of health as part of your intake process can help uncover potential treatment disrupters and allow for better care coordination and use of available resources.

At Cone Health Cancer Center, we have found that access to transportation plays a huge role in treatment compliance. Securing safe and reliable transportation to daily radiation treatments or multiple clinic visits is difficult for some patients. Because transportation disruptions can result in missed appointments, treatment delays, and potentially adverse health outcomes, we must help ensure that our patients have access to safe and reliable means of transportation.

Offering patients gas cards and bus vouchers can be a positive step toward closing care gaps. But transportation needs can sometimes run deeper than a patient’s ability to drive their own vehicle or navigate public transportation. In these cases, developing more coordinated efforts to provide rideshares or non-emergency medical transportation may be necessary. But for cancer programs, offering transportation to patients can entail significant costs and expose cancer centers to liability risk.

Managing Risk

When assessing risk, you must first accept that there is no way to avoid it. The best you—and your institution—can do is mitigate your risk and proceed forward. Creating rider safety waivers and releasing liability documents are incredibly useful tools to communicate to patients the risks involved in their participation in a transportation program. These tools are also an easy and effective way to mitigate risk to the institution.

With our healthcare system transforming into one that prioritizes and pays for value, Cone Health Cancer Center sought to develop a comprehensive patient transportation program that would not violate federal anti-kickback statutes. The safe harbor provisions created by the Centers for Medicare & Medicaid Services and the Office of the Inspector General (OIG) under the Department of Health and Human Services allows institutions to pay for activities or incentives that can help eliminate health disparities and close care gaps. The provisions focus on delivering better value to patients by creating exceptions to civil monetary penalties that prohibit inducements to beneficiaries.

On October 17, 2019, the OIG published a notice of proposed rulemaking to add or amend various regulatory protections under the federal anti-kickback statute to create protections for certain value-based arrangements that can improve the quality, outcomes, and efficiency of healthcare. According to the rule in the Federal Register, “this includes modifying the existing safe harbor for local transportation furnished to beneficiaries (paragraph 1001.952(bb)). We are finalizing, with modifications, changes to expand mileage limits for rural areas (up to 75 miles) and eliminate mileage limits for transportation to convey patients discharged from the hospital to their place of residence (discussed at section III.B.12). We also clarify that the safe harbor is available for transportation provided through rideshare arrangements.” At the recommendation of our compliance department, we developed a policy that outlines these safe harbor provisions.

Managing Costs

Once your transportation program or services are deemed compliant, the second issue institutions must address is cost. And costs are inevitable, whether they are the financial costs to your program to provide transportation for your patients, or the economic and human capital costs of poor health outcomes incurred as a result of socioeconomic differences.

For institutions looking to develop a similar program, I offer a phrase often repeated by my mother: “Del dicho al hecho hay mucho trecho.” Loosely translated, it means that in certain circumstances, there can be a great distance from what you say you will do and what you actually do. I’ve found this to be the case with offering transportation assistance to our patients. Your institution knows it’s the right thing to do, and it makes sense to do it, but intentions may get lost in the time and distance it takes to get it accomplished. Below are three steps to help you cross the finish line:

1. Understand the problem and who it affects. Offer the transportation solution that is right for your patient population. To do this, you must first assess how transportation barriers are affecting your communities and patients. At Cone Health Cancer Center, we used our data and analytics to understand which patients were missing their appointments and who was most likely to cancel or delay treatment. These data allowed us to understand where and when we needed to offer assistance. Additionally, we developed a profile of the community resources we could leverage to help us identify where—and how—our institution can fill existing gaps.
2. Articulate the value and what is at risk if you do nothing. Once you understand the problem, you can better articulate potential solutions. For our institution, we leveraged our organizational commitment to health equity and discussed our treatment disparities. Being a rural delivery system, public transit was not a feasible option for our patients, so we decided to offer rideshare and non-emergency medical transport. We identified the relevant safe harbor protections, calculated the dollar value associated with missed appointments, and calculated the revenue generated from treatment compliance and adherence.
3. Continuously improve. Monitoring outcomes is imperative to ensure your solution(s) is moving the needle. If something is not working, go back and start again. Keeping patients in the forefront means that no effort is in vain. We pivoted several times when developing our transportation program, from working with vendors to provide transit to bringing those services in house and providing transportation ourselves.

Developing and implementing programs to identify and then address social determinants of health take time, resources, and planning. In the case of our free transportation program for patients with cancer, we have found our efforts to be rewarding and compliant.

Rachel Marquez, MPH, is the director for Transportation Services at Cone Health in Greensboro, N.C. Rachel has experience connecting clinical services and community assets so everyone has equitable access to health information, clinical services, behavioral supports, and healthy living conditions to optimize their opportunities for long and healthy lives.