Health Policy$ense

Giving Patients a Ride: a Tricky Legal Line

NEJM Perspective highlights challenges to innovation

What if health systems provided rides for elderly patients with limited transportation options or poor patients unable to access public transportation? We might applaud them for a creative strategy to improve access for vulnerable populations. However, their actions might be illegal.

We navigated these legal challenges as we designed a rideshare-based medical transportation service using Lyft to help Medicaid patients get to their primary care appointment.[1] Rides are only offered to patients who have established care at the primary care practices and we were required to limit eligibility to those within a reasonable distance to contain costs. Violating these boundaries would put the health system at risk for inducing patients to unfairly drive demand away from competitors.

Triggers for investigating fraud have a low threshold: increasing referrals doesn’t have to be the primary reason for providing the service or good — it just needs to be one possible reason or consequence.

In the New England Journal of Medicine, we explore the conflict between our efforts to provide services that may help vulnerable patients access health care and laws meant to prevent unfair competition and curb inducements due to greed. With an increasing number of health care innovations using social services or monetary incentives to shape patient behavior for the sake of better health (e.g., increased medication adherence or primary care attendance), these laws may stand in the way.

Under the Anti-Kickback Statute, no provider or institution receiving federal dollars can offer anything of financial value that may increase referrals for any of their patients, publicly or privately insured. Violators risk criminal penalties and substantial fines per kickback under the Civil Money Penalty Law. That law allows some incentives for care, a nominal value exception of no more than $15 per item or $75 per year per patient. Triggers for investigating fraud have a low threshold: increasing referrals doesn’t have to be the primary reason for providing the service or good — it just needs to be one possible reason or consequence.

In the context of payment reform and increased risk sharing, these laws present significant challenges for adapting health systems who are taking on greater risk through payment bundles and readmission penalties. Value has become the growing mantra as fee-for-service health care financing becomes less prominent. This week in the Journal of the American Medical Association, the National Academy of Medicine’s “Vital Directions” report calls for greater integration of social services with medical services because they, like many experts, believe these efforts can improve health outcomes, save money, and improve equity.

We believe hospitals inducing patient demand for appropriate, high-value care should be praised, not penalized. As health systems consider services traditionally seen as outside the scope of health care (e.g., transportation, housing, food parcels), and if those services achieve the outcomes patients and payers want, they shouldn’t worry about being accused of unfair business practices. We should judge inducements by the value they provide.

In our ongoing clinical trial, we have assigned nearly 700 patients to an intervention arm (who receive a Lyft ride to clinic) and control arm (usual care). Soon, we’ll know if our transportation service improved health care access by monitoring for increased clinic attendance and decreased emergency department utilization. However, before we scale our intervention, we all need to reconsider the value of inducements and what they can achieve.

 

[1] This clinical trial is funded by pilot funds from the Leonard Davis Institute of Health Economics.