ATHENS — Appalachian Ohio officials are concerned that a pending change to how the state runs Medicaid-funded transportation to non-emergency medical care appointments will hurt people in their poor, rural counties who lack easy access to doctors and public transit.

The state currently gives county Job and Family Services agencies the funding to provide people on Medicaid, the state and federally funded health insurance program for the poor, with transportation to doctor visits, dialysis, mental-health counseling and other non-emergency medical care. Medicaid managed-care organizations also receive funding for transportation services.

The current state budget, however, authorizes replacing the county-based system with a statewide, third-party "transportation broker" to manage non-emergency medical transportation services. The Ohio Department of Medicaid would pay the broker a fixed monthly payment per person, regardless of how much or how little the person used the services, to cover the cost of administering transportation services. The approach is similar to how Ohio Medicaid pays for most medical services now through managed-care organizations.

States are federally required to provide Medicaid recipients with non-emergency medical transportation services. Most states use third-party brokers to coordinate it, paying them a set amount per person, said MaryBeth Musumeci, an associate director at the Kaiser Family Foundation's Program on Medicaid and the Uninsured.

Whether run by a statewide broker or at the county level, Musumeci said, providing Medicaid-insured people with non-emergency transportation is generally cost-effective for states because it helps avoid more expensive treatment later if people require an emergency room visit or hospitalization. Paying a fixed amount per person also provides states with cost predictability, she said.

The Ohio Department of Medicaid hasn't hired a company yet. The department issued a request for information in October, a precursor to seeking requests for proposals, asking potential vendors about their capacity to serve Ohio's approximately 3 million Medicaid recipients. Officials also are seeking community input.

Unique challenges

State Rep. Jay Edwards, a Nelsonville Republican, said Athens County and other counties in the region do a good job getting Medicaid-insured people back and forth to non-emergency medical care, and questions whether one state broker could do it better.

"We think people here know the area better and can devise a plan specifically for what the people here need," Edwards said.

Nelsonville resident Elizabeth Nelson said she relies on transportation arranged by Athens County Job and Family Services to take her to medical appointments in Athens, Logan and Lancaster. Nelson, 62, who has had surgery and radiation for breast cancer and also is being treated for a form of pneumonia, doesn't drive. Her husband, Tim, 65, can no longer drive because he has been disabled by a stroke.

"It's really a help," Nelson said. "I do use it. I hope they keep it."

The change is needed because the current system works inconsistently in delivering transportation services from county to county, and has limited accountability for what is provided and how the money is spent, Ohio Medicaid spokeswoman Melissa Ayers said.

"The goal is to provide consistent transportation services for all Ohioans covered by Medicaid and more efficiently arrange for their transportation needs," Ayers said.

Details on potential savings to the state are not known yet, she said.

Rural, southeastern and southern Ohio counties have unique challenges, said Jack Frech, who advises the Appalachian Ohio advocacy group Mayors' Partnership for Progress, a consortium of mayors from 13 counties in the region.

"We have a higher percentage of poor people; poor people are less likely to have their own transportation and people have to travel farther to get medical services," he said.

In comparison, Frech said, metropolitan counties have medical professionals located closer to where people live, and people also have more access to public transit. This is why the average non-emergency transportation cost per Medicaid patient generally is lower in metro areas than in the rural, Appalachian counties.

Frech is concerned that a statewide broker paid a set amount per person to run transportation services could wind up making money in the urban counties and losing money in Appalachian Ohio areas. He fears that could lead to reductions in the transportation services available in his region.

Unanswered questions

Some states like Ohio that have concentrated urban areas and sparsely populated rural regions, including Colorado, Michigan and Texas, use a system that pays the transportation broker a "capitated" or fixed amount per person for rides in densely populated areas and on a fee-for-service basis for rides in rural areas, says a report by the National Conference of State Legislatures.

Reports by the U.S. Government Accountability Office and the older-adult advocacy organization Justice in Aging have cited the general, inherent challenges to running non-emergency medical transportation in rural areas of the country.

More generally, advocates for the poor are concerned that paying transportation brokers fixed amounts could lead the brokers to reduce services, said Georgia Burke, an attorney with Justice in Aging.

"By definition, capitated means you get to keep more money the less you spend providing services," she said.

Uncertainty about Ohio's proposed system is prompting questions.

Jody Walker, director of South Central Job and Family Services, which includes Hocking, Ross and Vinton counties, said it's unclear, for example, whether people have to call two days ahead or two weeks ahead to arrange rides to the doctor's office or if there will be enough transportation service to accommodate the demand.

Among a total combined population of about 120,000 in Hocking, Ross and Vinton counties, about 40,000 people have Medicaid insurance, including about 10,000 added under Ohio's Medicaid expansion, Walker said.

His agency has contracts with 15 transit services, including Chillicothe Transit System and private companies, to provide non-emergency transportation.

Athens County Job and Family Services uses the Corporation for Ohio Appalachian Development, a nonprofit agency that uses senior citizen volunteers to drive Medicaid patients to appointments, locally operated cab company Green Cab and others to provide transportation, agency Director Scott Zielinski said.

"In our part of the state, where transportation is such a barrier for low-income people, it is imperative that systems to address the issue are created with as much local input and decision-making capability as possible," Zielinski said. "We do not believe that a statewide, or even regional, system will be able to individually address all of the unique challenges our part of the state faces."

Ohio Medicaid currently spends approximately $71 million from the total approximately $27 billion budget annually on non-emergency medical transportation, Ayers said.

Ohio Medicaid officials will continue to seek community input in developing the new system, she said. When the new system will start has not been established.

Mary Beth Lane is a reporter with the Columbus Dispatch.