So Near and Yet So Far

Patients with health insurance often don’t think about how they’re going to get to the hospital or a doctor’s appointment, simply feeling secure in the promise of medical care when needed.

After all, if there’s an emergency, they can call 911 and their insurance generally will cover all or most of the ambulance trip.

But they can get stuck--physically and financially--going home from the emergency room or obtaining medical transportation for routine care should they become unable to drive or even sit comfortably in a car. For those who need wheelchairs or gurneys, the difficulties are compounded.

Without a ride, patients who can’t come up with the money to pay their own way can miss important health appointments or suffer needlessly while awaiting medical attention.

Nonemergency medical transportation is only rarely covered by insurance, and many times family members can’t take time off work to help out. Disability or illness often makes it impossible for patients to maneuver to a curb and climb into a bus or van, and taxi rides can be enormously expensive.

Local health advocacy groups are increasingly being asked to help solve transportation troubles, and long-term care facilities and nursing homes also are reporting difficulty guaranteeing residents a ride to the doctor.

As health plans impose tighter cost controls and the population of elderly and disabled patients swells, the lack of medical transportation is expected to worsen.

To date, however, the powerful American Assn. of Retired Persons, a senior lobby, hasn’t yet put the issue on its agenda, a spokesman said, although it expects to do so sometime in the future. Nor has the trade group representing California hospitals assessed the extent of the transportation problem, said Jim Lott, spokesman for the Healthcare Assn. of Southern California.

Instead, response has been scattershot, with individual families, hospitals and clinics--especially those that serve a disproportionate number of seniors--addressing transportation on their own.

Premy Mahandru, 67, of Chatsworth is among those patients cobbling together a system of transportation. For the most part, he depends on his two sons, friends and others to get to his medical appointments.

Mahandru, whose vision is poor because of cataracts, has had open-heart surgery and suffers from kidney disease and diabetes.

“He literally has to go to four appointments each week,” said son Butch Mahandru, 41, of Agoura. “In turn, I and my brother take him. We kill ourselves doing it.”

Although Medi-Van, an Anaheim-based van service, was taking Mahandru to multiple weekly blood treatments for kidney failure, the Medi-Cal authorizations ran out, his son said.

“We’ve never had to cancel an appointment because he’s very particular about his health,” Butch Mahandru said. But the son added that to drive his father, he must close his travel agency office for several hours.

Aftermath of an Emergency

Emergency ambulance trips are usually covered by health plans under the “prudent layperson” standard adopted by Medi-Cal and Medicare: If a layperson perceives a medical crisis, such as chest pain or a severe asthma attack, he or she should call 911 immediately.

But ambulance runs are expensive--in California, the average cost of staff in an ambulance outfitted with life-saving equipment is $380--and many health plans advise members to limit 911 calls to life-threatening crises.

Some health plans, including Medi-Cal, won’t pay to send patients home by ambulance if they’re reasonably stable, able to walk and could travel by other means. However, because many hospitals still follow a practice of sending patients who arrived by ambulance home the way they came, patients can be stuck paying out-of-pocket.

Many hospitals try to coordinate other transportation through social workers or patient representatives.

“We’ll try to get them to call somebody, but the family sometimes just doesn’t want to pick them up, or they can’t, or they’re working. It’s not a trivial problem,” said Dr. Brian Johnston, medical director of the emergency department at White Memorial Medical Center in East Los Angeles.

He noted that when patients ready for discharge can’t get a ride home, emergency room care gets stalled: “We can’t move them out and can’t move patients in who need to come in,” he said.

A few health plans have begun including patient transportation as a benefit.

Blue Shield of California, through its HMO program for Medicare recipients, offers transportation in Los Angeles, Orange, San Diego, Riverside and Santa Barbara counties, said Donovan Ayers, the plan’s director of Medicare compliance. He said studies indicate that seniors average about eight medical visits a year.

“We provide 12 one-way trips at a $2.50 co-pay,” he said. “In addition, we have an information referral service that’s part of our core benefit.”

Senior Care Action Network, or SCAN, a Long Beach-based Medicare HMO plan that provides services to help patients avoid nursing homes as long as possible, offers patients round-trip, door-to-door transportation to health appointments for $8.50.

But these plans are exceptions.

“Normal transportation is not covered; medically necessary transportation is,” said Kaiser Permanente spokesman Jim Anderson. He said Kaiser covers ambulance transportation in an emergency or when it’s authorized by a doctor and entails airway monitoring, cardiac monitoring, IV lines or other medical attention during the ride. Kaiser doctors may also request nonemergency ambulance service to transport a patient.

And the transportation shortage is often worse for patients enrolled in Medi-Cal. Door-to-door wheelchair or van services contend Medi-Cal doesn’t pay them enough to make it worth their while to carry patients and wade through the paperwork required to get the trips authorized.

Secure Horizons, a Medicare HMO run by Pacificare, doesn’t generally cover nonemergency transportation but is helping plan participants locate rides through a community resource guide.

Given the few plans that provide rides, local communities try to offer what they can.

Many Southern California communities offer dial-a-ride or curb-to-curb transportation services for seniors, the disabled, and others who need help getting to medical appointments (many also take them to nonmedical appointments as well) either free or for a small fee, but these may not always be convenient for patients with special needs, said Eileen Harper, acting executive director of the Center for Health Care Rights in Los Angeles. Some require transfers or long waits. Others won’t cross city boundaries.

Doing Whatever It Takes

Health care facilities are increasingly improvising to make sure their patients get where they have to go.

Parkview Community Hospital Medical Center in Riverside, an area with a large number of retirees, operates its own transportation service. And UCLA Medical Center provides a van to bring its community clinic patients to and from the main medical center in Los Angeles for tests, chemotherapy or other special treatments, said patient service representative Lisa Peltekian.

At Windsor Manor Retirement Community in Glendale, executives say they’re lucky: They operate two buses and a van at a charge of $1.50 per round trip and can’t imagine how other facilities operate without such vehicles.

Many HMOs require their patients to come in for care, rather than be treated by medical staff at the facility, said Mark Herrera, Windsor Manor’s executive director.

“We had to figure out a way to get them there.”

Flagship Healthcare, a 157-bed nursing home in Newport Beach, is a typical facility with many Medi-Cal patients needing frequent rides to medical appointments. It’s especially tough for their staffs to arrange those rides on short notice because of the extensive paperwork involved in getting a Medi-Cal authorization, said executive director Peter Steamblock.

“It’s very rare we can get a service out there to transfer a Medi-Cal patient on demand,” he said. “We just revert back to the family and say you have to take responsibility getting this patient to a doctor appointment. Many times they’re just not available to do that. So the patient’s treatment either gets delayed or put off indefinitely.”

Steamblock and other residential facility administrators say some transportation services limit their Medi-Cal trips, in part because of low reimbursement rates and the paperwork burden.

But that could ease a bit. Gov. Gray Davis in May proposed a 20% Medi-Cal increase for nonemergency medical transportation. Medi-Cal currently pays $117.16 for a nonemergency ambulance trip, plus mileage, and a base rate of $14.71 for a nonemergency van trip for a single patient, according to the California Department of Health Services.

“We’re concerned. We do think we have an access problem now. That’s why we put such a large increase in,” said Stan Rosenstein, the department’s assistant deputy director of medical services.

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Resources for Catching a Ride

The Los Angeles County Area Agency on Aging can advise seniors on transportation services available in their areas. (800) 510-2020 and (213) 738-4004

* The city of Los Angeles’ Department of Aging can provide applications and referrals to the City Ride program. Disabled city residents may request information on the county’s Access Services program. City residents over 60 can request referrals to a senior center in their area where they can obtain services. (213) 368-4030

* Two local organizations within the statewide Health Consumer Alliance can help hook up seniors with transportation services. The Health Consumer Center of Los Angeles, part of San Fernando Valley Legal Services, can be reached at (800) 896-3203. Its counselors can also help with referrals in neighboring counties. The Orange County Health Consumer Action Center can be reached at (800) 834-5001 or (714) 571-5200.

* Secure Horizons, a Medicare HMO, has a community resource guide available to members at (800) 228-2144. The information is available to anyone through the plan’s Web site, https://www.securehorizons.com.

* For seniors and disabled residents who are having problems getting ambulance services paid for, the Center for Health Care Rights in Los Angeles can provide assistance and counseling. The telephone number is (800) 824-0780.