Is Transportation Healthcare?

Welcome to Transit Unplugged. I'm Paul Comfort. Each week we talk with the leaders, the innovators, and the change-makers shaping the future of public transportation, hearing their stories, learning from their experiences, and sharing ideas that can move our industry forward. We're shifting over to video podcasting.

We're excited to have with us today as our guest, Steven Feist. He is vice president and chief operating officer of Coordinated Transportation, Solutions in Connecticut, but they serve a big swath of area on the East Coast. And, uh, we're gonna talk about something we haven't spent a lot of time talking about on this show, and that's a whole other mode of public transportation called non-emergency medical transportation or NEMT. Uh, NEMT is, uh, something I've been involved in earlier in my career, running it locally.

It is getting people who are on Medicaid to the doctors and medical appointments. As Steven points out in the beginning of the conversation, you know, what good is it to have medical insurance if you can't get to the doctor? So we unpack how all that works, how they integrate with the local transit systems like they do in Philadelphia and SEPTA and buy, uh, 2,000 passes a month from them, I think he said. So this is a great conversation on video as we unpack NEMT.

Enjoy this conversation with Steven Feist So I'm with Steven Feist. vice president and COO of Coordinated Transportation Solutions, and you're up in Connecticut, right, Steven? That's correct Yeah, thanks for being on the show, man. This is a great, uh, opportunity for us to talk about something here on Transit Unplugged that we really haven't focused on a lot.

It's a big component of the overall, uh, cornucopia of services that are provided in public transportation, and it's non-emergency medical transportation, or NEMT. It's something that, you know, I've done in the past as a provider, but you've been doing it a long time, haven't you? Yeah, I have, uh, you know, over 20 years, uh, and worked very closely with transits in, in Colorado, Texas, Oklahoma, and other places to, uh, really put together a program that served the public well So why don't we start by unpacking what is NEMT?

For people who maybe aren't familiar with it, we have a lot of listeners around the world, as well as just work in transit agencies. Tell us what all that is and how it works. You know nonemergent medical transportation goes way back when, uh, Medicaid, uh, was told that they had to eliminate barriers, uh, to healthcare, right? Because Medicaid's basically an insurance, but if you can't get to see the doctor for preventive care and other things, um, how good is the insurance really?

Uh, so they told the states they had to remove barriers, and the biggest barrier at that time was, uh, transportation. So NEMT was born, uh, was managed mostly by the counties at the county level for a long time. Uh, then at, at some point, the brokers came in and said, "Look, you know, we think we could help manage this better. We can run the call center.

We can send the trips out to the most appropriate providers, whether it be a mass transit system, whether it be gas reimbursement, uh, livery, uh, wheelchair ambulance." And NEMT in the broker realm was, was born at that point in time. Um, and it has evolved from that time to where it is today, uh, which is that it used to require a very large waiver be filled out, sent to the CMS, and it was very difficult for a state to really get on board. Uh, CMS saw how well it worked, not only in cost savings, but the number of trips that people got taken to their appointments, and it did provide better health outcomes.

So, uh, they lowered the requirement for states to get in. Uh, then MCO started taking over state Medicaid, Medicare business, and they saw the importance of transportation and got on board with the NEMT model, and they worked with brokers to make sure that they could get people to their appointments. and really, the, the broker's job is to answer that call, schedule that appointment, and then make sure that the appropriate transportation is available and gets people picked up where they need to be picked up, dropped off where they need to be dropped off at, and then taken back home after their appointment.

they really create that link between being at home and being with your healthcare provider. Yeah. That's great, man. And, uh, so how does it work as a broker?

Do you, are you like, do you have your own vehicles or do you contract that out to people or how does that work? So each broker works a little bit differently. There are some brokers who do own some of their own vehicles, usually in states where transportation is very, very difficult to provide. However, back when CMS decided to put this model together, they said, "It's better to not have the fox watching the henhouse."

So we would like the brokers to manage the call center, manage the payment system, make sure all the providers get the trips that they need, but we don't want them to really operate their own vehicles, right? It would give them an unfair advantage, and maybe a provider would only get the worst trips and be hard for them to survive. So, uh, CMS really made it to where the broker really was the logistics arm of the transportation side of things. and they've kept it that way, uh, over the years, uh, and it seems to have really worked for the best Yeah.

That's interesting. So tell me about, uh, the company you work with, Coordinated Transportation Solutions or CTS. explain maybe the scope of what you do and where you do it, those kind of things. So CTS is a not-for-profit going on twenty-five years in the Connecticut area, and we have several contracts.

Uh, we provide, uh, Medicaid transportation in New Hampshire, some Medicaid transportation in the Philadelphia area, partner with SEPTA out there. we provide a lot of dual-eligible transportation for those Medicaid/Medicare, uh, members who are, you know, the neediest of the needy a lot of times in the Massachusetts area. Uh, but we also have specialty transportation where we take care of, school kids who can't ride the normal bus, because of different maladies that they might have.

And we also have quite a few veterans programs, and we also work a little bit with workers' comp to get people to those workers' comp appointments, get them to their SSI appointments. but everything that we do is focused on healthy communities through transportation, whether it be Medicaid, Medicare, the veteran, or a, a schoolchild that needs to get to their, their school, on a regular basis Now, when I was doing, uh, NEMT transportation, here in Queen Anne's County, Maryland, I remember we had to call, and this was, this was more than 20 years ago, but only people that actually received Medicaid, obviously, could take the transportation service, and we had to call every morning to validate with their ID number, uh, to validate that they were providers.

Do you remember doing that? I, I do. In Colorado, we, we had that system. And I will tell you, I, I'll walk you through a little history of, of what I've seen over the years, if you don't mind.

Yeah. I started in Colorado, and we had a system where we had to call and punch in the, the number, and the phone would say they're eligible, and we would book the trip. about a year after I started there, the system was put in place where every night it would download a list of all the trips we had and all the member numbers, and it would validate the trips overnight. And that was the first automation that I saw.

Then as we moved forward, uh, we started getting eligibility files in advance. Uh, we would get them monthly. and then we were just kind of at risk for if anybody fell off the rolls during the month. Oh, yeah.

Then they evolved to where we got a monthly file, and then we got daily updates, And that's perfect because we could know somebody wasn't eligible for three days from now. They could maybe call and get their eligibility updated so that they didn't miss the trip, or if they truly weren't eligible, the government didn't pay for a trip that wasn't eligible. I will tell you a, a story. Uh, Oklahoma, managing transportation, and we had just gotten to the point where we were faxing manifests out to all of our providers.

And then a year after I get there, we get to the point where people can go online and download their manifests, and that was fabulous for providers. Saved them a lot of time. But we still had a gentleman that we were calling every night. He lived out in the country.

He ran a couple of vehicles, uh, essential to getting these people from the country into their medical appointments, and we were still calling him every night. And we had to actually send somebody out, teach him how to hook up a fax machine, and receive fax manifests. Fast-forward to today, people have a, an app on their tablet or their phone, and we send the manifests out. the provider who runs five or six vehicles, he gets a master manifest.

He looks at it on his desktop, and each driver gets their manifest on their phone in the morning. Uh, just… Oh, wow. Right? So, you know, over 20… Like an Uber driver.

Yeah, o- over 20 years, we've gone to calling people and them writing down their trips to, uh, them just picking up their smartphone and seeing their trip in the morning and organizing their schedule over a cup of coffee. It's, it's been great to see, uh, things move forward like this. It seems kinda parallel to ADA paratransit, which I've run a lot of in my career, including in Washington, DC, where people book a trip, uh, it's individualized. Sometimes there might be more than one person on the vehicle, but usually 80 to 90% of the time, at least for ADA a lot of times.

Tell us how all that is. So, so you're absolutely right. And ADA paratransit is an essential part of, of NEMT, right? And, And, over the years, I always partnered very well with my transit agencies, whether they were the, uh, fifty-three eleven, fifty-three ten, uh, transits who got different federal and state money.

Uh, they're running the ADA paratransit and the complementary, uh, transit for the bus systems. And we were able to work closely with them to get their riders to them, and then pay them with the Medicaid funding so that they would have some additional matching money. Now, why does this make sense? Well, it makes sense that someone already using ADA paratransit also get that transportation to their medical provider because they're comfortable with that transportation.

They know that vendor, and that means they're gonna be more comfortable going to their medical appointment with that same transportation. Secondly, I was on the United We Ride board in Denver and in Oklahoma, which was an initiative to try and weave together the different transportation funding sources so that we would get more bang for our buck. So if, you know, if I use a paratransit where they're available and provide them with some funding that they can then match with federal funding to strengthen their system, it strengthens our community overall.

And then my private providers can manage the trips that are most appropriate for them. They get the, the trips that make them most successful, and as a transportation organization, w-we're all successful together. So tell me how that works in Philadelphia, where you mentioned you do some work with, uh, SEPTA there? So we have, uh, folks in, in Philadelphia who, uh, use the bus, and they require, uh, bus passes.

The actual down and dirty part of it, I'm not that familiar with, 'cause I've got staff that does that. But it's become much more electronic, instead of people having to show up and pick up the passes. we book the trips, we put them in our system, we send the information, uh, out, and then, uh, a lot of the riders are using the app on their phone, is my understanding. that way, uh, you know, about two thousand passes, a little, little shy of two thousand passes a month, uh, for two thousand different people, uh, we're able to fund, uh, through the Medicaid transportation program and the insurance, uh, vendor that we partner with out there, the passes for the members.

And SEPTA is able to then, probably lighten their administrative burden a little bit, focus on the folks that walk through the door to get a pass or that go online to order a pass. Uh, and again, um, it allows us to free up other resources for people who are maybe a little sicker, or a little older, that can't use the mass transit system. and again, just a, a great partnership, and, uh, I think the partnership has gotten better over the years. When I first came into the industry, um, there was this love-hate relationship with ADA and paratransit, which I didn't come into the industry with.

I came from an ambulance background where I got to see every day people go to the hospital in an ambulance who could have avoided it if they had transportation to healthcare weeks prior to me showing up at their door. So my goal was to make sure people got to their appointments. I was able to build some great relationships, uh, with OTA out in Oklahoma, uh, Texas Transit Association. Uh, pretty much everywhere I went, I, I - first thing I did was try to build that relationship and, and create an environment where we could use all of our resources for the best benefit Yeah, that's great coordination, Steven.

I think especially with fixed route transit, I imagine that lowers the cost, the overall cost of providing service, obviously, because you're probably paying the normal fare rate versus 20 bucks or 30 bucks if they're riding with someone else, It's… so it all depends. There are, um, on the complementary routes, sometimes we normally would maybe pay, uh, the fully allocated rate. On fixed routes, if people were just taking, uh, the fixed route bus, uh, we might buy them coupons at the coupon rate or, or a monthly pass.

but it does have a, a big benefit, you know, that the Medicaid dollars are a small slice of the pie for transportation But the government and the taxpayers wanna see that small slice of the pie used efficiently every year. So they're always looking for the broker or the county, if the county is still doing that transportation, to manage that money as best possible and find ways to decrease the cost. Yeah We can't decrease the cost on the backs of delivery drivers. We can't decrease the cost on the back of ADA, right?

Having ADA vehicles replaced on an annual basis or semi-annual basis, inspections, training, paying drivers appropriately, uh, to handle those fragile patients, that cost doesn't go down year over year just because technology gets a little bit better. So we have to manage the cost through the technology that we have to get the, the right transportation to the right person, sometimes that means gas reimbursement. sometimes it means a, a bus ticket, and somebody can stand on the corner, catch their, their, uh, bus, a-and go to their quarterly, uh, diabetic blood draw, uh, for a buck and a half instead of twenty-five dollars.

and the savings can go back into the program and make sure that we take care of a greater number of people That's great. And we'll be back right after this quick word. Thanks for listening to the Transit Unplugged Podcast. We are so glad you're here.

If you're enjoying this show, we know you'll love our other transit industry programs. On Transit Unplugged TV, Paul Comfort explores the food, culture, and transit systems around the globe. You get to see everything. You'll love this show.

And every week we also offer up the Transit Unplugged News Minute, where you can get the latest industry headlines in less than 60 seconds. You can find out more at transitunplugged.com. Now back to Paul Comfort for this edition of the award-winning Transit Unplugged Podcast and we're back with Steven Feist.

He is the vice president and COO of Coordinated Transportation Solutions in Connecticut, but also all over the East Coast. And we were just talking about, Steven, how, uh, you interact with so many agencies. Uh, you interact, like, with the public transit agencies. You've got providers.

You've got, um, other programs you're working with. The technology behind the scenes must be, pretty robust, huh? it it is absolutely, and it, and it's changed, and it's evolved, uh, over the years incredibly. Uh, you know, when I mentioned when we first started, uh, we were faxing manifests out.

We were doing these things. And the best that we could do at that time, uh, and we, we had an in-house software. Some people used, uh, outside software. We use Momentm, uh, right now.

the best we could do back then was to maybe group the trips together by zip codes, send them out to our providers. Our providers would sit up at night and map these things. Uh, then eventually they started mapping them in Google Maps, and, and the providers were spending hours at night doing that. And so as things move forward, fast-forward, w-we now are able to create polygons in the software.

You'll look at specific areas. The software, you can connect out with APIs to Google Maps or Bing Maps or other things and actually go, "Okay, this is how long the trip is, and this is how long it's gonna take you to get there." It's, you know, the same thing that when I, uh, jump in my car and I wanna go to the coffee shop and it says it's gonna take me five minutes. Some of those things are now built into the softwares that we use.

and, and you know, the software is definitely evolving, but it has to do more than just math. It has to manage the eligibility file to make sure that we're giving the right trip to the right person, and make sure that if they have value-added trips, right, which would take them maybe to go to Silver Sneakers or to go to a nutritional appointment or to go to a health food store. Those trips come out of a different bucket than the healthcare trips, and the software has to manage all of that behind the scenes so that we get the right money from the right part of the, the, the program, right?

So, call taking, uh, right, we, we have virtual agents now that help to take care of some of the simplest, uh Trips and, and calls and, and things that we do. uh, somebody might be calling in, uh, to ask who they're riding with tomorrow. Well, they wanna know that they're gonna be with Paul's Transportation. We can either have a person look that up, or now we could have a virtual agent look that up, or a member can look on their phone and look that up, or a facility can look at a web portal and look that up.

You know, and again, currently we, we work with a vendor, Momentm, and they build those things for us that all connect into their software so that we are one single connected universe of transportation, management, right? it's come a, a long, long ways and, uh, and it's still moving forward, and we find ways to move it forward, all the time. And that works through, members letting us know what their pain points are, transportation providers letting us know what their pain points are, facilities, MCOs.

Um, and then we let our vendor, uh, or vendors, you know, we have several vendors. We have a phone system vendor, we have, uh, you know, our application vendor, we've got our, our AI vendor. We let them all know what the pain points are, what we believe is the s- the fix to the pain points, right? I sit in a position where I've done this for twenty years, and I have a lot of contacts, so I have a lot of contacts and a lot of context for here's what the solution might be.

So yeah, let's talk about that a little bit. Uh, s- uh, what I've seen in the past is there's been, like, sometimes there's local brokers, like at the county level working with the health department, but other times there's big statewide contracts where, like, a whole state may say, "Hey, we're gonna contract out and have one broker," and then they'll have a bunch of providers. Uh, you know, give me some of the background on that. So, so I've worked in, in both of those systems, right?

I managed, uh, out of Texas for a while. Texas is a pretty big state. Um, and there were at one point, I think five brokers that managed the different parts of the state. Um, and there were areas where we overlapped, and we had to work together to, to make sure trips got, got run.

you know, Louisiana has quite a few MCOs. They each choose their own broker. Um, and it was, uh, a little disconnected and difficult to run for a while. they went and decided to go with one broker.

All of their MCOs use the same broker now, and the system runs much more smoothly. Other states have multiple brokers, but the geography is broken up in such a way that, you know, there's a mountain range or there's something going on that the cities and the populace don't really intermingle, so it's a little easier to have two separate brokers. used to be all done at the county level. but most, most of the time now it, it's gone to a regional level, a local level, state level, or done by the MCO.

I think what I've seen is by grouping the population together as one whole population versus a lot of small populations, been able to get, some benefits from that, right? Like economies of scale. Economies of scale. Understanding the, different, uh, needs of, of the different members, an ability to make one change that has a positive impact across all of the counties, uh, for instance.

Now, with that said, sometimes a rural population has a need that's very, very different, than an urban population. so sometimes one size doesn't fit all. You know, sometimes your health agencies, they wanna hear from the people and they'll do surveys and, and they get good, good input from that as well. And all those things combined, I think is what has improved the, the system That's great.

Let's take a quick look at the future as you wrap up, Steven. where do, uh, like autonomous vehicles fit in this? You know, fully digital unlocking for fraud control and performance AI. What do you see coming in the next five years for NEMT from your perspective?

So I think, you know, we're in an age right now where GPS tracking is, is doing a lot and, and helping, manage people's fears about whether their vehicle will be there, if it's gonna be on time, and so forth. And a lot of that GPS tracking and that information will possibly drive some autonomous vehicle, usage. However, I think what we have to understand is those autonomous vehicles will be part of the whole toolkit, just like gas reimbursement, ADA paratransit. an autonomous vehicle does not have a driver that was trained in CPR and first aid If I'm putting my dad in a vehicle to go for his, his heart checkup with his cardiologist, I would like a person in the vehicle, right?

If my dad is going for a routine blood draw, an autonomous vehicle might be the way to go. So I think they will possibly be part of the system. Uh, the NEMT system was fairly slow to change for a long time, and a lot of that had to do with, uh, you're dealing with people, a lot of older people, a lot of people with different illnesses, and we had to evolve slowly to make sure people were comfortable because the idea is if they don't use it, it's no good. I think people will become comfortable with that, and we will see that a little bit.

I think the other thing that we're gonna see is telehealth, uh, peaked its head during the, the, pandemic. and then it's kind of subsided back a little bit. But I do think telehealth in the future is going to be, something that, changes NEMT. Do I think that all of a sudden we don't need NE-NEMT?

No. I just think that NEMT, is gonna be used more for the high acuity and chronic needs, and less for things that can be managed by telehealth. But with that said, the telehealth will create early warnings for more people who will possibly require transportation. So for every trip that it takes out of the NEMT, uh, sphere, I think it's gonna add one or two trips back in, uh, because the need for a physician, uh, a mental health professional, uh, to have hands-on, eyes-on a person will still be there.

Uh, we found that coming out of the pandemic, A lot of people, had telehealth, but they weren't as healthy as they were before they were just on telehealth. So I think, you know, we'll see that. I think we should see, and if we do see this, it's gonna be a great thing, uh, for NEMT. Uh, and, it-it - we should see it stop living in silos, right?

I have talked a lot about how I attempt to use ADA paratransit, uh, you know, fixed route buses, gas reimbursement to create an ecosystem of transportation for medical health needs. I would say that not everybody does that. Although it's become easier to do that, not everybody does that. And I think those silos are gonna continue to be broken down because those folks who do break down those silos are gonna create the environments that are successful in driving positive health outcomes.

that's what NEMT is about. It, it's not just taking someone to, to Sprouts to get food. They're going to Sprouts to get food because they, they need to manage their diabetes, they need to not have pesticides, whatever it is that they've got going on medically, that's why they get that s- quote unquote, social trip." it's to help create a, a healthy outcome.

That's good. Well, thank you, Steven, for a really fascinating conversation. Hopefully you've had, uh, if you've been listening today through this whole conversation, you've had a great kind of now understanding of how public transportation works. That's what stood out to me was, in this conversation, how that, um, NEMT plays an important critical role in providing transportation to people that have medical needs, but also coordinates greatly with public transportation.

And remember, until next time, listen, learn, and lead, because when we learn from each other, we build better transit together Thank you for listening to this episode of Transit Unplugged, the world's number one transit executive podcast. I'm Julie Gates, executive producer of the podcast. Many thanks to the team that makes this show happen: host and producer Paul Comfort, producer Chris O'Keefe, editor Patrick Emile, associate producer Cyndi Raskin. Transit Unplugged is being brought to you by Modaxo, passionate about moving the world's people.

If you would enjoy behind-the-scenes insights and updates from the show, sign up for our weekly newsletter, which has links to can't-miss conversations with the biggest names in mobility. Head to transitunplugged.com and scroll to the bottom of the page to sign up.