Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 3. Travel to Care Providers Is Often Difficult

01/01/2002

Losing one’s ability to travel independently not only inhibits access to care, but represents a major life change that can cause emotional distress. Independent travel, particularly driving, is an essential element in seniors’ autonomy. Also, a large fraction of seniors’ trips outside the home are related to medical care and other essential services. For example, Retchin (1998) found that among seniors 80 to 84 years old, approximately 17 percent of all trips outside the home are for medical reasons. Since frail elders are particularly likely to experience health problems if they miss medical treatments and appointments, the loss of driving ability can create serious problems, particularly for seniors who live where alternatives to personal vehicles are limited.

Physicians in our focus groups noted that it was often difficult to get seniors to stop driving. Not only was it hard to tell seniors the bad news that their impairments make driving unsafe, but there was the concern that a request to stop driving will limit the senior’s subsequent access to care. One physician discussed the quandary that loss of driving privileges can present for doctor appointments for his patients, and the influence on physician selection:

You see a lot of couples that seem to do pretty well while one or the other is driving, and then you get to that point where neither one really can safely drive, and suddenly they’ve become landlocked and it’s a huge problem. I don’t know that there are resources really that are very reasonable “cost-wise” to get most of their patients back and forth to their doctors’ appointments. They tend to choose providers based on geography more and more, and their ability to get back and forth is very tough.

Physicians and staff with the Area Agencies on Aging also reported that a lack of transportation deters some frail elders from seeking needed care. This issue was reported most frequently during our site visits to the two group model MCOs (Aspen and Kaiser Colorado), where primary care (and much specialty care) was delivered at a small number of clinics. In contrast, this issue arose seldom during our visits to the two IPA organizations (HMO Oregon and Keystone East), which delivered care through a dispersed network of physician offices. Overall, we got the sense that the clinic-based delivery approach of the group models may be a disadvantage for seniors whose driving abilities have become impaired. Kaiser Colorado has taken specific steps to address this issue by including a transportation benefit in its Medicare + Choice plan.

Transportation assistance tended to be available in cities and nearby suburbs for all four case study communities. However, the people we interviewed generally agreed that seniors who lived on the edges of the metropolitan areas had few, if any, options for obtaining transportation assistance.

Even those seniors who could obtain a ride service noted that they still have trouble obtaining care. These problems arise because of the frequent inflexibility of transportation schedules combined with delays in medical appointments. One senior found that physicians’ tight schedules, combined with time constraints due to scheduled transportation pickup times, could make it difficult to obtain care:

If you’re more than 15 minutes late, a lot of doctors will not see you, and you may not be able to get another doctor’s appointment for like . . . another four to five weeks.

In an extreme case, a senior reported returning home without seeing a physician, because her scheduled ride home came before her physician was available to see her.

Problems can also arise for those frail elders who need assistance getting from their homes to the vans, because many transportation services provide only curb-to-curb service. This means seniors must be able to get from their home to the curbside, something several seniors found difficult to do without assistance.

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