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{ timecode: 0, handler: 'blob', id: 1, data: {text: 'DAVE WHITE: Good morning ladies and gentlemen. Good morning. All right. Everybody made it here at 8:30; a little earlier start today. Thank you all for coming back and getting this second day started '}},
{ timecode: 19, handler: 'blob', id: 2, data: {text: 'with us. Today we\'ve got a full day, of course, ahead of us. I am Dave White. I am the President, Coordinated Transportation Solutions with headquarters right down the road in Connecticut. Listening'}},
{ timecode: 36, handler: 'blob', id: 3, data: {text: 'yesterday to that session on long distance transportation, I was thinking that some of those trips that were usually over a couple of hundred miles, I was thinking myself, you know, it took me less '}},
{ timecode: 50, handler: 'blob', id: 4, data: {text: 'than 2 hours to get from home to here on Saturday, and I was thinking about how long maybe some of those dialysis patients were going three days a week and were going longer to get to their dialysis '}},
{ timecode: 65, handler: 'blob', id: 5, data: {text: 'three days a week than it took me just to get here to Providence. When you think about it those terms it’s pretty daunting for those folks. It kind of puts things into perspective as to why we '}},
{ timecode: 79, handler: 'blob', id: 6, data: {text: 'are here. So, yesterday was a great day, I thought. We got a lot accomplished and we have a lot to do today and we are going to start off with a great panel and then I am going to talk about in just a '}},
{ timecode: 93, handler: 'blob', id: 7, data: {text: 'second, but before that we obviously have some housekeeping items to go over. Once again, very basic, restrooms are out to the left. We are going to have a break at 10:00 o’clock after our first '}},
{ timecode: 116, handler: 'blob', id: 8, data: {text: 'session for everyone. I want to remind everyone here that at 12:00 o’clock is the conference luncheon for everyone, not only this group, but for all of the sessions going on today and CTAA is '}},
{ timecode: 135, handler: 'blob', id: 9, data: {text: 'very pleased that the new FTA Administrator Peter Rogoff will be with us. He is newly approved by the Senate just last week, I believe, so this will be his first public appearance since being approved '}},
{ timecode: 159, handler: 'blob', id: 10, data: {text: 'by the Senate will be here at CTAA, so hopefully all of you will join us at the conference luncheon to listen to Peter and his remarks. I was a little bit remiss yesterday and did not recognize the '}},
{ timecode: 179, handler: 'blob', id: 11, data: {text: 'sponsors of the Wellness Conference and, of course, that is the American Cancer Society, The Children’s Health Fund, and the National Center on Senior Transportation, who have helped make this '}},
{ timecode: 193, handler: 'blob', id: 12, data: {text: 'conference possible and without their assistance it couldn’t have been possible. So I wonder if everybody would just give those three very important organizations a hand. (Clapping). I have also '}},
{ timecode: 210, handler: 'blob', id: 13, data: {text: 'been asked to point out these two flip charts on either side of the room here. We would like, during the day, if you would consider thinking about how you would like us to work together after the '}},
{ timecode: 231, handler: 'blob', id: 14, data: {text: 'conference is over – over the weeks and months ahead. How we are going to communicate with one another so that the work of the conference goes on and one thought would be a Google group, but '}},
{ timecode: 245, handler: 'blob', id: 15, data: {text: 'there may be some other ways that you would like to stay together through CTAA and Valerie’s office. How are we going to communicate your work with each other? If you have some ideas just jot '}},
{ timecode: 264, handler: 'blob', id: 16, data: {text: 'them down on the flip charts and Valerie and the rest of the CTAA staff will take those ideas and we’ll see if we can’t start some collaboration going forward, so that will be great. I '}},
{ timecode: 282, handler: 'blob', id: 17, data: {text: 'think I got about everything. Okay, before I introduce the panel I am going to do one more survey, I was famous for my survey yesterday. Maybe I went a little bit too long, but I am going to do one '}},
{ timecode: 300, handler: 'blob', id: 18, data: {text: 'more short survey this morning just to get an idea of our group. This is a regional survey, so how many people do we have here (you have to think about this a second) how many people do we have here '}},
{ timecode: 316, handler: 'blob', id: 19, data: {text: 'from New England that live north and east of Hartford? Okay, we have a few. How many people do we have that live in New York? Right, okay. Now, how many people here do we have that are Red Sox fans? '}},
{ timecode: 340, handler: 'blob', id: 20, data: {text: 'Okay. How many do we have that are Yankee fans? AUDIENCE MEMBER: Mets fan. DAVE WHITE: Mets fan okay well, that solves the problem for me because as we know that our panelist are made up of some New '}},
{ timecode: 360, handler: 'blob', id: 21, data: {text: 'Yorkers and I was a little worried that I might have to bring in some extra security since the Yankees are now in first place, but it is only, I have been reminded, It‘s only May. AUDIENCE '}},
{ timecode: 375, handler: 'blob', id: 22, data: {text: 'MEMBER: In other words a natural order has been restored. DAVE WHITE: Those are fighting words and I do live in Southern Connecticut, and so I think you might have an idea where my allegiances lie. '}},
{ timecode: 390, handler: 'blob', id: 23, data: {text: 'Yes, the natural order has been restored, at least for the time being but we will see. With that comment I would like to introduce our panel this morning. This is I think it’s a great panel to '}},
{ timecode: 405, handler: 'blob', id: 24, data: {text: 'start the day. It’s talking about kids and transporting kids. In my organization, actually, CTS, as we primarily work with managed care organizations we deal and have traditionally dealt with'}},
{ timecode: 429, handler: 'blob', id: 25, data: {text: 'transporting kids under Medicaid and special education transportation, so we are very, very used to this and the challenges of transporting children. So, I am very pleased to have this panel as part '}},
{ timecode: 447, handler: 'blob', id: 26, data: {text: 'of our conference and to have Dennis Johnson with us. I am going to let Dennis introduce the rest of this panel, but I have had the privilege of being in the audience when Dennis presented at another '}},
{ timecode: 463, handler: 'blob', id: 27, data: {text: 'CTAA convention and presented on his work at the Children’s Health Fund and what they have been doing, because, you know, kids, they present so many challenges. All of us are parents, I am sure, '}},
{ timecode: 482, handler: 'blob', id: 28, data: {text: 'or most of us, and you know on some days they make us incredibly proud in the morning and in the afternoon we are pulling our hair out. That’s the way it is with transporting kids. You know, '}},
{ timecode: 497, handler: 'blob', id: 29, data: {text: 'everything goes smoothly one minute and the next minute we have our hands full with them, so I am just going to leave it at that and just sort of turn it over to Dennis and his panel and thank them '}},
{ timecode: 512, handler: 'blob', id: 30, data: {text: 'very much for coming. DENNIS JOHNSON: Thanks, good morning everyone. I am still trying to figure out and glad to see that we were able to get Howard Dean’s twin brother to come and chair our '}},
{ timecode: 530, handler: 'blob', id: 31, data: {text: 'panel for us. Thanks very much for that kind introduction. I am looking out into the audience and see quite a few faces that I recognize and that tells me that I am finally kind of getting to where '}},
{ timecode: 542, handler: 'blob', id: 32, data: {text: 'I’d always hoped I would get in terms of blending the work that the Health Fund does which I will talk about in a moment and the work that you all do on the transportation side and increasingly '}},
{ timecode: 555, handler: 'blob', id: 33, data: {text: 'seeing ways that we’re working together effectively to help children and others do something that you’ve always done, help people get access to human services, but something that at least '}},
{ timecode: 568, handler: 'blob', id: 34, data: {text: 'the folks on my side of the equation on health side often don’t get. So it’s been kind of a crusade over the past decade for me personally, and member of my organization as we have tried '}},
{ timecode: 582, handler: 'blob', id: 35, data: {text: 'to successfully integrate transportation into the model care that we think is so important for kids to have access to. My name is Dennis Johnson and I have been with the Children’s Health Fund '}},
{ timecode: 596, handler: 'blob', id: 36, data: {text: 'for 17 years. I am a parent, I have three kids. I have been involved in healthcare for those 17 years helping and trying to figure out ways to make the model of healthcare delivery that we have out '}},
{ timecode: 613, handler: 'blob', id: 37, data: {text: 'there for kids more successful in serving kids, particularly medically underserved kids. So the way we see the presentation rolling out just as an overview, I am going to talk about the work of my '}},
{ timecode: 626, handler: 'blob', id: 38, data: {text: 'organization and how we get to be where we are today in terms of identifying transportation as a health access barrier. My colleague, Roy Grant, who is our Director of Research, will talk about the '}},
{ timecode: 638, handler: 'blob', id: 39, data: {text: 'work we have done on the research side to try and identify the extent of the problem. Some of the quantitative and qualitative research that the organization has been involved with over the past'}},
{ timecode: 651, handler: 'blob', id: 40, data: {text: 'decade. Steve Borders, who works with the fund as a consultant will drill down into some of the exciting stuff that we are doing currently to help identify transportation disadvantage as a key '}},
{ timecode: 665, handler: 'blob', id: 41, data: {text: 'determinant of healthcare access. We will try and do that with a minimum. Valerie has made it quite clear that she doesn’t want us to drill you into the ground with information and it’s a'}},
{ timecode: 677, handler: 'blob', id: 42, data: {text: 'more informal setting and we will try to keep to that though unfortunately are going to have to default to power point because we find it very difficult to get away from, but also because some of the '}},
{ timecode: 688, handler: 'blob', id: 43, data: {text: 'stuff is fairly detailed so we want to at least throw it up there so you can see it prior to the discussion phase of our presentation. So, to begin, the Health Fund is an organization that was started '}},
{ timecode: 699, handler: 'blob', id: 44, data: {text: 'in 1987 by Paul Simon the singer and my boss Dr. Irwin Redlener, a pediatrician who has spent his career trying to deal with health access issues for medically underserved children. Our organization '}},
{ timecode: 716, handler: 'blob', id: 45, data: {text: 'is committed to providing healthcare to the nation’s most medically underserved kids through the development of primary care programs, response to public health crisis such as hurricane Katrina, '}},
{ timecode: 726, handler: 'blob', id: 46, data: {text: 'and the promotion of guaranteed access to appropriate healthcare for all kids and that refers to the advocacy work that we use that we leverage throughout clinical work. Now, we have a network of '}},
{ timecode: 738, handler: 'blob', id: 47, data: {text: 'programs, 22 programs, soon to be 24 around the country. This is our map. So we have pretty good distribution of our programs. Most of these programs are mobile medical programs involving mobile units '}},
{ timecode: 752, handler: 'blob', id: 48, data: {text: 'that bring a medical home model of care to kids. This is a schematic of our mobile unit. There are a lot of mobile units on the road for all sorts of purposes and they are all worthy. For our program '}},
{ timecode: 767, handler: 'blob', id: 49, data: {text: 'we have what amounts to a doctor’s clinic on wheels and you can see that we have exam rooms, places for meds, we’ve got stuff to do education work, we have a registrar that uses our '}},
{ timecode: 783, handler: 'blob', id: 50, data: {text: 'electronic health record to enroll kids, etc. Essentially, this is everything you’d anticipate for your child if you went to a pediatrician’s office. So as I mentioned our program has 22 '}},
{ timecode: 795, handler: 'blob', id: 51, data: {text: 'projects. They are in urban and rural locations. They are based in the mobile setting but also in school based clinics and community based clinics. FQHCs and school base health centers. Since 1987 we '}},
{ timecode: 809, handler: 'blob', id: 52, data: {text: 'have had more than 1.7 million encounters. Now, the need. We we’re a wealthy country, but you all know, I am sure you read the news, we are in the throes of a healthcare debate about how we '}},
{ timecode: 825, handler: 'blob', id: 53, data: {text: 'reform this system so we make healthcare access a reality for all Americans. Our concerns are the 20 million kids who we think don’t have appropriate access to healthcare, and there are many '}},
{ timecode: 838, handler: 'blob', id: 54, data: {text: 'things that contribute to this. There are fiscal barriers, lacking insurance, but there are also communities where there are not enough doctors to provide healthcare to residents of so called health'}},
{ timecode: 849, handler: 'blob', id: 55, data: {text: 'professional shortage areas or HPSAs. We know that limited transportation is a barrier and prevents people from having appropriate access to care. Now we build our program model on the idea of a '}},
{ timecode: 865, handler: 'blob', id: 56, data: {text: 'medical home. A medical home model is something that, as parents, most of us would assume would be available for our kids, but for millions of kids, tens of millions, that isn’t the case. '}},
{ timecode: 877, handler: 'blob', id: 57, data: {text: 'Medical home model involves a model that is continuous access to care. It is comprehensive care for primary and specialty care. It is fully accessible. It’s family centered, it‘s '}},
{ timecode: 889, handler: 'blob', id: 58, data: {text: 'coordinated and it‘s compassionate and culturally effective. When you need that care you pick up the phone you call your doctor, there are certain things that you expect. You expect the system '}},
{ timecode: 900, handler: 'blob', id: 59, data: {text: 'to respond to you in a certain way and you wouldn’t accept anything less. If it didn’t you would intervene and you would force it to respond. Well, for millions of kids that isn’t '}},
{ timecode: 913, handler: 'blob', id: 60, data: {text: 'the case. They rely on the ER. They rely on episodic care, and for all sorts of reasons they don’t have access to that type of care and we think they deserve that access. Of course the medical '}},
{ timecode: 926, handler: 'blob', id: 61, data: {text: 'model is something that a lot of folks adhere to and that’s been promulgated. The idea was conceived by the American Academy of Pediatrics and a lot of folks have adopted it. But, what '}},
{ timecode: 938, handler: 'blob', id: 62, data: {text: 'we’ve found as things have gotten increasingly complicated with children and healthcare over the past few generations, that to really connect kids to the kind of care they need we have to look '}},
{ timecode: 948, handler: 'blob', id: 63, data: {text: 'at an even more advanced model of the medical home which we refer to as the enhanced medical home. And in order to have this level of care we think the following needs to be part of constellation of'}},
{ timecode: 960, handler: 'blob', id: 64, data: {text: 'services that are available. Mental health, oral health, we need to adopt electronic health record technology as we move forwards in terms of information technology. We need to look at tele-medicine '}},
{ timecode: 973, handler: 'blob', id: 65, data: {text: 'options in communities that are very rural or remote and we do need to have explicit focus on transportation services as part of the enhanced medical home. This is new to the discussion, both on '}},
{ timecode: 986, handler: 'blob', id: 66, data: {text: 'health side and I think less so on the transportation side because, as I have taken on this issue, as the organizations taken on this issue, over the years we have found that while transportation '}},
{ timecode: 997, handler: 'blob', id: 67, data: {text: 'folks tend to understand what we are saying quite readily, on the health side there is more resistance and more of a lack of understanding of the key role that transportation plays in health access. '}},
{ timecode: 1011, handler: 'blob', id: 68, data: {text: 'So, the organization that I work for, the combination of programs around the country and the policy and advocacy work that we do is unique blend. We are very active in Washington. This falls directly '}},
{ timecode: 1026, handler: 'blob', id: 69, data: {text: 'into my area of responsibility. I take the messages around children’s access to care to congress. We try to educate policy makers about the importance of appropriate health access and in doing '}},
{ timecode: 1039, handler: 'blob', id: 70, data: {text: 'that work I’ve often discussed transportation as a health barrier. Unlike a lot of organizations that just focus on the policy side, we are able to drive our message through the clinical '}},
{ timecode: 1053, handler: 'blob', id: 71, data: {text: 'experience that we see in our programs every day. Because we are serving the most medically underserved kids in the country, we do have very compelling stories and in many respects we are like '}},
{ timecode: 1064, handler: 'blob', id: 72, data: {text: 'canaries in a coal mine. When things start to go south as they have economically we start to hear the stories soon thereafter and we are able then to go to congress and to go to other folks and make a '}},
{ timecode: 1078, handler: 'blob', id: 73, data: {text: 'case for addressing problems now rather than when they get past a certain point and kids really start to feel the negative impact. So lack of transportation is a critical access barrier for kids. What '}},
{ timecode: 1093, handler: 'blob', id: 74, data: {text: 'we found is that lack of access to reliable transportation is one of the most pervasive barriers to healthcare for children in the United States. The result of that lack of access is missed '}},
{ timecode: 1104, handler: 'blob', id: 75, data: {text: 'opportunities for routine care. You would think, okay, if a child has a health problem and they need to be seen by a doctor urgently they will get to that doctor. That is in fact true. You have '}},
{ timecode: 1116, handler: 'blob', id: 76, data: {text: 'emergency care available in just about every setting even if you have to air vac a kid to the ER. What we are talking about is the missing of routine care and the reason that’s important is '}},
{ timecode: 1130, handler: 'blob', id: 77, data: {text: 'because when you have untreated chronic illness or kids don’t get immunizations according to schedule, what we have are the diseases and conditions that go from manageable to unmanageable. The '}},
{ timecode: 1142, handler: 'blob', id: 78, data: {text: 'cost to the healthcare system is fairly astounding and, of course, the human cost in terms of kids missing out on educational opportunities and having a diminished quality of life is also fairly '}},
{ timecode: 1157, handler: 'blob', id: 79, data: {text: 'extensive. So it’s the routine care, kids not getting to well child treatment, etc. that really is the problem here. In health professional shortage areas we found that such areas were also '}},
{ timecode: 1172, handler: 'blob', id: 80, data: {text: 'likely to be transportation disadvantaged which is a double whammy in many communities. So you have rural communities where there aren’t enough doctors and there isn’t any real access to '}},
{ timecode: 1181, handler: 'blob', id: 81, data: {text: 'transportation, so the access to healthcare is that much more diminished. To address this problem the Children’s Health Fund decided about 6 or 7 years ago to launch a major initiative called '}},
{ timecode: 1194, handler: 'blob', id: 82, data: {text: 'CHF Transportation Initiative. The challenge was to address transportation barrier to child healthcare access. We have major partners in the Kellogg Foundation and the FTA. Our activities include '}},
{ timecode: 1206, handler: 'blob', id: 83, data: {text: 'development of innovative models within our network of programs to address transportation barriers in the communities where they are sited. We have some very interesting policy and research '}},
{ timecode: 1217, handler: 'blob', id: 84, data: {text: 'initiatives to get at some of the issues—the underlying issues that need to be addressed to help resolve some of these issues. To do public education and advocacy work in congress and other '}},
{ timecode: 1231, handler: 'blob', id: 85, data: {text: 'foray to educate folks about the need to collaborate around these issues. What I like to think of when I talk about the medical home and I come before a transportation audience like I am today to say '}},
{ timecode: 1244, handler: 'blob', id: 86, data: {text: 'that it’s not enough for transportation providers to get the person who needs services up to the front door of the community health center or the mobile unit what have you. That we think that '}},
{ timecode: 1259, handler: 'blob', id: 87, data: {text: 'transportation provider needs to be inside the door and to be considered part of the model, part of the team whose goal it is to make sure those kids and families have true access to healthcare. Thank '}},
{ timecode: 1273, handler: 'blob', id: 88, data: {text: 'you. What we are hoping to do finally and Steve and Roy will get at some of this, is to develop some new tools to support our clinical and policy objectives. We do have, just to name the places where '}},
{ timecode: 1289, handler: 'blob', id: 89, data: {text: 'we have established our model programs. In Clarksdale Mississippi, Aurelia Jones-Taylor, who heads our program in Clarksdale, sitting in the audience. I am glad to see her here today. In Marianna '}},
{ timecode: 1303, handler: 'blob', id: 90, data: {text: 'Arkansas, Gulfport Biloxi Mississippi, and in western Colorado. We have two programs that are currently in development in New Orleans and in Memphis. The overarching objectives for these pilot '}},
{ timecode: 1315, handler: 'blob', id: 91, data: {text: 'projects is to identify and bring together local stake holders in the health and transportation sectors, getting them sitting at the same table to identify common problems and getting them to feel '}},
{ timecode: 1325, handler: 'blob', id: 92, data: {text: 'that they are part of the same team to initiate or enhance high impact child healthcare transportation solutions. That involves making investments in innovative ways, some of which would probably '}},
{ timecode: 1337, handler: 'blob', id: 93, data: {text: 'occur to you as being fairly straight forward and common sense but on the healthcare side I can’t stress strongly enough that there isn’t a degree of understanding of how transportation '}},
{ timecode: 1349, handler: 'blob', id: 94, data: {text: 'programs work. There needs to be in order for this model to work correctly. Finally to evaluate for potential applicability and replicability in other communities. One added thing is that the '}},
{ timecode: 1363, handler: 'blob', id: 95, data: {text: 'Children’s Health Fund has made a major investment as part of this initiative in our transportation referral management systems or TRAMS, which is an open source web based referral tracking '}},
{ timecode: 1373, handler: 'blob', id: 96, data: {text: 'logistics management system. It grows out of a referral management initiative that we pioneered to dramatically improve access and completion of specialty care appointments for medically underserved '}},
{ timecode: 1386, handler: 'blob', id: 97, data: {text: 'families and we are very excited about this because as you know the nation is moving very, very aggressively around health information technology. A lot of folks are looking to electronic health '}},
{ timecode: 1397, handler: 'blob', id: 98, data: {text: 'records as a panacea for driving down healthcare costs. We see a very, very interesting and critical application of electronic health records as being integration of transportation information to help '}},
{ timecode: 1416, handler: 'blob', id: 99, data: {text: 'families who are scheduling appointments to also schedule transportation and to have it all part of the same information system so when you are getting that referral you also get a way to get to that '}},
{ timecode: 1430, handler: 'blob', id: 100, data: {text: 'referral and to thereby dramatically improving the likelihood that that referral will actually occur. Finally, I do not want to get to far ahead on this, we are looking very closely at the development '}},
{ timecode: 1443, handler: 'blob', id: 101, data: {text: 'of an index for transportation disadvantage where we are looking at the potential policy ramifications of developing a corollary to the health professional shortage area designation which is used by '}},
{ timecode: 1457, handler: 'blob', id: 102, data: {text: 'the federal government to drive reimbursement and allocation of resources into communities that don’t have enough healthcare professionals. We want to overlay a transportation disadvantage on '}},
{ timecode: 1468, handler: 'blob', id: 103, data: {text: 'top of that to define and identify critical hotspots and to essentially lobby for even more funding for those communities that are afflicted with the double whammy of not having enough doctors and not '}},
{ timecode: 1483, handler: 'blob', id: 104, data: {text: 'having enough transportation. The bottom line, transportation is a key component of the enhanced medical home. Transportation accessibility and promotion and utilization will contribute to improved '}},
{ timecode: 1493, handler: 'blob', id: 105, data: {text: 'health outcomes for children and families. Medical transportation provider organizations must be committed to being part of the healthcare team to create a more seamless system and improve health '}},
{ timecode: 1504, handler: 'blob', id: 106, data: {text: 'access. That is my part; I would like to introduce Roy Grant who is our director of research. ROY GRANT: Thanks Dennis and I are going to try to go through a lot of data fairly quickly. Part of the '}},
{ timecode: 1524, handler: 'blob', id: 107, data: {text: 'reason we are doing power point is that at least for me too many numbers and all I do is hear them they kind of get all jumbled up. I think this will just make it easier to get some of the data '}},
{ timecode: 1535, handler: 'blob', id: 108, data: {text: 'across. Part of the reason that we have looked at ways to quantify transportation as a health barrier, and this has been really interesting for me since we got started with this like in 2000 actually. '}},
{ timecode: 1552, handler: 'blob', id: 109, data: {text: 'The transportation community really understands that transportation is an issue with respect to health access. The health community is kind of coming along towards it but doesn’t quite get the '}},
{ timecode: 1568, handler: 'blob', id: 110, data: {text: 'hang of this first bullet here, insurance is not enough. I am always very careful to say that it’s wonderful that SCHIP was reauthorized, insurance is absolutely essential, or certainly the '}},
{ timecode: 1579, handler: 'blob', id: 111, data: {text: 'ability to is essential and financial barriers to health access are extremely powerful and need to be addressed but the health community has been rather monomaniacally focused on insurance and '}},
{ timecode: 1595, handler: 'blob', id: 112, data: {text: 'doesn’t really always get it that having an insurance card in your pocket doesn’t really equate getting to the doctor when you need to. So we have been trying very, very hard to make the '}},
{ timecode: 1608, handler: 'blob', id: 113, data: {text: 'point that there are non-economic barriers that in some case are equally powerful and especially in these health professional shortage areas where you have a very limited workforce which means the '}},
{ timecode: 1622, handler: 'blob', id: 114, data: {text: 'distance from where you are to your health professional is that much longer and we will have some data on that coming up. So transportation and of course poverty is higher in our rural communities '}},
{ timecode: 1637, handler: 'blob', id: 115, data: {text: 'which tend to be overwhelmingly health professional shortage areas, low income rural communities have tremendous problems with attracting and retaining health professionals. Low population density '}},
{ timecode: 1653, handler: 'blob', id: 116, data: {text: 'means there is not a very high patient volume, high poverty rates means that you have Medicaid reimbursement really to look forward to in terms of how you are going to get paid and that equates to a '}},
{ timecode: 1665, handler: 'blob', id: 117, data: {text: 'bad business plan. It just doesn’t remain financially viable to maintain a practice there so there are protracted health professional shortages and the people that have stayed, what the data is '}},
{ timecode: 1677, handler: 'blob', id: 118, data: {text: 'showing, are getting ready to retire. There are not a lot of people jumping in to say “Okay, we\'re the next generation of rural health providers.” There is a small but growing literature on the'}},
{ timecode: 1692, handler: 'blob', id: 119, data: {text: 'health side with regard to transportation most of these studies that have been done with regard to impact of transportation in health access are with adults. Most of it is adults with chronic '}},
{ timecode: 1705, handler: 'blob', id: 120, data: {text: 'conditions. Diabetes is a major one. Kidney dialysis is another. As you can see in rural South Carolina 16% of parents were unable to make routine healthcare appointments and interestingly it is also '}},
{ timecode: 1726, handler: 'blob', id: 121, data: {text: 'a problem in urban settings. Part of the reason for that especially with regard to specialty care is that hospitals are very often, I am told this has to do with the availability of land on which to '}},
{ timecode: 1740, handler: 'blob', id: 122, data: {text: 'build a hospital, but they are very often a little off the beaten track. So even if you have a good transportation system, transportation to hospitals can be quite problematic. If there are any '}},
{ timecode: 1758, handler: 'blob', id: 123, data: {text: 'researchers in the house, the methodology we have used is telephone survey random digit dialing and so forth. Our first cut on this was in 2001 with Zogby. I have to say that Microsoft spell check '}},
{ timecode: 1775, handler: 'blob', id: 124, data: {text: 'very, very helpfully suggested that I call this the CHF zombie transportation survey. It is one of those things where if you absent mindedly say replace all you would truly be wondering just what the '}},
{ timecode: 1790, handler: 'blob', id: 125, data: {text: 'mode of transportation is for the living dead. What Zogby did was to over sample low income families so this non-nationally representative sample. All of the families had incomes below 50,000, nearly '}},
{ timecode: 1804, handler: 'blob', id: 126, data: {text: 'a third were below 25,000. 31%, and this is interesting because we have a national representative sample coming up, lived more than 10 miles and that seems to be kind of a breaking point with regard '}},
{ timecode: 1818, handler: 'blob', id: 127, data: {text: 'to distance to travel. Nearly a third are more than 10 miles away from the usual source of care. 47% didn’t have access to a public transportation system. That is a little skewed because of the '}},
{ timecode: 1831, handler: 'blob', id: 128, data: {text: 'sample. But this number we have verified later, 75% in rural communities have no public transit system. So yeah we have a recession, we have been through some incredibly high gas prices. Even if you '}},
{ timecode: 1849, handler: 'blob', id: 129, data: {text: 'have a car you may not be in good shape, or you may have one car which is driven by the head of household that works, goes to a job, has the car, other parent is home with kids and doesn’t have '}},
{ timecode: 1861, handler: 'blob', id: 130, data: {text: 'a car. No way to get anywhere including to the doctor. In this sample 9% of families had missed at least one child health appointment because of transportation in the previous twelve months. And if '}},
{ timecode: 1874, handler: 'blob', id: 131, data: {text: 'you go to poverty, and this is significantly below federal poverty level of under 15,000, one out of five had missed at least one of appointment and that’s where you get into if you have a car '}},
{ timecode: 1888, handler: 'blob', id: 132, data: {text: 'you can’t maintain it in good repair, you can’t afford to keep the gas tank full. This is something that we have come across in our other surveys as well. Referring only to Medicaid '}},
{ timecode: 1900, handler: 'blob', id: 133, data: {text: 'recipients, nearly 60% were unaware that Medicaid provided transportation and only 12% had actually used Medicaid transportation benefits. So there is a marketing element to this as well. We then went '}},
{ timecode: 1916, handler: 'blob', id: 134, data: {text: 'ahead, this is now five years later, with a nationally representative sample, meaning that the respondents followed United States Census Bureau data for region in which they lived, race, ethnicity,'}},
{ timecode: 1934, handler: 'blob', id: 135, data: {text: 'socioeconomic status, etc. 39% no public transportation. It is a bit lower than the other survey which as I said was really a lower income group, but still four out of ten, no public transportation. '}},
{ timecode: 1950, handler: 'blob', id: 136, data: {text: 'We got into some of, do you use public transportation? I was a little stunned at how little used it was. Only 25% used it at least sometimes and this is referring to people who have public '}},
{ timecode: 1963, handler: 'blob', id: 137, data: {text: 'transportation readily available in their community and in terms of drilling down regionally it was the south and central regions which are heavily rural relative to the more urban northeast. Distance '}},
{ timecode: 1981, handler: 'blob', id: 138, data: {text: 'from home again 38% more than ten miles so this is a significant problem. Exactly the same number in rural communities 75% no public transportation in their communities. Obviously big cities are much '}},
{ timecode: 1999, handler: 'blob', id: 139, data: {text: 'more likely to have public transportation. Reason why public transportation was not used? The predominant reason was simply a preference for one’s own automobile. But then you get into some of the'}},
{ timecode: 2012, handler: 'blob', id: 140, data: {text: 'other issues, service problems, and that was sort of an aggregated things like, it’s unreliable, I don’t feel safe, etc. Schedule was a big issue and route was a big issue. It’s '}},
{ timecode: 2027, handler: 'blob', id: 141, data: {text: 'simply not close to where I live or where it leaves me off is of no use to me. We also asked questions very specifically about transportation and healthcare so assuming one had transportation one out '}},
{ timecode: 2044, handler: 'blob', id: 142, data: {text: 'of five it didn’t get to where their healthcare was and that includes emergency departments. I think that has to do with the location of hospitals simply being off a lot of public transportation '}},
{ timecode: 2057, handler: 'blob', id: 143, data: {text: 'routes even in places like Washington DC as certainly good transit system but in a very utilitarian way. It brings people into center city to get to business and it goes to where government offices '}},
{ timecode: 2073, handler: 'blob', id: 144, data: {text: 'are and so forth but in between those spots there are some pretty difficult accesses. The children’s hospital in particular is pretty hard to get to by public transportation. This last bullet is '}},
{ timecode: 2089, handler: 'blob', id: 145, data: {text: 'the bottom line to the survey. 4% of children, and this is nationally represented of sample, regardless of their income, regardless of their insurance status, regardless of where they live, miss at '}},
{ timecode: 2103, handler: 'blob', id: 146, data: {text: 'least one health appointment because of transportation a year and because the previous survey was focused exclusively on under 50,000 dollars we looked at that subset in that income and it was 9% in '}},
{ timecode: 2117, handler: 'blob', id: 147, data: {text: '2001 and 7% in 2000 so it is a pretty stable number. Now this is where the cost to the health system is picked up. Almost a third and this was a very carefully worded question, thinking about the '}},
{ timecode: 2132, handler: 'blob', id: 148, data: {text: 'condition for which you missed the health appointment because of transportation did you later need or seek emergency department care? Nearly a third said yes. We took the most conservative possible '}},
{ timecode: 2147, handler: 'blob', id: 149, data: {text: 'estimates for the cost of an emergency room visit, we didn’t include all the extras like 50.00 aspirins or whatever, it adds up pretty quickly. Getting an estimate of the cost of ambulance care '}},
{ timecode: 2163, handler: 'blob', id: 150, data: {text: 'was really, really wild the variation is such that is was almost impossible to come up with, and there were two economists working on this with me so it is not just my pathetic economic sense that was '}},
{ timecode: 2175, handler: 'blob', id: 151, data: {text: 'at work here. It was very, very hard to come up with a number that we felt comfortable with. We went with really the lowest estimate that we thought was even plausible. So that is the bottom line '}},
{ timecode: 2191, handler: 'blob', id: 152, data: {text: 'number. We adjusted for the year that we processed the survey which was 2007, 870 million in emergency room visits and a very conservative estimate of how many of them required ambulances and what '}},
{ timecode: 2206, handler: 'blob', id: 153, data: {text: 'those ambulances would cost. So the next step for us is to look at ways to identify those communities where this problem is greatest. Health professional shortage area and some type of way of saying '}},
{ timecode: 2221, handler: 'blob', id: 154, data: {text: 'this is a transportation disadvantaged community and that is what Steve Borders is working on among so many other things. But that is what he is working on now for us. STEVE BORDERS: Well since we '}},
{ timecode: 2240, handler: 'blob', id: 155, data: {text: 'were talking about baseball earlier I’ll admit that I am a long suffering Cubs fan. I thought about not raising my hand but Cubbie fans have to be sort of tough. So I’ll preface this too '}},
{ timecode: 2256, handler: 'blob', id: 156, data: {text: 'and talk a little bit about my background with this even though I am in Michigan I do have to tell you a funny story that I did not grow up in Michigan if you can believe that. But I actually had two '}},
{ timecode: 2272, handler: 'blob', id: 157, data: {text: 'people on two separate occasions ask me if I was from Australia. That is the honest to god truth. I said South Australia. But that is true. Anyway I spent most of my professional career in Texas and I '}},
{ timecode: 2288, handler: 'blob', id: 158, data: {text: 'was one of those faceless state Medicaid bureaucrats for a number of years and then went back to graduate school to Texas A & M. So I have worked on the medical transportation, the non-emergency '}},
{ timecode: 2300, handler: 'blob', id: 159, data: {text: 'medical transportation side from a policy standpoint as well as a research standpoint. I think to you know what’s interesting when you look at this is that in sort of reiterating some of the '}},
{ timecode: 2313, handler: 'blob', id: 160, data: {text: 'things that Dennis and Roy talked about earlier are that when you look at transportation barriers you find if you do a literature review of this, you’ll find that a lot of people say '}},
{ timecode: 2322, handler: 'blob', id: 161, data: {text: 'transportation is a barrier but that’s sort of where it ends. I think that’s the difficulty we are having is sort of putting some real substance with what are these transportation '}},
{ timecode: 2335, handler: 'blob', id: 162, data: {text: 'barriers. So again thinking about what’s happening with my experience, the Texas legislature had looked at this, this is called the Sunset Commission inTexas, and transportation is among the '}},
{ timecode: 2347, handler: 'blob', id: 163, data: {text: 'most frequently cited barriers to service delivery for healthy human services clients in Texas. So they have found that. Again if you look at a lot of these Medicaid class actions suit across the '}},
{ timecode: 2359, handler: 'blob', id: 164, data: {text: 'nation they always say that transportation is a barrier. That’s one of the things that I have been doing in Texas is doing an evaluation of the non-emergency medical transportation program. This '}},
{ timecode: 2372, handler: 'blob', id: 165, data: {text: 'part of a class action lawsuit on access. So it’s just one piece of sort of the whole entire EPSDT which is sort of the well child program for children in Texas. But this is one piece of it that'}},
{ timecode: 2387, handler: 'blob', id: 166, data: {text: 'has gotten really big and in the interest of the plaintiffs there. So again we’ve found sort of these same things in access lawsuits in Oklahoma, Tennessee, New York, Connecticut, Florida, and '}},
{ timecode: 2398, handler: 'blob', id: 167, data: {text: 'Texas. Looking at what this, you know we call this non-emergency transportation; again I think reiterating what Dennis and Roy said earlier, is that they’re lightly utilized. Again about 10% '}},
{ timecode: 2412, handler: 'blob', id: 168, data: {text: 'nationally but only about 6% in Texas. What we found too is that they’re significant proportions of the population that could potentially benefit from non-emergency medical transportation '}},
{ timecode: 2427, handler: 'blob', id: 169, data: {text: 'services. So I am sorry I am going to turn my back and use my pointer here a little bit but this is part of what some of the research that we are doing now. We typically had done these surveys once a '}},
{ timecode: 2440, handler: 'blob', id: 170, data: {text: 'year and now we are looking at these sort of over time so this is some the quarterly, the most recent quarterly data that we have and we had this measure of need. Those that did not use the '}},
{ timecode: 2452, handler: 'blob', id: 171, data: {text: 'non-emergency medical transportation program in Texas and then estimating about how many children, again these are just children, that could benefit from this and of course many of you may not know '}},
{ timecode: 2464, handler: 'blob', id: 172, data: {text: 'this but the Texas Medicaid population is approaching 3 million in Texas today. So a lot of folks there and again when we think about what health reform is likely to look at is probably and expansion '}},
{ timecode: 2476, handler: 'blob', id: 173, data: {text: 'of Medicaid and an expansion of SCHIP. So again these are the places I think to look. So in 2008 the first quarter about 18% had transportation needs as measured from our survey. So that translates '}},
{ timecode: 2492, handler: 'blob', id: 174, data: {text: 'into about 510,000 children in Texas. Again as the economy has weakened this is no surprise here but almost 30% of those express transportation needs during most recent quarterly survey. Approaching '}},
{ timecode: 2510, handler: 'blob', id: 175, data: {text: 'about 725,000 children that unmet transportation needs in the State of Texas. I think that this is also an interesting point too is that non-emergency transportation works. Now even if we think about '}},
{ timecode: 2526, handler: 'blob', id: 176, data: {text: 'where these children are getting services, we think about how many times they’ve gone to the doctor. Perhaps they are more ill than others that don’t need to go so you know that could be '}},
{ timecode: 2538, handler: 'blob', id: 177, data: {text: 'part of it. But what we do see is that they have greater access. But I think the most important thing here to think about too is that how many time you or your child saw a healthcare professional for '}},
{ timecode: 2549, handler: 'blob', id: 178, data: {text: 'preventive care, again that’s what they call that EPSDT check up, the well child check up. We see that those that use the program, this is the burgundy bar, then the blue bar; they have'}},
{ timecode: 2562, handler: 'blob', id: 179, data: {text: 'significantly higher visits then those that don’t. About the same for dental but again higher well child checkups which again I think is reiterating what Dennis is talking about thinking about '}},
{ timecode: 2575, handler: 'blob', id: 180, data: {text: 'that medical home that there are getting in to get preventive care. So this is an important part of it. Again if we think that only 6% of the population is using these services and that we have '}},
{ timecode: 2587, handler: 'blob', id: 181, data: {text: '700,000 that could benefit from it, there is a lot of room to work here. When Dennis and Roy were talking to me about, “How do we develop a model for this?” One of the things that we were '}},
{ timecode: 2603, handler: 'blob', id: 182, data: {text: 'looking at is that obviously to do this survey research is expensive so one of the things that we were thinking about, “How could we do this and develop this nationwide and think about a way to '}},
{ timecode: 2613, handler: 'blob', id: 183, data: {text: 'identify these transportation areas within states that are problematic for children in accessing healthcare services?” Again there is no data that we found at a national level that we could '}},
{ timecode: 2629, handler: 'blob', id: 184, data: {text: 'easily tap into and think about where all of those problems are. So what we’re trying to do is develop those through publicly available data sources so that we can model these in Connecticut. We '}},
{ timecode: 2642, handler: 'blob', id: 185, data: {text: 'can model these in New Mexico, we can model these in all other states and again think about bring that health professional shortage area to perhaps a transportation shortage area as well. That was '}},
{ timecode: 2655, handler: 'blob', id: 186, data: {text: 'sort of Dennis’s idea of this transportation disadvantaged index. I am sorry, this maybe a little difficult to see but again in thinking about what’s the upshot of when kids miss health '}},
{ timecode: 2669, handler: 'blob', id: 187, data: {text: 'appointments? If we think about how to model these, we have the transportation barriers, socio-demographic barriers, and provider barriers. What sort of happens is that what do we see? We see that '}},
{ timecode: 2680, handler: 'blob', id: 188, data: {text: 'inappropriate use of the emergency room. So those are the things that we are looking at. What happens right, we have these missed opportunities for preventive health services. That translates into '}},
{ timecode: 2691, handler: 'blob', id: 189, data: {text: 'that inappropriate emergency room use. So we are using a thing called ambulatory care sensitive conditions. Again those are what we call emergency room visits that are defined as those that could be '}},
{ timecode: 2709, handler: 'blob', id: 190, data: {text: 'treated in a physician’s office or could be treated had the person or the child received proper care rather than having to end up in the emergency room. So that’s what we’re doing. '}},
{ timecode: 2723, handler: 'blob', id: 191, data: {text: 'Again you may have seen that term before but this is again sort of this health term that we see these ambulatory care sensitive conditions. Here is sort of my example. These are these medical problems '}},
{ timecode: 2735, handler: 'blob', id: 192, data: {text: 'that are potentially preventable, for example earaches are often a condition that can be treated outside of a hospital with proper medication and management of care. Most children should not need an '}},
{ timecode: 2747, handler: 'blob', id: 193, data: {text: 'emergency room visit or be hospitalized for an earache. For ACS conditions an ER visit or hospital admission shows us that the patient probably did not get care that worked. So admission to the ER or '}},
{ timecode: 2758, handler: 'blob', id: 194, data: {text: 'the hospital in this situation is a failure of the healthcare system in some way, be it transportation, primary care, so again those are the things that we’re looking at. Here are the things '}},
{ timecode: 2769, handler: 'blob', id: 195, data: {text: 'that I’m trying to model again using that ambulatory care sensitive condition as my dependent variable. So that’s the thing that we are trying to predict. Where would we see a high number '}},
{ timecode: 2781, handler: 'blob', id: 196, data: {text: 'of these ER admissions that are the result of poor primary care? What are the things that we’re looking at? I have had again since I knew people in Texas; this was sort of easy for me to get '}},
{ timecode: 2794, handler: 'blob', id: 197, data: {text: 'data, so if we are looking at transportation the number of vehicles per adult population. I am also trying to get data to look at the age of the vehicle and of course if any of you have ever been to '}},
{ timecode: 2804, handler: 'blob', id: 198, data: {text: 'Texas you know that people love their cars in Texas. That’s an important thing. The percentage of households with no vehicle. Workers with daily commutes and excess of 30 minutes, again sort of '}},
{ timecode: 2816, handler: 'blob', id: 199, data: {text: 'thinking about we find that a lot of people actually have automobiles but of course someone needs to go to work and provide for the family so even though the office is open 8 to 5 it’s those '}},
{ timecode: 2828, handler: 'blob', id: 200, data: {text: 'after hours. Those are the things that cause problems. The availability of public transportation. Something that I’m having difficulty modeling and I’m hoping too that you might have some '}},
{ timecode: 2840, handler: 'blob', id: 201, data: {text: 'ideas about how to account for some of these things. The percent of the population living in urban and rural areas when we think about distance to providers. What are some of those social and '}},
{ timecode: 2851, handler: 'blob', id: 202, data: {text: 'demographic variables that we might look at? Sort of our percent of minority population, the percent of the population that has little or no English skills, the percent of the population with less '}},
{ timecode: 2863, handler: 'blob', id: 203, data: {text: 'than a high school degree, the percent of households living in poverty, the median income, sort of all of those things. If we look at provider variables, the health professional shortage areas, the '}},
{ timecode: 2873, handler: 'blob', id: 204, data: {text: 'ratio of Medicaid providers to the Medicaid population. We are looking at sort of those that provide those well child checkups. We want to take out the anesthesiologist and those types of folks. Look'}},
{ timecode: 2887, handler: 'blob', id: 205, data: {text: 'at those providers that are delivering primary care. The percent of the population on Medicaid. There is also another term called medically underserved areas, and again the percent of the population '}},
{ timecode: 2900, handler: 'blob', id: 206, data: {text: 'living in a medically underserved area. What are some of the results that I’ve done? We’ve looked at Texas in Austin and specific….. I’ve looked at Texas because of the data '}},
{ timecode: 2917, handler: 'blob', id: 207, data: {text: 'availability. It seemed to have a good mix of urban and rural population, good mix of poor and affluent populations, minority populations are well represented. There is some mass transit available in '}},
{ timecode: 2929, handler: 'blob', id: 208, data: {text: 'that area. Here are some of the maps that we’ve developed. Again I’ll apologize for turning my back to you. These are the percent of the emergency room admissions classified as ambulatory '}},
{ timecode: 2944, handler: 'blob', id: 209, data: {text: 'care sensitive. If you’ve ever been to Texas which is kind of interesting, is that it’s a very segregated area here, everything east of I-35 is largely poor and minority. Everything west '}},
{ timecode: 2959, handler: 'blob', id: 210, data: {text: 'of I-35 is largely more affluent and more white. So what’s interesting is that where I expected to see more of these ambulatory care sensitive conditions here actually the power point changed '}},
{ timecode: 2978, handler: 'blob', id: 211, data: {text: 'the federally qualified health centers to dollar signs, they were little…..so that’s kind of interesting. They weren’t dollar signs on the map that I created so…. But those '}},
{ timecode: 2995, handler: 'blob', id: 212, data: {text: 'are sort of the clinics that you guys maybe familiar with. I think you know what it shows too is that these clinics are largely doing a good job when we think about providing care within the Austin '}},
{ timecode: 3009, handler: 'blob', id: 213, data: {text: 'area but of course too as we start to get out into these more rural areas, Burnet County, Lee, Giddings, Bastrop and Caldwell there are some areas with some obvious problems there. So what I am trying '}},
{ timecode: 3024, handler: 'blob', id: 214, data: {text: 'to do is to overlay these maps and find out where some of these variables that we looked at are correlated with some of these ambulatory care sensitive conditions. Here is another variable again sort '}},
{ timecode: 3038, handler: 'blob', id: 215, data: {text: 'of a subset of that ambulatory care model, is the percent of emergency room admissions, these are called primary care treatable. Again those that could be treated within a provider’s office. '}},
{ timecode: 3051, handler: 'blob', id: 216, data: {text: 'They didn’t necessarily need …. again I think you know what’s interesting, what do you notice here, green is good, orange, red as we get towards red that means those are higher '}},
{ timecode: 3063, handler: 'blob', id: 217, data: {text: 'there. As we move away from the center of the metropolitan area here of Austin we see that these rural areas have some access problems. Percent of households with no vehicles. This is kind of '}},
{ timecode: 3078, handler: 'blob', id: 218, data: {text: 'interesting too if you look in central Austin there’s a lot of problems here with access but again here are some of these same areas too which again represent transportation barriers. The '}},
{ timecode: 3090, handler: 'blob', id: 219, data: {text: 'percent of population that’s minority, I think this really demonstrates Austin if I took one of the other things that I’ve mapped to is the median income if you do it looks a lot like this '}},
{ timecode: 3109, handler: 'blob', id: 220, data: {text: 'too, again this area is largely Hispanic, African Americans to the north or Austin and then there are some African American pockets here in Lee County as well. Again some of these are up to 95% '}},
{ timecode: 3128, handler: 'blob', id: 221, data: {text: 'minority. The percent of the population under the age of 18 on Medicaid and again you see sort of these same patterns emerge. So here is where our heavy Medicaid population is. If we follow sort of '}},
{ timecode: 3144, handler: 'blob', id: 222, data: {text: 'the logic that’s where we expect most of our ambulatory care sensitive conditions to be but that wasn’t always necessarily the case. The percent of the population living in rural areas by '}},
{ timecode: 3157, handler: 'blob', id: 223, data: {text: 'zip code so these more rural areas….. these are really, really rural areas, Blanco, Johnson City where LBJs farm is, Lee County, very rural area, Bastrop is too. What are some of the thoughts '}},
{ timecode: 3179, handler: 'blob', id: 224, data: {text: 'on the maps? There seems to be some spatial patterns about this emergency room use but they don’t always fall where I expected those to be and I think part of this is that of course when mom and '}},
{ timecode: 3193, handler: 'blob', id: 225, data: {text: 'dad thinks is an emergency, it’s an emergency right? We hear this all the time is that if it’s your child and your child is suffering an asthma attack you’re going to go to the '}},
{ timecode: 3202, handler: 'blob', id: 226, data: {text: 'emergency room whether it could be treated in the physician’s office or not. So if it’s an emergency to mom and dad it’s an emergency. So I think those are some of the things that '}},
{ timecode: 3211, handler: 'blob', id: 227, data: {text: 'cloud this picture a little bit but there do seem to be some real correlations between the distance and emergency department use for these ambulatory care sensitive conditions. Of course I think those '}},
{ timecode: 3224, handler: 'blob', id: 228, data: {text: 'FQHCs the dollar signs seem to make a big difference in reducing emergency room use for those ambulatory care sensitive conditions. So we’re still working on all of those. Obviously there is '}},
{ timecode: 3238, handler: 'blob', id: 229, data: {text: 'more work to do here. When I have taken some of the transit data from Texas, especially the Austin metro area, what percent of the population is using public transportation, what are they using it '}},
{ timecode: 3255, handler: 'blob', id: 230, data: {text: 'for, again those are difficult things, but again those are things that I want to integrate into this model as well. Is there transportation that we’ve overlooked and again I’m not a '}},
{ timecode: 3269, handler: 'blob', id: 231, data: {text: 'transportation person per se so I was hoping to that some of you might have some ideas about publicly available data that we might think about including in this model. I guess I’ll turn it over '}},
{ timecode: 3284, handler: 'blob', id: 232, data: {text: 'there and we can start with some questions. Again there is Dennis, Roy, and my contact information if you need ever contact us. I have a number of these technical reports on the medical transportation '}},
{ timecode: 3300, handler: 'blob', id: 233, data: {text: 'program that are available. David Raphael who is a colleague of yours and I had worked on an article that’s coming out in a couple of months on the SCHIP program and transportation. So there are '}},
{ timecode: 3318, handler: 'blob', id: 234, data: {text: 'a number of things that we are working and thinking on and I’d be happy to talk to anyone about this as well. VALERIE MILLER: Okay, all right we will turn a question over to David. DAVID '}},
{ timecode: 3339, handler: 'blob', id: 235, data: {text: 'RAPHAEL’S: Steve and Dennis I think this is great. We’ve really needed for a long time some kind of measure of transportation disadvantage when it came to health. Two quick questions. One '}},
{ timecode: 3354, handler: 'blob', id: 236, data: {text: 'on the Texas lawsuit, did it only focus on children’s access to Medicaid? And does your conclusions, is the court also keeping an eye on adult access to healthcare and how the MTP program, '}},
{ timecode: 3369, handler: 'blob', id: 237, data: {text: 'medical transportation program is meeting those? Secondly would there be anything different in your analysis here, these overlays of transportation barriers if you were substituting adults or the dire '}},
{ timecode: 3383, handler: 'blob', id: 238, data: {text: 'disadvantage population and not just kids? STEVE BORDERS: That’s a good question. The Texas lawsuit is strictly about children. Again not to beat up Texas but there isn’t much available '}},
{ timecode: 3401, handler: 'blob', id: 239, data: {text: 'for adults on Medicaid in Texas. It really is more of a children’s program about…. unless you’re disabled it’s real difficult to qualify for Medicaid in Texas. So it is about '}},
{ timecode: 3417, handler: 'blob', id: 240, data: {text: '65% to 70% of the Medicaid population in Texas is children and then again most of those are over and above that you know are the long term care population. Those that are in institutions and then '}},
{ timecode: 3435, handler: 'blob', id: 241, data: {text: 'pregnant women are really, so it’s the mothers. But you know they roll off the Medicaid rolls real quick because the poverty levels don’t go up very high in Texas. Yes the other good '}},
{ timecode: 3453, handler: 'blob', id: 242, data: {text: 'question, I am sorry I should have prefaced that too, I did map these ambulatory care sensitive conditions for adults. Very different and I think one of the things is that it’s a lot …. '}},
{ timecode: 3464, handler: 'blob', id: 243, data: {text: 'there are a lot more measures for adults in this when you think about the complications of diabetes, the complications of congestive heart failure, so that’s where a lot of the research is on '}},
{ timecode: 3476, handler: 'blob', id: 244, data: {text: 'these ambulatory care sensitive conditions. So if you map the adults it looks a lot different then what I’ve done for strictly the children here. So there is a lot more data there that would '}},
{ timecode: 3492, handler: 'blob', id: 245, data: {text: 'present a much different picture. AUDIENCE MEMBER: I have a question with regard to the use, you said less than 10% use an MTP nationally, and about 6% in Texas and I like the remark you made kind of '}},
{ timecode: 3509, handler: 'blob', id: 246, data: {text: 'on the side, you said it’s probably due to marketing. Are you going to advise the Medicaid offices in their respective states about how that is a problem? STEVE BORDERS: We’ve been telling '}},
{ timecode: 3525, handler: 'blob', id: 247, data: {text: 'them that for years. It’s ….. and it’s interesting; in some states it’s a well kept secret. And I think you know that again was part of the original complaint from the '}},
{ timecode: 3538, handler: 'blob', id: 248, data: {text: 'plaintiffs was that no one knows about it and we’re finding those same things that echoes in Roy’s survey that the people just don’t know. So I think you know that in and of itself '}},
{ timecode: 3553, handler: 'blob', id: 249, data: {text: 'is a huge barrier to access. VALERIE MILLER: And that could actually whether the person is informed or not could actually act as an independent variable in your scheme of things. STEVE BORDERS: Yeah '}},
{ timecode: 3567, handler: 'blob', id: 250, data: {text: 'absolutely. And it certainly could again if we’re thinking about publicly available data. I think that’s our problem is that trying to model what this transportation disadvantage index '}},
{ timecode: 3583, handler: 'blob', id: 251, data: {text: 'because, is there a survey like this in Mississippi, is there a survey like this in New Mexico, other places where we think that the transportation is also a big problem? So yes I completely agree and '}},
{ timecode: 3598, handler: 'blob', id: 252, data: {text: 'there are a lot of things that we could use from the data that we have in Texas but wouldn’t necessarily apply to other states because that’s where our experience is. ROY GRANT: We have '}},
{ timecode: 3616, handler: 'blob', id: 253, data: {text: 'actually another aspect of our research is with a research partner at Delta State University who is actually an expert in social marketing. That’s John Green’s expertise so we’ll be '}},
{ timecode: 3630, handler: 'blob', id: 254, data: {text: 'doing some focus groups to get to some real strategies to see why if transportation were available it none the less would not be used and I think that there is some of that but the second survey, the '}},
{ timecode: 3644, handler: 'blob', id: 255, data: {text: 'Marris survey had a lot of questions about what…. well I thought that it would be useful to know for example if there are differences in availability of transportation as an insurance benefit '}},
{ timecode: 3658, handler: 'blob', id: 256, data: {text: 'based on whether or not it’s managed care, HMO model, or straight fee for service model. I forget the percentage but what I learned from that is that people don’t know if they are an HMO '}},
{ timecode: 3669, handler: 'blob', id: 257, data: {text: 'or managed care model. Of course this is a survey where 3% of people didn’t know if they owned a car and I was a little fascinated by that finding as well. So what people know about insurance is '}},
{ timecode: 3682, handler: 'blob', id: 258, data: {text: 'extremely problematic. People don’t understand the scope of benefit, and this is just…. I don’t know if it’s an intention to keep things from being used by not communicating '}},
{ timecode: 3694, handler: 'blob', id: 259, data: {text: 'that they are available for use or whether it’s just a flat out communication issue or it just wasn’t or it’s put in language that nobody could decode into normal English so that '}},
{ timecode: 3705, handler: 'blob', id: 260, data: {text: 'they actually knew what their insurance benefit is. But it’s a huge problem. I do think that the data shows that even if transportation is available there are reasons why people won’t use '}},
{ timecode: 3715, handler: 'blob', id: 261, data: {text: 'it and we will be doing focus group qualitative research to get to that. And yeah we’ll make it available to state Medicaid people and I think that probably people of goodwill will welcome it. '}},
{ timecode: 3728, handler: 'blob', id: 262, data: {text: 'AUDIENCE MEMBER: Hi my name’s Blaine Gordon, I’m from Maine. Your information really supports I think our experience in Maine. My question is for Dennis, you made a comment I think that '}},
{ timecode: 3737, handler: 'blob', id: 263, data: {text: 'the interaction between the health care professional, the client, and the transportation provider shouldn’t end at the door. I am just wondering how you, what your vision of that interaction '}},
{ timecode: 3748, handler: 'blob', id: 264, data: {text: 'might be? DENNIS JOHNSON: Well what we’re looking at currently within the model programs that I discussed which albeit small that they do involve for the first time many circumstances. The'}},
{ timecode: 3761, handler: 'blob', id: 265, data: {text: 'health providers and the transportation providers really talking to one another about working in a collaborative way with the goal being the child or family essentially getting appropriate access in '}},
{ timecode: 3776, handler: 'blob', id: 266, data: {text: 'that community. Now we’ve been fortunate….. the learning curve for us was pretty steep at first and we were fortunate in being able to work with folks at CTAA and folks at the FTA, I see '}},
{ timecode: 3790, handler: 'blob', id: 267, data: {text: 'that Doug Birnie is in the room who has been sort of a mentor on some of this stuff to us. You know we’ve felt that there is an initial gap in understanding between the two sectors. I would go '}},
{ timecode: 3807, handler: 'blob', id: 268, data: {text: 'to meetings on the health side and we’ve been pushing a lot of issues on the advocacy side for children for the past…… for my entire career and I would sit a room full of very, '}},
{ timecode: 3820, handler: 'blob', id: 269, data: {text: 'very smart people on the health side and would, we would talk, you know until our noses were bleeding about health insurance and the impact that putting money into the system for health insurance '}},
{ timecode: 3836, handler: 'blob', id: 270, data: {text: 'coverage would have on kids getting access to care and I would raise the transportation as an issue and essentially they would shut down, they weren’t able to absorb it as an issue. I think that '}},
{ timecode: 3850, handler: 'blob', id: 271, data: {text: 'it’s been a slow process but over the past decade I think that there has been much more uptake about the correlation between access to transportation and children and families actually enjoying '}},
{ timecode: 3863, handler: 'blob', id: 272, data: {text: 'better health care outcomes. In terms of practical application on the ground what we’ve done is we’ve sought to identify members of the health care team that could be trained to better '}},
{ timecode: 3877, handler: 'blob', id: 273, data: {text: 'understand the availability of transportation resources and how to coordinate them in communities. So for instance we have a program in very rural Arkansas, Lee County, where we have an FQHC and they '}},
{ timecode: 3894, handler: 'blob', id: 274, data: {text: 'actually happen to own a small fleet of vehicles that they make available when the Medicaid brokerage arrangement doesn’t work for their clients. What we did was we were able to work with the '}},
{ timecode: 3910, handler: 'blob', id: 275, data: {text: 'CTAA to get a person who is identified on staff trained as a transportation resource coordinator for that community. Then we had that person trained on our TRAMS, the management software that I '}},
{ timecode: 3925, handler: 'blob', id: 276, data: {text: 'referred to in my presentation, and now that person is charged with coordinating care using the vehicles that they own to get people who are part of that community health center out to specialty care '}},
{ timecode: 3939, handler: 'blob', id: 277, data: {text: 'appointments, being able to provide information to clients in real time when they are scheduling their visits about their transportation options and to provide a call in response service and to pick '}},
{ timecode: 3954, handler: 'blob', id: 278, data: {text: 'them up and to bring them to Memphis or where ever for their specialty care and then back to Marianna. So you know … having…. that’s one way that we’ve done it. In other '}},
{ timecode: 3965, handler: 'blob', id: 279, data: {text: 'places we’ve you know we’ve hosted meetings where the transportation providers in that community are now part of the conversation and are talking directly to the staff at the clinic. They '}},
{ timecode: 3981, handler: 'blob', id: 280, data: {text: 'are just working more closely together. So things that seem fairly rudimentary but don’t occur because the emphasis isn’t on getting the appropriate folks to sit down around the same table '}},
{ timecode: 3994, handler: 'blob', id: 281, data: {text: 'to discuss the problem. That, those are some of the ways that we’ve been able to implement fairly low cost but very effective solutions in our local network. We have yet in New Orleans where we '}},
{ timecode: 4009, handler: 'blob', id: 282, data: {text: 'have a mobile clinic that visits a fixed schedule of sites in the lower 9th ward. Very devastated community with a kind of circuitous transportation route that circles the 9th ward but doesn’t '}},
{ timecode: 4025, handler: 'blob', id: 283, data: {text: 'provide very easy access for people who are living within the body of the 9th ward to get from point A to B. It would have to go to the outer perimeter of the ward and then come back into what would '}},
{ timecode: 4036, handler: 'blob', id: 284, data: {text: 'be a 20 minute direct ride or 15 minutes becomes 45 minutes or an hour and 15 minutes. What we did was we met with the local transit authority and they were about to launch a new program called '}},
{ timecode: 4050, handler: 'blob', id: 285, data: {text: '“Little Easy” with little vehicles, little small buses, and they are now working directly with our mobile program so that the folks who have appointments can schedule, can call a number '}},
{ timecode: 4066, handler: 'blob', id: 286, data: {text: 'and schedule a ride and get directly to the clinic. Picked up at home and taken directly to the clinic for a very nominal cost which we subsidize through our grant. So, you know each community is '}},
{ timecode: 4079, handler: 'blob', id: 287, data: {text: 'different but we find that when we connect people in a direct way and they begin talking that generally they can come up with very good and effective and community based solutions to some of these '}},
{ timecode: 4094, handler: 'blob', id: 288, data: {text: 'problems. AUDIENCE MEMBER: Hi I’m Gail Vows. I’m from Tri Met in Portland Oregon. We have a fairly robust brokerage system throughout the state and do pretty significant numbers of '}},
{ timecode: 4108, handler: 'blob', id: 289, data: {text: 'Medicaid transportation trips. One of the things that we’ve run across however is that we’ve noticed that parents aren’t always available to take their children to scheduled '}},
{ timecode: 4117, handler: 'blob', id: 290, data: {text: 'appointments. What we’re really wondering is do you in any of your research, or have you in any of your research, come up with any recommendations at which you would feel comfortable having a '}},
{ timecode: 4129, handler: 'blob', id: 291, data: {text: 'child be transported without their parent to a medical appointment? ROY GRANT: There are a lot of issues with that. There are also either…. you know one of the models, and I know you all know '}},
{ timecode: 4142, handler: 'blob', id: 292, data: {text: 'this at CTAA that talks about multi-use of vehicles that are for specific purpose being used for example for another purpose instead of lying idle. One of the things that come up when you try to use a '}},
{ timecode: 4158, handler: 'blob', id: 293, data: {text: 'transportation vehicle that’s intended for adults with kids is supervision. And states have different regulations about what the ratio of adults to children must be or even what some of the '}},
{ timecode: 4172, handler: 'blob', id: 294, data: {text: 'qualifications of a bus monitor would be. So there are all kinds of issues, there are liability issues, with that. There are providers who don’t particularly want to see a kid, especially a'}},
{ timecode: 4185, handler: 'blob', id: 295, data: {text: 'young child, in isolation from a parent because of information. The child can’t really say, when did it start, and give precise information that the physician or nurse practitioner needs to '}},
{ timecode: 4196, handler: 'blob', id: 296, data: {text: 'have. So there are a lot of issues. School based health centers routinely see children in the absence of their parents because they see them during the school day. There is a lot of ways that they '}},
{ timecode: 4209, handler: 'blob', id: 297, data: {text: 'work with that, a lot of controls that they have in place. But that’s…. and there are other models, there’s a dental program in New York City at NYU School of Dentistry that '}},
{ timecode: 4222, handler: 'blob', id: 298, data: {text: 'transports kids without their parents for dental care. So there are a lot of different models for people who have a different threshold for it but it’s intrinsically problematic in terms of '}},
{ timecode: 4235, handler: 'blob', id: 299, data: {text: 'liabilities and from a health delivery point of view. There are some issues that I think many primary care providers would have with seeing, especially non-teenagers or wherever you draw the line, '}},
{ timecode: 4249, handler: 'blob', id: 300, data: {text: 'eight years, twelve years, however old you think a kid needs to be to function independently at that level. There could be problems with kids younger than that. (Asked to repeat from the audience) '}},
{ timecode: 4256, handler: 'blob', id: 301, data: {text: 'There are going to be problems with kids younger than that, that can’t give the information, that the doctor or nurse would need. STEVE BORDERS: I think on the flip side of your question too, '}},
{ timecode: 4270, handler: 'blob', id: 302, data: {text: 'you know in Texas we … the other problem we had was that parents with several children and if both children are not going for a Medicaid covered service the child who was not going could not '}},
{ timecode: 4283, handler: 'blob', id: 303, data: {text: 'go. So it’s a childcare problem. So you know it’s problematic because it goes in so many different directions so I think that’s the same thing, so the parent was left with a choice '}},
{ timecode: 4299, handler: 'blob', id: 304, data: {text: 'of who do I, what do I do with my child that doesn’t need to go to the doctor? So who can I leave them with? So then the childcare aspect of it also became a big problem. AUDIENCE MEMBER: This '}},
{ timecode: 4312, handler: 'blob', id: 305, data: {text: 'question’s for you Steve. In the graph that you showed you showed that at the bottom I think Bastrop in Texas. Yeah Bastrop. The red parts are the hospitals in that area as per se the main '}},
{ timecode: 4334, handler: 'blob', id: 306, data: {text: 'health facility or where the doctors are? STEVE BORDERS: That’s a good question. You know I don’t know. That’s something I should certainly look into. AUDIENCE MEMBER: I mean I '}},
{ timecode: 4347, handler: 'blob', id: 307, data: {text: 'understand your graph, I can only go by, and I was discussing this yesterday, and I’ll take Georgia as an example. Up in the lower mountains or higher mountains of Georgia you have some small '}},
{ timecode: 4362, handler: 'blob', id: 308, data: {text: 'hospitals up there and most of your providers are in that area. So say they don’t want to come into North Regional which is in Hall County Georgia. They go to that provider there and it’s '}},
{ timecode: 4378, handler: 'blob', id: 309, data: {text: 'just an ear infection. So the cost doubles and it shows as a double compared so when I see a graph like that, I would suggest that you look at what medical providers are in that specific area, If '}},
{ timecode: 4392, handler: 'blob', id: 310, data: {text: 'it’s a hospital they are going to levitate to that ER instead of going to a regular doctor that maybe 30 or 40 miles away. STEVE BORDERS: Yeah, that’s a good point and some of the map that '}},
{ timecode: 4406, handler: 'blob', id: 311, data: {text: 'I don’t have up here is the ratio of providers to especially those that provide well child care, those that are in the business of providing direct care services. The family doctor kind of '}},
{ timecode: 4420, handler: 'blob', id: 312, data: {text: 'folks. And there are a lot of zip codes with no providers in them at all. So you are exactly right. ROY GRANT: We also have some data from another study to show that some of what we may criticize or '}},
{ timecode: 4438, handler: 'blob', id: 313, data: {text: 'have feelings that it’s inappropriate about use of emergency departments for non-urgent care. The system is set up in a way that that’s really much more convenient in some communities and '}},
{ timecode: 4451, handler: 'blob', id: 314, data: {text: 'there are real …. the incentives are to use the emergency department because of where it’s located, because it’s no appointment in advance, because everyone can be seen without '}},
{ timecode: 4464, handler: 'blob', id: 315, data: {text: 'being turned away. So there really are some health systems issues, availability of physicians and practices, but also the way that the hours of operation of clinics where as emergency rooms are 24 '}},
{ timecode: 4478, handler: 'blob', id: 316, data: {text: 'hours open and things of that nature. Yeah that’s a very, very, good point that there are health systems issues that drive up costly use of emergency departments for non-urgent care. DENNIS '}},
{ timecode: 4491, handler: 'blob', id: 317, data: {text: 'JOHNSON: I think that one of the things we have to be mindful of and that’s most concerning to us going forward. There is a great deal of excitement about the fact that we may be getting at some '}},
{ timecode: 4501, handler: 'blob', id: 318, data: {text: 'of these issues of coverage in the near term as the nation starts to take a really close look and debate health reform and how to get the 45, 48 million Americans who are currently without coverage '}},
{ timecode: 4516, handler: 'blob', id: 319, data: {text: 'into the health care system. With S-CHIP being reauthorized we now have a shot at getting an additional 4 million children. That is already funded and they are starting to move forward with it. When '}},
{ timecode: 4529, handler: 'blob', id: 320, data: {text: 'we look at the system and the system’s capacity there are tremendous concerns because it is very difficult in the current status of things, that lack of providers and diminishing numbers of '}},
{ timecode: 4544, handler: 'blob', id: 321, data: {text: 'primary care providers and people going into primary care, the transportation difficulties and the other barriers that exist. What will the landscape look like when we have this tremendous influx of '}},
{ timecode: 4556, handler: 'blob', id: 322, data: {text: 'newly insured folks? How will the system handle that surge without any additional capacity being added? On the transportation side it is a significant challenge. If we have a new—unbelievable '}},
{ timecode: 4574, handler: 'blob', id: 323, data: {text: 'large cohort of kids coming into the system, how are they going to get to the doctor? How are we going to manage those situation that is already obviously under significant stress to add all of those '}},
{ timecode: 4588, handler: 'blob', id: 324, data: {text: 'additional new subscribers to the health care system? It is a real challenge. I think we will have to look at building capacity on the health care side but on the transportation side as well. It will '}},
{ timecode: 4601, handler: 'blob', id: 325, data: {text: 'be in our best interest to think about it now and figure out how we can plan to deal with it than to wait for the tsunami of newly insured to start demanding the access that they feel they have '}},
{ timecode: 4615, handler: 'blob', id: 326, data: {text: 'acquired in becoming insured. VALERIE MILLER: Dennis would you spell out S-CHIP for us. DENNIS JOHNSON: Well, they are not even saying S-CHIP now, they are just calling it CHIP because they are '}},
{ timecode: 4625, handler: 'blob', id: 327, data: {text: 'looking to federalize it in terms of—instead of it being the number of state programs they want it to just be known as a Child Health Insurance Program. Very much, this administration has made '}},
{ timecode: 4641, handler: 'blob', id: 328, data: {text: 'universal coverage for children one the main pillars of its health care agenda. So you say spell it out. Child Health Insurance Program. ROY GRANT: It picks up where Medicaid leaves off in terms of'}},
{ timecode: 4658, handler: 'blob', id: 329, data: {text: 'income eligibility. Its target is that group of families that are over the income threshold for Medicaid but are not at an income level where they can afford commercial insurance product out of '}},
{ timecode: 4671, handler: 'blob', id: 330, data: {text: 'pocket. AUDIENCE MEMBER: I had just a comment, partly on, it has gone past a few comments now. I come from an upstate rural New York county of about 646 square miles, population of about 110,000. Our '}},
{ timecode: 4690, handler: 'blob', id: 331, data: {text: 'Medicaid transportation is $1.2 million a year. It amazes me how there are any areas that don’t provide Medicaid transportation. And the good point that it has been challenged, our county '}},
{ timecode: 4708, handler: 'blob', id: 332, data: {text: 'adjacent to us does not provide it and why it is not being challenged, I still don’t understand. Back to the point, yes, we do provide that transportation and we are a very human side of it. '}},
{ timecode: 4722, handler: 'blob', id: 333, data: {text: 'Very often there will be a household with a vehicle, and if that household has a vehicle then Medicaid says no you can’t do it. But yes, the primary bread winner is using that vehicle and mom '}},
{ timecode: 4736, handler: 'blob', id: 334, data: {text: 'can say I have an emergency but I can’t take my child until dad gets home with the car or Medicaid should take them. The flip side of that is that Medicaid could say, well we will take you but '}},
{ timecode: 4750, handler: 'blob', id: 335, data: {text: 'you can only bring one child with you and that is the sick one. Well I have 4 other children that I have to leave behind, what do I do with them. There is a catch 22. Transportation, yes, it is '}},
{ timecode: 4762, handler: 'blob', id: 336, data: {text: 'needed. But there is a whole lot of other pieces that have to be addressed. Not to even mention the ones that are in a wheelchair and need all special types of transportation. ROY GRANT: What county '}},
{ timecode: 4774, handler: 'blob', id: 337, data: {text: 'are you in that provides the transportation? Ontario? DENNIS JOHNSON: I echo what you are saying. I agree that it is often complex. Now New York State in terms of Medicaid transportation is a good '}},
{ timecode: 4789, handler: 'blob', id: 338, data: {text: 'state. There is a—in fact—in many ways could probably do with some over site to reorganize some of the resources. Just on a personal note I will tell you, my grandmother, who is no longer '}},
{ timecode: 4807, handler: 'blob', id: 339, data: {text: 'with us but is still in my heart. She had a provider in Brooklyn that she was very fond of and needed to see on a regular basis, whether she had any medical need or not. There was kind of a, as you '}},
{ timecode: 4825, handler: 'blob', id: 340, data: {text: 'got on in years, she liked the social interaction. When he relocated out to Long Island, 60-70 miles away, she was able to get an ambulette to come and take her all the way out there on a regular'}},
{ timecode: 4837, handler: 'blob', id: 341, data: {text: 'basis. Now that’s an essentially a poor use of state dollars to maintain a relationship when there is one right down the street. So New York is—the Medicaid provider network in New York is '}},
{ timecode: 4856, handler: 'blob', id: 342, data: {text: 'very well funded and will remain so as long as, frankly, Medicaid network transportation providers are able to influence the political process. There really does need to be a rational look at how '}},
{ timecode: 4871, handler: 'blob', id: 343, data: {text: 'Medicaid dollars are spent for NEMT in places like New York. There also needs to be a more advocacy on the federal side to encourage states that don’t provide the benefit the way they ought to'}},
{ timecode: 4887, handler: 'blob', id: 344, data: {text: 'and doing so deny appropriate access to care for children and families. We are hoping that through some of the work we are doing that we will be able, if we can create—provide the empirical '}},
{ timecode: 4905, handler: 'blob', id: 345, data: {text: 'evidence that shows where the communities are most in need, both in terms of providers and in terms of transportation services and can highlight that need and demonstrate some effective interventions '}},
{ timecode: 4919, handler: 'blob', id: 346, data: {text: 'that bring in all the community stake holders and take it to congress and explain to them how this would be a good use of federal dollars as we expand the health care system to include many more '}},
{ timecode: 4933, handler: 'blob', id: 347, data: {text: 'people who are currently uninsured. If we are going to spend the money, let’s get the possible outcomes. Let’s make that money well spent and let’s bring them the evidence and get '}},
{ timecode: 4944, handler: 'blob', id: 348, data: {text: 'them to subsidize these types of efforts. Hopefully, at the end of the day, even though we are spending the money, people will have appropriate access and we will be getting better health care '}},
{ timecode: 4955, handler: 'blob', id: 349, data: {text: 'outcomes. That is the optimum outcome for all of this work and the advocacy that we intended. ROY GRANT: That’s the other evidence that we need to show. If Steve gets to some of that—some '}},
{ timecode: 4966, handler: 'blob', id: 350, data: {text: 'of our data on emergency department use that while this increases the cost to get people to ambulatory services, it saves money on the other side of ambulatory services which is urgent-emergent care '}},
{ timecode: 4980, handler: 'blob', id: 351, data: {text: 'which is way more costly. That is one where those of you that are doing non-emergency medical transportation if you can find a way to keep track of that, that can be enormously helpful. We know with '}},
{ timecode: 4996, handler: 'blob', id: 352, data: {text: 'adults if you manage somebody’s diabetes they are less likely to need—really drastic kinds of things like an amputation or that they would lose their eye sight or whatever. On the human '}},
{ timecode: 5009, handler: 'blob', id: 353, data: {text: 'level we know that but there are also tremendous costs that are associated with not having access to timely appropriate care on an as needed basis. Keeping track of that and costing it out is going to '}},
{ timecode: 5024, handler: 'blob', id: 354, data: {text: 'be really important to make the case that we should spend $1.2 million in a relatively small county for Medicaid transportation. VALERIE MILLER: We have more questions over here. Then I am looking at '}},
{ timecode: 5037, handler: 'blob', id: 355, data: {text: 'about time to wrap it up. But I think you all could take a couple of more questions during the break too. AUDIENCE MEMBER: Now my comments are like getting out of date here. How about right here? '}},
{ timecode: 5057, handler: 'blob', id: 356, data: {text: 'Good. Okay. First of all a ways back there I was thinking if we could get people to take—if the children could be treated for well child type visits at school instead of the emergency room. '}},
{ timecode: 5073, handler: 'blob', id: 357, data: {text: 'Wouldn’t that be a shift right there. I don’t know how feasible it would be but it seems like it could be. The other comment I was going to make though is that this kind of information and '}},
{ timecode: 5083, handler: 'blob', id: 358, data: {text: 'the kind of tools that you are developing here, I see as being useful to people who have coordinated planning groups and coordinated plans. I often hear that they’ve got a handle on the people '}},
{ timecode: 5098, handler: 'blob', id: 359, data: {text: 'with disabilities and the elderly needs for transportation. They are working on the work related rides but they don’t have a good handle on the young children and the women with young children. '}},
{ timecode: 5108, handler: 'blob', id: 360, data: {text: 'This has come up several times and kind of surprised me how much that is brought up. So, that is another group or place where the information could be valuable. I just wanted to make that point '}},
{ timecode: 5122, handler: 'blob', id: 361, data: {text: 'because earlier we were talking about who should know about this. ROY GRANT: The routine care is the least well served for transportation. Disabilities, mentally ill, elderly, it is a lot of the '}},
{ timecode: 5135, handler: 'blob', id: 362, data: {text: 'available transportation resources are specifically targeted. If it is early childhood it is to bring kids to Head Start, then the vehicle sits for 3 hours or 5 hours idle while the kids are in Head '}},
{ timecode: 5150, handler: 'blob', id: 363, data: {text: 'Start. As to your first comment about kids receiving acute health care services in school. School based health centers do a splendid job of doing that but they are not that well distributed around the '}},
{ timecode: 5162, handler: 'blob', id: 364, data: {text: 'country. They tend to be state initiatives. States have different degrees of commitment and funding to them. But it is a tremendous model. I don’t know what the status is in your state off hand '}},
{ timecode: 5175, handler: 'blob', id: 365, data: {text: 'but states like New York, Louisiana, Texas, there are a number of states that have rather large networks of school based health centers that are state funded. It really is a superb model for medically'}},
{ timecode: 5189, handler: 'blob', id: 366, data: {text: 'underserved kids who can have timely access. AUDIENCE MEMBER: Does it show less use of the emergency room. ROY GRANT: Yes, specifically the studies were done around asthma. It clearly shows reduced '}},
{ timecode: 5200, handler: 'blob', id: 367, data: {text: 'use of emergency rooms. But even in a pragmatic way, if a kid is wheezing and there are no medical resources in the school typically the kid sits in the principal’s office until somebody either '}},
{ timecode: 5211, handler: 'blob', id: 368, data: {text: 'takes him home or he is sent to the emergency room. If you have a school based health center, he goes there, he gets a nebulizer treatment and he is back in his classroom in 20 minutes and spends a '}},
{ timecode: 5220, handler: 'blob', id: 369, data: {text: 'productive day at school. DENNIS JOHNSON: Another problem with school based health center is that you run into—if you bring a comprehensive model into schools you run into opposition at the '}},
{ timecode: 5229, handler: 'blob', id: 370, data: {text: 'local area often around the reproductive health care services. Because you are now talking about providing, as kids get older, in middle school etc.., reproductive health services are often a sticking '}},
{ timecode: 5243, handler: 'blob', id: 371, data: {text: 'point in many communities. They don’t want birth control or that kind of stuff. Becomes a cultural issue. STEVE BORDERS: If I could add one more thing to that. This is sort of an anecdote in'}},
{ timecode: 5257, handler: 'blob', id: 372, data: {text: 'Texas. I was there back in the early 90’s when we were making the move from fee for service to managed care. You know once you begin capitating those, Texas really defunded all the school based '}},
{ timecode: 5271, handler: 'blob', id: 373, data: {text: 'health centers. Really wanted all health departments to be out of the business of delivering direct care services because they say well you know if we are going to get the private providers into this '}},
{ timecode: 5283, handler: 'blob', id: 374, data: {text: 'that they will be delivering the care rather than the school based health centers and these public health departments. What happens is that the private doctors are in these urbanized areas and they '}},
{ timecode: 5297, handler: 'blob', id: 375, data: {text: 'are not in the poor neighborhoods anymore which created another layer. Of course if you think about the way capitation works, you have already paid a doctor to provide service for someone. So what '}},
{ timecode: 5311, handler: 'blob', id: 376, data: {text: 'happened is that the school based health center, the local health department provide the well child checkup and then they will bill the state and they go we have already paid somebody to do that. They '}},
{ timecode: 5321, handler: 'blob', id: 377, data: {text: 'say if you want to be paid you need to talk to Dr. Smith who is the one who is this primary care provider for these children so it has created a huge problem. The pendulum is kind of swinging back as '}},
{ timecode: 5335, handler: 'blob', id: 378, data: {text: 'you see these FQHCs open again in Texas. I think that was the realization that the race to privatization and capitation has not worked. It has created a lot of problems. Of course at a state with 26, '}},
{ timecode: 5351, handler: 'blob', id: 379, data: {text: '27% without insurance you need these local health departments, the fairly qualified health centers to provide these direct care services. ROY GRANT: Just one brief comment. New York confronted the '}},
{ timecode: 5365, handler: 'blob', id: 380, data: {text: 'same problem very very differently. So people are interested in a successful financial model with respect to sustaining school based health center in a managed care Medicaid environment I can give you '}},
{ timecode: 5378, handler: 'blob', id: 381, data: {text: 'the details. It works very very differently in other states. DENNIS JOHNSON: Finally on capitation. Can you think of a sadder situation than having a capitated program being subsidized by your tax '}},
{ timecode: 5389, handler: 'blob', id: 382, data: {text: 'dollars where people who are enrolled in an insurance program cannot get to the doctor because of transportation? That money is going out the door on a monthly basis for services that are not being '}},
{ timecode: 5399, handler: 'blob', id: 383, data: {text: 'provided. That is actually a bad deal for states but poor use of public dollars to promote health care. That is one reason why we need to make sure that the transportation is there so that people can '}},
{ timecode: 5414, handler: 'blob', id: 384, data: {text: 'actually get to the doctor. VALERIE MILLER: I would like to thank Dennis, Roy, and Steve very much for this wonderful presentation. Let\'s give them a hand.'}},
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