The authors of “Rideshare Transportation to Health Care: Evidence From a Medicaid Implementation” respond to a letter to the editor.
Am J Manag Care. 2021;27(7):In Press
We appreciate the opportunity to address Lyft’s concerns with our study on rideshare-based nonemergency medical transportation (R-NEMT). Our study found that a higher proportion of rideshare trips was not associated with ride quality but was associated with reporting late and failed pickups—potentially affecting health care access.1 Lyft’s letter criticizes our methodology and internal/external validity, which we will address here. It is important to note that although we studied a program with similarities to Lyft, Lyft was not involved. Overall, readers should recognize that our study was conducted within the scope of evaluation research using the best data and measures available, while noting its limitations. Moreover, our article appears to have achieved one of its primary goals: to contribute to a dearth of published literature on R-NEMT and promote discussion on the topic.
Lyft indicates that its experience and previous studies have found a positive relationship with R-NEMT and health care access. Indeed, our article highlights extant findings but also cites the mixed results in peer-reviewed literature and a limited number of studies reporting outcomes. One study cited by Lyft found fewer missed primary care appointments among R-NEMT compared with usual care.2 However, when scaled up to a larger study, R-NEMT was not associated with fewer missed appointments.3 The other source cited in Lyft’s letter was a short blog post, which lacks crucial information, including methods and measures, to assess the validity of the findings.4
Lyft’s letter implies that our findings lack external validity because the program was not administered by a large national rideshare company and is therefore not representative. An alternative view is that these evaluation findings add a valuable perspective: Not all R-NEMT is provided by large national companies, so we should not dismiss research on R-NEMT implementation within smaller rideshare companies.
Another concern was the absence of trip-level outcome data, a valuable component of specific trip analysis; however, data required for such an analysis were unavailable. Rather, we focused on perceptions of ride quality and access as part of a statewide NEMT evaluation. Our study employed a survey using common measures of perceptions in transportation and health care literature.5 Importantly, we described in our paper1 how such perceptions may be associated with an individual’s willingness to use NEMT. We argue that it is not only the individual-trip experiences that affect perceptions but also the cumulative experiences of the NEMT service. This is not a case of ecological fallacy but a difference in research aims.
Lyft’s letter suggests that it was inappropriate to compare consumers who use R-NEMT and traditional NEMT because some may have different needs. Yet, our study accounts for many of those needs by including factors such as age, mobility, and developmental disabilities. We also note that 29% of the people who use manual wheelchairs or powerchairs did have at least 1 rideshare trip, suggesting that excluding them from the analysis (as indicated by Lyft) is not appropriate. Additionally, Lyft suggests that the R-NEMT categories we used in our analysis were too coarse and that our attempt to control for potential confounding using “total trips” was insufficient. We disagree: “Total trips” is a valuable confounder that controls for frequency of rides. Additionally, we ran models (not shown here) with a continuous variable instead of the R-NEMT categories and found similar results.
High-quality R-NEMT research is needed. We call on rideshare companies and state Medicaid agencies contracting with them to facilitate experimentation through independent research evaluations. Specifically, there is a need for longitudinal research that employs randomized controlled trial or quasi-experimental design. Nonetheless, there is value in nonexperimental cross-sectional designs, especially to inform this burgeoning area of R-NEMT evaluation.
Author Affiliations: Department of Disability and Human Development, University of Illinois at Chicago (YE, CC), Chicago, IL; College of Education and Human Development, University of Nevada (RO), Reno, NV.
Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (YE, RO, CC); drafting of the manuscript (YE, RO, CC); critical revision of the manuscript for important intellectual content (YE, RO, CC); statistical analysis (YE); obtaining funding (RO); administrative, technical, or logistic support (YE, RO, CC); and supervision (YE, RO).
Address Correspondence to: Yochai Eisenberg, PhD, Department of Disability and Human Development, University of Illinois at Chicago, 1640 W Roosevelt Rd, MC 626, Chicago, IL 60608. Email: firstname.lastname@example.org.
1. Eisenberg Y, Owen R, Crabb C, Morales M. Rideshare transportation to health care: evidence from a Medicaid implementation. Am J Manag Care. 2020;26(9):e276-e281. doi:10.37765/ajmc.2020.88492
2. Chaiyachati KH, Hubbard RA, Yeager A, et al. Rideshare-based medical transportation for Medicaid patients and primary care show rates: a difference-in-difference analysis of a pilot program. J Gen Intern Med. 2018;33(6):863-868. doi:10.1007/s11606-018-4306-0
3. Chaiyachati KH, Hubbard RA, Yeager A, et al. Association of rideshare-based transportation
services and missed primary care appointments. JAMA Intern Med. 2018;178(3):383-389. doi:10.1001/jamainternmed.2017.8336
4. Powers B, Rinefort S, Jain SH. Shifting nonemergency medical transportation to Lyft improves patient experience and lowers costs. Health Affairs. September 13, 2018. Accessed December 8, 2020. https://www.healthaffairs.org/do/10.1377/hblog20180907.685440/full/
5. About CAHPS. Agency for Healthcare Research and Quality. Accessed December 8, 2020.