Some things about wheelchair tipovers are easy to grasp by those not in the transportation field. But others would never dawn on the most brilliant attorney who is merely a mastermind expert in the law. One such parameter that accounts for almost all the tipovers in non-emergency medical service is the service provider’s reimbursement rate.
Even before brokers exploded onto the scene – between 20 and 30 years ago – for most common formula for a funding agency that engaged contractors to provide service to disabled individuals was $X/trip plus $Y/mile. This is the same formula paid to taxis. Except that taxis have meters. So when the taxi is not moving, the vehicle (part of this income goes to the driver) still generates income – just at a lower rate than when it is moving.
Non-emergency medical transportation (NEMT) services, which are now almost completely dominated by brokers (the largest of which are basically criminal enterprises), employ the same payment formula, even while their contract agreements with their funding agencies rarely require them to.
One salient characteristic of this approach is that the vehicle (and its owner) are not making any money unless the vehicle is moving – and usually only when the vehicle is moving with a disabled passenger on board. Helping an ambulatory or even semi-ambulatory passenger on board – even using the lift or ramp – takes very little extra time. The same is not so for a wheelchair user, since that passenger’s wheelchair must be secured to the vehicle – a task that can easily take five minutes, as it includes affixing the three-point occupant restraint to the user once his or her chair has been secured (at all four points, according to the industry standard).
Almost always insured (and carriers make a fortune investing their premiums in the stock market), and in a country where a huge percentage of the population has no values, and in an industry whose owners often have no values: Why do this? The company is not a charity. So why should the company effectively donate time to do something where, when it goes wrong, an insurance company pays the bill? This “why?” question explains not only why drivers are instructed not to secure wheelchairs, but it also explains why many NEMT system owners literally sabotage their securement systems so that no driver can secure a wheelchair even if he or she wanted to.
There actually are remedies to this problem. The simplest would appear to be paying owners by the hour for the use of their vehicles. Many NEMT brokers argue vehemently against this, claiming that paying a service provider by the hour yields no incentive to provide the service efficiently. Since funds for NEMT service run from a Federal healthcare agency (Health and Human Services) to a healthcare agency at the state, county or municipal level, the officials in these agencies buy off on this nonsense because, even if they could spell “monitoring” forwards, they barely know what it means, have no idea how to do it to watch over the service providers they engage, and would not care about these even if they did know how.
In the past – from roughly 1965, when MediCare and Medicaid were enacted, to roughly 2000 – when there were no brokers, most of the money spent on NEMT service was simply wasted: Service providers submitted fraudulent invoices (often known as “Trip Authorization Requests,” or TARs) to the funding agencies, and he funding agencies simply paid them. Otherwise, when service providers were actually assigned trips intelligently (or before the era of brokers, when they built up their density of passengers by providing excellent on-time performance), many service providers picked up a handful of passengers and, instead of taking them to or from their destinations with reasonable ride-times (yet still efficiently enough to earn them a handsome profit, since rates were designed for share rides), they then drove them around in circles for a couple of hours, and ten dropped them off. This was, at say, $3.00/trip and $2.00/mile, with a lot of time spent speeding on freeways, a service provider could earn hundreds of dollars per hour with its vehicles. With no ability to monitor whether trips were even provided, these agencies got bilked – as did the taxpayers financing these services in the Deep State.
Brokers actually tunneled their way into prominence in this sector of public transportation by claiming that they could “police” phantom trips. In my experience reviewing their data, they appear to often accomplish this task. At the same time, they consume most of the budget by doing absolutely nothing, claiming that they can manage the system through the collection and submittal of reports (which they often do not submit, sometimes for years). Plus some of them racketeer their service providers – who actually provide the trips – out of the small percentage of the budget left for them after the brokers have effectively stolen the bulk of the transportation funds.
The answer, or course, is not brokers. The answer is to, first, place this form of transportation in the hands of at least a transportation bureaucracy, not a healthcare bureaucracy. The next step is to monitor what the service providers they select actually do – prioritizing it by (a) safety, (b) reliability (i.e. measured on-time performance) and (c) efficiency. For the latter, the now-transportation agency would have to know how to design a demand-responsive system (which almost no one in the country can now do, after decades of relying on software to do this). Regardless, there are countless ways to monitor service.
In one of his lesser-known books, Puddin’head Wilson, Mark Twain wrote that, “Only a fool is afraid to put all his marbles in one basket. A wise man puts all his marbles in one basket and watches the basket.”
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