Non-emergency medical transportation practice in Shanghai

NEMT operating environment in China’s mainland

Policy context

From the websites of local Health Commissions on China’s mainland, we collected relevant NEMT policies. By July 2021, 12 (38.70%) provinces and 35 (11.95%) prefecture-level cities had issued policies and regulations to support the market operation of NEMT. Most of these provinces and prefecture-level cities are more developed and located in the east part of China. With the prominent contradiction between supply and demand of NEMT, more province-level and city-level policies will be developed and improved. Although quite a few provinces or cities issued NEMT-related policies, there were no NEMT standards to regulate the business before 2022. The quality of NEMT services varied among providers, with various internal standards if they existed.

NEMT used to be a service provided by the local emergency medical centers (EMC) belonging to public institutions, and the 2013 policy ‘Management Approach of Pre-hospital Medical Emergency’ does not specify what kind of entities should conduct NEMT business and how it will operate. Most provinces and cities have explored their own business models, and 45 cities have been piloting NEMT services since 2013; more than half of the cities are from Guangdong, Jiangsu, and Shandong Provinces. In the way that 120 is used as an emergency call number throughout China’s mainland, similarly, some cities or areas such as Shanghai, Tianjin, Nanjing, Qingdao, Hangzhou, etc., used unified NEMT service numbers.

Operating environment

There were over 5000 companies running NEMT businesses up to July 2022, according to Qichacha. Most NEMT companies were founded in 2020 and 2021, with about 60% being founded in 2020. Over 70% of these companies belong to the national industries of health and social work, and the remaining companies are widely distributed in the industries of resident services, repairing and other services, transportation, warehousing and postal services, and wholesale and retail services.

Guangdong province owns half of the NEMT companies, followed by Shandong province (around 10%) and Jiangsu province (around 8%).

After analysis, we identified three core-operating types of NEMT services: 1) a NEMT department under the local EMC; 2) a NEMT company running independently; and 3) a unified NEMT service platform integrating local private companies.

Type 1: a NEMT department under the local EMC. In some cities, such as Shanghai and Tianjin, the NEMT department was created as a branch of the local EMC. The critical feature of this type is that NEMT is owned and operated by nonprofit local EMCs, and NEMT’s special calling line is set up under 120 command and dispatch centers.

Type 2: a NEMT company running independently. NEMT companies can be state-owned enterprises, private medical institutions, or other private enterprises. These companies can operate independently with their own service calls, APPs, mini-programs, etc. Some provinces or cities, such as Ningxia Hui Autonomous Region, have allowed the operation of private enterprises approved by local administration for market regulations; however, others, such as Hubei Province, need them approved by not only local administration for market regulations but also health commissions as well. Some provinces or cities have also ordered that NEMT personnel should accept the training provided by the local medical emergency center and obtain a first-aid certificate.

Type 3: a unified NEMT service platform integrating local private companies. The unified NEMT service platform, such as the NEMT Service Platform of Qingdao, has incorporated qualified NEMT companies, uses consistent service specifications and charging systems, and provides one unified service phone number, APP, official account, and mini-program.

NEMT service environment in Shanghai

Shanghai is the most advanced city in China, and is a city with the highest degree of population aging. According to statistics, the population of residents aged 65 and above has exceeded 4 million, accounting for 16.3% of the total population (https://www.shanghai.gov.cn/nw12344/20210518/001a0cef127c499eb381fa8dc3208e95.html).

In 2020, the total number of medical visits to Shanghai medical institutions was over 240 million, with outpatient and emergency visits reaching more than 216 million, and inpatient surgeries exceeding 3 million (http://wsjkw.sh.gov.cn/tjsj2/20210426/eb18f046dea54e129bd3acb3dfbc95cc.html). As the largest destination for medical treatment in China, Shanghai has accepted approximately 0.14% of medical visits by patients from other regions. According to the statistics from the National Health Commission, there were more than 370 thousand patients outside Shanghai in 2016.³

Shanghai has over 980 ambulances and 175 first-aid stations by 2020 (http://wsjkw.sh.gov.cn/rdhy/20200428/6a533e9e7cd24f56a86cc0e1ac8ee470.html). The average service radius has been shortened to 3.5 kilometers, and the average first-aid response time was within 12 minutes in April 2021. In 2020, Shanghai EMC completed over 19 million kilometers of pre-hospital first aid throughout the year, with 921 thousand first-aid deliveries.

In 2018, Shanghai EMC set up a NEMT service line for the public, with 30 NEMT vehicles from the beginning and 50 by the end of 2021, providing around 100 thousand NEMT trips per year (accounting for about 12–16% of emergency services) (https://wsjkw.sh.gov.cn/rddbjydf/20200629/0b24f845d350437891db0080c79c28a6.html). Previous research has shown that the percentage of NEMT in total trips of local EMC varied from over 10% to 60%, and it was about 30% in Shanghai.^1,2 There is still a considerable gap between NEMT supply and demand. Private institutions have a great opportunity to enter this big market.

Furthermore, NEMT provided by Shanghai EMC serves only residents who live in the Shanghai area. A certain number of patients living outside Shanghai have to depend on other NEMT vehicles.

Data source

We conducted this study at a professional NEMT company, which is the first government-approval private NEMT company in Shanghai. The company received the NEMT service approval from a district health commission of Shanghai in December 2019 and began to operate in August 2020. After nearly half a year of trial operation with three NEMT vehicles, the company became officially operational in March 2021 with 10 NEMT vehicles, and all the crew members were trained and certified by Shanghai EMC.

The operation database of the company consists of about 5000 trips with longitudinal data, including transportation time, departure address, destination address, hospital type, and transportation type.

Statistical analyses

The data for this study were collected from March 2021 until February 2022, with a total of 3426 trips. The data were populated into Excel first, and then transferred to and checked in SPSS version 21 (RRID:SCR_002865). Descriptive statistics were used to explain the characteristics of NEMT trips. Log-linear analyses were performed to check the difference in the transportation type between groups of trips inside Shanghai and trips to/from other areas.

Geographic characteristics of departure or destination locations

Of the 3426 trips in this study, there were 2962 trips inside Shanghai (86.5%) and 464 trips to/from other areas (13.5%). Departure or destination locations of trips to/from other areas covered nine provinces, with 315 trips (9.2%) to/from Jiangsu province, 77 trips (2.2%) to/from Zhejiang province, and 42 trips (1.2%) to/from Anhui province (Figure 1). The number of trips to/from each province is related to the distance to Shanghai. There were also 53 trips to/from Shanghai railway station or airport. That means some patients from other areas used not only NEMT services but also long-distance public transportation such as flights or trains to travel to/from medical institutions in Shanghai.

Figure 1. Geographic distribution of transportation.

Transportation types

We grouped transportation types into discharge, admission, referral, and others. The leading transportation type of trip was referral (1881, 54.9%), followed by discharge (1312, 38.3%). The smallest portion was others (59, 1.7%), which included trips where neither the departure nor destination location was medical institutions, such as trips from homes to nursing institutions, stations to homes, etc. (Table 1). With regards to trips inside Shanghai, referral accounted for most trips (1736, 47.6%), about 1018 trips were for discharge (34.4%), 157 (5.3%) were for admission, and about 51 (1.7%) trips served other purposes; In trips to/from other areas, most trips were for discharge (294, 63.4%), followed by 145 (25.2%) for referral, 17 (3.7%) for admission, and 8 (1.7%) for others.

When comparing transportation types between trips inside Shanghai and to/from other areas, there was a significant difference (χ²=144.87, p<0.001). According to log-linear analysis, transportation types of discharges and referrals were the most significantly different types, with a significantly larger proportion of trips for discharge to/from other areas, and a significantly larger proportion of referrals for trips inside Shanghai.

The transportation type of referral has been further classified, as referral has different modes. For trips inside Shanghai, we classified referrals into downward referral, upward referral, and same-level referral. Downward referral often means patients in an upper-level hospital who have reached the convalescent or stable stage and can be transferred to a lower-level hospital. Upward referral refers to patients with critical or complicated diseases in a lower-level hospital who can be transferred to an upper-level hospital. Same-level referral refers to patients who may be transferred between same-level hospitals to different departments or hospitals with different specialties. There were 1736 referral trips, and most of the trips were downward referral (1410, 81.2%), while trips in upward referral and same-level referral shared almost the same numbers with 166 (9.6%) and 160 (9.2%), respectively.

In the group of trips to/from other areas, we classified referrals into referrals to Shanghai and referrals from Shanghai, for it is difficult to evaluate the medical level of hospitals between different areas. Most of the trips in referral type were referrals from Shanghai (136, 93.8%), and there were only eight trips in referrals to Shanghai (5.5%) (Table 2).

Transportation to/from Class A tertiary hospitals

Class A tertiary hospitals (3A hospitals) are the highest level medical institutions classified in accordance with the Administrative Measures for Hospital Classification in China. Admissions, discharges and referrals are transportation types whose departure or/and destination locations are hospitals. A total of 3367 trips were the types of admission, discharge and referral, and 2558 (76.0%) trips involved 3A hospitals (Table 3).

In trips inside Shanghai, there were 2189 (75.2%) trips to/from 3A hospitals, of which 82 (52.2%) were trips for admission from homes to 3A hospitals, 686 (67.4%) were trips for discharge from 3A hospitals to homes, and 1421 (81.9%) were trips for referrals to/from 3A hospitals. In trips to/from other areas, there were 369 (80.9%) trips to/from 3A hospitals, of which 16 (94.1%) were trips for admission from homes to 3A hospitals, 231 (78.6%) were trips for discharge from 3A hospitals to homes, and 122 (84.1%) were trips for referrals to/from 3A hospitals.

In trips to/from other areas, there were 24 (96.0%) trips to 3A hospitals in Shanghai including 17 trips for admission and 8 trips for referral to Shanghai. One trip was to a hospital outside Shanghai (Table 3).

Six 3A hospitals with the highest number of trips are listed in Figure 2. There were 2366 trips to/from the six hospitals, accounting for 70% of total trips for admission, discharge and referral. The first three 3A hospitals with the highest number of trips in both groups of trips inside Shanghai and trips to/from Shanghai were the same: Shanghai 6th People’s Hospital, Zhongshan Hospital, and Changzheng Hospital, and the proportion of trips to/from them surpassed half of the total trips involving hospitals (64.7%).

Figure 2. The six 3A hospitals with the highest number of trips.

Trips to/from the Shanghai 6th People’s Hospital were the largest proportion (42.8%). The most featured department in both Shanghai 6th People’s Hospital and Changzheng Hospital was orthopedics. When interviewing NEMT dispatchers and escorts, we received the experienced information that about 80–90% of the patients were for orthopedics, followed by cardio-cerebrovascular disease and neurology.

Findings

Many countries have mature NEMT markets with national or local service standards and regulations. NEMT services are quite different among these countries. In the USA, NEMT often means rides for Medicaid-eligible individuals to and from the doctor’s office, the hospital, or another medical office for Medicaid-approved care (https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Non-Emergency-Medical-Transport), and NEMT vehicles might be wheelchair vans, taxis, stretcher cars, and buses, depending on the patient’s needs and State rules (https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/nemt-booklet.pdf). In Australia, NEMT generally refers to trips provided for persons to or from medical services using a stretcher-carrying vehicle, with specialist clinical care or monitoring, and the NEMT rides should be authorized by the State Ambulance Service (https://www.qld.gov.au/seniors/transport/transport-assistance/non-emergency-medical-transport, https://www.health.tas.gov.au/professionals/non-emergency-patient-transport#eligibility-requirements-for-nept-services, https://www.legislation.vic.gov.au/in-force/acts/non-emergency-patient-transport-act-2003/014). In China, the definition of NEMT varies slightly among provinces and cities, however NEMT vehicles are similar among provinces and cities. NEMT was defined as trips from medical institutions to non-medical institutions requiring special vehicles without any medical actions in the report ‘Implementation Opinions on Improving the Classification of the Pre-hospital First Aid System in Shanghai’ (http://wsjkw.sh.gov.cn/yzgl3/20180815/0012-59762.html). The special vehicle often means disabled transfer vehicles such as wheelchair or stretcher-carrying vans. NEMT vehicles used in China are consistent with those in Australia.

We have analyzed the operation data of the biggest private NEMT company in Shanghai, and the results would be valuable for promoting NEMT service capabilities in Shanghai.

The company completed a total of 3426 trips from March 2021 to February 2022, and the figure accounted for about only 3.4% of those by Shanghai EMC. The operation is not at full capacity for the following reasons: 1. residents are prone to trust the government-owned NEMT department; 2. the NEMT department in Shanghai EMC with government subsidies provides a much more competitive price; and 3. NEMT is still a new service that lacks public awareness.

Shanghai has always been the city with the highest influx of patients from other provinces, and tertiary hospitals accepted over 2.4 million patients outside Shanghai in 2019, accounting for 40.12% of total migrant patients in China. Among 3426 total trips, there were 2962 trips inside Shanghai (86.5%) and 464 trips to/from other areas (13.5%). The top three provinces with the largest number of trips to/from outside Shanghai were Jiangsu, Zhejiang, and Anhui, and the finding is consistent with statistical results from National Health Commission.³ Other provinces included Jiangxi, Fujian, Henan, Shandong, Hebei, and Hainan. The number of trips between other provinces and Shanghai is related to the distance, and Jiangsu has the most cities closest to Shanghai, followed by Zhejiang and Anhui. The longest trip was to Hainan, a distance of more than 1300 miles.

The leading transportation type of trip was referral (1881, 54.9%), followed by discharge (1312, 38.3%), and admission (174, 5.1%). The smallest proportion was others (59, 1.7%). Over 90% of the trips were for referral and discharge. The number of trips for referral exceeded those for discharge, and the ratio of referral to discharge (54.9:38.3, 1.43) was consistent with previous figures from transportation statistics of Shanghai EMC in 2010 (23.4:17.9, 1.31).⁴ This ratio was quite different from those in other cities such as Qingdao (14.0:29.6, 0.48), Suzhou (34.8:65.2, 0.53), and Wuhan (21.4:54.3, 0.39) between 2014 and 2018.^2,5,6 In the latter cities, the number of trips for referral was far below that for discharge.

Although China has advocated tiered diagnosis and treatment since 2006, when ‘Guidelines on the Development of Urban Community Health Services’ was issued by the State Council (http://www.nhc.gov.cn/wjw/gfxwj/201304/df3e35e26b3a4f5987bd898ddce70404.shtml), patients are more willing to visit tertiary hospitals and be discharged from them when completely recovered, as tertiary hospitals provide a higher quality of medical resources and better medical services, leading to more NEMT trips for discharge than for referral. The ratio results in Qingdao, Suzhou and Wuhan have revealed patients’ choices during 2014–2018. With the further implementation of ‘Guidelines on Promoting the Construction of Hierarchical Medical System’ issued by the State Council in 2015 (http://www.nhc.gov.cn/cms-search/xxgk/getManuscriptXxgk.htm?id=c30041e1016a427f9477774c9e864eb4), trips for referral might gradually increase.

Unlike many other cities in China, Shanghai has begun to create medical alliances since 2003, and most of the 3A hospitals established hospital groups or consortiums with medical institutions in 10 districts and suburban counties around 2006. Referrals among medical alliances have been much more frequent than in other cities. Efficient implementation of medical alliances reduces the length of stay and promotes bed turnover rates. According to statistics in 2018, the average length of stay in tertiary hospitals in Shanghai was 6.4 days, far below the figure in tertiary hospitals nationwide (9.1 days). This may explain the reason why there are more NEMT trips for referral than for discharge in Shanghai.

There was a significant difference between groups of trips inside Shanghai and trips to/from other areas, with more trips for referral in Shanghai, and more trips for discharge to/from other provinces. Part of the reason was that most patients from other provinces received therapy from 3A hospitals in Shanghai then transferred to a rehabilitation hospital within 3A hospital alliances to achieve full recovery before going back home, and these data were grouped into trips for referral inside Shanghai.

There were 2558 trips with 3A hospitals as departure or destination locations, accounting for 76.0% among 3367 trips for admission, discharge, and referral. With regards to trips for admission, about half of the Shanghai patients visited 3A hospitals, while almost all the patients from other provinces were admitted to 3A hospitals in Shanghai. Although 3A hospitals are of the highest level among all the medical institutions in China, medical quality is quite different among 3A hospitals across the nation. Top level 3A hospitals are mainly located in Beijing, Shanghai, Guangzhou and some coastal regions, and 11 of the best 50 3A hospitals are in Shanghai. Therefore, patients from other provinces would rather spend more on transportation and accommodation to seek the best medical treatment in Shanghai.

Although the company did not collect trip purposes at this time, we can infer from the hospital specialty and the experience of dispatchers and escorts that the three leading primary purposes for patients who requested NEMT were for the departments of orthopedics, cardio-cerebrovascular, and neurology disease. This finding is quite different from that of a study in the USA.⁷ The research in the USA found that the leading primary trip purposes were for dialysis, doctor visits, substance use, and mental health. Over 77% of round trips were for travelers who required no assistance devices, and no more than 4% required a stretcher. Almost all the NEMT vehicles in China are stretcher vans, and patients themselves pay for transportation expenses; as a result, only disabled passengers or those who cannot move request NEMT services, while the types of NEMT vehicles in the USA are much broader and passengers have their transportation fee paid by Medicaid. Therefore, any patients with Medicaid can use NEMT to/from medical institutions.

Limitations

We must acknowledge the limitations associated with this study that hindered our ability to achieve more valuable and accurate results. First, it is important to note that we extracted data from a newly operated company and their data repository was not complete enough to reveal the complete transportation characteristics. The analyses are somewhat limited as the patients’ age, gender, trip purpose, required equipment, and trip distance were not available. Previous research has shown that one of the priorities for an NEMT vendor is data driven. Inadequate data collection may lead to unknown patient profiles and needs, and unknown NEMT influence on patient satisfaction, hospital bed turnover, clinical results, and financial outcomes.⁸

Without patient profiles at this time, we can only compare trips inside Shanghai with trips to/from Shanghai, as patients from other provinces might transfer between hospitals in Shanghai for further rehabilitation. Therefore, the data could not accurately represent the patients from other provinces.

Implications for practice

Given the findings and limitations, there are some practical implications for both policymakers and NEMT companies. First, standardization of the NEMT process would be both valuable and easy to implement as an intervention for reducing risk and increasing efficiency.⁹ NEMT practitioners have begun to realize the importance of developing NEMT-related standards, and two social organization standards for NEMT service specifications have been issued since May 2022 (http://www.ttbz.org.cn/StandardManage/Detail/65630/; http://www.ttbz.org.cn/StandardManage/Detail/60985/). It may be a good beginning to initiate a series of standards for process, vehicles, personnel, etc.

Second, NEMT in China is a service entirely paid for by the patients, and, because the expense is much higher than a taxi service, only patients with severe fractures, neurological diseases, or cardiovascular diseases who are limited in mobility use NEMT; however, there are other health-care needs that are prevalent among people with transportation disadvantages including dialysis, prenatal care, cancer treatment, and mental health and substance-use treatment.¹⁰ Medical insurance that partially covers NEMT would benefit patients with a broader spectrum of diseases by allowing them to access health care more efficiently and smoothly.

Third, to lower the NEMT service costs, companies could initiate rideshare services. In the USA, although NEMT is an important Medicaid benefit, it confronts service and funding cuts, strict enrollment, and various restrictions. Rideshare-based medical transportation (RMT) has become an NEMT alternative that may provide cost reduction and flexibility for riders. Rideshare companies such as Uber and Lyft extended their business to include NEMT around 2016, and more states accept rideshare services as NEMT alternatives.^11,12 In China, rideshare services have not entered NEMT yet, and operating RMT may be hindered by two main reasons. The first reason is that most NEMT vehicles are stretcher vans to take patients with mobility disabilities, and they may have no extra space to pick up more passengers. Even Rideshare services in the USA do not provide rides to passengers using wheelchairs/stretchers. The second reason is that, as most passengers are also patients, they might feel upset sharing a vehicle with other patients. To be initiated, RMT services need to extend vehicle types or revise current vehicles available for more passengers, and arrange shared passengers according to their disease types, avoiding passengers having to share vehicles with patients with certain diseases.

Fourth, almost all the patients from other provinces go to visit 3A hospitals in Shanghai for it provides the highest-level medical diagnoses and treatments; however, the best medical resource has been accessed mostly by patients from surrounding areas, and patients from many inland areas can hardly gain access because of the cost burden and transportation barriers. With all the difficulties, patients with serious or complicated diseases would like to find the best medical hospitals. The rapid development of high-speed trains with much lower expenses than flights makes it possible for patients who live far away from Shanghai to be admitted to medical hospitals in Shanghai. High-speed trains significantly reduce transportation time, and NEMT companies could extend transportation to combine high-speed trains with NEMT vehicles; that is, at departure locations, NEMT vehicles could bring patients to the high-speed train station, and escorts could help patients with wheelchairs/stretchers into carriages and through the train transportation. After arriving at the destination station, escorts could help deliver patients to NEMT vehicles and finally bring patients to destination locations. The NEMT company in this study has begun to operate high-speed trains plus NEMT services and successfully finished one Shanghai to Beijing transportation business within 5.5 hours, compared with more than 13 hours with NEMT vehicles only.

Preregistered data analysis

The authors did not preregister the research at an independent registry.