Obligations, Opportunities and Pitfalls: A National Perspective on

the Free/Charitable Clinic Sector in the Reform Era

Statewide Meeting of Tennessee’s Charitable ClinicsMay 30-31, 2013

Nashville

Mark R. Cruise, MDiv, PrincipalFree Clinic Solutions

About Free Clinic Solutions National firm, established in 2006 in

Richmond, VA and now based in St. Petersburg, FL

Provides full-service consulting, training and technical assistance, research, health policy analysis, and planning facilitation

Exclusively serves free/charitable clinics, their associations, and partners and vendors who support them

FCS consultants have extensive experience in free/charitable clinics and the health care safety net

70+ organizations served since inception

March 2010 October 2010

Health Care Reform in America

ACA Has Sparked Many Reactions and Responses in Our Sector

The ACA and Free/Charitable Clinics ACA is the most significant public policy

development our sector has ever faced ACA stands to reduce the non-elderly

uninsured population from 18.9% to 8.7% in the U.S. , and thus make a major dent what has been our sector’s single greatest raison d’êtres

There are no mandates, but if free/charitable clinics are “gap-fillers” (Julie Darnell), what will be the new gaps clinics tackle post ACA?

But we have a big problem…

OUR BIGGEST PROBLEM!!

Those who have previously supported our clinics (e.g. donors, funders, volunteers, and partners) are starting to abandon our cause because they are assuming the ACA will eliminate the need for our clinics, and they are not hearing any messages from us to the contrary.

OBLIGATION #1:Make Sure Your Supporters Know There’s Still a Need for Your Clinic

and You Are Not Closing Your Doors

Sample Statement (for website homepage, newsletters, presentations, annual reports, etc.)

Many are asking about the future of our clinic in light of the Affordable Care Act. As with other health care organizations, we have sought to understand the Act – its provisions, its implementation in our state, and its likely impact on safety net providers and those they serve. We have concluded that for the foreseeable future thousands of residents in our community will continue to lack access to affordable health insurance and health care. Thus the demand for our clinic and others like it remains substantial. If you would like more information about our analysis of this issue, please let us know. Your continued support is much appreciated!

OBLIGATION #2: Plan to Be Part of

ENROLL-o-rama!

o-rama: suffix meaning "spectacular display or instance of," 1824, abstracted from panorama, ultimately from Greek horama [ὅραμα] "sight."

Source: Kaiser Commission on Medicaid and the Uninsured, 2010

o Uninsured adult Americans are more than twice as likely to delay or forgo needed care compared to adults with health insurance.

o Uninsured adult Americans are nearly twice as likely to be in poor health compared to adults with health insurance.

o Uninsured adult Americans are three times more likely to not be able to pay for basic necessities because of their medical bills compared to adults with insurance.

If Insurance Makes a Difference, We Need to Get People Enrolled!

Source: Enroll America, 2013

18Source: Enroll America, 2013

Coverage Expansions and Enrollment Assistance by Free/Charitable Clinics

If history is any guide, the free/charitable clinic sector will play a vital role in helping people get enrolled in the newly-available coverage

Examples are S-CHIP (State Children’s Health Insurance Program) in mid 1990’s and Medicare Part D in mid 2000’s

In various parts of the country, some in the sector got funding to pay for this service

OBLIGATION #3:Consider the Remaining Uninsured

Who Will Be Left Behind by the ACA!

1 in 10 U.S. Residents Will Still Be Uninsured Following Implementation of the ACA

Source: Congressional Budget Office

Individuals Exempt From the Mandate• Those whose required contribution to self-only coverage in

a health insurance plan exceeds 8% of household income• Those whose household income is less than the filing

threshold for federal income taxes for the applicable tax year

• Undocumented immigrants and those who have been naturalized for 5 years or less

• Those without coverage for less than three months (“churn”)

• Those with qualifying religious exemptions• Those who are part of a health care sharing ministry• Members of an Indian tribe• Incarcerated individuals

Source: Avalere State Reform Insights, May 14, 2013

Why Some People Will Choose to Pay Penalty and Remain Uninsured Initially

Subsidies and cost-sharing for people between 100-250% FPL will be more generous than for those between 250-400% FPL

Penalty taxes (for not buying health insurance) are very nominal in the beginning:

• $95 or 1% of income in 2014• $325 or 2% of income in 2015• $695 or 2.5% of income in 2016• Increases with cost-of-living

starting 2017

Distribution of the Uninsured After ACApre-SCOTUS rulings

Source: Robert Wood Johnson Foundation, 2011

How Many People Will Benefit from the ACA in Your Community, and Who

Will be Left Behind?

That sure would be good to know right now, as well as

who the remaining uninsured will be and what their

demographic profile is.

Some of the Uninsured Will Be Those in the “Churn”

o Within six months, it is estimated that nearly 40 percent of adults under 133% FPL will experience a disruption in their Medicaid coverage due to changes in income or family composition.

o After 12 months, 38 percent would no longer be Medicaid-eligible, and an additional 16 percent would lose and regain Medicaid coverage. After four years, only 19 percent of adults would be continuously eligible for Medicaid.

o Among adults with incomes between 133 and 200 percent FPL who would be eligible for premium subsidies under the ACA, only 31 percent would remain continuously eligible for subsidies over four years, and many would have experienced multiple disruptions in coverage.

Source: Benjamin D. Sommers and Sara Rosenbaum, Health Affairs, 2011

OBLIGATION #4:Make Sure Your Board Governance is Positioned to Address Strategic

Issues in the ACA Era

As Health Care Reform Implementation Unfolds, Effective Clinic Boards…

Ensure that their governance process allows them to focus more on the strategic than the tactical

Actively solicit information and expert analysis on the implications of ACA on the community, the clinic, and its patients

Engage in meaningful dialogue with other community stakeholders and decision-makers

Make careful, informed judgments and decisions about changes in future purpose and role

OBLIGATION #5:Commit to Whole-Person Care and

Health Improvement

Whole Person Care

The whole-person approach does not depend on the bio-medical model alone but seeks to integrate the best from the

bio-medical approach with social science, psychology and other appropriate models

of humanity, including spirituality.

Illness = disease + person

Determinants of Health

Source: World Health Organization, 2009

IMPLICATIONS FOR CLINICS Integrate an emphasis on

weight loss, healthy eating, and overall fitness into the clinic delivery system

Develop partnerships with local fitness trainers and facilities (e.g. YMCA) to facilitate patient access to programs

Build, model, and reinforce a culture of health, weight control, and fitness among clinic staff and volunteers

Church Health Center - Wellness Center Memphis

OBLIGATION #6:Help Develop the Next Generation

of Primary Care Providers

Source: U.S. Senate Sub-Committee on Primary Health and Aging, 2013

TN IS 20th WORST PREPARED STATE IN TERMS OF NUMBER OF PRIMARY CARE PHYSICIANS TO TREAT NEW MEDICAID ENROLLEES UNDER HEALTH CARE REFORM

Source: George Washington University, 2011

Primary Care Training Partner with medical schools,

residency programs, and other health professional training programs

Offer your clinic for community health rotations, internships, preceptorships

Understand that an investment in education and training will take time today but pay dividends in the future

CCHF is a community of Christian healthcare professionals and

students who are committed to living out the gospel through

healthcare to the poor

OPPORTUNITY #1:Develop and/or Expand a Dental or Vision Program

URL: http://freeclinicstoday.org/libraries/types/1/87

OPPORTUNITY #2:Participate in Community Health

Needs Assessments with Your Not-for-Profit Hospital Partners

Not-for-Profit Hospitals and Community Health Needs Assessments

o Per ACA, not-for-profit hospitals must conduct a community health needs assessment every three years; must include individuals with community health expertise (that’s you!)

o Every year hospital must report results on their Form 990

o Free/charitable clinics can help hospitals address unmet CHNA goals and meet community benefit requirements

47

OPPORTUNITY #3:Focus on Creating Integrated

Systems of Care

Smart communities are realizing that, in the post health care reform

era, it is not just about building bigger and better safety net

organizations but rather planning and executing an organized,

rational, coordinated system of care

for vulnerable populations.

Maximizing Health Care for Colorado’s Underserved: An Operational Handbook and

Responsive Web Resourcewww.maximizinghealthcare.org

OPPORTUNITY #4:Build High-Performing Care

Coordination Capacity

Care CoordinationA client-centered, assessment-based

interdisciplinary approach to integrating health care and social support services in

which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and

monitored by an identified care coordination following evidence-based standards of care.

OPPORTUNITY #5:Give Retired Providers a Chance to

Get Back in the Game

Source: The Physicians Foundation. 2010 Survey: Physicians and Health Reform

40% of physicians said they would drop out of patient care in the next one to three years, either by retiring, seeking a non-clinical job within healthcare, or by seeking a non-healthcare related job.

About half of physicians (49%) said their attitude toward medicine was “somewhat negative” or “very negative” before health reform was enacted. Since reform was enacted, about two-thirds (65%) said their attitude toward medicine was “somewhat negative” or “very negative.”

2010 Survey of Physicians

Source: Medscape Physician Compensation Report – 2013 Results

The good news is…physicians generally LOVE practicing in free/charitable clinics

Reasons Providers Love Practicing in Free/Charitable Clinics

No hospital call No worries about malpractice No billing or claims issues Get to spend time with patients Get to interact with like-minded

peers Know that patients’ other care

needs (e.g. labs, meds, specialty care, etc.) will be handled

Get to decide how often they want to volunteer

The truth is…physicians don’t retire very well, they get bored

pretty quickly, and they miss the practice of medicine.

Find them and give them a chance to get back into the profession

they love.

PITFALL #1:Decide to Change Your Business Model Too Quickly and Without

Performing Due Diligence

Clinic Business Model Choices in a Post Health Care Reform Era

• Continue to be a free/charitable clinic serving the uninsured

• Become a “regular” Medicaid provider, especially in a state that is expanding Medicaid

• Become an Essential Community Provider that one or more Qualified Health Plans may add to their network

• Become an FHQC (likely not a new one, but an expansion site of an existing FQHC)

• Become an FQHC Look-Alike• Develop a “hybrid” model (combining free or

low-fee care for the uninsured with Medicaid and/or other payors)

• Build a high-performing care coordination service that hospitals and others may engage/pay for

PITFALL #2:Plan Strategy and Future Focus

in a Vacuum

Planning in the Post Health Care Reform Era Necessitates Community Engagement

• Highly tempting to come up with a grand idea and want to make a go of it unilaterally

• Smart clinics test ideas and assumptions with key informants, thought leaders, and community decision-makers

• Planning must take into consideration what hospitals, physicians, drug companies, state governments and other safety net providers are planning and/or doing in the future

Final Words of AdviceYou’re not alone“Rome wasn’t built in a day”Remain circumspect, keep your wits, and

continue gathering information and dataRely on advice and guidance from others

whose opinions you trustAfter you’ve done your homework, don’t

be afraid to act, innovate, and be transformational

QUESTIONS?

Mark R. Cruise, PrincipalFree Clinic Solutions

400 4th Avenue South, #304St. Petersburg, FL 33701

(804) 306-3975mark@freeclinicsolutions.com