Saving money by giving care for free
From the March ACP Hospitalist, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
At most hospitals, paying for medical care means handing over proof of insurance or a credit card. At The Caring Place in Allentown, Pa., it can mean reading to children, baking cookies or translating for other patients.
The Caring Place, a free clinic affiliated with Lehigh Valley Hospital, is one of a number of hospital-funded programs exploring innovative methods of providing primary care for low-income patients without insurance. Many of these programs have been developed in an effort to reduce costs, as hospitals realize that uninsured patients drive up expenses with emergency visits and admissions that could have been averted through preventive care.
Abby Letcher, MD, medical director of The Caring Place Family Health Program in Allentown, Pa.
"Most of the people that we see say that their primary care site would be one of the local emergency rooms," said Abby Letcher, MD, medical director of The Caring Place Family Health Program.
The Caring Place provides everything from prenatal to geriatric care. Although the care is officially free, the clinic also allows patients to pay for medical care with services of their own, such as reading to children in the waiting room or being trained as translators for Spanish-speaking hospital patients.
The system, which is based on an economic idea called timebanking, trades an hour of volunteering for an hour of medical care or any of the other services offered at the clinic, such as yoga classes and massages.
"We're using the idea of timebanking to honor people's contributions and their dignity," Dr. Letcher said.
The Caring Place began as a four-hour-per-week clinic staffed by college student volunteers. It has gradually expanded because of patient demand and Lehigh Valley Hospital's recognition that providing free primary care is less expensive than providing emergency care.
The Caring Place doesn't have the staff to quantitatively measure the cost savings for the hospital. But economic models based on the Caring Place's current budget and patient load have shown that a year of care at the clinic costs approximately as much as one emergency department visit, Dr. Letcher noted.
"If we can prevent even one ER visit, we've paid for their primary care for the year," she said.
Using a team approach
If reducing emergency department visits by uninsured patients lowers costs for a hospital, preventing an admission can save even more while improving patients' health. At least that's the theory behind the University of New Mexico Health Science Center's Care One Program.
The experimental program includes about 1,000 uninsured patients with complex, chronic medical problems, including hypertension, renal disease and cardiac problems.
|
"If you look at CareNet patients versus the other free care patients ... the length of stay was shorter, charges per admission were less and there was less out-of-network activity." — Richard Kalish, MD |
"It's that 1% or 2% of the patient population that costs about 20% of the health care dollar, so we're looking at a different way in which we can manage those patients, whether they have reimbursement or not," said Paul B. Roth, MD, the University of New Mexico's executive vice president for the health sciences.
Care One patients are assigned to a health team, which provides frequent attention in a clinical setting as well as home visits to help manage the patients' conditions. The hospital's nursing staff provides most of the care and also works with community organizations to meet patients' nonmedical needs, such as housing or nutrition.
"The goal is to improve the quality of life for the patient and reduce utilization of the health care system," Dr. Roth said. "It's a bigger issue in my view than trying to prove we can save some money. It has to do with our social mission as an academic medical center."
It's not only medical centers that are concerned with reducing the cost of care for the uninsured. In North Carolina, physicians led the development of a pilot program of care for low-income patients.
Community Care of North Carolina was developed to improve the care of Medicaid patients through intensive case management. Case managers assign patients with complex diseases to primary care physicians (PCPs) and then follow up to make sure appropriate treatments are being received.
Local physicians have guided the program, as well as associated quality improvement efforts targeting asthma and diabetes disease management.
"In various states, this case management has been outsourced to private companies and physicians didn't want to lose that control. We know our communities best and we have a sense of how we can control cost," said Beat Steiner, MD, a family physician involved in the network.
With grant funding, as well as hospital and community health center contributions, the system has recently been expanded to include uninsured patients. Management of Medicaid patients saved approximately $124 million in 2004, and care for the uninsured has similar potential to reduce costs, according to Dr. Steiner.
"The system somehow is paying for uninsured care currently and if we provide that in a more compassionate way, I see that this could be a model for most anyplace," he said.
Working toward future solutions
One hospital's free care program has become a model for an entire state's health care reform. Boston Medical Center in Massachusetts has had an organized system for providing free primary care at affiliated community health centers since 1996, funded by the hospital and the state.
The approximately 11,000 uninsured patients enrolled in the CareNet Plan are each assigned to a PCP at one of the community health centers and receive a card (similar to a commercial insurance card) that eases their way through the free care system. The card also entitles them to perks like a 24/7 nurse advice hotline.
Patients are encouraged to visit their PCPs instead of the emergency department, and providers are contacted, but not penalized, when their CareNet patients incur more than $25,000 in charges or visit the emergency department twice in a quarter. The system has had both financial and medical benefits, said Richard Kalish, MD, medical director of CareNet and internist at the South Boston Community Health Center.
"If you look at CareNet patients versus the other free care patients, it was a big savings in the top 100 [most costly] patients. They had equal rates of cancer, substance abuse and other mental health issues, but the length of stay was shorter, charges per admission were less and there was less out-of-network inpatient activity," he said.
Low-income patients can receive free care at the community health centers without enrolling in CareNet, but the clinic's providers have urged patients to enroll in the program to improve continuity of care as well as to reduce expenses.
The CareNet program is expected to shrink under Massachusetts' new health care reform, which requires all state residents to buy insurance by July 1 or face tax penalties. CareNet will continue to serve patients ineligible for coverage because of citizenship issues, Dr. Kalish said.
However, most CareNet patients are eligible for Commonwealth Care, the state's new free insurance coverage for low-income patients, and will be gradually rolled over into the program. When promoting the new mandatory insurance coverage, state officials pointed to CareNet as a model for cost-effectively managing the care of uninsured patients, Dr. Kalish noted.
"Hopefully what was done with CareNet over the years will pay off. You give someone a card and have a system that they're working with and a PCP and things will fall into place," Dr. Kalish said.
More from ACP Press
IM Essentials for Clerkship Students: Augment your learning with ACP's authoritative text and online supplemental resources.
Electronic Health Records
-
This user-friendly guide teaches you how to evaluate, purchase, implement and use an electronic health records system (EHR).
New SEP Points Option with MKSAP 14!
MKSAP 14 subscribers now have a new option for earning Self-Evaluation of Medical Knowledge points in the American Board of Internal Medicine (ABIM) Maintenance of Certification program.