The Role of Safety Net Providers

Attached a link to an article published in the recent edition of Health Affairs titled " Safety-Net Providers In Some US Communities Have Increasingly Embraced Coordinated Care Models." The findings of this study were also the focus of an article by John Dorschner published in the Miami Herald titled " Jackson Memorial Hospital too weak, county too divided to provide good safety net, study says." Here are some background information, facts and study findings excerpted from the article: FACTS: Safety-net providers play a crucial role in providing health services to uninsured and low-income people. Although the Affordable Care Act is expected to expand coverage to more than thirty million uninsured people, it is generally recognized that the safety net will still be needed to provide services to an estimated twenty million people who will remain uninsured. In addition, in all likelihood, many existing Medicaid and newly insured patients will continue to use safety-net providers rather than private mainstream providers because the safety net can better meet low-income people’s specialized needs related to language, culture, and transportation PROBLEM: Delivery of health services through the safety net historically has been fragmented. Usually hospitals, community health centers, and private physicians providing charity care have operated independently of each other, with little or no coordination of the care of a patient. Such fragmentation can result in severe gaps in the availability of services, reduce quality, lead to redundant use, and increase the costs to providers who typically operate with limited resources and thin margins. SOLUTIONS: During the past decade, however, a variety of community efforts to better coordinate care for the uninsured that reduce the use of emergency departments and increase the use of primary care providers have been documented. Most community initiatives focus on providers’ efforts to better manage care for their uninsured patients; stretch limited public and private funds; and address serious gaps in services, particularly the lack of access to specialty care. Often these programs improve access to care for the uninsured at a much lower cost than either private insurance or local Medicaid programs. STUDY DESIGN: The Community Tracking Study, conducted by the Center for Studying Health System Change, consists of in-depth tracking of health system changes in twelve randomly selected metropolitan areas from 1996 to 2010. Representative of US metropolitan areas, the communities are Boston, Massachusetts; Miami, Florida; Orange County, California; northern New Jersey; Cleveland, Ohio; Indianapolis, Indiana; Phoenix, Arizona; Seattle, Washington; Lansing, Michigan; Syracuse, New York; Greenville/Spartanburg, South Carolina; and Little Rock, Arkansas. The article describes safety-net coordination efforts in twelve randomly selected communities and illustrates how these efforts evolved during the past decade. In particular, we focus on initiatives that attempted to coordinate care across multiple providers and were often communitywide in scope. These initiatives were better able to manage the care of uninsured patients than a more fragmented system of care (for example, the initiatives used more outpatient primary care to reduce inpatient and emergency department use). Some evidence obtained from the twelve communities indicates that initiatives to coordinate care across providers reduce high levels of emergency department use and reduce the cost of providing care to the uninsured, but barriers to coordination remain. SELECTED KEY ASPECTS & FINDINGS OF THE STUDY : Nine of the twelve communities studied had some type of organized safety-net program in 2010, compared to only three communities in 2000 Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. Five of the six programs explicitly require patients to have a medical home that they use for all primary care needs. A primary care physician practice that serves as a medical home is generally responsible for authorizing referrals for specialty care. Generally, a single primary care physician serves as the medical home for program participants. An exception is HealthNet in Boston, which is organized around the fifteen participating federally qualified health centers that serve as medical homes for the patients who are referred to Boston Medical Center (the safety-net hospital that administers HealthNet) for specialty and inpatient care. Centralized referral networks are the most common type of community initiative and have grown most quickly during the past decade. They focus primarily on providing a centralized location where patients can receive referrals to physicians and schedule appointments with private practice physicians (mostly specialists) who agree to treat uninsured patients for free or at reduced costs. A few of the (MEDICAL HOME) programs use provider incentives, such as capitation or enhanced fees, to encourage appropriate utilization of services for patients. For instance, the Medical Services Initiative in Orange County offers financial incentives for physicians to join the network. The program also includes extra payments for medical homes to provide at least one visit for each patient per year (two for people with chronic conditions), pay-for-performance incentives for medical homes to improve utilization of preventive services, and incentives for providers to reduce emergency department utilization. Health Advantage in Indianapolis pays capitated rates to primary care physicians to motivate physicians to encourage appropriate use of services and build relationships with their patients. It is unknown, however, whether these incentives are inadvertently discouraging the use of appropriate or necessary services. Formal evaluations of the six coordinated care programs have not been conducted or are not publicly available. One reason may be a lack of staff availability or other resources. However, available data show that Health Advantage in Indianapolis has been successful in decreasing inpatient use and emergency department use. In the first eighteen months after the program began, inpatient days for uninsured people decreased by 50 percent, and emergency department use decreased by 30 percent. In addition, in collaboration with researchers from the University of California, Los Angeles, the Medical Services Initiative in Orange County found that the ER Connect program reduced emergency department visits and increased the number of visits to primary care providers.Recent research on similar programs not included in the Community Tracking Study found that their patient costs were 25–50 percent lower than for patients enrolled in local Medicaid programs or through private insurance. What are the challenges and problems safety-net providers face? Many of the programs lack the capacity to serve all of the eligible uninsured. Providers’ practices are often full, and they have limited availability to see new patients, especially uninsured patients for whom they provide care for free or for reduced fees. Publicly subsidized programs are vulnerable to cuts in funding, especially given the strained local and state budgets of recent years. A major concern is the potential loss of funding for programs that have relied on Medicaid’s disproportionate-share hospital payments, extra payments to hospitals that serve a large number of Medicaid and uninsured patients, which are to be reduced under the Affordable Care Act. Health insurance coverage expansions in the Affordable Care Act may create the perception that the uninsured problem has been solved and these safety-net programs are no longer needed, potentially bringing an end to such efforts. Despite efforts at greater community collaboration, fragmentation and competition among safety-net providers remains. Competition among safety-net providers for Medicaid patients can inhibit closer cooperation. Most safety-net hospitals and federally qualified health centers depend on Medicaid patients for their financial viability both because reimbursements are based on the cost of care (and therefore are considerably higher than reimbursement rates to private physicians) and because grant revenue often doesn’t cover the full cost of care to the uninsured. Community health centers may be reluctant to participate in collaborative arrangements if they think that such cooperation could result in a loss of Medicaid patients. For example, interview respondents from Miami noted that some federally qualified health centers in the community were concerned that efforts by Jackson Health System (the main public hospital) to convert some of its primary care clinics to federally qualified health centers would increase competition for Medicaid patients, given the higher Medicaid rate that the hospital-based clinics receive. Safety-net hospitals are often the natural leaders for community integration efforts given their size and broad service area, not all safety-net hospitals are willing or able to assume that role. For example, Jackson Health System is the primary safety-net hospital for Miami-Dade County but generally does not provide a leadership role in coordinating care and services with other safety-net providers in the community. Part of this reflects Jackson’s financial troubles at the time of the site visit (Jackson lost about $240 million in 2009 and $100 million in 2010), which forced it to cut back on some services. But it also reflects the fragmented nature of Miami’s safety net, which respondents characterize as having more competition than coordination and collaboration among providers to provide care to low-income Medicaid and uninsured patients. Outlook & Opportunities: Safety-net providers—including health centers and hospitals—can form accountable care organizations to participate in Medicare’s Shared Savings Program, in which networks of providers that jointly take responsibility for the cost and quality of care provided to their patients can share in Medicare savings. New demonstration projects to test new payment and care delivery models have a potential impact on safety-net coordination.15 For instance, the bundled payment model involves a single payment to multiple providers for an episode of care, which motivates providers to coordinate and deliver care more efficiently. Safety-net coordination initiatives are also well poised to facilitate the insurance coverage expansions and health insurance exchanges created in the Affordable Care Act because of their established centralized enrollment systems that screen for eligibility for other public insurance. A MUST read article! Yours Bernd