Delivery of Care

The catchers in the rye

For people still falling off the cliff in health care delivery, the R.I. Free Clinic is the safety net of the safety net

Photo by Richard Asinof

Marie Ghazal, CEO of the Rhode Island Free Clinic, showing a diagram of how the clinic intersects and connects with the health care delivery system in Rhode Island.

By Richard Asinof
Posted 7/21/14
The implementation of the Affordable Care Act and the efforts here in Rhode Island to introduce health care reform through the state’s health insurance exchange have helped to push down the requested rate increases for health insurance premiums for 2015. But the medical trends and pharmacy costs are still increasing.
On the other side of the equation, there are still about 50,000 Rhode Island adults who are uninsured – and only about 4,000 of them are being seen by the R.I. Free Clinic and Clinica Esperanza, leaving an estimated 46,000 adults out in the cold.
In the upcoming studies on total cost of medical care in Rhode Island, how will the role of the Rhode Island Free Clinic and Clinica Esperanza be integrated into the equation? Is it possible to quantify the extra costs of health care delivery for the uninsured in terms of uncompensated care? When will members of the R.I. General Assembly consider the value of transparency in having consumers and small businesses being able to see and compare the actual costs of health insurance plans?
Lack of access to quality, affordable health care is seen as a denial of basic human rights, according to advocates. There is an equally strong argument to be made about the economic consequences of denying access to health care – and how that hurts productivity and increases costs to everyone.
Here in Rhode Island, there are numerous innovative efforts and pilot programs to improve the quality and the delivery of health care. But the public awareness of these programs is lacking; there is no comprehensive database or mapping of the initiatives. They remain separate and siloed and somehow never become part of the larger conversation about policy. The challenge for Rhode Island is to make them more visible.

PROVIDENCE – Years ago, when writing television scripts for “The Rockford Files,” which starred the late James Garner, the show’s top writer, Steven Cannell, explained the process for dealing with TV censors.

It’s a matter of give-and-take, he explained. In the Rockford pilot, Cannell intentionally put in a slew of hells and damns as a bargaining point – all to serve as a basis of negotiation to keep one word, “queer,” in a pivotal scene, where Rockford sucker punches a character in the men’s room.

“I’ll give you three hells and four damns for queer,” he said, explaining his successful negotiation pitch to the censors in 1974, a much more circumspect and less enlightened era.

ConvergenceRI was reminded of Cannell’s negotiation strategy with the TV censors when news that the latest round of proposed health insurance rate hikes for 2015 had been “reduced” by R.I. Health Insurance Commissioner Dr. Kathleen Hittner. The rates still went up, corresponding to increasing medical trends and pharmacy costs, but the reductions were viewed as a victory.

Indeed, the news was greeted by some officials as a positive sign that the system was working, competition was beginning to take hold in the marketplace, premium rate hikes had been held down, and the ever-escalating cost curve was being bent.

“Thanks to the health reform efforts of the Lt. Gov.’s office and HealthSource RI, the OHIC rate announcement today reflects more competition in Rhode Island’s individual insurance market,” Hittner said, saying that with three insurance carriers in the market, there is more choice of plans, including plans that cost less than they did last year.

Hittner, however, did not explain that the reduction in the Neighborhood Health Plan of Rhode Island in the individual market was driven in part by the very low number of purchasers for its previous plan.

In harmony with Hittner, Lt. Gov. Elizabeth H. Roberts also put a positive spin on the new rates, thanking Hittner for pushing for lower premium increases than requested. “Together with the work and progress of HealthSource RI, there will now be more competition in the market and more choices for Rhode Islanders to obtain affordable coverage,” she said.

The R.I. Health Insurance Small Employer Task Force, an advocacy effort funded by OHIC and administered by The Providence Plan, also issued a statement in apparent coordination with the others, taking some credit for the results. “The public input from Task Force members and others contributed to [Hittner] approving lower rates than what was requested in several cases,” the statement said, acknowledging that many carriers were allowed significant increases.

Reality vs. spin
The actual details of the rate increase, however, show how much work remains to be done if there is be any cost containment. Blue Cross & Blue Shield of Rhode Island, for instance, in its premiums for individuals, had its rate reduced from $341.68 to $328.25 per month, or a decrease of $161.16 a year, based upon reductions to 4.3 percent from 5.4 percent projected increases in inpatient hospital utilization, as well as reduction to 5.4 percent from 5.7 percent in projected increases in total medical trend. The numbers were based on premium rates for a 21-year-old.

While any reductions may seem like a hard-fought victory, the reality is that a yearly increase in the medical trend of 5.4 percent is not really a cause to celebrate.

Christine Ferguson, executive director of HealthSourceRI, in an interview with ConvergenceRI following the rate decision announcement, said that going forward, there would be better data and analytics to look at outcomes and other components, in order to give consumers a better understanding of how hospital trend numbers translated into costs.

In the mean time, Ferguson continued, “It’s the state actuaries vs. the carriers’ actuaries, a dance that gets done all the time.”

While the rate decision compares apples to apples for 21-year-olds in Rhode Island, the breakdown by age of the how the premium increases will affect cost will soon be available through HealthSourceRI, when the comparison rate sheets are published for each of the plans in the individual and small business markets, according to Ferguson.

This year, the exchange will be publishing actual breakdown of rates for plans on the exchange and off the exchange for small businesses, so that firms with under 50 employees will be able to see what they will be paying for in advance of getting their actual renewal notices, according to Ferguson. “They’ll know what the pricing will be far in advance,” she said.

Safety net for the safety net
There are still some big holes in the safety net for Rhode Islanders, with only a few catchers in the rye to try and save them.

Despite the best efforts to implement health care reform in Rhode Island and get people signed up for commercial health insurance or coverage under the expanded Medicaid program, there are still about 50,000 Rhode Islanders without access to health insurance and medical care, according to Marie Ghazal, CEO of the Rhode Island Free Clinic.

“The Rhode Island Free Clinic is the safety net for the safety net,” Ghazal told ConvergenceRI is a recent interview at the clinic’s headquarters at 655 Broad St. in Providence.

The numbers tell the story: in 2013, the Free Clinic saw 2,059 uninsured adults, providing 9,182 patient visits, diverted some 600 uncompensated emergency room visits at a cost savings of $3.9 million, and saved the state about $866,000 in comprehensive care and counseling for uninsured diabetics. To do this, the Free Clinic mobilized more than 700 volunteers, including 31,000 volunteer hours from doctors, nurses and medical support personnel valued at $796,000.

Quite simply, the Free Clinic serves as the model for how to care for uninsured adults who slip through the cracks of the health care delivery system, according to Ghazal. It costs about $500 a patient to deliver primary care services, she said.

The demand for services at the Free Clinic had been consistently high, forcing them to institute a lottery, where people seeking services came on the first Thursday of every month for a chance to be seen at the Free Clinic. With the Affordable Care Act implementation, the board of the Free Clinic, beginning in June has been able to dispense with the lottery and begun to see clients when they call, if they meet eligibility requirements.

“We’ve been able to transfer about 300 to 400 patients out of the clinic who now have health insurance,” Ghazal explained. “Our mission is to serve people who have no insurance. As more people have gotten on insurance, it has opened up more slots.”

As a result, the Free Clinic has been able to become more accessible and serve more people statewide, Ghazal said. A few years ago, the Free Clinic was turning away 50 to 100 people a month. For the moment, the lottery is suspended: “We don’t know what’s going to happen,” she said. “We could end up back in the situation where we were before.”

If an uninsured adult calls, they can get an appointment to be seen within about two weeks or a month at the Free Clinic, according to Ghazal.

“We’ve heard that at other places, they are not taking a lot of new patients right now,” she said. “Doctors and practices are stressed and stretched as to what they can deliver,” she said, adding that she believes that community health centers do a great job and the state is fortunate to have such a great network of community health centers. “But given the expansion of Medicaid, everyone is stressed to capacity.”

An integral part of the state’ health infrastructure
Ghazal believes that the Free Clinic needs to be recognized as an important part of the state’s health care delivery infrastructure – an entry point into the system.

“If you’re going to be eligible for health insurance, we’re not going to take you,” she said. “We’re not going to duplicate services. That’s why this model is a successful one for the state. We saved the state a tremendous amount of money.”

By taking care of patients without health insurance, and then helping them to transfer out of the Free Clinic – to a private doctor or to a community health center – Ghazal said that the cost savings are substantial.

“I think that the Free Clinic has to become part or the state’s health care delivery infrastructure,” Ghazal said. “We consider ourselves the safety net for the safety. We have to be there, so that [Rhode Island] can invest in everyone getting access to health care. It’s inhuman to see people suffer. People should not be walking around when they’ve had a stroke, or with diabetes.”

The Free Clinic role is as a charitable organization that is volunteer-based, Ghazal continued. But the state, she said, needed to recognize that the Free Clinic played an important role in supporting a seamless system of health care.

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