Clinic Obligations, Opportunities and Pitfalls in Health Care Reform Implementation FCWR Annual Conference San Dimas, CA April 4, 2013 Mark R. Cruise, Principal Free 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 professional coaching Exclusively serve the free/charitable/community-funded safety net clinic sector and those who support it FCS consultants have extensive experience in the health care safety net 70+ organizations served since inception

March 2010October 2010

Health Care Reform in America

ACA Has Sparked Many Reactions and Responses in Our Sector

ACA and Free 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 sectors single greatest raison dêtres If clinics are gap-fillers (Darnell), what will be the new gaps clinics tackle post ACA?

ACA Creates No Mandates On Free Clinics However…IMHO, free clinics have a moral obligation to do certain things as the implementation of ACA unfolds

OBLIGATION #1: ENROLL-o-rama! o-rama: suffix meaning "spectacular display or instance of," 1824, abstracted from panorama, ultimately from Greek horama [ ραμα] "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

15 Source: Enroll America, 2013

Coverage Expansions and Enrollment Assistance by Free Clinics If history is any guide, the free clinic sector will play a vital role in helping people get enrolled in the newly-available coverage Examples are S-CHIP (State Childrens Health Insurance Program) in mid 1990s and Medicare Part D in mid 2000s In various parts of the country, some in the sector got funding to pay for this service

OBLIGATION #2: Consider the Remaining Uninsured!

1 in 10 U.S. Residents Will Still Be Uninsured Following Implementation of the ACA Source: Congressional Budget Office

Why Some People Will Choose to Pay Penalty and Remain Uninsured Initially Subsidies and cost-sharing for people between % FPL will be more generous than for those between % FPL Penalty taxes (for not buying health insurance) are very nominal in the beginning: -$95 or 1% of income in $325 or 2% of income in $695 or 2.5% of income in Increases with cost-of-living starting 2017

Distribution of the Uninsured After ACA pre-SCOTUS rulings Source: Robert Wood Johnson Foundation, 2011

How Many People Will Benefit from the ACA in Your County, and Who Will be Left Behind? That sure would be good to know right now, as well as who the remaining uninsured are and what their demographic profile is.

OBLIGATION #3: Make Sure Your Board Governance is Positioned for 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 #4: 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 #5: Help Develop the Next Generation of Primary Care Providers

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

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 Program

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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 (thats you!) o Every year hospital must report results on their Form 990 o Free clinics can help hospitals address unmet CHNA goals and meet community benefit requirements 45

OPPORTUNITY #3: Focus on Creating Systems of Care

Smart communities are realizing that, in the post health care reform era, it is not about bolstering individual safety net organizations but rather planning and executing an organized, rational, coordinated system of care for vulnerable populations.

Maximizing Health Care for Colorados Underserved: An Operational Handbook and Responsive Web Resource (to be released April 5, 2013)

OPPORTUNITY #4: Build High-Performing Care Coordination Capacity

Care Coordination A client-centered, assessment-based interdisciplinary approach to integrating health care and social support services in which an individuals 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 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 Survey of Physicians

Source: Medscape Physician Compensation Report – 2012 Results

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

Reasons Providers Love Practicing in Free 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 dont retire very well, they get bored pretty quickly, and they miss the practice of medicine.

PITFALL #1: Decide to become a Medicaid (or Private Health Plan) Provider Without Performing Due Diligence

Factors in Becoming A Medicaid Provider May be relevant and timely, esp. for clinics in states that implement Medicaid expansion Assess current Medicaid provider capacity and impact on existing Medicaid providers Providers must be credentialed Determine in-house vs third-party billing Coding and documentation requirements are substantial; most common place for errors Conduct cost/benefit analysis, including financial, patient access, impact on community

PITFALL #2: Assume The Public and Those Closest to Your Clinic Understand the ACA and Its Impact on Your Clinic

Many People Believe the ACA Will Solve The Problem of the Uninsured o Unless you tell them otherwise (in meetings, presentations, website, Facebook home page, newsletters, direct correspondence, etc.) o Dont assume your own volunteers, donors, funders, community partners, Board, staff, and patients know there will be a need for your clinic in the future o Develop boiler plate messages, share them with your constituents and the public at large, and repeat, repeat, repeat

PITFALL #3: Plan Strategy and Future Focus in a Vacuum

Planning in the Post ACA 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 Advice Youre not alone Rome wasnt built in a day Remain circumspect, keep your wits, and continue gathering information and data Rely on advice and guidance from others whose opinions you trust After youve done your homework, dont be afraid to act, innovate, and be transformational 69

QUESTIONS? Mark R. Cruise, Principal Free Clinic Solutions th Avenue South, #304 St. Petersburg, FL (804)