1. 1 AmeriCares U.S. Medical Assistance Program The Role of Free Clinics in the Era of Health Reform Washington Free and Charitable Care Conference Meredith Newman, MPA September 12, 2014

2. 2 AmeriCares Overview Emergency response and global health non-profit Disaster management, global public health, model clinics Founded in 1982 Distribute medicines, vaccines and supplies to 3,500 local health institution partners in 90 countries and 48 states Support of U.S. free clinics began after Hurricane Katrina $500 million in aid last year; $11 billion to date 25+ disaster responses annually

3. 3 Largest provider of donated medicines, vaccines and medical supplies in the United States Working to expand access to care, enhance delivery of comprehensive treatment, and improve outcomes among the poor and underserved Partner with health care safety net organizations to serve the uninsured and underinsured with incomes <300% FPL Licensed in all 50 states Online ordering at www.usaccess.americares.orgwww.usaccess.americares.org No membership, product or shipping fees for partner organizations Free product donations for patients Provide targeted clinical and capacity-building resources at www.safetynetcenter.org www.safetynetcenter.org Facilitate AmeriCares domestic emergency response efforts Supported by the GE Foundation U.S. Medical Assistance Program

4. 4 Partner Organizations Free clinics: 53% Health departments: 21% FQHCs: 19% Other: 7% Health Delivery Sites and Patient Volume in FY14 Associated sites: 1,718 Unique Patients: 4,718,774 Visits: 16,411,668

5. 5 Becoming a Partner Clinics must be operational for 6 months before receiving their first product donation Create account & complete application at www.usaccess.americares.org www.usaccess.americares.org Complete introductory phone call with AmeriCares staff member Once approved, each partner is required to: Maintain up-to-date licenses in USAccess account Update contact information as needed in USAccess account Renew Medical Professional and Partnership Agreements annually Confirm receipt of all shipments

6. 6 USAccess

7. 7 Product Donation Impact Rating of Strongly Agree/Agree – Current product donations from AmeriCares… % of partners provide budget relief for my organization93% fill product gaps85% relieve product shortages at my organization55% improve care at my organization94% enable my organization to see more patients71% enable my organization to expand its services67% reduce out-of-pocket expenses for my organization’s patients92% improve patient adherence66% improve patient retention75% improve staff effectiveness95% October 2013 Partner Feedback

8. 8 Capacity Building Programs Chronic Disease Initiative BI Produce to Give Initiative Chronic Disease Care Program Transforming Prediabetes Care Initiative Depression Care Transformation Initiative

9. 9 Chronic Disease Care Program (CDCP) Overarching program designed to build capacity in free/ charitable clinics to address chronic disease in their patients, improve outcomes – Transforming Prediabetes Care Initiative – Transforming Depression Care Initiative (to be launched late 2014) – Research, evaluation and dissemination – Generously supported by the General Electric (GE) Foundation CDCP Prediabetes Initiative 7 Free and Charitable Clinics Depression Initiative 7 Free and Charitable Clinics Research/Evaluation

10. 10 Prediabetes is a preventable health condition that increases risk of type 2 diabetes, heart disease and stroke; 79 million Americans are prediabetic Transforming Prediabetes Care Initiative: A National Demonstration for Free and Charitable Clinics Goal: increase the identification of prediabetes, improve health outcomes for eligible free clinic patients, improve quality of care How it will work: – Clinics: 7 free clinics will be chosen via application/ proposal process (Deadline: 9/22) – Resources: $10,000 grant, laptop, incentives, training – Staff: Identify Prediabetes Care Manager(s)/ Lifestyle Coach(es) – Training: CDC’s National Diabetes Prevention Program (DPP) for 2 staff members – Screening & identification: ongoing identification, recruitment, enrollment – Implementation of the DPP: 22 sessions (16 core sessions/ 6 post-core sessions) – Data reporting: ongoing data collection & reporting for research study, CDC recognition – Participation: TA, onsite visits, webinars, PR activities, etc. – Initiative Collaborators: AMA, UIC and certified training institution for DPP

11. 11 Transforming Depression Care Initiative: A National Demonstration for Free and Charitable Clinics Depression is leading cause of disability worldwide; prevalence of depression higher among un- and underinsured and those with chronic medical illnesses Goal: improve screening, identification, treatment and management of depression among free clinic patients, improve quality of care Interventions – Clinics: 7 free clinics will be chosen via application/ proposal process – Identify Depression Care Manager – Universal depression screening for free clinic patients using validated tool (PHQ-9) – Training on evidence-based depression interventions – Assessment and diagnosis – Medication management – Utilizing disease registry and data – Making effective referrals and engaging patients in care – Key Measures: screening adoption in clinic, number of patients screened, screened positive, adherence to treatment recommendations, improvements in PHQ-9, etc. – Initiative Collaborators: UCD and UIC

12. 12 Benefits to Participation – Designed to elevate the work of free clinics, showcase what can be done as group, capacity building – $10,000 grants, laptop to support data collection, travel & training related expenses, and incentives for patients – Opportunity to participate in research study; interventions standardized, data & results aggregated – Findings targeted for publication in peer reviewed journal articles, disseminated to sector – Highlight contribution to national demonstration in local, state, national advocacy – Formal training – AmeriCares will monitor & support ongoing implementation; TA calls, webinars provided by trained healthcare coach – Foster and cultivate learning community among participating clinics – Training on data collection and reporting, improved clinic capacity to report on outcomes – Skills transferrable to other areas of chronic disease management – Clinic assessment at beginning and end of initiative to determine elements related to the transformation of patient care

13. 13 Materials & Resources Safety Net Center – CDCP Page http://www.safetynetcenter.org/chronic-disease-care-program-cdcp http://www.safetynetcenter.org/chronic-disease-care-program-cdcp Link to Prediabetes RFP, details requirements, benefits Link to application to be submitted online Two-pager on Prediabetes Initiative Timeline of Implementation Activities Staff Roles, Tasks and Qualifications Patient and Clinic Incentive Guidelines Letter of Agreement CDC’s Diabetes Prevention Program http://www.cdc.gov/diabetes/prevention/ http://www.cdc.gov/diabetes/prevention/ Clinic capacity assessment Standards for Diabetes Prevention Program Recognition

14. 14 Safety Net Center Online resource library for safety net providers and institutions Information-sharing platform for safety net sector Resources available on the following topics:  Behavioral health integration  Oral health  Access to pharmaceutical, supply and equipment donations  Volunteer and staff management  Disease states  Quality improvement  HIT  Risk management  Medical home

15. 15 Free & Charitable Clinic HIPAA Toolbox Practical tools for ensuring HIPAA compliance ·Toolbox commissioned in response to demand and changing safety net landscape – Response to questions raised by network – Passage of the ACA – Increased adoption of EMR by free & charitable clinics – Recent HIPAA updates ·Ten component kit developed by Ropes & Gray – Frequently Asked Questions – HIPAA Guide – Sample Staff HIPAA and Omnibus Trainings – Compliance Self-Assessment Checklist – Templates for download and use by clinics ·Funded by the GE Foundation with additional support from the NAFC

16. 16 Assessment of Free Clinic Capacity and Needs

17. 17 Report on the Burden of Cardiovascular Disease at Free Clinics

18. 18 Report on Mental Health Capacity and Needs at Free Clinics

19. 19 The Role of Free Clinics in the Era of Health Reform

20. 20 Pre-ACA 48 million uninsured in 2012 32 million underinsured in 2012 Post-ACA Rate of uninsured down to approx. 13% in June 2014 10.3 million gained coverage as of June 2014 U.S. Health Insurance Coverage Rates

21. 21 56% (27.7 million people) of the previously uninsured are now eligible for Medicaid, CHIP or HIX subsidy 65% eligible in states that expanded Medicaid 44% eligible in states that did not expand Medicaid 71% would be eligible if all states expanded Medicaid The ACA is projected to reduce the number of uninsured by: 56% in states expanding Medicaid 34% in states not expanding Medicaid 27.1 million people are projected to remain uninsured by 2016 37% would be eligible for Medicaid, CHIP or HIX subsidy 25% would not be eligible due to immigration status 17% would not be eligible due to income levels 22% would be low-income people in states not expanding Medicaid Projected Coverage Changes Under the ACA Source: Urban Institute and Robert Wood Johnson Foundation Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States

22. 22 Most are in the income groups targeted by the ACA 49% have family incomes <138% FPL 40% have family incomes that qualify them for HIX subsidies 50% are in the 15-34 age group 17% report fair or poor health 36% do not have a usual source of care 48% did not have a check-up in the past year Newly Insured Adults Source: Urban Institute Health Reform Monitoring Survey

23. 23 Medicaid Expansion 27 states and Washington DC expanded Medicaid Over 6 million additional people enrolled in Medicaid and CHIP since October 5 million of the poorest people will remain uninsured because they lives in states not expanding Medicaid and have incomes <100% FPL and therefore do not qualify for a tax subsidy for the HIXs http://kff.org/interactive/uninsured-gap/

24. 24 http://kff.org/health-reform/slide/state-decisions-for-creating-health-insurance-exchanges/

25. 25 Health Insurance Exchanges 8 million people signed up for a HIX plan during open enrollment 2.6 million signed up in the state-based marketplaces 5.4 million signed up in the federally-facilitated marketplace States participating in federal or partnership exchanges are receiving less money than states that created their own Awareness that HIXs are available among non-elderly adults is higher in states with state-run programs than those that have federally-run exchanges Many low-income people who obtain health coverage through the HIXs will not be able to access care due to the cost of deductibles and co-pays Bronze & Silver plans leave patients to cover 30-40% of costs

26. 26 Expansion in Washington http://kff.org/interactive/uninsured-gap/ 346,000 people became newly eligible under ACA Uninsured rate down to 8.65% as of July Estimated at 16% before ACA

27. 27 Anticipated Impact of the ACA on Free Clinics Product and Service Needs Anticipated Impact of the ACA on patient load and product/service needs Free Clinics N=197% Increase in number of unique patients6432% Increased need for products donations from AmeriCares7840% Increased need for medications from Patient Assistance Programs (PAPs) 7639% Increase in scope of services provided5528%

28. 28 Anticipated Impact of the ACA on Clinics Planned and Implemented Changes

29. 29 Anticipated Impact of the ACA on Free Clinics Medicaid Expansion vs. Non-Expansion States

30. 30 Billing Adoption at Free Clinics

31. 31 23 states did not expand Medicaid Many people who purchased insurance through the HIXs will drop their coverage or be unable to access care due to the high cost of deductibles and co-pays Disproportionate Share Hospitals received $500M in cuts in FY14 and $600M in FY15 Many of the newly insured will have difficulty accessing care due to provider shortages 31 million are projected to remain uninsured by 2024 The need and demand for care will continue to exceed what free clinics can meet Long-Term Outlook for Free Clinics

32. 32 Questions? Meredith Newman Senior Associate, U.S. Partnerships and Programs mnewman@americares.org 203-658-9566 http://usaccess.americares.org/ http://www.safetynetcenter.org/