Transcript PPACA and Free Clinics - Virginia Health Care Foundation

Patient Protection and Affordable
Care Act and Free Clinics
by
Debbie Oswalt
Virginia Health Care Foundation
“Although we are challenging the Patient
Protection and Affordable Care Act, it is
currently the law of the land and it would be
irresponsible not to prepare for its
implementation”.
--Governor Bob McDonnell
via
Virginia Secretary of Health and Human Resources Bill Hazel
(August 2010)
Over 1 Million Virginians Uninsured in 2010
Total Nonelderly
Uninsured,
14.6%
Insured,
85.4%
1,004,000 uninsured nonelderly
Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates
reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage
estimates were developed under a grant from the Robert Wood Johnson Foundation.
The uninsured rate for adults in Virginia
increased between 2009 and 2010
% Point
Change
+1.1% Points
-0.3% Points
+1.6% Points
Note: Asterisks indicate a change in percent of people that is statistical significant at the .10 level.
Source: Urban Institute, February 2012. Based on the 2009 and 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS).
Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al,
2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.
VA Medicaid eligibility criteria
lower than other states
% FPL
* Only 7 states cover non-disabled childless adults.
Source: Heberlein, M., T. Brooks, S. Artiga, and J. Stephens. 2011. “Holding Steady, Looking Ahead: Annual Findings of A 50-State
Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost Sharing Practices in Medicaid and CHIP, 2010-2011.”
Washington, DC: Kaiser Commission on Medicaid and the Uninsured.
Nearly 70 percent of uninsured Virginians live in families
with at least one full or part-time worker in 2010
Share of Nonelderly Uninsured
Notes: Family work status is based on the highest level of employment among the adults in the health insurance unit. Estimates may not sum to 100% due to
rounding.
Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS).
Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage
(See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.
Just under half of the uninsured in
Virginia were white, non-Hispanic in 2010
Share of Nonelderly Uninsured
Notes: Estimates may not sum to 100% due to rounding.
Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates
reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage
estimates were developed under a grant from the Robert Wood Johnson Foundation.
(E.L. Freeman)
Young adults (19-34) comprised over half (51.7%) of
uninsured Virginians in 2010
Notes: Asterisks indicate a percentage that is statistically different from the reference group (Age 0-18) percentage at the .10 level.
Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates
reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage
estimates were developed under a grant from the Robert Wood Johnson Foundation.
A vast majority (89.2%) of uninsured Virginians
lived at or below 200 percent of FPL in 2010
40%
35%
34.1%
30.1%
30%
% Uninsured
Total Nonelderly
25.0%
25%
20%
16.0%
15%
8.9%
10%
5%
2.6%
0%
<100%
100-138%
139-200%
201-300%
301-400%
401+%
Family Federal Poverty Level (FPL)
Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2010 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau.
Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates
reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage
estimates were developed under a grant from the Robert Wood Johnson Foundation.
Major Medicaid Provisions of
Federal Health Reform
Source: DMAS November 2010
Change in health insurance coverage with PPACA
Thousands of nonelderly Virginians
Insured
5,888,000
Insured
6,414,000
Uninsured
Without reform
Uninsured
With reform
Uninsured
Decline in uninsured persons by income group
Source: Urban Institute analysis, HIPSM 2011
*Note: We simulate provisions of the Affordable Care Act fully implemented in 2011.
Those left uninsured under reform
N=515,000
Source: Urban Institute analysis, HIPSM 2011
*Note: We simulate provisions of the Affordable
Care Act fully implemented in 2011.
Profile of Virginia Free Clinic Medical Patients
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63,884 in 2010 (50% treated in 13 free clinics)
Almost two thirds are 35-64 years of age
70% have one or more chronic illnesses
An average of about 75% will be eligible for
Medicaid in 2014
Will vary among clinics
Assessing Local Impact of
PPACA Medicaid Expansion:
• Assess impact within clinic
Number of patients eligible for Medicaid in 2014
(income and citizenship)
•Assess impact on Medicaid eligible free clinic
patients
Acuity level of these patients
Nature of clinic’s relationship with these patients,
i.e. a medical home?
Availability of Medicaid providers in area (taking new
patients?)
•See Free Clinic Planning Tool for help
What About Patients without Coverage in 2014?
• Determine the number and nature of clinic
patients not eligible for Medicaid
• Estimate the number and nature of people within
the clinic’s service area who are likely to remain
uninsured post-PPACA implementation
• See Free Clinic Planning Tool for help
PPACA Medicaid Expansion:
Free Clinic Options
• Maintain current free clinic business model
• Current model, and allow Medicaid eligible at
clinic, without charge
• Transition to a “hybrid” model
• In eligible areas of state:
 Apply to become a Federally Qualified Health Center
(FQHC)
 Become an FQHC “Look-a-like”
 Become a Rural Health Clinic
• Transition eligible patients to Medicaid, help them
find a provider, and close clinic
What Is a Hybrid Model?
• Enables a free clinic to become a Medicaid
provider, and maintain its “free clinic roots” and
mission.
Provides medical care to low income patients
(uninsured and Medicaid)
Utilizes paid providers, often supplemented with
volunteers (providers and otherwise)
Charges fee for services on a sliding scale, which can
allow for free care for lowest income patients
Examples of Hybrid Models
Good Samaritan Health Center (Atlanta, GA)
• Large urban clinic, 93% uninsured, and 7%
Medicaid/Medicare
• 19,000 volunteer hours/year
• Medical, dental, mental health services = 27,000 visits/year
Doctors Care (Littleton, CO)
• Free specialty care for 5 years
added pediatrics
(CHIP/Medicaid)
19-30 year olds (set fee or sliding scale)
• Lots of volunteers (Family Practice residency program)
• Medical services = 8,000 visits/year
Examples of Hybrid Models
San Jose Clinic (Houston, TX)
• Large 89 year old clinic, in process of becoming a Medicaid
provider
• 140 volunteer providers (specialists, resident programs), 200 lay
volunteers
• 42 staff
• Medical, dental, mental health and pharmacy services = 30,500
visits/year
Olde Towne Medical Center (Williamsburg, VA)
• Large 20 year old clinic that became a hybrid early on
• 500-600 hrs/mo of volunteer providers (more for dental)
• Medical, dental and mental health services = 16,000
visits/year
• Became a rural health clinic = 10% payment bump
(Medicaid/Medicare)
Core Elements of Becoming a Hybrid Clinic
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Clarity regarding mission and target patient population
Community understanding and support
Viable business plan
Determine mix and allocation of paid and volunteer
providers
• Adequate infrastructure
Electronic health record system
HIPAA compliant
Credentialing providers (contracted)
Billing capacity (in-house or contracted)
Administrative staff
Facility space
Summary
• PPACA coverage expansions will cut the number of uninsured
Virginians in half.
 Many, including 75% of free clinic patients, will be eligible for
Medicaid
• About 289,000 Virginians ≤ 200% FPL will remain uninsured.
(undocumented immigrants, those who can’t afford insurance)
• This creates locality-specific opportunities and challenges for
Virginia’s free clinics.
• One option under consideration by a growing number of
clinics is transitioning to be a hybrid clinic:
 Blends paid and volunteer providers to treat low income patients
(uninsured and Medicaid)
 Requires thoughtful planning and sufficient infrastructure
• Each free clinic must evaluate the impact of PPACA on its
patients and community, in determining its future direction.
For more information visit: www.vhcf.org
or contact:
Debbie Oswalt
Executive Director
Virginia Health Care Foundation
(804) 828-5804
[email protected]