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"From the Front Lines of Health Care" by Bill Walczak

For the purposes of this blog, the first thing you should know about Codman Square Health Center is that it is a good location from which to look at the effects of health reform. An area with a very large low income and working poor population, we have had as many as 49% of the 21,000 individuals we see annually among the ranks of the uninsured. This was in the year before health reform was implemented.

Health reform is a very big deal to Codman Square. The impact of it on our patients has a huge impact on our finances and therefore the level of services we’re able to provide to our community. And so we study the numbers that come out of our computers monthly to see trends. The numbers our computers give us monthly point in a number of directions.

Here are some items from our data:

• The number of uninsured is way down - from 49% of patients two years ago to 14% today. Much of that change happened during 2007 and up to March of this year. The overall number of uninsured has been stable since March, 2008. About 2/3 of the uninsured are covered by the Health Safety Net, formerly known as the Free Care Pool.
• Access to insurance seems to have translated into more use of health services. We’re seeing increased demand, about a 10% increase in visits, such that our waiting time for appointments has increased to 3-4 weeks for many services.
• Bad Debt is up over 50% from last year, which was up over the previous year.
• Patients having Commonwealth Care insurance fluctuate up and down, but overall the number is flat since January.

So what does it all mean? Most important, many more people have insurance, and the patients who have this new insurance certainly seem to appreciate it and are using it. But it is also true that it is, as has been pointed out, a “near” universal system.

There is still a significant number of people who do not qualify for the new system, or are not participating.

The people who do not or are not qualifying for services are leading to more bad debt. At a health center directors’ meeting recently, many directors said that their bad debt is up. The main reason for this is that the old free care pool covered patients who qualified for it for six months prior to the time they qualified for free care. So, if a patient came in for services without insurance, qualifying for free care meant that they would be covered for the visit that day. In today’s system, insurance kicks in 30 or more days after all the patient’s forms are submitted. And a certain number of patients also seem to allow their insurance to lapse, so that we have to re-qualify them when they show up for the appointments after their insurance lapses. As a result, a safety net provider has to make a decision on whether to see a patient without insurance and not get paid, or turn away the patient until they get insurance or come up with money to cover the service. Health Centers do not turn away patients in need of care, and so they see the patients and do not get paid, which typically turns into bad debt.

The increase in patient demand is putting more pressure on an already overwrought primary care system. This, combined with information from a recent study that showed that only 2% of medical students plan on going into primary care, makes this situation untenable. The notion that new “minute clinics” will alleviate this crisis is foolish. The problem is supply of primary care providers. Creating new access points for a limited number of providers just re-arranges the chairs on this sinking vessel.

Finally, another issue the institutions on the front lines are currently grappling with is the state financial condition. We all know that EOHHS has sent a list of possible 9C cuts (emergency cuts to the budget that the governor can make under certain circumstances) to the governor, and we’ve all heard rumors about where these cuts may hit. The most frightening rumors have the governor cutting safety net programs like the Essential Community Provider fund and Section 122 funding. This would devastate some parts of the safety net system. We also are facing increasing cost from having to add insurance staff to help our patients navigate the various insurance systems, which used to be much simpler and required fewer staff with the old free care pool system. And we’re doing this at a time when the planned increase in reimbursement in Commonwealth Care is expected to be between one half of one percent and two percent. Yes, we may have some scary times ahead.

Bill Walczak
CEO, Codman Square Health Center

This program aired on September 18, 2008. The audio for this program is not available.

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