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Service Delivery Innovation Profile

Donated Care Program Enhances Access to Ongoing Care for Uninsured Patients, Resulting in Significant Reductions in ED Visits, Hospitalizations, and Costs


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Snapshot

Summary

A donated care program known as CarePartners matches uninsured Maine residents with local primary care physicians who are willing to provide free care to up to 10 patients. The program also provides care management services to enrollees, including helping them obtain access to specialist and hospital services from providers willing to offer free services and access to free or low-cost drugs through prescription assistance programs offered by drug companies and low cost generic programs at local pharmacies. The consistent preventive services offered by the program have helped to significantly reduce emergency department visits, hospitalizations, and costs among participants, to levels that are well below the average for Medicaid patients. The program has proven to be popular with providers as well, with 60 percent of practicing primary care physicians participating and area hospitals (which view the program as a way to reduce the costs of uncompensated care) agreeing to fund 90 percent of program costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hospitalizations, ED visits, and medical costs by enrollees.
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Developing Organizations

CarePartners; MaineHealth
CarePartners is located in Augusta, ME. MaineHealth is located in Portland.end do

Use By Other Organizations

  • A number of organizations have put in place similar kinds of programs that are designed to reduce administrative barriers and redistribute the responsibility for providing free care to the indigent and uninsured. These programs—which already serve 2.5 million primarily uninsured patients in approximately 2,000 communities around the country—are working to increase the number of physicians willing to provide care. For example, Project Access is a specialty-care referral network in Buncombe County, NC that has recruited 630 of the county's 700 physicians, 70 percent of whom are specialists, to provide free care to uninsured patients.
  • A detailed summary of what other local organizations are doing to promote charity care across the United States can be found in the Volunteer Health Care Programs Report by the W.K. Kellogg Foundation, available at http://www.wkkf.org/knowledge-center/resources/2007/05/Volunteer-Health-Care-Programs-Appendix.aspx.
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Patient Population

Vulnerable Populations > Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

Many Americans lack health insurance, which often causes them to postpone receiving care and not follow recommended treatments when they do receive such care, thus resulting in a deterioration in health status that can lead to the need for costly urgent, emergent, and/or inpatient care.
  • Americans and Maine residents: In 2009, 50 million Americans under the age of 65 years lacked health insurance. More than 8 in 10 of these individuals come from working families, which typically means they make too much to qualify for Medicaid but too little to afford private health insurance.1 For these individuals, there are few health care safety net programs available. The State of Maine is not immune from this problem. A study of Cumberland, Lincoln, and Kennebec counties found that 12 percent of residents lacked insurance, ranging from 10 percent in southern Maine's more affluent and urban Cumberland County to 18 percent in rural Lincoln County. Seventy-one percent of the uninsured Mainers surveyed were employed on a full- or part-time basis. The majority (56 percent) of uninsured Maine adults with income below 300 percent of the Federal poverty level lacked any kind of health insurance for 5 years or more.2
  • Greater likelihood to forgo or postpone care: Uninsured adults are far more likely than the insured to postpone or forgo health care altogether and are less able to follow through with recommended treatments. About one-fourth of uninsured adults say that they have postponed care in the past year, often because they do not have a regular place to go when they are sick. Anticipating high medical bills, many uninsured are not able to follow recommended treatments, and nearly one-fourth report that they did not fill a drug prescription in the past year because they could not afford it.3
  • Net result is need for emergency department (ED) or hospital care: The consequences of reduced access to care can be severe, particularly when preventable conditions go undetected. Many uninsured in Maine go to hospital EDs, which are required by state law to care for all patients regardless of their ability to pay. As a result, the number of uninsured and indigent patients seeking care at Maine's EDs has increased in recent years. For example, in 2004, there were 76,593 ED visits at Maine Medical Center in Portland, and the hospital provided $8.3 million in free care. In 2006, ED visits climbed to 80,393, and the hospital provided $17.4 million in free care.

What They Did

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Description of the Innovative Activity

A collaborative program between Maine hospitals, primary care physicians (PCPs), and specialists provides care to uninsured Mainers through a donated or charity-care model. Leadership and funding for the program is provided by MaineHealth, a nonprofit health system based in Portland and five affiliated hospitals. The CarePartners program matches uninsured Maine residents (typically those who are working) in four counties with a local PCP who is willing to treat up to 10 patients for free. Case managers help enrollees access other needed services, including specialty care, hospital care, and free or low-cost prescription drugs through pharmaceutical companies and local pharmacies. Key elements of the program are described below:
  • Eligibility requirements: The program targets adults between the ages of 18 and 65 years with incomes below 175 percent of federal poverty level and assets of $10,000 or less for an individual and $12,000 for a family. Those families who own their home and/or have have one car for each driver in the household are also excluded. The program also accepts those whose health insurance premiums and deductibles exceed 5 percent of their gross incomes. Individuals are referred to the program from the Maine Department of Health and Human Services (which administers the state's Medicaid program), hospital social workers, and other sources, including physicians who refer their own patients who lose a job or insurance coverage.
  • Enrollee demographics: About 66 percent of enrollees are female, 70 percent are single, and the average age is 41 years. Many participants are in their early 20s or late 50s and often work in part-time and/or service industry jobs that do not offer insurance. Most enrollees remain in the program for 6 to 18 months until they "age out" and become eligible for Medicare or Veterans Administration coverage or their incomes decline enough to qualify for Medicaid coverage. In 2006, only 9 percent of those who left the program obtained private health insurance coverage.
  • Enrollee responsibility: Each patient is expected to pay a $10 copay to the provider, per illness episode. If a patient sees a provider twice for treatment and followup during an illness, he or she pays a total of $10.
  • Common health issues: Most enrollees have at least one chronic health condition, which has often been neglected. The most common conditions include musculoskeletal conditions, depression or other mental health conditions, hypertension, gastrointestinal conditions, and/or diabetes. The most common unmet medical need is for a hip and/or knee replacement, which is the most commonly delivered service to members. Before this program began, most uninsured individuals could not get a hip or knee replacement, because the typical hospital's "free-care" program only provides services for life-threatening conditions.
  • Participating providers: Seven participating hospitals provide free inpatient and outpatient services, whereas participating PCPs and specialists provide free physician care. (Dental care is not covered by the program.) In Cumberland County, 12 medical practices with 120 doctors that participate in CarePartners are affiliated with MaineHealth, but a number of smaller, unaffiliated primary care practices also participate. Practices with 20 or more physicians make up 5 percent of participating practices, while practices with two to five physicians make up 46 percent of participating practices. In late 2007, about 300 PCPs in three counties were actively rendering care to 1,500 CarePartners members. Many participating doctors care for 1 to 2 enrollees, with some caring for up to 14. Participating providers often refer their own patients who have lost jobs and insurance coverage to the program and then continue to care for them. As of 2006, 40 percent of all licensed MDs or osteopaths (including PCPs and specialists) in Lincoln County participated in CarePartners, 55 percent participated in Kennebec County in central Maine, and 66 percent participated in Cumberland County in southern Maine. The American Project Access Network, a national nonprofit organization that helps communities establish charity care programs, considers a 50 percent participation rate to be highly successful.
  • Case managers to facilitate access to needed services: The program's case management services set it apart from other free-care programs. CarePartners' case managers work out of physician offices in hospital-affiliated practices in Kennebec County and in regional offices in the other two counties (where most practices are not affiliated with the sponsoring hospitals). Case managers help enrollees find a local PCP, assist them in applying for free or low-cost drugs through prescription assistance programs offered by pharmaceutical companies, and help enrollees secure access to other services when needed, including specialist or hospital care, mental health services, and/or tobacco cessation programs. In 2006, CarePartners helped 1,500 enrollees obtain more than $2 million worth of free prescription drugs (covering about 70 percent of the drugs required by enrollees), while Maine physicians and specialists donated $1.25 million in services. Participating PCPs cite the case management service (including the confidence that the service will secure access to prescribed medications for patients) as a major reason that they support and continue to participate in the program. When case managers come across applicants who do not quality for CarePartner coverage or who may be eligible for Medicaid or other public programs, they provide appropriate referrals and assistance in obtaining coverage.
  • Donated utilization tracking services: Anthem Blue Cross/Blue Shield of Maine provides free third-party administration by processing claims and providing CarePartners enrollees with insurance cards. Enrollees present their cards when visiting any provider, hospital, or pharmacy. Anthem processes the claims and collects the data on PCP and specialist health care utilization but never sends any payment. However, only 75 percent of participating PCPs send CarePartner patient claims to Anthem, as many small, rural providers choose not to burden their internal staff with CarePartners claims processing, because they receive no compensation for it. Every month, Anthem sends the raw data on CarePartners enrollee utilization to a vendor, Martins Point Informatics, which analyzes the data and produces a utilization report for CarePartners. Both Martins Point and Anthem donate these services.
  • Processing of prescription drug claims: Anthem also serves as the program's pharmacy benefit manager. When a new enrollee needs prescription drugs immediately (before there is time to obtain free- or low-cost drugs through a prescription assistance program application), the enrollee has the prescription filled at a pharmacy, paying up to $25 as a copayment. Anthem processes the claim and bills CarePartners for the administrative handling and for the cost of the drug.

Context of the Innovation

Physicians have long played a key role in the nation's health care safety net, providing free or reduced-cost care to uninsured patients in their practices or volunteering at free clinics. However, financial and time pressures and changes in health care financing have contributed to a decline in the proportion of physicians providing charity care nationwide (from 71.5 percent in 2000 to 2001 to 68.2 percent in 2004 to 2005) and an increase in ED visits and unmet medical needs for the uninsured.4

Hospitals in Maine were not immune from these trends, and hospital leaders decided to band together to do something about it. Maine hospitals already provided free care to residents whose incomes fell below 200 percent of Federal poverty level, and, as a result, unreimbursed care had become a major expense for hospitals. Maine Medical Center in Portland, for example, provided $8.3 million in free care in 2004, but by 2006 this figure had more than doubled to $17.4 million.5 To improve the quality of medical care to the uninsured and reduce the number of unnecessary, uncompensated ED and hospital visits, the MaineHealth system created the CarePartners program in 2001 to match uninsured Mainers with providers willing to provide charity care to a limited number of patients. The program targeted Cumberland, Kennebec, and Lincoln counties, where MaineHealth-affiliated hospitals and physician practices were available. In November 2009, CarePartners expanded to Waldo County and Waldo County General Hospital. They have offices in Portland, Auguta, Waterville, Belfast, and Damariscotta, ME. The program was initially modeled after a similar program in Kennebec County that placed care managers in member physician practices.

Did It Work?

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Results

The CarePartners program has significantly reduced medical costs, ED visits, and hospitalizations by providing uninsured Maine residents with consistent access to timely medical care.
  • Declining medical costs and utilization: A study of CarePartner enrollees over 18 months shows a dramatic decrease in health care costs and utilization after enrollees receive consistent medical care and access to needed prescription drugs. For example, medical costs dropped from $336 per member per month on enrollment, to $173 per member per month after 18 months of coverage.
  • Reduced ED visits: In June 2002, shortly after the program began, CarePartner enrollees' ED visits were 51.7 per 1,000 member months, similar to levels found in Maine's Medicaid population. By December 2006, CarePartner enrollee ED visits declined to 42.6 per 1,000 member months, well below the national ED visit rate for Medicaid enrollees of 54.4 per 1,000 member months.
  • Reduced hospitalizations: In June 2002 (shortly after the program began), the hospital discharge rate per 1,000 CarePartner member months was 15, well above national benchmarks. By December 2006, hospitalization rates had declined to 7.3, below the average Medicaid hospitalization rate of 8.1 per 1,000 member months.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hospitalizations, ED visits, and medical costs by enrollees.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • PCP recruitment: Participating hospitals aggressively encouraged their physicians to participate. In addition, word-of-mouth endorsement within Maine's smaller communities helped in recruiting the many smaller practices that are unaffiliated with MaineHealth hospitals. For example, one doctor reported that CarePartners patients tended to be older, committed to improving their health, and treatment compliant; these kind of word-of-mouth endorsements within Maine's small physician communities has helped recruitment efforts.
  • Specialist and rural PCP recruitment: Recruiting specialists (urologists; ear, nose, and throat specialists; and oral surgeons) and PCPs in rural Lincoln County has proven challenging because few physician practices are owned by or affiliated with participating hospitals. The key to successful recruitment of specialists has been to leverage existing personal relationships between PCPs and specialists, with the PCP appealing to the specialists' good will in caring for their CarePartner patients. However, problems with accessing specialists still remain, as one-third of PCPs in the program report difficulty in finding specialists for their patients. Many specialty practices operate at full capacity, often with patients for whom care is fully reimbursed. Asking practices to forego paying customers to serve nonpaying patients can be difficult.

Resources Used and Skills Needed

  • Staffing: Each CarePartner case manager cares for 175 to 200 enrollees. Care managers have college degrees and average salaries of $35,000. In addition, administrators with networking skills are needed to work with hospitals, integrated health care systems, physician organizations, and other agencies to recruit PCPs, specialists, and in-kind services.
  • Costs: Most services are provided without charge by the hospitals, specialists, physicians, and drug companies, which collectively provide more than $4 million a year in services. CarePartners' 2007 operating budget was $1.3 million; administrative expenses were 10 percent in 2005 and 9 percent in 2006, well below the 12-percent average for private, small group health insurers (in spite of the intensive case management services offered).
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Funding Sources

Health Resources and Services Administration; Robert Wood Johnson Foundation; The Bingham Program
  • Startup funding: Approximately 80 percent of CarePartners's funding for its first year of operation came from grants from the Robert Wood Johnson Foundation ($235,570), the U.S. Health Resources and Services Administration ($400,000), and The Bingham Program ($25,000). About 20 percent of its funding came from MaineHealth member and affiliated hospitals.
  • Ongoing funding: In fiscal year 2007, health system and hospital funding made up 90 percent of CarePartners' annual budget. In addition, CarePartners received a $125,500 grant from the Maine Health Access Foundation. In fiscal year 2008, the total project budget was $1,300,000. Of that, $1,166,000 (90 percent) paid for by Local Hospitals and Health Care System and $134,000 (10 percent) was paid for by foundations.
  • In-kind donated services: In addition to the $4 million in donated medical services provided by hospitals, physicians, and pharmaceutical companies, Anthem Blue Cross/Blue Shield donates CarePartners insurance cards and performs medical services claims processing, while Martin's Point Informatics donates analytic support.
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Adoption Considerations

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Getting Started with This Innovation

  • Secure initial funding to cover startup costs until enough evidence is available to demonstrate the effectiveness of the program to area hospitals.
  • Get support from physician organizations and practices to aid in recruitment of PCPs and specialists.

Sustaining This Innovation

  • Once the data are available, show hospital leaders evidence of decreased enrollee hospitalizations and ED visits and effective leveraging of prescription assistance programs to secure enrollee access to prescription drugs. This evidence, which is critical in securing much-needed, ongoing hospital support and funding, can be especially persuasive in situations in which physician practices are affiliated with hospitals, or in capitated systems in which cost avoidance benefits both hospitals and physician practices.
  • Sustain physician participation by emphasizing the positive benefits of case management on enrolled patients. PCPs who participate in CarePartners, for example, report that enrollees' adherence to prescribed medications and their strong commitment to preventive health practices are important factors in their decision to remain with the program.
  • Whenever possible, consider locating case managers in PCP offices where they have regular access to patients, providers, and electronic medical records, thus facilitating their ability to support enrollees and physicians.

Use By Other Organizations

  • A number of organizations have put in place similar kinds of programs that are designed to reduce administrative barriers and redistribute the responsibility for providing free care to the indigent and uninsured. These programs—which already serve 2.5 million primarily uninsured patients in approximately 2,000 communities around the country—are working to increase the number of physicians willing to provide care. For example, Project Access is a specialty-care referral network in Buncombe County, NC that has recruited 630 of the county's 700 physicians, 70 percent of whom are specialists, to provide free care to uninsured patients.
  • A detailed summary of what other local organizations are doing to promote charity care across the United States can be found in the Volunteer Health Care Programs Report by the W.K. Kellogg Foundation, available at http://www.wkkf.org/knowledge-center/resources/2007/05/Volunteer-Health-Care-Programs-Appendix.aspx.

More Information

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Contact the Innovator

Carol Zechman
Director, CarePartners/MedAccess
241 Oxford St.
Portland, ME 04101
Phone: (207) 662-7960
E-mail: zechmc@mainehealth.org

Innovator Disclosures

Ms. Zechman has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile

References/Related Articles

Description of CarePartners Web site. Communities in Charge, 2002. Available at: http://www.communitiesincharge.org/Documents/PhaseII%20PressRelease/Portland.htm

CarePartners Web site. Available at: http://www.mmc.org/mh_body.cfm?id=3441

Isaacs SL, Jellinek P. Volunteer health care programs. A report to the W.K. Kellogg Foundation. March 2006. Available at: http://www.wkkf.org/resource-directory/resource/2007/05/volunteer-health-care-programs-appendix

Kaiser Commission on Medicaid and the Uninsured. The uninsured: a primer. Key facts about Americans without health insurance. Washington, DC: The Henry J. Kaiser Family Foundation; December 2010. Publication No. 7451-06. Available at: http://www.kff.org/uninsured/upload/7451-06.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Pauly MV, Pagán JA. Spillovers and vulnerability: the case of community uninsurance. Health Aff (Millwood). 2007;26(5):1304-14. [PubMed] Available at: http://content.healthaffairs.org/content/26/5/1304

Isaacs SL, Jellinek P. Is there a (volunteer) doctor in the house? Free clinics and volunteer physician referral networks in the United States. Health Aff (Millwood). 2007;26(3):871-6. [PubMed] Available at: http://content.healthaffairs.org/cgi/content/abstract/26/3/871

Footnotes

1 Kaiser Commission on Medicaid and the Uninsured. The uninsured: a primer. Key facts about Americans without health insurance. Washington, DC: The Henry J. Kaiser Family Foundation; December, 2010. Publication No. 7451-06. Available at: http://coverageforall.org/pdf/KFF_UninsuredPrimer_December2010.pdf.
2 Ormond C, Salley S, Kilbreth E. MaineHealth access project: profiling uninsured persons in three Maine Counties. 2000. Portland, ME: The Institute for Health Policy, Edmund S. Muskie School of Public Service, University of Southern Maine; August 2000.
3 Isaacs SL, Jellinek P. Volunteer health care programs. A report to the W.K. Kellogg Foundation. March 2006. Available at: http://www.wkkf.org/resource-directory/resource/2007/05/volunteer-health-care-programs
4 Cunningham P, May J. A growing hole in the safety net: physician charity care declines again. Tracking report No. 13. Washington, DC: Center for Studying Health System Change; March 2006. Available at: http://www.hschange.com/CONTENT/826/826.pdf
5 Maine Medical Center report, Portland, ME. March 2007.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 07, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.