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Policy Innovation Profile

Community Partnership Connects Low-Income Patients With Providers Who Serve Them at Discounted Rates, Enhancing Access and Reducing Emergency Department Use


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Snapshot

Summary

Doctors Care, a community-funded, nonprofit organization, matches eligible uninsured and underinsured patients in a three-county area outside of Denver County, CO, with providers who agree to serve them at a discounted rate. Governed by a board of community stakeholders, Doctors Care signs formal agreements with both providers (including physicians, hospitals, and others) and patients that lay out the key requirements and policies related to patient participation. The organization then supports both providers and patients in meeting these requirements by assigning a care coordinator to help patients overcome obstacles to accessing care and adhering to their treatment plan. The program has generated high levels of participation among area providers and enhanced access to care for patients, leading to fewer emergency department visits.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of area providers participating in the program, the dollar value of care provided to uninsured and underinsured patients, and comparisons of emergency department visits among program participants with national and local statistics.
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Developing Organizations

Doctors Care
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Date First Implemented

1988
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Patient Population

Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsuredend pp

Problem Addressed

Individuals who lack adequate insurance generally face substantial obstacles to accessing affordable health care, particularly specialty care. As a result, they often go without care until an acute crisis manifests that requires expensive emergency department (ED) and/or inpatient care, and they face an increased risk of poor outcomes, including death. Those fortunate enough to secure access to specialty services often cannot get needed help navigating the complex health care system and connecting with available community resources.
  • Many without adequate insurance: Up to half of adults in the United States are uninsured or have insurance that does not cover the full cost of care.1 In the State of Colorado in 2011, more than 1.5 million residents did not have adequate health insurance, and about one-fourth of Coloradans between the ages of 19 and 54 had no insurance at all.2
  • Multiple obstacles to accessing care, particularly specialty services: Uninsured and underinsured individuals often lack access to needed care, particularly specialty care. Many specialty providers will not treat Medicaid beneficiaries and/or the uninsured, making it impossible for these patients to afford their services. Consequently, most uninsured and underinsured individuals seek care at safety net providers, many of which do not offer specialty care. For example, in Colorado, a third of safety net clinics do not offer specialty care, and those that do generally offer care in only a limited range of specialties. Some safety net hospitals limit the provision of specialty services to those who live within a certain service area, leaving those outside the area without access to such care.3 Even when specialists provide free or reduced-cost physician care to uninsured patients, these patients often need additional specialty services (such as pharmacy, hospital, or therapy services) not available at a discounted price.
  • High use of expensive settings, worse health outcomes: People who do not have health insurance or a regular source of medical care generally forgo care until an acute crisis develops, often creating the need for expensive ED or inpatient care. They are also less likely to receive followup care for chronic conditions and early screening and treatment for cancer and other preventable or treatable diseases. As a result, they face an increased risk of poor health outcomes, including death due to preventable causes.1
  • Little or no support navigating system: Low-income patients with chronic or complex health issues who are fortunate enough to have access to specialty care often need assistance in navigating the health care system and connecting with available community resources that can help. Yet such support is seldom available.

What They Did

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Description of the Innovative Activity

Doctors Care, a community-funded, nonprofit organization, matches eligible uninsured and underinsured patients in a three-county area outside of Denver County with providers who agree to serve them at a discounted rate. Governed by a board of community stakeholders, Doctors Care signs formal agreements with providers (including physicians, hospitals, and others) and patients and lays out the key requirements and policies related to patient participation. Doctors Care then supports both in meeting these requirements, including assigning a care coordinator to help patients overcome obstacles to accessing services and adhering to their treatment plan. Key components of this initiative include the following:
  • Governance by board of stakeholders: The board of directors of Doctors Care meets every 2 months to discuss how area providers can better work together to meet the needs of the uninsured and underinsured. The organization's bylaws specify that certain board slots be filled by members of the provider community, including representatives of participating hospitals, the Arapahoe-Douglas-Elbert Medical Society, a nearby family practice residency program, and providers of other health care services, such as radiology, pharmacy, primary care, and specialty care. The bylaws also require that the board include representation from local community and volunteer organizations. Although not a designated seat, the board also includes a representative from the medical malpractice liability insurer (COPIC) that covers a majority of Colorado physicians.
  • Provider recruitment and agreements for working relationship: One staff member focuses solely on meeting with individual physicians, physician practices, hospitals, and other providers to explain the program and encourage their participation. For those that agree, Doctors Care and the provider sign a simple, customized memorandum of understanding (MOU). The provider is allowed to specify the terms of the agreement based on his or her desired level of commitment to the program. The specific components of the relationship between Doctors Care and participating providers are outlined below:
    • Physician-specified commitment: Doctors Care signs agreements with community-based primary care providers to serve patients over the age of 30 and with specialists to serve patients of all ages. (Doctors Care operates its own dedicated primary care and mental health clinic for those under age 30.) As part of the MOU, participating physicians specify the key terms under which they would like to participate, including how many (and, if desired, what type of) patients they will accept. For example, some physicians may be willing to accept only one patient a month, while others may take more. In addition, some may be willing to provide only certain types of services. This approach helps to boost participation rates by giving physicians some control over when, where, and how care is provided to patients under the agreement.
    • Sliding-scale fees for patients and other financial arrangements: Doctors Care specifies the fees to be paid by patients, which are based on a sliding-fee scale determined by the patient's income. (Patients pay a minimum of $10 for a physician visit, as discussed in more detail below.) In exchange for signing up, participating doctors also receive a discount from the Arapahoe-Douglas-Elbert Medical Society on their membership fees. COPIC ensures that doctors who see uninsured patients have the same medical liability coverage as when they see insured patients. These arrangements resulted from negotiations between Doctors Care and the two organizations.
    • Similar agreements with other providers: Hospitals, pharmacies, diagnostic testing centers, and other providers sign similar types of agreements with Doctors Care. Agreements are signed with individual hospitals, even those part of a larger system. National chain pharmacies sign agreements to honor discounted prescription prices and give lists of these prices to participating doctors for reference when prescribing medications. Over time, Doctors Care has signed participation agreements with other types of providers to boost primary care capacity and better cover the care continuum; examples include agreements with nurse practitioners, physician assistants, hospice care providers, and providers of complementary and alternative medicine.
    • Clear processes for resolving problems: Doctors Care provides physicians with clear, written instructions related to program participation, including procedures and expectations for both parties related to solving problems with individual patients. To that end, Doctors Care provides contact information and instructions to call about any patient problem, such as nonpayment, noncompliance with medication regimens, and difficulties in scheduling or getting to appointments.
  • Photo of a patient surrounded by two staff members participating in Doctor’s Care.

    Figure 1. A patient surrounded by two participating staff members. Click the image to enlarge. Image courtesy of Bebe Kleinman. Used with permission.

  • Matching eligible patients to providers: Using a sophisticated care management software package, Doctors Care screens patients for eligibility (based on income, county of residence, and insurance status and coverage) and matches each eligible patient with a specific primary care physician, pharmacy, and hospital based on where the patient lives and his or her unique health care needs (see Figure 1).
  • Participation contracts with patients: As part of the matching process, patients sign a contract with Doctors Care that lays out the provider assignments, required patient cost sharing via the sliding-fee payment scale, and other requirements related to their participation, including a 2-year limit on use of services and a "three strikes" provision related to when patients can be removed from the program.  Additional details are outlined below:
    • Required payment via sliding-fee scale: The contract specifies that patients are responsible for paying the provider for services or working out a payment plan with the Doctors Care patient care coordinator assigned to them. Payments are based on a set scale specified in the contract, with fees ranging from 5 to 65 percent of the normal provider charge, depending on patient income and type of service provided. The minimum payment is $10, which the organization believes encourages personal responsibility for health care. Patients who refuse to pay and do not make acceptable payment plan arrangements may be terminated from the program. 
    • Guidelines for service use: Patients agree to use only the providers assigned to them (primary care provider, pharmacy, and hospital), unless they have a referral from Doctors Care to seek care from a specialist. They also agree to use ED services only in true emergencies or with the permission of their primary care provider.
    • Requirement to follow through with recommendations: Patients agree to make and keep their own appointments and comply with provider recommendations. If patients do not comply with recommended treatment, the patient care coordinator meets with them and/or the provider to determine and address obstacles, such as difficulty paying for other needed services (e.g., prescription drugs, diagnostic tests), mental health issues, disagreement with the course of treatment, or transportation needs.
    • Limitation on care for chronic pain: Doctors Care expressly excludes treatment for chronic pain, although providers will treat pain from an acute condition. This policy reduces the chance that patients will use the program to obtain drugs to feed an addiction.
    • Three-strikes policy: Whenever a patient violates the agreement, the patient care coordinator uses the violation as an opportunity to teach the patient about personal responsibility and how to navigate the health care system. If the patient violates the agreement three times, he or she can be terminated from the program. 
    • 2-year limit, transition to permanent coverage: The agreement remains in place for a maximum of 2 years, generally enough time to get the patient through an acute crisis and stabilize the situation. This policy ensures that slots can be opened up for new patients with more immediate needs. Throughout the 2-year period, care coordinators help to connect patients with more permanent coverage. For example, several Doctors Care employees recently became certified assistance guides to help people sign up for insurance through Connect for Health Colorado, the state's online health insurance marketplace. Doctors Care can adjust the time limit as needed for patients who cannot obtain suitable coverage within the 2-year timeframe.
  • Support for participating providers and patients: On an ongoing basis, Doctors Care staff work to support participating providers and patients, as outlined below:
    • Care coordinator supported by care management software: A care coordinator supports both the physician and patient by acting as a liaison between the two and helping patients navigate the health care system so that they can follow through with physician recommendations. To assist in this work, the care coordinator has access to a care management software program. In addition to matching patients with providers, this system tracks medical history, diagnoses, procedure codes, and effectiveness of treatment, thus giving the coordinator and program leaders a better understanding of individual patients and the patient population as a whole. The system can receive data from partner hospitals, physicians, laboratories, and pharmacies.
    • Volunteers to extend capabilities: To bolster the capacity of the care coordinator, Doctors Care recruits and trains volunteers who help patients navigate the health care system, fill out forms, arrange for transportation, and follow through with physician recommendations. The organization has developed an extensive volunteer handbook that serves as a reference to volunteers.
    • Procedures to address issues with difficult patients: Doctors Care staff, volunteer providers, and others address specific situations in which individual patients face challenges accessing care and/or following through with recommendations. The staff members get together regularly to brainstorm solutions to problems experienced by patients with complex medical and/or social needs. 

Context of the Innovation

Doctors Care was founded in 1988 in response to a decision by Denver County to restrict use of its public hospital to county residents. This decision had a major negative effect on access to care for Medicaid beneficiaries and uninsured and underinsured residents in the three other countries in the Denver Metropolitan area, none of which operated a public hospital. The next closest public hospital for these residents was in Colorado Springs, nearly 65 miles away. Recognizing the situation facing these individuals, the leaders of private hospitals in the area feared they would be overburdened with uncompensated and charity care. As detailed in the Planning and Development Process section below, a group of community stakeholders came together to evaluate alternative strategies for addressing the problem and ultimately decided to create Doctors Care.

Did It Work?

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Results

The program has generated high levels of participation among area providers and has enhanced access to care for patients, leading to fewer ED visits.
  • High participation by wide range of providers: More than 1,000 physicians (about a third of those in the area) from 90 specialties participate in the program. All six area hospitals (Swedish Medical Center, Porter Adventist Hospital, Littleton Adventist Hospital, Sky Ridge Medical Center, Parker Adventist Hospital, and Castle Rock Adventist Health campus) and their laboratories and pharmacies also participate. Competing health care systems (Centura and HealthOne) hold places on the board. In 2012, more than 100 additional physicians joined the network.
  • Enhanced access to care: In 2012, the organization made 690 referrals for 855 patients to specialists leading to more than $13 million in care donated by partner hospitals and providers.
  • Fewer ED visits: Only 15 percent of Doctors Care uninsured patients used ED services one or more times in 2012, well below the 21-percent rate of ED use among uninsured patients nationwide. Less than 5 percent of Doctors Care patients had repeat ED visits, well below the 12.5-percent rate among uninsured patients nationally. Using national averages as benchmarks, these differences translate into savings of as much as 40 percent on uncompensated ED visits in 2012.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of area providers participating in the program, the dollar value of care provided to uninsured and underinsured patients, and comparisons of emergency department visits among program participants with national and local statistics.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Forming committee to explore alternatives: Arapahoe-Douglas-Elbert Medical Society formed a committee to look at various ways the community could respond to the decision by Denver County to restrict access to its public hospital. Local physicians and representatives of the two health systems with hospitals in the area served on the committee.
  • Developing model: The committee decided that the best approach was to create a system that would spread the care of uninsured and underinsured individuals over many providers, so that everyone would contribute a little and no one would bear a huge burden. Committee members believed that most physicians would be willing to provide care for reduced fees if economically and logistically feasible to do so. To that end, the committee worked with providers to design an appropriate model that could meet their needs and those of their patients.
  • Fostering culture of expectation: Leaders of the Arapahoe-Douglas-Elbert Medical Society initially decided that all of their physician members would automatically participate in the program unless they expressly opted out of doing so. This approach created a culture of expectation based on peer pressure to serve. The Medical Society no longer uses this approach, but instead provides Doctors Care with the names of new physician members so that staff can approach them about participating.
  • Developing matching software: In the early days of the program (when 300 physicians and 2 hospitals participated), program managers used an Excel spreadsheet to match patients and providers and track care delivery. As the number and type of providers grew and the organization began offering more care coordination services, they developed a more robust software system by adapting an existing care management software package (originally developed for insurance companies) to meet the needs of the organization.
  • Expanding service offerings: To provide the full continuum of care, the organization started working with area pharmacies, laboratories, and allied health providers to ensure that patients could access the care recommended by physicians. As noted earlier, Doctors Care has continued to add or adapt services over time by signing participation agreements with providers of other services (e.g., hospice, complementary and alternative medicine) and has boosted capacity by signing agreements with nurse practitioners and physician assistants.

Resources Used and Skills Needed

  • Staffing: The organization has three full-time paid staff: a program director, care coordinator, and volunteer coordinator. Doctors Care also has a part-time physician recruiter and roughly 20 volunteers who work on patient eligibility screening and intake, assistance with health system navigation, and other aspects of of patient and provider support.
  • Costs: The annual budget totals $1.25 million, $400,000 of which goes to support the program team that recruits providers and volunteers, screens and educates patients, matches patients with providers, and provides care management services. The remainder of the budget is used to run the Doctors Care primary care clinic for patients under age 30.
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Funding Sources

Caring for Colorado Foundation; Colorado Health Foundation; Primary Care Foundation; The Denver Post Foundation
More than 20 organizations have provided funding support to Doctors Care; this list includes those that contributed $40,000 or more.
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Tools and Other Resources

Doctors Care, Maximizing Health Care for Colorado’s Underserved: An Operations Handbook and Web Resource for Safety-Net Medical Homes. 2013. Available at http://www.maximizinghealthcare.org/.

More information about Doctors Care can be found at http://www.doctorscare.org.


Adoption Considerations

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Getting Started with This Innovation

  • Start small: Initial startup requirements are generally quite modest, with one staff person, office space, and a basic spreadsheet the only "must have" requirements. Existing community-based providers do not need additional resources to begin participating in the program.
  • Find provider champion: Clinicians often respond more favorably to a peer. Doctors Care benefits from the involvement of Gary VanderArk, MD, a physician who helped found the organization and continues to advocate for it, urging his colleagues and peers to participate.
  • Work with local professional associations: Working with the Arapahoe-Douglas-Elbert Medical Society has given Doctors Care access to the names and addresses of local physicians. In addition, Arapahoe Medical Society leaders agreed to offer discounts on membership fees to those who sign up to participate in Doctors Care.
  • Offer more than physician services: Doctors depend on pharmacies, laboratories, and other providers to deliver the full spectrum of care needed by at-risk patients. Design the system so that physicians know that patients will not face structural barriers to accessing this type of care.
  • Recruit qualified volunteers: Doctors Care depends on volunteers to keep costs down. Program leaders work with local service groups and volunteer organizations to recruit qualified volunteers and also provide training and support to these volunteers to ensure they stick with the program.
  • Create strategic partnerships: From the beginning, Doctors Care forged a strategic alliance with COPIC. As noted earlier, COPIC agreed to provide discounts on liability coverage to physicians who volunteer with Doctors Care, and this incentive has proven to be quite popular among doctors. (The company also provides free liability coverage for care delivered by volunteer physicians at the Doctors Care Clinic in Littleton, CO.)

Sustaining This Innovation

  • Maintain multiple, balanced sources of funding: Doctors Care raises a roughly equivalent amount of money from three sources: donors and grants, sliding-scale fees from patients and reimbursement from insurers for care provided at the in-house clinic, and in-kind services from volunteers, including providers, care coordinators, and other professionals such as lawyers. This balance helps to ensure sustainability.
  • Make it easy for physicians to try program: A successful recruitment campaign, titled “Try Just 1,” encouraged doctors to see how easy it was to participate by allowing them to take care of just one Doctors Care patient.
  • Grow information technology infrastructure as needed: As noted, the organization initially used an Excel spreadsheet to match patients with providers but found that it needed a more sophisticated approach as the program grew. Using a grant from the Colorado Health Foundation, the organization purchased the care management program described earlier.
  • Share data on program benefits with stakeholders: In response to the increased focus nationwide on readmissions and ED visits, program leaders began tracking data on the impact of Doctors Care on these metrics. Consequently, they can now show partner organizations data proving that this approach reduces use of these expensive services. Sharing this information helps to keep both providers and funders engaged.
  • Continue recruiting and engaging providers: Provider recruitment is an ongoing job. Doctors Care staff personally contact every physician who comes into the community and look for opportunities to network on a regular basis with those already in the program to make sure they remain satisfied with it. In addition, staff have developed relationships with practice managers and office managers. Program leaders suggest having at least one staff member dedicated to physician recruitment activities.
  • Work with local federally qualified health centers (FQHCs): In some cases, FQHC patients may have trouble accessing specialty care or hospital services. In these cases, Doctors Care works with the FQHC to transition patients to Doctors Care for the duration of the specialty care and then move them back to the FQHC after the situation has stabilized. This system works in everyone’s favor; few, if any, turf issues arise.
  • Continue to support patients transitioning to Medicaid: Doctors Care continues to support patients who qualify for Medicaid to ensure they maintain access to the services they need. By providing care coordination services to these transitioning patents, Doctors Care is generally able to convince physicians to retain these Medicaid patients.
  • Take advantage of other opportunities to secure coverage: Doctors Care applied to provide assistance for people seeking insurance through Colorado’s Connect for Health marketplace. As a result, five staff members and eight volunteers are now certified to help with the enrollment process. Program leaders expect that many Doctors Care patients will qualify for affordable health insurance under the Affordable Care Act.
  • Work with medical schools and residency programs: This strategy helps build the organization’s capacity and introduces future clinicians to the idea of caring for underserved populations at discounted rates.

More Information

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Contact the Innovator

Bebe Kleinman, MNM
Executive Director
Doctors Care
609 West Littleton Boulevard, Suite 100
Littleton, CO 80120
Direct phone: (720) 458-6226
Main phone: (303) 730-1313
Fax: (720) 458-6202
E-mail: bkleinman@doctorscare.org

Innovator Disclosures

Ms. Kleinman reported having no financial interests or professional/business relationships relevant to the work described in this profile, other than the organizations that have provided grants to Doctors Care. A list of major donors is included in the Funding Sources section.

References/Related Articles

Colorado Health Institute. 2010 Colorado Safety Net Specialty Care Assessment. March 2011. Available at http://www.coloradohealthinstitute.org/uploads/postfiles/SpecialtyCare.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

The Colorado Trust. Colorado Health Access Survey Issue Brief: Overview of Coloradan’s Health Care Coverage, Access and Utilization. November 2011. Available at http://www.coloradotrust.org/attachments/0001/6590/IssueBrief_Overview_FINAL_11_9_11.pdf.

Footnotes

1 Collins SR, Robertson R, Garber T, et al. Insuring the future: current trends in health coverage and the effects of implementing the Affordable Care Act. The Commonwealth Fund. April 2013. Available at http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Apr/Insuring-the-Future.aspx.
2 The Colorado Trust. Colorado Health Access Survey Issue Brief: Overview of Coloradan’s health care coverage, access and utilization. November 2011. Available at http://www.coloradotrust.org/attachments/0001/6590/IssueBrief_Overview_FINAL_11_9_11.pdf.
3 Colorado Health Institute. 2010 Colorado safety net specialty care assessment. March 2011. Available at http://www.coloradohealthinstitute.org/uploads/postfiles/SpecialtyCare.pdf.
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Original publication: February 12, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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