A community report on the changes, challenges of free clinics and covering the uninsured
A female patient recently visited the East Orlando clinic of Shepherd’s Hope to have her blood pressure medication refilled. During the nurse’s examination, the patient disclosed that rationing the medication made it last longer. In the 15 minutes between seeing the nurse and waiting for the doctor, the patient began experiencing active stages of a heart attack and was quickly transported to a hospital.
“Unfortunately, those types of situations aren’t unusual, when patients come in for routine care and it turns into an emergency situation because symptoms have gone unchecked for too long,” said Marni Stahlman, CEO of Shepherd’s Hope, a faith-based healthcare nonprofit provider established in Orlando in 1997. “Thank goodness we were able to help her. The concern was that if she’d waited one more day to come see us, she would’ve had that heart attack at home alone.”
A Transforming Nation
Shepherd’s Hope, a network of five free clinics in Central Florida, has remained viable during a critical time when nationally free and charitable clinics for the uninsured are closing at a record pace. Others are floundering because of funding shortfalls and what some experts view as the misperception of universal healthcare. Closings of some of the approximately 1,200 free and charity clinics in the United States, which reported roughly 5.5 million visits last year, have taken place in 28 states. About half the clinics operate on annual budgets of less than $100,000.
According to a 2014 report by the National Association of Free and Charitable Clinics, patient demand has jumped 40 percent while donations have dropped 20 percent.
“As soon as there was the perception of universal healthcare, the likelihood of receiving donations goes down,” Colin McRae, JD, told the Wall Street Journal in December.
For the last two fiscal reports ending June 30, Shepherd’s Hope has experienced a 22 percent increase in patient volume, seeing 16,973 patients in 2012-13, and nearly 21,000 patients in 2013-14. Based on trends, the free clinic expects patient volume to climb to 24,000 for the 2014-15 fiscal year.
“It’s a concoction of the most toxic kind without the resources to resolve it,” said Stahlman, noting a May 2013 report by the Congressional Budget Office showed how even though the healthcare law is expected to reduce the number of uninsured by 25 million in 2023, 31 million Americans will remain uninsured. “The role of the free clinic is more critical than ever.”
Hitting Home in Florida
With 18 million residents, Florida is the nation’s fourth most populated state, with the highest percentage of 65 and older adults in the United States.
Even though Affordable Care Act (ACA) enrollment for newcomers is open through Feb. 15 – the deadline for existing members to make enrollment changes was Dec. 15 – more than 500,000 Central Floridians will likely remain uninsured.
Florida ranks 41 of 50 states with the highest volume of uninsured residents nationwide.
Because Florida lawmakers haven’t expanded healthcare coverage and Medicaid eligibility criteria, an estimated 750,000 residents have fallen into “the gap,” earning too much money qualify for assistance.
“What you have is a really bad sandwich. Without resources, insurance, or access to healthcare, many Central Floridians who’ve been captured in the healthcare coverage (Medicaid) expansion gap find themselves without anything,” said Stahlman. “There’s also a gap on the high end. With federal poverty guidelines set at a level they don’t meet, a family of four at $42,000 is forced into the healthcare exchange. A schoolteacher in a local public school making $45,000 with two children may not be eligible to qualify for the federal subsidy to offset the premium. When she goes onto the exchange for a general plan, even at the lowest premium, she’ll find it costs $350 a month, with a $2,000 deductible and co-payments. It’s expensive and out of reach.”
An obvious misperception about patients of Shepherd’s Hope is they’re at 200 percent (or below) the federal poverty level, probably on the brink of homelessness, and/or unemployed, said Stahlman.
“In actuality, 29 percent of our patient population in 2014 reports they’re fully employed, making not necessarily a living wage, but surviving,” she said. “It’s a heartache for single parents to decide whether to pay $350 for healthcare insurance or child care.”
Other relative newcomers to the state’s safety net program, which includes 48 federally-qualified health centers (FQHCs): Employees who have seen their hours drop from 40 to 32 weekly, as a result of the employer mandate provision of the ACA. Massive layoffs have also impacted employees’ access to healthcare. In December, Sea World announced 311 layoffs after CEO Jim Atchison was ousted, soon after bad press about the mistreatment of killer whales became public.
On the other end of the income spectrum, a self-employed professional couple in Jacksonville – he’s 60; she’s 54 – is paying more than $1,300 a month for “decent” health coverage through Blue Cross Blue Shield of Florida. The couple, who requested anonymity, shopped around for catastrophic health coverage, which cost more than the plan they acquired.
“The premiums are more than our house note,” she lamented. “But what can you do? There’s a penalty for not having health coverage. That doesn’t seem very American.”
Adding to the mix: the lack of understanding of the new federal penalty.
“When you do your taxes this year, a new form requires you to attest to healthcare coverage,” explained Stahlman. “If you don’t sign or can prove you had coverage, the fine system goes into place. Let’s say you can’t attest because you don’t have health coverage. How do they get the fine? It’s supposed to go through the IRS. Does that mean the IRS could become a lienholder on property until you pay it? How do you make someone pay for insurance they can’t afford? There are lots of gray areas.”
Following the Money Trail
“For several years, we’ve asked patients how long it’s been since they’ve had healthcare coverage,” said Stahlman. “Last year, 17 percent reported they’d had and lost insurance within the last six to 12 months. That was four months before October enrollment for the first part of the ACA. We knew then that we’d have a large portion of the population that saw their benefits drop. This year, the number jumped to almost 20 percent.”
Concurrently, Shepherd’s Hope asks patients two pertinent questions: Where did you previously seek healthcare intervention services? If you didn’t have access to Shepherd’s Hope, where would you go?
“The number one answer: the emergency department,” said Stahlman.
Florida Hospital CEO Lars Houmann pointed out the uninsured visit emergency rooms “for problems big and small.”
“It’s not a question of whether we’ll treat them,” he said. “We must. The question is who pays for that treatment, and the answer is all of us. Federal, state and local funding sources cover some but not all costs. And so the burden also is passed on to insured patients and their employers in what’s commonly called the cost shift … a hidden tax applied to premiums, co-pays and deductibles.”
According to a 2014 Modern Healthcare report, the nation’s busiest emergency room is Florida Hospital, with 206,800 visits to emergency departments at Florida Hospitals in Altamonte, Apopka, Celebration Health, East Orlando, and Kissimmee – and Winter Park Memorial Hospital.
Orlando Regional Medical Center accounted for the nation’s fifth busiest ER, including emergency departments at the Arnold Palmer Hospital for Children, University of Florida (UF) Health Cancer Center, Dr. P. Phillips Hospital, Lucerne Hospital, South Seminole Hospital and the Winnie Palmer Hospital for Women & Babies.
“Florida is at a particular disadvantage because we have one of the highest uninsured rates in the nation, and a comparatively smaller percentage of residents on employer healthcare plans to absorb the cost,” said Houmann.
UF economists predict $4.7 billion in Medicaid dollars will be sent to other states in 2016, including nearly $400 million to Ohio, where Republican Gov. John Kasich has reduced the state’s budget by $404 million over two years by expanding coverage.
If Florida legislators extend healthcare coverage under its Medicaid program, Houmann said “the long-term beneficiaries would be all of us. We would see savings in our healthcare costs, as well as growth in our economy. This isn’t a theory. We’re seeing state after state that expands coverage gain from the decision.”
Despite previous opposition to the idea, Florida Gov. Rick Scott announced on Feb. 20, 2013, that he supports a legislature-approved, three-year Medicaid expansion.
David Strong, who will take over as CEO of Orlando Health in April, is relocating from North Carolina, where the general assembly under Republican Gov. Pat McCrory also hasn’t voted for Medicaid expansion.
“One aspect that doesn’t get talked about much but is important: the bulk of every state’s Medicaid program is already funded by the federal government,” said Strong. “All states are relying on significant federal funds now. Unfortunately, by not expanding Medicaid, Florida and North Carolina are among the biggest losers in the country because of the population base. Ultimately, we all bear the burden for the lack of expansion because people will continue to seek care in our emergency departments and facilities.”
Strong pointed to states like Arkansas and Kentucky, which have historically experienced high numbers of uninsured residents and recently approved Medicaid expansion.
“Those numbers (of uninsured) have dropped,” he said. “Certainly, a solution in Florida is something we’ll need to sit down with members of the (state legislature) and work through.”
The Shifting Role of Free Clinics
Even though the original mission of Shepherd’s Hope was to serve the urgent health needs of the uninsured who were living at 200 percent or below the federal poverty guidelines, Shepherd’s Hope has morphed into the role of secondary/specialty care clinical provider.
“Over the last few years, we’ve seen a new mix of individuals who find themselves entering the safety net community for healthcare services for the first time in their lives,” said Stahlman. “Some were even previous donors! Now they’re standing in line, telling us, ‘I’ve never not had a doctor, I have no idea what to do.’ We’ve become the alternative to the emergency department hoping to mitigate the financial impact to our community.”
Stahlman pointed out the average admission cost of an ER visit is roughly $4,600.
“For example, we reported roughly 21,000 visits last year, where we didn’t charge patients anything,” she explained. “Those visits are valued at our costs at $77. Do the math on that ($1.6 million), versus $4,600 times 21,000 ($96.6 million), you can easily see why it’s a good investment for Shepherd’s Hope to be here. Our hospital partners get it right away.”
Roughly one-third of Shepherd’s Hope urgent care patients return for secondary specialty care services.
“For example, we might have a female patient with upper respiratory problems who hasn’t had a mammogram in eight years,” said Stahlman. “We’ll refer them for a screening with our partners. Then if a breast cancer diagnosis is made, they’re referred to our other specialty partners.”
Last autumn, Shepherd’s Hope and Sand Lake Imaging aligned for a Pink October initiative, which garnered 219 free mammograms.
Houmann noted: “All too often, our hospital sees people after the damage is done. A lump that could have been contained spreads with disastrous consequences.”
Coming Full Circle
Stahlman believes the greatest difference separating Shepherd’s Hope from other free and charitable clinics across the nation is the strong alliance of health partners in the Central Florida community.
Central Florida Regional Hospital, Florida Hospital and Orlando Health – Shepherd’s Hope’s primary partners – provided the free clinics with nearly $22 million of in-kind contributions and services last year. Many of the volunteer doctors and nurses at a clinic nightly are coming from work as an employee at one of these hospitals.
In 2014, Shepherd’s Hope initiated a pilot project to attract more pediatric providers.
“Only about 8 percent of our population is 18 and under. It’s not because they don’t come; it’s because we don’t have enough pediatric clinical volunteers. We approached Nemours in late July to streamline a process for uninsured children to get required school physicals at Shepherd’s Hope. With no primary medical home of their own, over two days, our two teams saw 108 children at two locations. That’s remarkable.”
Stahlman emphasized that Shepherd’s Hope’s volunteer roster includes more than 500 doctors, physician assistants and nurse practitioners.
“Some don’t actually come to our clinics to volunteer,” she said. “We also have a community provider program where we’re able to extend sovereign immunity through the Department of Health for those healthcare providers who see our referred patients in their office and agree not to charge them. (See sidebar.) For many area physicians, it’s a way for them to participate with us without leaving their office, which is sometimes very difficult. We’re very grateful for the support of the local physician and practitioner community. That makes us very distinctive.”
Dispelling Concerns about Medical Malpractice Liability as a Volunteer
In 2012, state lawmakers updated Florida’s Sovereign Immunity Law to protect licensed medical providers through the Volunteer Healthcare Provider Program under Florida’s Department of Health (Florida S.S. 766.28 Sovereign Immunity Law).
Any licensed medical provider, while practicing within the scope of their license at a free clinic in Florida, is granted extended sovereign immunity. The law also applies to medical practices, where licensed medical providers often see patients on a volunteer basis.
As a precaution, if a volunteer physician sees a patient who is later determined not to fit the eligibility criteria, the physician would have 30 days of extended sovereign immunity.
If a volunteer physician is affiliated with a Professional Association (PA), the Florida Department of Health recommends establishing a sovereign immunity contract to protect the corporation.
Also, if a patient of a volunteer healthcare provider files a lawsuit under the contract, the patient may only file the lawsuit against the state, not the individual provider. In that case, the Department of Insurance will provide legal services, and if the court decides the patient suffered damages as a result, the patient may be awarded damages up to $100,000, which would be paid by the state.
“In the 18 years we’ve been operating, nobody has had a challenge,” said Marni Stahlman, CEO of Shepherd’s Hope, a faith-based healthcare nonprofit provider headquartered in Orlando. “Shepherd’s Hope is in need of additional volunteer health professionals and it’s important for those considering it to realize this protection benefit.”
Shepherd’s Hope, Inc. has three primary fundraisers for 2015:
Thursday, April 9: Call to Hope Breakfast: Find Your Moment to Change a Life, slated for the Presidential Ballroom at Church Street, 225 South Garland Avenue, in Orlando. Registration begins at 8 am; RSVP is required.
Thursday-Friday, July 23-24: Celebrity Golf Classic at Reunion Resort, a Wyndham Grand Resort in Orlando. The two-day event will begin with a Pairings Party on July 23, matching three players with a celebrity golfer, and also featuring live entertainment and a three-bedroom suite at the resort. (Foursomes are $2,500.) On July 24, a day of golf includes breakfast, on-course games, food and drinks, and an awards program.
Saturday, Oct. 24: Famous Faces Masquerade Ball at Universal Orlando’s Loews Royal Pacific Resort. The evening, beginning at 6:30 pm, will include a three-course gourmet meal, fine wines and spirits, costume contests, live music, dancing, live and silent auctions. Individual tickets are $250.
For more information, contact Morgan.Hargrove@ShepherdsHope.org or call Hargrove at (407) 876-6699, extension 230.