Positioning itself for the future of healthcare reform, when population health and patient outcomes will drive hospital payments, Jackson Health System is taking a new approach to managing care for the uninsured: re-branding its charity care program as Jackson Prime, with new services and a goal of improving customer satisfaction while lowering costs in the long run.
With more uninsured patients than any hospital system in the state and the most at financial risk in the state’s continuing impasse over healthcare policy and funding — an estimated $200 million a year in federal money could be lost — Jackson officials say the Prime program will help reduce emergency room visits and escalations of illnesses.
“We’re doing more for prevention than curing,’’ said Ed O’Dell, a Jackson spokesman. “There will be a move toward a population that is more healthy, so we start avoiding some of the costs.’’
O’Dell said uninsured patient visits to Jackson’s emergency rooms number about 1,500 a month at an average cost of $1,200 per visit. But ER visits by the uninsured are only part of Jackson’s total expense for unfunded care, which also includes the charity care program as well as the cost of caring for county jail inmates.
The total cost of unfunded care at Jackson for the year ending Sept. 30 was about $440 million, which was offset by $365 million in local property and sales taxes.
While the Prime program aims to reduce the cost of unfunded care for Jackson, it also may be the result of added pressure from Medicaid managed care providers, whose clients account for about a fifth of all patient stays at Jackson this year. Those providers’ payments from the state are tied to the health status of those patients. Better health brings bonuses, while poor outcomes lead to penalties.
The Prime program also will make the hospital system more attractive to patients if Medicaid is expanded in Florida — a question that caused an impasse in the Legislature and forced a special session set to begin June 1. If more patients qualify for Medicaid or for financial aid to make an Obamacare plan affordable, they’ll be able to exercise a choice in their hospital and doctor, rather than automatically going to Jackson.
Cary Nieves, an assistant vice president and chief nursing officer, said the Prime program will provide the uninsured with social workers, nutritionists and nurse “navigators” who will help speed up authorizations for specialist referrals and follow-up visits, reducing delays in treatment.
The wait to see a specialist at Jackson can run five to six months or as little as two weeks, depending on the medical specialty. Urology, pulmonary and ear, nose and throat have the longest waits because the clinics are only available limited hours since they are used for teaching.
But Nieves, speaking at a meeting of Jackson’s board of trustees this week, noted that delays also have been due to an inefficient process for managing uninsured patients.
“There was always a gap,’’ she said, “with patients leaving clinics without knowing if their appointment was going to be approved to see a specialist. We need to reposition ourselves ... so when they get managed Medicaid or an Affordable Care Act plan that they come back to Jackson rather than leaving us and going elsewhere.’’
The social workers, nutritionists and nurse navigators also will work at five Jackson community clinics, including the Ambulatory Care Clinic at Jackson Memorial, the North Dade Health Center, the Dr. Rafael A. Peñalver Clinic, the Jefferson Reaves Sr. Health Center and the Rosie Lee Wesley Health Center.
That means patients will receive approval of future appointments and referrals right away rather than having to wait for a phone call referral, Nieves said. Nurse navigators also can confirm that patients have met all criteria before approving referrals, such as necessary tests.
In addition to “de-centralizing” those services, O’Dell said, Jackson has hired two additional staff members at a cost of about $100,000 a year. Prime program patients also will receive free parking and free wireless Internet access.
Advocates for the uninsured said they applaud Jackson’s efforts but they note that other issues remain to help ensure access and improve outcomes for the uninsured.
“If you’re going to look at population health, and it’s great that they’re doing that, it has to be more than just words,” said Miriam Harmatz, an attorney with Florida Legal Services, a legal aid group. “They have to change program policies so their services are available to people to use in a preventive way.’’
In August, Florida Legal filed administrative complaints with the IRS and the Department of Health and Human Services alleging that Jackson created unnecessary barriers to care for low-income county residents.
Among the complaints were that Jackson used an onerous and time-consuming application process, taking as long as three months to schedule appointments; that Jackson charged co-payments for doctor’s visits and other services to patients with incomes below poverty, and used out-of-network physicians who bill uninsured patients at full price.
None of those issues appear to be addressed by the Prime program, Harmatz said, but she takes particular issue with Jackson’s policy of charging co-payments for the poorest qualified patients, such as $6.50 for prescription drugs, $40 for an emergency room visit or $100 a day for outpatient procedures.
“You can’t have that copay charge,’’ she said, calling it “a serious if not insurmountable barrier.”
Harmatz said federal agencies have not yet responded to Florida Legal’s administrative complaints. But Florida Legal is now focusing its efforts on advocating for expansion of Medicaid eligibility, an issue that has divided the Florida Legislature.
If Florida were to adopt a plan to expand Medicaid eligibility that met federal regulations, an estimated 850,000 poor adults in the state would gain coverage, including about 140,000 in Miami-Dade, according to the Urban Institute, a nonprofit health policy research group.