Frustrated with providing episodic care to the uninsured, county-owned Wishard Health Services in Indianapolis has launched a program to coordinate indigent care.
Dubbed Wishard Advantage, the program targets Marion County, Ind., residents with incomes less than twice the poverty level.
Wishard Advantage resembles a commercial or Medicaid managed-care plan right down to its membership cards, member handbook and primary-care providers. But unlike insurance, it doesn't cover services outside the system.
"We think it's important to practice one standard of healthcare," said E. Mitchell Roob Jr., president of Health and Hospital Corporation of Marion County, which operates Wishard.
"For a patient with commercial insurance to receive care in a managed manner and for the indigent population to receive it in an unmanaged manner didn't make a lot of sense, particularly because people move on and off Medicaid."
The National Association of Public Hospitals and Health Systems says at least five other counties have launched managed-care programs for the indigent since 1980 (See box).
Wishard provides 80% of indigent care in Marion County at an annual cost of $65 million, about one-third of its budget. Of that, $50 million is paid by a property tax stipend and $15 million is shifted from Medicare, Medicaid and private payers.
Roob doesn't anticipate short-term savings for taxpayers, since the system will be meeting pent-up demand. Long term, the program could reduce utilization of expensive services, which could reduce public spending on indigent care. However, Roob cautioned, improvements in health status and cost savings are expected to be difficult to track.
The program carries some risk. It might be too attractive for its own good, removing the incentive for those who gain eligibility to move into Medicaid or commercial plans.
"Are we creating an incentive for these individuals not to get health insurance?" Roob asked. "I think we'll need to be working with employers and be very attuned to that. We cannot afford to create an entitlement in perpetuity."
Membership cards went to 10,000 indigent patients last month, more than 7,500 of whom responded by selecting a primary-care provider. The remainder will have physicians assigned to them.
Those with incomes between 150% and 200% of the poverty level pay a sliding-scale portion of the monthly per-member per-month fee of $11.50, which covers primary care. For those making less than 150% of poverty level, Health and Hospital Corp. pays 100%.
Primary care is provided by Indiana Health Care, a group of 70 full-time-equivalent physicians affiliated with Wishard and Indiana University School of Medicine.
Primary-care physicians authorize specialty services provided at Wishard clinics or by IU medical school faculty. The county's 473-bed Wishard Memorial Hospital provides inpatient and ancillary services. Health and Hospital Corp. picks up any uncompensated specialty and hospital care.
The medical group's member services answer enrollee questions and assist them in choosing or changing a primary-care physician, initially choosing from doctors at six sites. Patients may change primary-care physicians with 30 days' notice.
Routine dental and vision care and mental health services are not included.