The root of the problem

In Spartanburg County, S.C., one in 10 adults doesn't have any teeth.

It's a shocking statistic that local providers learned just last year when they began assessing barriers to care among low-income uninsured.

“We asked, ‘How is this possible?' ” said Renee Romberger, vice president of community health policy and strategy at Spartanburg (S.C.) Regional Healthcare System.

As the only safety net hospital in the county, not-for-profit Spartanburg Regional spent about $1 million last year on unreimbursed emergency dental care.

But officials there didn't know the extent of the problem the uninsured face in terms of dental care and other unmet health needs until they embarked on a communitywide assessment of local health services.

They learned that there are no adult dental providers for the uninsured in the county. About once a month, a dentist visits a homeless center in the area and does tooth extractions free of charge. Tooth-pulling is, for many uninsured, the only low-cost solution to the painful, chronic problem of tooth decay.

The dire need for adult dental care isn't isolated to Spartanburg, a rural county near the North Carolina border.

Untreated tooth decay is the No. 1 reason for preventable emergency room visits in South Carolina's rural counties among uninsured adults aged 18 to 64. In South Carolina overall, dental care is the third most common reason why uninsured adults visit ERs.

“This was not something we expected,” said Amy Martin, deputy director of the South Carolina Office of Rural Health, at the University of South Carolina. “Dental is a huge unmet need. It's not a high-dollar ER visit, but it's a high-volume ER visit.”

Providers recognized immediately that the dental crisis in the region reverberates through the local economy.

“It's very hard to get a job if you don't have teeth,” Martin said. With the manufacturing, textile and tobacco sectors shrinking, tourism has become a leading job-creator in South Carolina. But nobody in the tourism industry wants to hire workers without teeth, Martin said.

“Adult dental care is so important from an economic standpoint,” Martin said. “But there has been a certain hopelessness around adult dental.”

Now, some providers in the Carolinas are working together to turn that hopelessness around.

They are embarking on a new, coordinated push to serve the uninsured, thanks to long-term support from the Duke Endowment in Charlotte, N.C., and the South Carolina Hospital Association, among others.

kickoff of Cover the Uninsured Week on March 14, the work in the Carolinas may serve as a model for other regions looking to ramp up their efforts to cover more uninsured. And whether national health reform becomes a reality, providers in the Carolinas say that better care coordination is necessary to care for low-income, chronically ill patients.

What it means in the Carolinas is that funding and technical support have become available just in the past two years for communities that want to improve care for the uninsured.

So far, 14 counties out of 46 in South Carolina have committed to improve access for low-income uninsured. In North Carolina, 51 out of 100 counties are participating.

In South Carolina, a new organization called AccessHealth SC is coordinating the endeavor. It is incubated at the South Carolina Hospital Association.

Networking

Melanie Matney, the executive director of AccessHealth SC, said the goals are to create networks of care that improve access and to improve the quality of care to the uninsured.

The first step is for communities, such as Spartanburg, to evaluate the health services and unmet needs. It is conducted by Martin and others at the University of South Carolina and includes the number of uninsured, services offered, utilization and outcomes.

Only after the independent assessment is completed, Matney said, can local providers work together to get a game plan, and apply for grants and other funding to improve services.

So far, five communities have completed the assessment process, including Spartanburg County.

“What's been extremely interesting to me is that all the communities are diverse, but the barriers tend to be the same,” Matney said. “So we can do statewide strategies around some of these issues. There's a lot of confusion in our state as to what services are available.”

But before the assessment can even begin, a wide swath of community partners needs to come to the table committed to working toward long-term solutions.

“It can't just be a free clinic participating,” Matney said. “It has to include the hospitals, the federally qualified health centers, the pharmacy outlet and others.”

In fact, many applications are initially rejected because there is not a strong enough communitywide commitment to improving care to the uninsured. “You can't really make a difference in the healthcare system if everyone doesn't have a say in how to improve it,” Matney said.

In Spartanburg County, the two hospital systems, Spartanburg Regional and Mary Black Health System, a for-profit system owned by Community Health Systems, are participating, along with the clinics, medical society, county mental and public health agencies, local United Way chapter, free pharmacy provider, and alcohol- and drug-abuse commission, among others.

“We're fortunate to have a broad spectrum of high-quality healthcare services in our community. But, too often, the uninsured believe the only place they can turn to for healthcare is a hospital emergency room—even when they are not facing a true health crisis,” Mary Black Health System said in an e-mailed statement. “As case managers from our hospital collaborate with other care providers across our community, we can help close the gap that often exists for uninsured patients.”

Other providers are working to boost care for the uninsured. A free dental clinic is planned for August in Greenville, an effort backed by the South Carolina Dental Association and the state hospital association, said W. Carter Brown, a Greenville dentist who coordinated a similar effort last August. The two-day clinic last year, backed mainly by the dental association, provided an estimated $600,000 worth of care, Brown said. With the hospital association's support, the clinic this year promises to be even larger, he said.

Spartanburg completed its assessment last year, and in December was awarded a $750,000 three-year implementation grant from the Duke Endowment. Participants expect to have a care-coordination program for the uninsured running by July 1. The goal is to reach 39,000 out of the total 75,000 uninsured in the county.

The community assessment was eye-opening, Romberger said. “They helped us uncover issues we didn't know about,” she said. “We could see where we do well, but also see where we are lacking and bring in folks to help up fill the gaps.”

Besides dental care, primary-care access was another problem unearthed. The county's only free clinic is open only for three hours, two evenings a week. At Spartanburg Regional, the wait time for new, uninsured primary-care patients is six months.

Primary-care providers have been wary of donating time because of a lack of liability protection for indigent care. So, the South Carolina Hospital Association, working with state lawmakers, introduced legislation to make it easier for providers to volunteer their time to care for the uninsured. The bill is now moving through the state Legislature.

“That's going to be huge for the state of South Carolina,” Romberger said.

And it's part of the advantage of housing the access program within the South Carolina Hospital Association, which helped get the legislation moving.

Placing the access program within the hospital association has created more opportunities to get providers involved, Matney said.

Indeed, many hospitals in the Carolinas are learning that it is in their best interest to conduct better care coordination of the uninsured.

“It's just a matter of time before hospitals stop being reimbursed for 30-day readmissions,” Romberger said. Without strong primary-care and other outpatient services for the uninsured, readmissions within 30 days will continue to happen, but won't be reimbursed by the CMS or other payers. About 48% of Spartanburg Regional's ER visits are nonurgent, and the system spends $100 million a year on charity care. Nearly 60% of its clinics are at capacity.

“We recognized that there was no way that we, as a health system, could address the problem by ourselves,” Romberger said.

Dollar days

Back in 1924, James B. Duke founded the Duke Endowment with an initial $40 million gift. As one of the endowment's first acts, Duke pledged to give Carolina not-for-profit hospitals $1 a day for each uninsured patient treated.

In the free-bed-day program, one dollar paid for up to one-third of the cost of hospital care per day in the 1920s.

Now with assets of $2.4 billion, the Duke Endowment has continued to make healthcare one of its four funding priorities.

But in recent years, endowment officials began exploring ways to improve their grantmaking to better serve the uninsured beyond a free hospital bed.

“While these individual programs do good work, it's rare that communitywide planning happens,” said Lin Hollowell, associate director of healthcare at the Duke Endowment. “Now we are trying to come up with a more complete solution instead of funding isolated components.”

The endowment has not specified an amount of money for this program because, Hollowell said, it does not want providers to think small and tailor ideas to the funding amount. “It's a priority funding area,” he said. “We are committed to it indefinitely.”

The Duke Endowment created two independent organizations to help communities in the Carolinas assess and identify ways to better serve the uninsured. AccessHealth SC is one. The other, in North Carolina, is called the Care Share Health Alliance, and is a stand-alone not-for-profit that is also funded by the North Carolina Blue Cross and Blue Shield Foundation and public funds.

Care Share Health Alliance has been in operation for about a year and provides strictly technical assistance to communities in North Carolina that want to better coordinate care for the uninsured. Its four staff members provide capacity building and sharing best practices, such as helping communities improve electronic health-record systems. The alliance has an operating budget this year of $930,000.

“We work on what resources communities have and identify the gaps and needs,” said Kellan Chapin, executive director of Care Share Health Alliance. “We help them use existing resources more efficiently.”

Community collaboration among providers in North Carolina took off during the Clinton administration, but budget cuts after 2001 slowed the process.

Today, North Carolina is helped by state dollars to develop these programs. For the 2009 to 2010 fiscal year, the state approved $4.8 million in recurring funds for community collaborations through a project called Health Net. Another $6.86 million was awarded in recurring funding for community health center grants.

The Health Net project taps into existing Medicaid community networks to help coordinate care for uninsured.

“The key is getting folks who are likely to be involved talking around the table,” says John Price, director of the North Carolina Office of Rural Health and Community Care. “Our desire is to not see any of these programs go by the wayside.”

To be sure, the need is great throughout the Carolinas.

In North Carolina, as of January 2009, between 1.8 million and 1.9 million people were uninsured, or about 21% of the nonelderly. In South Carolina, about 20% of the nonelderly population, or 764,000 people, were uninsured as of January 2009, according to the Duke Endowment.

Martin of the South Carolina Office of Rural Health has interviewed many uninsured patients as part of the community assessment project.

“It really is quite sobering,” Martin said. “Food and shelter are the priorities of the day. Next, the priority is the children's health. Then and only then, people say, am I going to worry about my health.”

Food insecurity is such a problem that churches have begun sponsoring free lunches for their members, many of whom have trouble feeding their families. “I was humbled by the high degree of food insecurity happening in South Carolina,” Martin said.

Public transportation is limited in many parts of the Carolinas, creating a barrier for access to care, she said.

But the solutions to the plight of the uninsured, as well as the problems, can be surprising.

Take hospital admissions. In South Carolina, untreated diabetes is the No. 1 preventable reason an uninsured adult is admitted to a hospital.

In the three-county Charleston area, emergency department visits among the uninsured have been pretty low. But the region's hospitals rank among the top 10% in the state for diabetes inpatient admissions.

“Where the wheels come off the wagon is on the inpatient side,” Martin said.

The community assessment uncovered a bottleneck in specialty care. The uninsured had access to primary care, but if patients needed to see a specialist, such as a podiatrist or ophthalmologist, the wait time was so great that they ended up admitted to a hospital.

“We found that this community is very good at keeping people out of the ER,” Martin said. “But things that should have been caught early were not.” Most of the free clinics in the area don't have case managers who could help patients better manage chronic conditions and gain access to a specialist when needed.

Charleston is now moving forward with the next phase of the AccessHealth SC program to secure grants to address some of these problems identified in the assessment.

Martin said she is encouraged by the ideas put forth by the communities. “My fear initially was that folks would think too small,” she said. “It's about revamping the system. To me, people need to be creative and think differently about patient flow.”

And what about the adult dental problem in Spartanburg? A federal qualified health center in the area was awarded a grant for a new dental clinic, which is expected to open in April.

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