The Marion County Indigent Care System was established to address issues of limited accessibility and availability of primary and specialty health care to the medically underserved, low income, uninsured and underinsured residents of Marion County. This public private partnership, under the auspices of the Indigent Oversight Board provides coordinated health care services that include preventive and comprehensive primary health care, immediate medical care for minor emergencies, specialty physician services, and hospital based inpatient and outpatient services. The Indigent Care System provides health care to residents with limited access to care, facilitates cooperation among health care providers in the community, helps promote volunteerism among providers, and conserves valuable resources by reducing unnecessary Emergency Department visits and decreasing inpatient hospitalizations.
The Marion County Indigent Care System, is a public private health care partnership, established to address issues of limited or no access to health care services to low income and indigent residents. Marion County covers an area of 1,579 square miles with a population of 298,390; the per capita income is only 80% of the state average. Eighty percent of the residents live in rural unincorporated areas. There are no mass transportation resources available in the rural areas. Forty-one percent of Marion County residents live at or below 150% Federal Poverty Guidelines. Adults comprise 73% of this population. Fifty-two percent of African American residents in Marion County residents live at or below 125% Federal Poverty Guidelines. More than 30% of all households have annual incomes below $15,000. Eighty-eight percent of Marion County businesses employ less than 20 employees and do not offer health insurance. Twenty-five percent of the residents are above 65, with the majority on fixed incomes. Morbidity and mortality rates per 100,000 are significantly higher in the county than in the state for heart disease, cancer, stroke and diabetes. Lack of access to health care can result in delayed diagnosis and treatment, an increase in complications, increased utilization of emergency rooms and longer inpatient hospital stays.
In 1989, the Marion County Commissioners appointed a task force who conducted a comprehensive needs assessment. The findings led to the establishment of the Marion County Indigent Care System, which has improved access to health care and health outcomes. The Marion County Indigent Care System has improved access to primary care, diagnostic testing, immediate medical care for minor illnesses and injuries and specialty care among the target population. No one is denied care due to inability to pay. Transportation services, extended hours, bilingual staff members and drug assistance programs help insure improved access.
Agency Community RolesThe Indigent Care Oversight Board provides guidance in problem solving and a forum for communication to the public private partnership. No individual provider runs the system and all perceive themselves as part of a team working together for a common purpose. All providers participate in the program decision-making. Oversight Board Members include the CEO's of the two local hospitals, the county's public health director, and three representatives from the Marion Medical Society, representatives from the local mental health provider, the county's hospital district, and the county commissioners, the school system, the Department of Children and Families, churches, businesses and residents of Marion County.
ImplementationThe Indigent Care System was implemented in 1992-93 and provided the following services in its' first year:
14,000 patients with chronic illnesses received comprehensive and continuous primary care through the Marion County Health Department.
15,000 patients were provided medical evaluation and treatment for conditions requiring immediate attention through the episodic care Center (CHS).
2,000 inpatients and 17,000 outpatients were served by local hospitals.
1,700 patients were referred to specialty physicians.
The health department received federal, state categorical and general revenue, grant and county funding. Initially there was state primary care funds, combined with general revenue and county money utilized to provide primary care services. All clients are financially screened for eligibility and clients at or below 125% of Federal Poverty Guidelines (FPG) are eligible for services through the Indigent Care System. Medicare and Medicaid are billed for services and all clients are required to apply for Medicaid within 90 days of initial service. Medicaid is billed for eligible clients and the remaining clients receive primary care services at no charge, or are charged on a sliding scale fee.
CHS staff is funded by both hospitals. The building is donated by the county who also pays for eligibility staff. Clients are screened for eligibility and are charged a co-pay for each visit. Advanced Registered Nurse Practitioner staff work under protocols signed by a physician volunteer, who is available for consult and also routinely reviews client records.
The CHD and CHS refer clients to the 'We Care" Program as needed. Specialty physicians volunteer services on a rotation basis by specialty. They see the clients in their offices and admit them to the hospital, if necessary. The physicians receive sovereign immunity through the Department of Health and there is no charge to clients. Following evaluation and treatment, the clients return to the CHD primary care provider for ongoing care. Clients requiring hospitalization are referred to one of the two local hospitals on a rotation basis. The hospital absorbs all related costs of the inpatient or outpatient admission. The county provides funding to both hospitals, the majority of which is utilized to fund CHS.
The Indigent Care Oversight Board meets bimonthly to review all aspects of the program. The program is in its 12th year and continues to grow with the increase of clients into the system. The stakeholders continue to exhibit commitment to the program through support and ongoing evaluation of need and assistance in obtaining additional funding to expand services to the target population. Through support and cost match, the Indigent Care System was able to enroll a significant number of children in the Healthy Kids program.
To meet the growing needs of the rural community with the additional barrier to access of limited transportation, the Indigent Care Oversight Board members supported the health department's application for a Primary Care Challenge Grant to establish a mobile clinic that travels to the rural areas to provide access to those residents who were unable to travel to established providers.
The Indigent Care System has grown with the community and the need for services. As the number of physicians in Marion County has increased, the number of volunteer physicians has increased. The numbers of clients seen at the CHD and CHS continue to increase, as do hospital admissions through the program. In the past year 267 physicians volunteered 3553 hours valued at $2.5 million. Physicians volunteering at the CHD (surgery, OB/GYN, podiatry, pulmonology) volunteered 1129 hours valued at $54,700. The Drug Assistance Programs provided medication to more than 10,254 clients, valued at greater than $2 million.
System is one of five winners in the "Models that Work "competition sponsored by the US Department of Health and Human Services, an unintended consequence. Another unintended consequence was the volume of need that became known following the implementation of the program. As the economy worsens, the need continues to grow.Since the inception of the system, the number of eligible clients in need of services has increased, resulting in long waits for appointments, especially for comprehensive primary care services. To better accommodate client needs, the CHD has gone to an open access system increasing the number of clients seen on a daily basis.
Clients discharged from the hospitals or ED's, as well as, clients unable to be seen go to CHS for an initial visit, and are referred to the CHD for primary care.
During the transition to open access internal medicine and family practice physicians in the "We Care" Program volunteered to see clients waiting for appointments to clear the backlog.