Pulse
Safe Harbor
An innovative safety-net program helps keep the uninsured out of the ER.
Sara Velasco, M.D., knows the influence a physician can have on a child. Growing up in Los Angeles, she used to accompany her mother, whose first language was Spanish, to doctor appointments in order to interpret for her. But what happened during those visits was much more powerful than anything medicine could do. In addition to addressing her mother’s health concerns, the doctor, George Moreland, would ask Velasco how she was doing in school and what was going on in her life. Those conversations made such an impression that by the time she was in fourth grade, Velasco had decided that she, too, wanted to become a physician. “I remember saying, ‘When I grow up, I want to be like Dr. Moreland,’” she recalls. “Truly, to this day, he is my hero.”
As medical director for HealthEast’s Salud Integral, a clinic on St. Paul’s East Side that shares a building with the Mexican Consulate and serves a large number of Latino patients, Velasco makes a point of taking an interest in the lives of the children she sees in her family medicine practice, emphasizing the importance of doing well in school.
But when kids and adults don’t have health insurance, it can be nearly impossible to develop those life-changing relationships, much less keep them current on their vaccinations or control their asthma or diabetes. With that in mind, Velasco began serving on the board of the nonprofit Portico Healthnet nearly two years ago.
Portico is a single thread in the health care safety net onto which a small percentage of people who have no insurance hold tightly. It isn’t a traditional health insurance plan (the program does not cover hospitalizations or emergency room visits). Rather, it provides coverage for primary and specialty care, preventive services such as mammograms and vaccinations, outpatient hospital services, outpatient mental health care, and prescription medications.
Created in 1995 as MetroEast Program for Health with $2 million in seed money from HealthEast, Portico was designed for people who are working but may not be able to afford the coverage offered by their employer; who may earn too much to qualify for government programs such as Medical Assistance, General Assistance Medical Care, or MinnesotaCare; or who are self-employed or unemployed and cannot afford coverage in the private market.
The program is financed in part by area hospitals, and that money pays for direct patient care. “The idea was that instead of providing charity care by default when people show up in the ER, it would be nice to direct some of the dollars upstream to keep people healthy,” says executive director Deb Holmgren.
In 2008, Portico operated with a budget of nearly $2.2 million, 46 percent of which came from contributions from hospitals in Ramsey, Dakota, and Washington counties. With additional support from UCare, it currently serves about 1,100 residents of those counties, with participants paying a monthly fee of $25 to $50 per household (which covers services unrelated to direct care) as well as small copays for some medical services.
Last year, Portico received a $500,000 grant from the UnitedHealth Foundation that supports expansion into Hennepin County. Hennepin County Medical Center, North Memorial Medical Center, and hospitals in the Allina and Fairview systems located in the west metro have also signed on with the program. Holmgren says they hope to have 800 Hennepin County residents enrolled by the end of 2009.
“It’s doing the right thing for the right reason,” says Jim Fox, senior vice president and chief financial officer for Fairview Health Services. “Giving people the proper health care at a physician level rather than in a high-resource area such as the emergency department is better management of our resources as well as their health.”
One Big Circle
Front-end health care isn’t all Portico provides. One of its critical elements is care management. When a person inquires about Portico, they’re screened in order to determine whether they qualify for government-sponsored health insurance. If they do not and if they’re accepted into Portico’s program, which has a waiting list of about 500, they then meet with a care manager who goes through an assessment with them. “They look for things that are directly health-related—chronic conditions, whether people in the family smoke,” says Holmgren. They also ask about more peripheral concerns that can affect people’s stress level and, ultimately, their health and well-being—whether they’ve had to borrow money or use credit cards to pay health costs during the last year, whether they can afford their medications, whether they missed school or work because of a health problem, and whether they have smoke detectors in the home, wear seatbelts in the car, and have enough to eat and stable housing.
In addition to connecting people with services in the community that can help with food, housing, and transportation, the care manager asks each family to set a goal for improving their health. That might be something as simple as having a baseline physical and getting connected with a clinic and a physician.
“Family medicine and other fields are picking up on the concept of a medical home,” Velasco says, explaining that it’s critical to create relationships with patients who are unaccustomed to having health insurance and getting preventive care so they feel comfortable enough to come back and talk about their health concerns before they become serious enough to affect their ability to work or go to school.
Velasco has seen how not having access to care has “a very negative impact,” especially on people with chronic disease. “An example– and we see a lot of this– is patients who have diabetes. For many, it’s a multisystem disease, so it’s not unusual to also have high blood pressure and high cholesterol. The medications they need to control these diseases are very expensive. It’s those people who, if they lose their health insurance, get out of control, and it’s a matter of time before they develop complications and wind up in the hospital.” Having no way to pay for their hospitalization can add to their stress and further their decline.
But those aren’t all who are affected. “Not having good health coverage is very important for issues like mental health,” she says. “Often, we see kids who are struggling in school and need a mental health assessment and maybe ongoing mental health care. We know that impacts their performance in school.
“Good health is the basis of being productive. So if your health is poor, your productivity at school or work is going to be much less than that of someone the same age who is healthy.”
Reducing Admissions
Thus far, Portico has produced impressive results. A 2007 study of people enrolled in the program for one year found that, compared with the 12 months prior to enrollment, their primary care visits had increased by 32 percent, emergency department visits fell by 33 percent, and inpatient hospital admissions decreased by 35 percent. In addition, 21 percent of participants said they were less likely to wait until they experienced a medical crisis to seek care, 10 percent were more likely to purchase needed medications, and 7 percent were less likely to borrow money or use credit cards to pay for health care than before they joined the program.
Fox says Fairview Ridges Hospital, which has been participating in Portico since 2006, has seen a 12 percent to 20 percent return on its investment in terms of decreased charity care. Although he doesn’t have exact figures for each hospital, Roger Green, vice president of strategy, policy, and communications for HealthEast, says HealthEast has also seen “a pretty significant return” for the system and for the community in general. “If people end up hospitalized, it gets in the way of their ability to work,” he says. “And certainly the whole idea that people have a personal responsibility for their health and a primary caregiver as a coach or partner to help the individual manage their health is a very strong reinforcer of self worth.”
Holmgren can share stories about the effect Portico has had on the lives of its participants. It helped one father manage his diabetes and, thus, stay out of the hospital and continue working. It provided diagnosis and treatment for a girl who had missed 30 days of school in one year because of behavioral issues; after being diagnosed with and treated for ADHD, the girl has since missed only two days of school. It provided affordable medications to a woman who has several chronic conditions and lost health care coverage. And it helped a number of self-employed individuals stay healthy until their businesses were successful enough that they could afford to buy insurance.
“We know that people who have coverage are better able to go to work and keep a job,” Holmgren says. Unfortunately, she says, many more people may find themselves without either in the coming year. Velasco says her clinic has seen the number of patients enrolled in Portico grow from about 20 to around 100 within the last year. And she suspects demand will increase, given the downturn in the economy. She recently found out about several patients losing their jobs.
“In the ideal world, the day will come when you don’t need a Portico Healthnet, that people will have access to care in other ways,” Green says. “I’m not optimistic that day will come anytime soon.”—Kim Kiser