Tue January 29, 2013
A New Era For 'Free' Clinics
Armed with more than 100 staff members and 1,000 volunteers, the bustling Kansas City Free Health Clinic in midtown is one of the largest free health clinics in the country, treating upward of 15,000 patients a year. “KC Free,” as it’s commonly called, doesn’t charge fees or bill patients for care. It only sees people who are uninsured.
But this year, all that changes.
Like several other free clinics across the country, KC Free will soon accept Medicaid and add a sliding fee scale. The dramatic shift in the 42-year-old non-profit’s business model is a necessary response to the unfolding federal health care law, its leaders say, and will allow the clinic to continue caring for many of Kansas City’s most vulnerable residents.
“The face of health care is changing, and we are changing with it. We must,” Sheri Wood, the clinic’s executive director, wrote in a letter to volunteers and supporters in December.
Similarly, the Health Partnership Clinic of Johnson County has shifted its structure; and the Duquesne Clinic in Kansas City, Kan., has changed the definition of who it serves and may start accepting Medicaid. Other health care providers are moving away from an urgent care approach in an effort to become a primary medical home for patients. Community mental health centers have started offering medical services to certain patients, too.
With the federal law aiming to expand health coverage, the entire safety net system is realigning in preparation for an influx of patients accessing care either for the very first time or for the first time in a very long time. And yet, parts of the law itself are still unclear, and much of how everything unfolds locally depends on how Missouri and Kansas implement the law.
“We are entering a new era and I think that free clinics are very consciously trying to decide what the best path is,” said Julie Darnell, professor of Health Policy at the University of Illinois-Chicago.
Initially a clinic “for hippies”
KC Free began 42 years ago, near its current location in midtown Kansas City. The hotel lobby and then house, functioning on month-to-month donations and volunteers, was a far cry from the sleek, three-story building that stands today, operating on a $12.5 million annual budget, through a combination of public grants and private fundraising efforts.
“It started for hippies with gonorrhea. And maybe a cold,” said local filmmaker Gary Jenkins, whom clinic leaders commissioned a few years ago to make a documentary about the clinic. “The attitude and spirit was that we don’t have anything to do with the government. We don’t need to take money. We just need to help people.”
But the clinic’s very first patient was an elderly woman, and one of many seniors in the neighborhood lacking good social supports that the clinic would serve. Its presence in local health care further progressed in the ‘80s and ‘90s, with the onset of the AIDS epidemic and the huge stigma associated with the disease. Many turned to the clinic for anonymous testing and other services.
“Everyone flocked there to get an AIDS test,” Jenkins said. “I did.”
Looking back on those early days, founding member Nancy Clark is in awe of how far the clinic has come. She said the mission of KC Free may have been on solid ground at the start, but the organization itself could have collapsed at any moment.
“We literally were working month to month to survive,” Clark said. “Our treasurer, who worked for the community blood bank, said he’d never been involved in an organization where you get to the end of the month, where there are bills – rent, utilities, phones, you name it – and we get right to that crisis, and then manna from heaven! We get a donation.”
Today the clinic boasts a robust array of general medicine, HIV, dental, substance abuse and mental health services. Wood said over the last several years, the clinic has seen a 40 percent increase in patients, and now had about 45,000 patient visits last year.
On the surface, little has changed yet at the Kansas City Free Health Clinic, other than the new name: Kansas City CARE Clinic. Flyers have been posted in elevators to notify patients of the change; a new Facebook page has been created; and later this month (February), the sign out front will be replaced.
Already the clinic requests $10 donations, but soon it will be required to try to collect payments from everyone who comes through the door. That will mean a new sliding scale fee, which Wood expects to be similar to the current donation requests.
No date has been set for the switchover, pending Medicaid approval, though Wood is shooting for April.
But there is already some sense of loss in the community. Randy Goodman, a founding clinic member, worries about where the clinic is headed and the additional “red tape” patients may now face when trying to get medical care, as the clinic puts in new protocols for billing and taking Medicaid.
“For me, it’s the end of an era,” he said. “It’s like a part of my life is gone.”
Jenkins, the filmmaker, supports the change but wonders if it will even be possible to understand the full impact, particularly on the homeless.
“A whole lot of people that live lives we don’t know much about, the word goes around that here’s a place you could get something if you get too sick. But those people, they’re like an invisible population,” Jenkins said. “People could just slip by the wayside and we will never know.
But the reason for changing, Woods said, is to keep people from falling through the cracks.
Under the new federal health law, states have the option to expand Medicaid, the public insurance program for the poor and disabled. In Missouri, an expansion could affect anywhere from 100,000 to 400,000 residents. Although there is strong resistance to the expansion in the statehouse, Gov. Jay Nixon is on board.
In 2014, every state also will have a health insurance exchange, essentially an online marketplace where individuals and small businesses will go to compare and shop for health coverage. No one will be turned away due to pre-existing conditions, and while most people will be required to have insurance, those at certain income levels will be eligible for subsidies.
The bottom line is that KC Free expects that as many as 90 percent of its patients will have some kind of health care coverage.
“There’s not capacity in the system to take that many who have insurance,” Wood said. “People will still need a place to go, and many have been with us for years, this has been their home.”
Another important driver in KC Free’s decision relates to its federal funding to provide HIV care. The clinic has about 700 HIV patients and is one of the main sources of HIV care in the area. Last year, Health and Human Services told the clinic that for any health care provider to receive those grants, they must accept Medicaid.
“We needed to move toward that,” said Wood, noting that the clinic is in a unique position as the only free clinic in the country receiving those funds.
But Wood doesn’t see KC Free’s shift as helping with current or future budget challenges.
“We don’t anticipate that reimbursement will come close to covering the cost,” said Wood, adding that the move will create additional staffing costs.
And already, a new electronic medical record system - an important step in being able to take Medicaid and insurance - cost the clinic between $150,000 and $200,000.
“Medicaid certainly won’t pay for the cost of care, especially in a free clinic that will now add an administrative layer,” said Marty Hiller, a free care consultant with Cleveland-based Hiller & Servaites. “Care is going to be more expensive to deliver in that environment and Medicaid is not going to be able to meet those costs.
KC Free is not the only Kansas City area provider moving away from the free model.
Health Partnership Clinic, a 20-year-old free clinic in Johnson County, became a federally designated health center last year and now takes Medicaid and private insurance.
“We’ve changed to a culture of anyone can come. We’ve gone from a culture of no to yes,” said Jason Wesco, the clinic’s director.
The federal designation, which is a step beyond KC Free’s new direction, brought more funding.
“Part of the problem in the past was we didn’t have the resources. Now we’re trying to do all the things I feel like we should be doing, which means when someone walks in door we should take care of them,” Wesco said.
Unlike traditional federal health centers, Wesco hopes to preserve Health Partnership’s volunteer legacy, a characteristic that often differentiates free clinics from other health settings. It hasn’t been smooth sailing: a new electronic record system and added administrative protocols have been frustrating for some. Wesco said two volunteers left.
Although the clinic now has sliding fee-scale for patients, Wesco doesn’t think that’s been a deterrent. Instead, it may encourage patients to take ownership of their care. Moreover, staff emphasizes no one will be turned away if they can’t pay.
“We had over 2,000 visits (in November). The highest before that was 1,500,” said Wesco. “So we’re doing something right and people are coming.”
But a total shift in business model isn’t the only option for free clinics.
JayDoc, a student-run clinic based out of Southwest Boulevard Family Health Care in Kansas City, Kan., sees just about anyone without charge. And they don’t plan on changing.
But the clinic now offers more than urgent care services, said Jennifer Strande, the clinic’s director and second-year student at KU Medical Center. It has specialty nights, catered toward referred patients that have chronic diseases, like diabetes. There are social workers, assisting patients with navigating the broader health system. Later this year, they’ll be launching a dental night in collaboration with University of Missouri-Kansas City’s dental school.
Even if Medicaid expands and other free clinics pick up more of those with coverage, Strande expects to remain relevant.
“We’ve always been a clinic that fills the gap between people who qualify for Medicaid or Medicare or disability versus people who can afford health insurance. A lot of patients might have jobs but can’t afford insurance. We’ll continue to see them,” she said.
For clinics that do move toward new models, volunteers are another wrinkle. Many doctors, nurses and the like - some retired, some students - are drawn to the mission-driven focus of free clinics. Federal and state governments programs provide otherwise costly malpractice coverage for those who provide charity care to the uninsured. But taking insurance may complicate that dynamic.
Not only that, some volunteers may not be as willing to work at a clinc that’s not free.
“It’s a challenge to create an experience for a volunteer at any level in a system where there’s insurance and billing and a lot of other requirements that make operating a system a little different,” said Hiller, the free clinic consultant.
At KC Free, whether or not an individual has insurance coverage also will determine whether they are cared for by a staff member or volunteer.
“On one side of the house, we will have volunteers taking care of people with no insurance,” Wood said. “Once we do third-party billing, then staff will take care of people with insurance.”
But Kirk Isenhour, director of marketing and development at the clinic, said the the most important message to the community is that the care won’t change.
“The spirit of the free health clinic will be there whether you have insurance or not, whether you can pay full dollar or whatever,” he said. “Those who can’t pay, won’t. Those who can, will.”
With tens of millions of people without health coverage, regardless of changes in the federal health law, Darnell, the professor of health policy at the University of Illinois-Chicago, noted that the role of free clinics in all of their variations is as important as ever. “
“What’s really pretty remarkable about the sector is that it’s always found the gaps that need filling and has been a highly innovative organizational form,” she said.
But Hiller -- a former director of a free clinic in Cleveland that recently transitioned to one that takes Medicaid -- said he personally has mixed feelings about clinics moving away from the classic free model.
“We developed a model where cost was eliminated for the patient,” Hiller said. “It wouldn’t surprise me if a ways down the road in the not-too distant future, there’s somebody standing around a kitchen table some place saying, ‘you know, there are people who just don’t come into our clinics, so if we have a free clinic, it would really meet some part of the community’s need. Life’s a cycle.’”
This story also appeared in The Kansas City Star.
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