COLUMBIA — Thousands of unhealthy South Carolinians without insurance could soon get a phone call or a knock on their door.
Under the state's “healthy outcomes initiative” launching Oct. 1, hospitals will be reaching out to their most frequent emergency room visitors and collaborating with area nonprofits to help solve their health issues rather than waiting for them to walk into the ER again and again.
The goal is to figure out how to help South Carolina's most vulnerable residents live healthier while lowering the state's health care costs. That involves evaluating patients' medical and social needs, coordinating with existing safety net programs offering free- or low-cost care, and checking back to ensure patients are following doctors' advice.
“If we can get them successfully in a medical home to provide them routine care, we can avoid very costly ER services,” said Brenda Williams, a vice president of Orangeburg's hospital, which is partnering with health clinics throughout Orangeburg, Bamberg and Calhoun counties.
The state's Medicaid agency gave each of the roughly 60 hospitals in South Carolina a target number of uninsured patients to help over the next year, ranging from 50 at some small, rural hospitals, to 750 each at the state's two biggest hospitals in Greenville and Charleston. In all, the hospitals are expected to find health care solutions for at least 8,511 people.
Critics of the state's opposition to the federal health care overhaul note that's a far cry from the hundreds of thousands of additional poor residents that could have been added to the state's Medicaid rolls by expanding eligibility – something the Republican leadership refused to do after the U.S. Supreme Court's ruling made it an option rather than a mandate. Legislators approved the “healthy outcomes” initiative as part of the 2013-14 state budget, though Democratic legislators blasted it as not doing nearly enough.
Director Tony Keck views the initiative as a critical first step.
“There are some who continue to believe that the path to good health is simply to give a Medicaid card. We're saying the path to good health is prevention, aggressive screening, finding people at risk, understanding their barriers and putting together comprehensive plans,” he said. “This does it in way that focuses on results first. Let's focus on the 8,500 sickest and most needy, because if we can't do it for 8,500, how do we do it for 350,000?”
Technically, the program is voluntary. But the price for saying no was steep.
The Department of Health and Human Services expects to distribute $475 million to hospitals statewide in 2013-14 for treating the uninsured – $17 million more than last year. For the first time, the agency is fully covering rural hospitals' costs for uncompensated care – up from the 60 percent all hospitals previously received. But they had to participate to get that extra money.
The agency warned hospitals not participating would cause them to lose out on a portion of their reimbursements, with each risking between $52,000 and $4.7 million.
To help health clinics handle more patients, the state is distributing an additional $4.4 million among those partnering with the state's 36 neediest hospitals.
All hospitals collectively submitted 46 plans by the Sept. 3 deadline, with some hospitals in the same region combining their efforts. Five have been sent back for more information, Keck said.
Wanting to encourage innovation, the agency set no cost-saving or care goals. Hospitals will provide monthly progress reports that will help officials evaluate what's successful and can be duplicated, he said.
Dr. Tripp Jennings, an ER doctor at the agency, said he was “blown away” by the proposals and their possibility to transform the fee-for-service system.
“The level of engagement is turning everything on its head,” he said. “This is paying for health, not service.”
For some hospitals, the initiative means expanding efforts that began several years ago through the state Hospital Association's AccessHealth program, which oversees about 10 community care networks across the state.
“I think this is a wonderful opportunity. It takes a program implemented on a much smaller scale and replicates it statewide in a different way,” said Debbie Slazyk, director of AccessHealth Lowcountry, which began assisting uninsured residents in Beaufort and Jasper counties in April. “The community collaboration it's fostered is particularly exciting. It's a psycho-social approach. It's not just giving somebody a prescription.”
Williams said she hopes the program proves successful enough to convince the GOP-led Legislature to expand Medicaid eligibility.
Keck said that's been part of his pitch to health providers who unsuccessfully lobbied for it this year.
“I told hospitals if you show you can improve these people's health by getting involved in their lives beyond what you see in the ER, then you'll have the perfect argument to go to the Legislature and say, `See, we can do it,“’ he said. “At the same time, if you can't show results, how will you ever get the Legislature to move in the way you want?”