How are free & charitable clinics faring under the Affordable Care Act? JULIE DARNELL, ASSOCIATE...

transcript

How are free & charitable clinics faring under the Affordable Care Act?

JULIE DARNELL, ASSOCIATE PROFESSOR, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF ILLINOIS AT CHICAGO

LINDSAY O’BRIEN, ASSOCIATE DIRECTOR, U.S. PROGRAMS, AMERICARES

143R D APHA ANNUAL MEETING & EXPO, NOVEMBER 2, 2015, CHICAGO, ILWe gratefully acknowledge support from the General Electric Foundation.

What are free & charitable clinics?

bills third-party payer

• 501(c)(3) entities• Target care to uninsured and/or underserved patients• Provide medical, dental, mental/behavioral health, medications• Utilize volunteers • Don’t bill third-party payers

Provides all goods and services at no charge, but may request donations

Provides goods & services for a fee

Charitable ClinicFree Clinic

Hybrid Clinic

Scope of the Free Clinic Sector ~ 1,000 free clinics in 2005-2006 Collectively served nearly 2 million mostly uninsured patients annually Provided 3.5 million medical and dental visits

Source: Darnell, J. S. (2010). Free clinics in the United States: a nationwide survey. Archives of Internal Medicine, 170(11), 946-953.

Newly Insured 22.8 million gained coverage between 9/2013 to 2/2015

◦ 9.6 million in employer-sponsored plans◦ 6.5 million in Medicaid plans◦ 4.1 million in individual marketplace◦ 1.2 million nonmarketplace individual plans◦ 1.5 million in other plans

5.9 million lost coverage 16.9 million (net) newly insured

Source: Carman, K. G. Trends in Health Insurance Enrollment, 2013-15, Health Affairs, v. 34, no. 6, June 2015, p. 1044-1048. [RAND STUDY]

Uninsured

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 20250

2927 27 26 26 26 26 27 27 27

Source: Congressional Budget Office. 2015. Insurance Coverage Provisions of the Affordable Care Act—CBO’s March 2015 Baseline.

NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, MI, PA and NH have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion.SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

RI PA*

IN* IL

Adopted (31 States including DC)

Adoption Under Discussion (1 State)

Not Adopting At This Time (19 States)

Current Status of Medicaid Expansion Decisions

Research Question and Hypotheses

Research Question: How are free & charitable clinics faring under the Affordable Care Act?Hypothesis 1: Clinics located in states that have expanded Medicaid are faring worse than clinics located in non-expansion states.

Hypothesis 2: Clinics located in states that have expanded Medicaid are more likely to have made changes to their clinic operations than clinics in non-expansion states.

AmeriCares Emergency response and global health organization whose mission is to improve health and save lives in communities affected by disaster and in those with limited resources

Model:◦ Product donations from more than 200 corporations◦ Service delivery through local health care partners◦ Leverage: for every $1 donated, AmeriCares provides $20 in aid

METHODS

Survey Who: Free and charitable clinic partners of AmeriCares What:

◦ Organizational characteristics◦ Levels of funding and in-kind support◦ Fundraising efforts◦ Staffing and volunteer levels◦ Changes to operations (clinic, patients, services)

When: October-November 2014 How: Web-based survey

RESULTS

Response Rate 156 out of 355 eligible clinic partners (43.9%)

Characteristic Odds ratio 95% CI p-valueWeekly hours .992 .979, 1.005 .223Budget .999 .999, 1 .048# Volunteers .999 .998, 1.002 .987# Paid staff 1.050 .998, 1.104 .058# Patients .999 .999, 1.000 .069# Patient visits 1.000 .999, 1.000 .346Medicaid expansion state 1.421 .901, 2.241 .130

Logistic regression of non-response

Notes: dependent variable = non-response to survey; n=339; CI=confidence interval.

AmeriCares Sample Characteristics

Characteristic Total(n=355)

Respondent(n=156)

Nonrespondent(n=199)

p-value

Mean weekly hours open (n=341)

29 28 30 .285

Mean annual budget (n=347) $620,929 $539,278 $684,576 .263Mean # of volunteers (n=345) 130 130 129 .939Mean # of paid staff (n=340) 7.7 7.8 7.7 .906Mean # of patients (n=347) 1,900 1,742 2,024 .278Mean # of patient visits (n=347) 6,007 5,991 6,019 .976% in Medicaid expansion state (n=355)

37.2 40.4 34.7 .269

Notes: We tested differences in means between respondents and nonrespondents with the t-test and differences in categorical variables with the chi-square test. Tests of significance were two-tailed. We performed statistical analyses with Stata (ver 14).

Hypothesis #1: Faring Worse in Expansion States

Trends in Funding: Fundraising

Harder to raise $ No change Easier to raise $ Don't know0

4.89.7

Medicaid expansion state Non expansion state

f clin

p-value=.009

Differences are statistically significant.

Trends in Funding

Yes No Don't know0

41.3 46

37.649.5

Decrease in FundingMedicaid expansion stateNon expansion state

f clin

Mean decrease0

20.8 22.4

Mean Percentage Decrease

Medicaid expansion stateNon expansion state

p-value=.896

Differences are NOT statistically significant.

p-value=.710

Trends in In-Kind Support

Decreased No change Increased Don't know0

38.142.9

6.412.7

f clin

p-value=.031

Trends in Staffing: Paid Positions

Decreased No change Increased Don't know

0102030405060708090

11.31.6

5.5 5.5

# of Paid PositionsMedicaid expansion stateNon expansion state

f clin

0102030405060708090

14.51.6

6.6 4.4

Hours of Paid Positions

f clin

icsp-value=.102

Differences are NOT statistically significant.

p-value=.053

Trends in Staffing: Volunteer Medical Positions

0102030405060708090

7.5 2.2

# of Volunteer PositionsMedicaid expansion stateNon expansion state

f clin

11.110

7.5 2.5

Hours of Volunteer PositionsMedicaid expansion stateNon expansion state

f clin

p-value=.018

p-value=.035

Trends in Scope of Services

Decreased No change Increased Don't know0

1.67.5

9.7 10.9

f clin

p-value=.000

Trends in Patient Volume: Patients & Visits

De-creased

No change

Increased Don't know

28.615.8

37.830

# Unduplicated PatientsMedicaid expansion stateNon expansion state

f clin

27.417.7

# Patient VisitsMedicaid expansion stateNon expansion state

f clin

icsp-value=.005

p-value=.024

Hypothesis #2: More Organizational Changes in Expansion States

Operational Changes: Organizational Delivery Model

Yes No Don't know0

f clin

p-value=.000

Operational Changes: Billing Model

Yes No Don’t know0

f clin

p-value=.018

Operational Changes: Clinic Flow

Yes No Don't know0

50.8 47.6

f clin

p-value=.000

Operational Changes: Technology Integration

Yes No Don't know0

f clin

p-value=.000

Operational Changes: Type of Data Collected

Yes No Don't know0

52.645.6

f clin

p-value=.001

Organizational Changes: Closure

Yes No Don't know0

1.66.5

Considered Closing

f clin

p-value=.290

Differences are not statistically significant.

Of the 8% (13 clinics) that “considered closing,” none reported actually planning to close

DISCUSSION

Hypothesis 1 Statistically significant differences between Medicaid expansion and non-expansion states in:◦ fundraising, in-kind support, # of volunteer medical positions,

# of patients, # of patient visits

No statistically significant differences in funding levels or in # of paid positions

Statistically significant differences in scope of services opposite hypothesized

Discussion of Hypothesis #1 Greater resource constraints facing clinics in expansion states, but able to retain paid staff at current levels

Greater difficulty fundraising by clinics in expansion states suggests that funders may perceive less of a need for these clinics

More widespread decreases in the # of volunteer medical positions in clinics in Medicaid expansion states could signal diminished interest in volunteering or, perhaps, may be due to a lessening in volunteer opportunities

Hypothesis 2 Statistically significant differences between Medicaid expansion states and nonexpansion states in:◦ organizational delivery model, billing model, clinic flow,

technology integration, type of data being collected (Hypothesis #2) and

◦ scope of services (Hypothesis #1)

No statistically significant difference in “considering” closure

Discussion of Hypothesis #2 More clinics in Medicaid expansion states are making changes to their clinic operations, which suggests that clinics are attempting to mitigate the environmental uncertainty arising from more of the low-income population gaining coverage

The kinds of changes that “expansion state” clinics are making are MAJOR

Sample

Characteristic2005-2006 National

Survey of Free Clinics

2014 AmeriCares Survey of

Free/Charitable ClinicsMean weekly hours open 18 28Mean annual budget $287,810 $539,278Mean # of paid staff 2.7 7.8Mean # of patients 1,796 1,742Mean # of patient visits 3,217 5,991

Source for 2005-2006 survey data: Darnell, J. S. (2010). Free clinics in the United States: a nationwide survey. Archives of Internal Medicine, 170(11), 946-953.

Limitations Cross sectional study is unable to establish causation Small sample of bigger and better-resourced clinics than the “average” free clinic (Darnell, 2010) Self-reported trends Clinics closing/planning to close less likely to respond

Conclusions Neither the impact nor the response to the Affordable Care Act has been uniform across free/charitable clinics and depends significantly on whether the clinic is located in a Medicaid expansion state

Challenging resource environment for clinics in Medicaid expansion states and non expansion states, but worse in expansion states

Free/charitable clinics are adapting to the new environment

Thank You!JULIE DARNELL, JDARNELL@UIC.EDU

LINDSAY OBRIEN, LOBRIEN@AMERICARES.ORG

How are free & charitable clinics faring under the Affordable Care Act? JULIE DARNELL, ASSOCIATE...

Documents