Caring for the Uninsured: How Free Clinics, Hospitals Can Partner to Treat a Community's Most Vulnerable

Beginning next year, Americans will be required to obtain health insurance coverage or pay a fine. After this "individual mandate" — part of the comprehensive healthcare reform law passed in 2010 — goes into effect, roughly 30 million previously uninsured Americans will have health coverage. This is a relief for hospitals and other healthcare providers that traditionally have written off the cost of caring for these patients. However, providers aren't completely off the hook: An estimated 23 million Americans in 2107 will be uninsured, according to the federal government. As a result, health systems must consider how they will continue to treat this population while maintaining their bottom lines.


Many hospitals and health systems provide charity care for uninsured individuals when they require acute care, but the most forward thinking ones are also concerned with caring for this population before they present to the emergency department. To provide this type of care, hospitals often work with community providers outside the four walls of the hospital, including safety-net clinics or other community organizations.


Safety-net clinics, which provide free services provided by volunteer healthcare professionals to uninsured patients, offer a number of benefits to health systems, says Hugh Greeley, board chair for Volunteers in Medicine, a non-profit organization that has assisted in the development of more than 100 free clinics since it was established in 1994. The organization was founded by Jack McConnell, MD, a physician who established the first VIM free clinic in Hilton Head, S.C. As success of his clinic — which was supported by community funding and donations and staffed by volunteer clinicians —spread, health systems and other organizations that wanted to create similar clinics in their communities came to Dr. McConnell for assistance. Eventually, he created VIM and brought on Executive Director Amy Hamlin, an experienced public health professional, to help respond to these requests.


Accordingly to Ms. Hamlin, the success of a safety-net clinic lies in its ties to the community. "These clinics are really embedded, owned and sustained by the community," she says. "The community needs safety-net clinics for those people who fall through the tracks, and based on where we are historically, I think they're going to be needed for quite sometime."


10 benefits
In addition to providing ambulatory care to at-risk populations, safety-net clinics provide several less obvious benefits to a health system.


1. Improved patient care. Safety-net clinics ensure patients who may not have otherwise had access to high-quality primary receive the care they need to stay healthy or manage their conditions. Hospitals that support these clinics, either through funding or volunteer relationships, help ensure quality care for all patients. "It is simply the right thing to do, and recommits a hospital to its founding purpose," says Mr. Greeley.

2. Alleviates pressure on emergency departments. Safety-net clinics also reduce uninsured patient visits to an ED for both emergent and non-emergent conditions. Better primary care reduces the chance that a patient will need to visit the ED, and for an uninsured patient that does present for a non-emergent condition, the patient could be referred to the clinic for treatment instead.

3. Helps reduce avoidable readmissions. Often, uninsured patients have difficulty finding a physician to treat them outside of the hospital. A free clinic can provide follow-up care to patients after discharge, thereby reducing the likelihood of a readmission.

4. Possible reduction in the number of uninsured in a community. "The services provided at a free clinic link eligible patients with public insurance programs, thus reducing the number of uninsured patients in a community," says Mr. Greeley.

5.  Volunteer outlet for physicians. "One of the unintended benefits of clinics is they provide a great opportunity for physicians to provide care and volunteer outside of their own office," says Mr. Greeley.


6. IRS community benefit. Safety-net clinics also assist a hospital in demonstrating the "community benefit" required to keep its tax exempt statues. "Most hospitals assist by providing start-up support and some sort of continued funding, which helps demonstrate to the IRS their community benefit," says Mr. Greeley.

7. Community Health Needs Assessment
. The IRS requires non-profit hospitals conduct a Community Health Needs Assessment every three years and then adopt and implement a plan to meet the community's health. The development of a free clinic requires such a study and "clearly demonstrates that the hospital taken action on the results," says Mr. Greeley.

8. Establishes community support and involvement. "Any hospital that develops a free clinic in conjunction with local businesses, governmental units and, in some cases, religious organizations, realizes significant new community support and involvement," he says. 

9. Medical staff accomplishment. The medical staff's involvement in establishing a free clinic provides the staff with an important professional accomplishment, and can help unify the staff and bring about improved alignment.

10. Reduction in morbidity and mortality. Numerous research studies show that patients with limited access to primary care have higher rates of morbidity and mortality. "A safety-net clinic very directly assists in a very simple way in creating a healthier community," says Mr. Greeley


Developing a free clinic: What role does the hospital play?
For health systems that are eager to experience these benefits, it is worth exploring whether a free clinic could be viable in their communities. "Hospitals are really ideal candidates [to develop a clinic] because of their board and their medical staffs; they have a lot of ties to community," says Ms. Hamlin. While the hospital isn't going to be the owner of the clinic, the clinic must have a close relationship with the hospital to be successful.


"The hospital may contribute financially, or it may contribute planning staff for a needs assessment, or hospitals often have relationships with a clinic to provide labs and other diagnostic tests," she adds.


Ms. Hamlin encourages hospital leaders to select one or two individuals to oversee the process and garner community support. "It has to be someone who just has a fire in his or her belly and is determined to see one of these clinics open," she says. "You are not only building a clinic but also building up a non-profit organization that can support the clinic."


For communities that fit the bill — they have a large uninsured population, significant community interest and a pool or physicians, both current working and retired, who are willing to volunteer — a free clinic could be just what the doctor ordered.


"A hospital-supported clinic assists in creating a healthier community, a stronger hospital,  a more satisfied medical staff, while simultaneously assisting with a hospital's tax exempt status, its community needs assessment and in creating operational efficiencies that contribute to the bottom line," says Mr. Greeley.


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