This article first appeared in the St. Louis Beacon, Oct. 23, 2013: Joyce Simms has been a St. Louis ConnectCare patient in the pulmonology program for four years. Because she has asthma, she sees her pulmonologist, Dr. Barbara Lutey, as often as every three months.
In August, Simms received a registered letter from ConnectCare telling her that the pulmonology clinic was closing. But Simms did not experience even a hiccup in service. She learned that she would be able to continue to see Lutey, but her appointments would be at the Center for Outpatient Health, a facility run by Barnes-Jewish Hospital on Forest Park Avenue.
She first saw her doctor in the new location in September. Lutey "already moved my charts and everything,” she said. “I’m very satisfied with the service that I got when I transferred. I got the same quality and that makes me feel good."
Simms, who lives in north county, says she had her own transportation to get to her doctor’s new clinic, something that not all patients have.
Health-care providers throughout St. Louis and St. Louis County have been scrambling to come up with places to treat more than 2,000 ConnectCare specialty-care patients.
ConnectCare story
Citing financial constraints, ConnectCare announced in July that as of Sept. 3 it would be closing its specialty clinics in pulmonology, neurology, hematology and surgery. In August, ConnectCare announced that it would also close other specialty care services as of Oct. 1, including dermatology, endocrinology, hepatology, cardiology, gastroenterology and orthopedic surgery.
“ConnectCare had about 2,300 appointments that were scheduled for specialty care post Oct. 1,” said Robert Fruend, director of the St. Louis Regional Health Commission. “We put a call out to all the major providers in town and said ‘help.’”
As of Oct. 19, slots had been identified for all patients.
“Our communities rallied. We got folks rescheduled,” he said.
Crisis transition team
Soon after ConnectCare announced its second wave of cuts, the Regional Health Commission organized a specialty care and short-term crisis planning team, which included leaders from BJC Healthcare, Barnes-Jewish Hospital, Mercy Health, SSM, SLUCare, and Washington University School of Medicine. Leaders from community health centers and city and county health officials were also involved.
Meeting for two hours at a time twice a week over three weeks, the committee discussed the specialty-care patients and found the resources within their own organizations to serve them, said Fruend, regardless of the patients’ ability to pay.
“Everyone came to the table and said, ‘How can these 2,300 patients get access to specialists?’” he said. "This has really been one of our finer moments. The patients have choice. We’ve found transportation.”
Dr. James Crane, who chaired the transition committee, agrees. Crane is CEO of the faculty practice plan at Washington University School of Medicine, associate vice chancellor for clinical affairs, and on the board of the Regional Health Commission.
“I was really pleased with the responsiveness we had in the committee,” he said.
“I watched the whole process,” says Rosetta Keeton, who manages community and volunteer services for ConnectCare, serves on the community advisory board of the Regional Health Commission and also served on the transition team. “I watched people go back and talk to their organizations and decide which services they could [provide].”
As a result, these patients have the opportunity to be seen at SLUCare, Washington University, St. Alexius, SSM, Mercy, and BJC, sometimes by the same physician they were seeing at ConnectCare.
The committee also found transportation for patients who needed it — at no cost to the patient.
But the committee’s work isn’t complete.
“Our committee has more work to be done in terms of permanent solutions,” said Crane.
Financial ramifications
All of the providers did so knowing that they might never be paid in full for the services they will provide.
“The community partners who stepped up to the plate agreed to do that at a loss,” Crane said.
One bright spot was the federal government’s decision in September to extend for another year the $30 million in annual funding for Gateway to Better Health, a local program administered by the Regional Health Commission. The program is a stopgap to cover people who make too much money to receive Medicaid under the current Missouri guideline of 19 percent of poverty level (combined with other barriers such as dependent children or a disability), but still cannot afford private insurance. Gateway to Better Health reimburses health-care providers at the same rates as Medicare for outpatient services. The Regional Health Commission estimates that it covers about 21,000 people in the St. Louis area.
The program, in place since July of 2010, originally covered primary-care services for people earning up to 133 percent of federal poverty level and specialty-care services for those earning up to 200 percent of poverty level.
However, the new Gateway to Health program, set to begin Jan. 1, is more restrictive and covers patients only up to 100 percent of federal poverty level.
Gateway to Better Health "has only been extended for those at 100 percent of federal poverty level; 3,000 or 4,000 patients who are enrolled in Gateway to Better Health will be disenrolled because their income is above federal poverty level,” said Melody Eskridge, CEO of ConnectCare.
While Gateway to Better Health will help finance specialty care through December 2014, there is no guarantee that it will be funded in 2015. And its budget is limited to $30 million.
“Most of the patients who come to our specialty clinics will require additional lab services, radiology and procedures. Those services could easily add up to hundreds of thousands of dollars in unreimbursed care,” said Dr. John Lynch, chief medical officer of Barnes-Jewish Hospital and a member of the transition team. “We’re considering these patients eventually uninsured.”
Funding cuts affect all providers
Without Medicaid expansion, health-care providers in Missouri are facing budget cuts to the gradual elimination of "disproportionate share hospital" payments (DSH payments) and cuts in Medicare, Fruend said.
Before the Affordable Care Act, hospitals serving vulnerable populations relied on federal DSH payments to cover the cost of treating low-income patients who were not eligible for Medicaid.
With health reform, DSH payments are being reduced, and will be eliminated as of 2021, to pay for the expansion of Medicaid, Fruend said. Starting in 2014, DSH payments in Missouri will be cut 5 percent each year from 2014-2016, and then will be phased out after larger cuts in subsequent years.
“There’s this massive cut in 2017,” Fruend said.
“It is hard to point to the individual impact of this additional ‘free care,' but ultimately safety-net providers like Christian Hospital and Barnes-Jewish Hospital and Washington University School of Medicine will have fewer resources for our programs, our employees and our facilities that serve the health-care needs of our community,” Lynch wrote in an email to the Beacon.
Two other sources of cuts are also worrying hospital officials: a 1 percent cut in Medicare and Medicare cuts associated with the budget sequestration.
“They’re taking all this money away. Missouri is choosing not to replace it,” said Fruend.
Cuts in Medicare, Medicaid and DSH programs account for about $4 billion in lost funding over the next six years, Fruend said. That is funding that would have been supplied by the Medicaid expansion.
“You’re taking $4 billion out of the system over six years. People will have to cut service,” he said.
Health-care layoffs
Fruend pointed to recent layoffs at ConnectCare, SSM and BJC Healthcare as evidence that the squeeze in health-care dollars has already started causing service reductions.
“Long term, if we don’t expand Medicaid, the ability to provide care is constrained,” said Fruend. “You’re going to see [workforce] reductions in the places that are left,” he said.
Lynch agrees.
“The reimbursements that would have flowed through the Medicaid expansion are not there,” he said. “You’re seeing it play out in the community. Hospital systems are trying to balance their budgets.” One potential result, he said, is reductions in workforce.
Future of ConnectCare
While ConnectCare may no longer offer specialty services, the clinic still offers radiology, a clinic for treatment of sexually transmitted infections and urgent care, Eskridge said.
Between 16,000 and 18,000 patients visit its urgent care center every year. The clinic also has 5,000 visits annually for sexually transmitted infections and around 10,000 radiology visits each year, she said.
Even though the clinic has cut staff and reduced services, it is still not out of the woods financially, according to Eskridge.
Although she was pleased that the health-care community stepped up to take care of patients, she was disappointed that a solution couldn’t be found to save ConnectCare’s specialty clinics.
In the meantime, clinic workers are calling to following up with specialty-care patients to make sure that they have gone to see the specialist at the new location.
“I wouldn’t call it completed until every patient with a referral has actually seen a specialist,” Eskridge said. “We are following up with their primary-care physician to make sure the handoff is going smoothly.”