A change 18 months ago in the way the County Health Department is funded by the County Hospital District has resulted in a drastic drop in the number of patients going to the Health Department for free healthcare – from an average of 80 visits a day to 18 – and this in turn has forced major staff cuts and a curtailment of the agency’s adult and pediatric primary care services.
According to officials, the plunge in patient visits came after the tax-levying Hospital District – which had been funding the Health Department’s clinic through an annual block grant of $2.5 million – switched to a fee-for-service reimbursement system which requires non-Medicaid or Medicare patients to bring in proof that they qualify for indigent care before they can be seen.
That mundane-sounding chore – bringing in things like proof of domicile and pay stubs – has proven very difficult for people living in poverty, said clinic administrator Miranda Hawker. “It’s very challenging for our patients to bring in all that documentation.”
But the result of the huge drop-off in patients being seen at the clinic was that the Hospital District “adjusted” the amount of money it was giving the Health Department down to $900,000 – a reduction of more than 60 percent. This in turn has led to cutbacks of 21 positions, including a doctor, a dentist, a nurse practitioner, several nurses and at least nine people involved in the very process of getting those patients approved.
As a result, adult primary care is now being offered only on a “limited basis,” according to clinic officials. Meanwhile, the Hospital District is suggesting patients use two other low-income health clinics in Vero Beach: Whole Family Health and Treasure Coast Community Health.
“We decided to pay the Health Department like we pay all the other providers,” said Hospital District Trustee Allen Jones. “It’s based on actual treatment for patients that meet the definition of indigent, so we can show the taxpayer that their money is going specifically for indigent care.”
Jones said while the Health Department claimed that was already the case, the numbers point to other uses. “It appears that that money wasn’t spent just for indigent. It’s been used to support a broad swath of Health Department projects, which are all good for the community, but I think we need to review the whole circumstance.”
The staffing cuts mostly affect adult primary care, which gets no funding from the state. Other programs that are funded by the state are not affected and are still offered, including family planning, immunizations, and treatment for communicable diseases such as TB and HIV.
Along with adult primary care, health department officials say pediatric and dental care are also provided now only “on a limited basis.”
The change brings the Health Department into line with other programs the District funds to provide healthcare to the indigent, the vast majority of its budget going to indigent care at Indian River Medical Center – though that could change if a takeover by Cleveland Clinic pans out, and that system agrees to provide indigent care.
The District-supported VNA mobile health unit made a similar transition to fee-for-service in 2016 but needed “some extra support from the District,” said District Board Chairman Marybeth Cunningham. The mobile unit got a year’s grace period for the transition, as did the Health Department. “The Health Department has taken longer so we actually gave them another year of transition (on top of the first year), covering their budget shortfalls.”
Cunningham points out that the Health Department is not typical among the state’s health departments in offering primary care, and that the District, not the state, funds that entire expense for those who qualify. The main offices of the Health Department are in the County Administration complex south of Airport Road; it also runs the Gifford Health Center Pediatric Clinic and WeCare, a program in which specialized care is given through physician volunteers.
Some of the Health Department’s patient load may be moving to two other clinics with sliding fee scales as well as Medicaid and Medicare: Whole Family Health and Treasure Coast Community Health, which is also a District beneficiary.
Vicki Soulé, CEO of Treasure Coast Community Health, said they have been getting more calls since the Health Department staffing cuts took effect. “Our call center staff recently reported receiving calls from individuals saying the Health Department suggested they call TCCH,” said Soulé.
Ironically, that clinic too was in a funding pinch for the past five months; it was resolved days after the last of the Health Department’s layoffs went into effect. Treasure Coast, along with all Federally Qualified Health Centers, saw its federal appropriation – almost a fifth of its budget – expire in September 2017 and then get stuck in limbo while Congress debated the Government Spending Bill. That finally passed Feb. 8 and included funding for Community Health Centers nationwide.
Last year, Treasure Coast Community Health Care centers saw nearly 20,000 patients. It gets a small portion of its funding – 4.4 percent – from the Hospital District, which recently increased support for a dental program.
Treasure Coast has recently added providers in medical, dental and behavioral health, Soulé said. It has also opened two additional clinics in the past year. “With Department of Health cutbacks, Treasure Coast Community Health expects and welcomes more referrals, both from the community and from Indian River Medical Center’s emergency department.”
Last week at its monthly Chairman’s meeting, the Hospital District agreed to consider whether to raise its income limit to qualify as indigent, thereby expanding the number of people it serves. By the District’s current standard, patients must have lived in the county for six months; they must earn no more than 150 percent of the federal poverty guidelines, and not qualify for other reimbursement including Medicaid.
The board will debate whether to raise income to 200 percent of federal guidelines. Medicaid covers those who earn only 120 percent of the poverty guidelines.
Several Hospital District officials were not aware of the layoffs at the Health Department or of the cutback in services. Trustee Jones expressed hope that the District could find a way to help. He pointed out that last year, the District added $300,000 to the clinic’s WeCare funding as a separate line item in its budget.
“There was a backlog of patients that needed specialty care like hernia repairs, and some were waiting over a year,” Jones said. “We said, Oh my gosh, we’ve got to help these WeCare patients get treatment.”
Said Ann Marie Suriano, the District’s executive director, “There should be no change in accessing public health services as that is the primary role of the Health Department.”
“The District and the trustees have been very kind to us and I’m grateful,” stressed Hawker. “If there is room to ask for some additional funding this coming year, we would do that, and perhaps they’d be receptive. But I’m also very respectful of what their good decisions are, and we are good partners with them.”