# Presentation: 807666

- Tanya Kahl
- January 21, 2004

## History

- May 1999: Coalition formed
- Sept. 2001: Awarded CAP Grant
- March 2002: Began serving clients

**Notes:**
Determine if the resources being spent to care for uninsured patients at hospitals (ED and inpatient) can be instead spent to provide non-emergency services that take care of health problems and prevent future hospital utilization. Can we involve providers not typically participating if we develop a coordinated system of care? 

## Preventable* Uninsured ED Visits in Salt Lake County

- 16,412 visits

- *Preventable ED visits include visits classified as non-emergent and emergent, primary care treatable. Billings, Parikh and Mijanovich, Commonwealth Fund, 2000.
- Source: Utah Hospital Emergency Department Patient Encounter Data, 2001. Utah Department of Health.

## Coordinated System

- Uninsured individual gets sick

- Hospital Emergency Room

**Health Access Project**

**Volunteer Physicians**
**Community Clinics**
**Hospitals**
**Outpatient Facilities**
**Laboratories**
**Medical Equipment Companies**
**Pharmacies**
**Volunteer Interpreters**

- Uninsured individual regains health

**HAP Case Manager arranges donated or discounted care from:**

*HAP Interventions:*
- Expand capacity of safety net
- Address cultural and linguistic barriers
- Implement case management

## Expand Safety Net Capacity

- Developed Volunteer Physician Network using Project Access model (physicians pledge to treat 12 patients/year in offices)
- Obtained agreements for donated/ discounted ancillary services (hospital care, lab, diagnostic tests, pharmacy, etc.)
- Bartered to obtain additional services for patients (made requests and offers)

## Multicultural Services

- Hired multilingual case managers
- Recruited and trained volunteers to interpret for patient appointments
- Provide training/resources to help providers treat diverse patients

## Case Management

- Identified target population
- Determined scope of services
- Established referral processes
- Made arrangements to outstation case managers at hospitals
- Purchased/developed software
- Determined how to measure impact

## Scope of Services

- Screen patients for assistance programs and assist them in applying
- Schedule appointments with volunteer physicians, community health centers, etc.
- Facilitate communication between MDs and patients and arrange follow-up care
- Refer patients to other community resources to meet non-medical needs
- Educate patients on US health care system

## Lessons Learned – Case Management

- Difficult to establish and maintain good referral processes
- Considerable case management time is spent trying to enroll clients
- Attempts to further streamline case management have proven difficult because of complexity of SLC health care system
- Extensive case management is key to changing ED use among frequent fliers

## HAP Outcomes

- HAP services provided between March 1, 2002 and December 31, 2003

- HAP has leveraged over $600,000 in donated physician care

## Evaluation Methodology

- Hospitals matched HAP clients with clients in their adminstrative databases and provided utilization data to HAP on matched clients
- HAP created a master database linking all hospital utilization data to client specific HAP administrative data
- Utilization data was characterized by the month the service was incurred relative to a clients enrollment date in HAP
- Sphere Institute conducted an independent evaluation using the data

## Acute Episode Analysis

- Define an “acute episode”
- monthly charges are above the 70th percentile of the distribution of positive monthly charges during the period of analysis
- monthly charges in the previous month were below the 70th percentile
- Sample
- “Post-HAP" includes all clients starting an acute episode in month of HAP intake (month 0)
- “Pre-HAP" includes all clients starting an acute episode during month -12 to -5

## Acute Episode Analysis (Visits)

- *Hospital data obtained on 288 clients out of 488 served during time frame of evaluation. Acute episode analysis includes 65% of hospital charges.

## Acute Episode Analysis (Charges)

- Despite lower number of visits, charges per compensated non-ER visit post-HAP were significantly higher than pre-HAP (49%).

## Projected effect of HAP Conclusions I

- Increases in visits/charges in year 2 were likely to have occurred without HAP
- In year 2, HAP likely to have:
- Reduced total visits (27%)
- Increased total charges (2%)
- Increased compensated charges (42%)

## Projected effect of HAP Conclusions II

- Assuming payment in full for a hypothetical cohort of 300 clients*
- Without HAP, predict a _net loss_ to local hospital partners of $108,642
- With HAP, predict a _net gain_ to local hospital partners of $200,571
- Net revenue (HAP minus no HAP):  $309,213 **

- *Over 2-year evaluation
- **Based on cost to charge ratio of 50% (Friedman B. et al. Journal of Health Care Financing, 2003). Actual net revenue depends on the fraction of compensated charges that can be recouped from third-party payers.

## Contact Information

- Tanya Kahl, Director
- Health Access Project
- 1800 S. West Temple, A128
- Salt Lake City, UT 84115
- (801) 412-3989
- (801) 412-3997
- _[tkahl@chc-ut.org](mailto:tkahl@chc-ut.org)_
- www.healthaccessproject.org