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An Early Gift?

Help arrives for Cuyahoga's uninsured — but how much remains a mystery



Beginning this month, Cuyahoga County residents in need of treatment and without health insurance could be spared some of the endless hoop-jumping required by hospitals and health clinics. How fast the red tape gets cleared, however — and how many patients will be welcomed into the long-awaited coordinated system of care — remains to be seen.

Since December 1, a partnership of all of Cleveland's major hospital systems and other health-care providers has been quietly rolling out a new system of care for low-income, uninsured adults. The group, known as the Cuyahoga Health Access Partnership (CHAP), also includes providers such as Kaiser Permanente and various local foundations and medical associations.

The launch comes as Cleveland Clinic, a member of CHAP, has announced plans to cut back charity care to residents outside of Cuyahoga County. Other hospitals in CHAP, including University Hospitals and MetroHealth, have not publicly discussed plans to alter their charitable care.

Under the old system, patients without insurance must be rated according to their income and assigned a sliding fee. The problem is, the criteria for being rated differ from hospital to hospital and from clinic to clinic. Transferring from one place to another — say, for a referral to specialty care or from an emergency room to ongoing care — can be a formidable and sometimes impossible challenge, involving repeated verification of documents at each place of treatment. Patients often put off treatment for primary care, either because they don't know about the programs or don't want to endure the hassles. Ultimately, many of those patients end up in the emergency room.

"I'm happy to see this is finally getting under way," says Peter Lawson Jones, one of the county commissioners who approved the CHAP program's launch more than two years ago. "We're trying to do something unique that hasn't been done before, and I understand the mechanics have to proceed deliberately."

The rollout comes some six months later than CHAP officials had expected. Ken Frisof, a physician at MetroHealth and vice chair of the CHAP project, told Scene in April that CHAP was hopeful for an early summer launch, with plans to add staff and publicize the program by the end of the year.

At the time, Frisof said CHAP could serve as many as 80,000 people countywide.

Kate Nagel, director of public health and research at Cleveland Clinic and chair of CHAP, says the program is being implemented "slowly — so we know we'll get it right." She declined to say where it is being tested initially or how many patients are being accepted, but she confirmed that CHAP's health-care providers will be enrolling patients in the program by the end of this month.

Nagel referred other questions to Robin Bachman, CHAP's head of communications.

According to Bachman, CHAP will enroll adults with incomes up to 200 percent of the federal poverty level ($10,830 for a single person; $22,050 for a family of four) who do not qualify for Medicare, Medicaid, or Veterans Administration benefits. Both Bachman and Nagel declined to comment on whether those enrolled in CHAP would receive free care or pay fees on a sliding scale. They said CHAP will be ready for a more "public launch" in January.

Current charity care programs at local hospitals accept patients with incomes up to 400 percent of poverty level. Bachman did not respond to an emailed question about what will happen to those who make more than 200 percent of the poverty level and are uninsured under CHAP.

Gary Benjamin, Northeast Ohio advocacy director for the Universal Health Care Action Network in Cleveland, says hospitals' charity care programs will remain even when CHAP is fully implemented. UHCAN is an independent group that promotes improved access to health care through legislation and public policies.

Cuyahoga County's CHAP program is similar to the Voices of Detroit Initiative, a 12-year-old coordinated-care system in Wayne County, Michigan. There, patients enter the system at one place and are not required to be rated again. The idea is to create a "medical home" — a base for the patient's complete care needs. The concept is also taking hold nationally for care of insured patients.

Last year, 58,000 patients were enrolled in Detroit's system. According to Voices' annual reports, the program has dramatically reduced emergency room visits for patients in need of primary care. Nearly all such care provided to uninsured patients took place at federally qualified health clinics, which are eligible to receive federal grants to provide care to underserved populations. Such clinics operate on a sliding fee scale and must be open to all patients, regardless of ability to pay.

When specialty care is necessary in Detroit's program, patients are often referred to area hospitals.

It is unclear where patients in the CHAP program will be directed. Federally qualified health clinics participating in CHAP include Neighborhood Family Practice, which has offices in Tremont and on Ridge Road in Cleveland; Care Alliance Health Center on Superior Avenue near downtown; and the Northeast Ohio Neighborhood Health System, which has five clinics on the east and southeast sides of the city.

CHAP's partners have declined to disclose how much is being spent on the project or how much is being committed by member hospitals.

Lawson Jones says the county has signed a contract with CHAP to commit $50,000 a year for each of the next two years. He adds that it will be up to the newly elected county council and County Executive Ed FitzGerald to determine whether to continue CHAP funding after that. There will be a "hue and cry" if they don't, he says — "And I'll be leading the hue and cry."

According to Bachman, a nonprofit organization has been formed to manage CHAP. Partners have spent the past year developing an "infrastructure," including establishment of a board, acquiring office space, selecting a logo, and choosing software for an enrollment database.

In September, the Washington, D.C.-based Center for Studying Health System Change published a study on Cleveland's health-care system in which it surveyed 45 medical and health-care management professionals. Those surveyed generally were positive about the CHAP model, but said implementation was moving at a "glacially slow pace." They also expressed concern about the ability of competing health systems to work together.

Lawson Jones says that any turf battles or competitive issues that might have existed at the outset have been ironed out. "We've gotten beyond that," he says, adding that logistical issues pertaining to how the program will work for patients are the key focus now.

UHCAN's Benjamin says that CHAP will not offer a comprehensive solution for the needs of the county's uninsured, noting that some will not be eligible. But he calls it an improvement over the current system — "especially since it includes the idea of a medical home."

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