In late 2017, the Marion County Hospital District commissioned a study to define the medically indigent, identify the current volume and costs of healthcare for the medically indigent population in Marion County, describe the providers that comprise the health care safety net, summarize the investments made in the health care safety net, outcomes of this level of investment, and identify ways the community might better invest in this system. In the context of a recent reduction in federally funding to Marion County hospitals, and a decrease in the local Department of Health (DOH) funding and hospital funding to support the multi-site Federally Qualified Health Center (FQHC) in the county (Heart of Florida), community investment in the FQHC was a particular area of interest. A series of questions generated by the Marion County Hospital District guided the study and framed the report. To answer these questions, HMA analyzed publicly available data and reports, obtained quantitative and qualitative data from over 40 key stakeholders.
In terms of a definition for medically indigent, HMA recommends that Marion County consider uninsured individuals with an income less than 200 percent of the Federal Poverty Level to be considered “medically indigent.” This equates to 30,988 individuals in Marion County. This definition is used by the state of Florida for several major programs, has been approved by the federal government, and is routinely used by hospitals in defining indigent care.
HMA found that the hospitals – Munroe Regional Medical Center and Ocala Health – provide services to approximately the same proportion of Medicaid patients on an inpatient basis, and that Munroe serves a disproportionate number of Medicaid patients compared to the State-wide average in their Emergency Department and in Labor and Delivery. Both hospitals combined incur $3 million in unreimbursed charity care cost for the medically indigent in Marion county.
Heart of Florida (HOF) is the single largest primary care provider in the county and has limited behavioral health services. Ocala Community Care (the county jail health service provider) is the next largest provider of indigent primary care and outpatient behavioral health, followed by Langley Health Center that has one primary care site in the county and offers some behavioral health services. HOF’s proportion of paying patients is less (66%) than Langley (80%) and HOF provided approximately 24,000 in uninsured visits to Langley’s 5,000.
The Centers is the traditional safety net behavioral health provider in the community and is the only provider that receives state funding for serving residents who are indigent; accessibility is an issue for many given the location of the main site. The Vines delivers inpatient, residential, and partial hospitalization services; they receive no funds from the state or county and report having delivered $4 million in charity care last year. Meridian Behavioral Health in Alachua County is serving nearly 600 Marion County residents, many who report access issues in Marion County. This led Meridian to begin a telemedicine relationship with HOF to address the need for more local behavioral health services.
Marion County budgets over $9 million for indigent health care (excluding an estimated $7 million for the county jail). This is primarily for statutorily required payments for Medicaid and funding for The Centers and the Department of Health. The Marion County Hospital District funded $1.6 million in local projects in its 2017 grant cycle.
The entirety of Marion County is federally designated as a Health Professions Shortage Area; demand exceeds supply of primary care and community behavioral health. There is an average of about 2 months wait for new patients to be seen at Heart of Florida, and Munroe Medical Center has a particularly high rate of low acuity Emergency Department visits (27.4%), many of which are likely individuals who are unable to access care in the community. The Centers reports that they have instituted a walk-in system for initial assessments, and that an appointment for outpatient therapy is typically scheduled within 2-3 weeks. The Medication Clinic is also walk-in but maximum capacity is reached about one-third of clinic days such that patients arriving after the maximum capacity is reached cannot be seen that day; these patients are given priority status for the next clinic day.
In the report, we present challenges and opportunities for the safety net provider organizations individually and collectively. A particular challenge has been HOF’s continued management of the three former Department of Health primary care sites given that these sites have particularly high rates of uninsured patients ranging from 43 – 61 percent. We present an analysis that concludes that these sites fill a community need and should continue to operate unless other alternatives become available. By contract, HOF will receive $800,000 from the DOH to help support operations of these three sites, but funding is scheduled to be reduced by 20% each year over a five-year period ending on September 30, 2021. In addition, the two hospitals are planning to discontinue their contributions to the HOF. Given the funding reductions anticipated, HMA’s opinion is that the county should continue to fund HOF at the current level of $380k at least for Fiscal Year (FY) 2019. We recommend that HOF be required to develop an operational plan to present to the county in FY 2019 to detail strategies to address the loss of their other funding streams. If HOF requires continued funding from the county it should clearly articulate how that funding would be utilized and the benefit it would bring to the community.
Given the primary care and behavioral health provider shortages in the county, HMA also analyzed and highlighted where new primary care/behavioral health sites might best be located and presented justifications with supporting maps.
Finally, HMA conducted an environmental scan to identify indigent care funding models and delivery system best practices. We developed a set of recommendations for the community that identifies particular models and best practices that drive care to the outpatient setting and reduces preventable and costly hospital utilization. The recommendations also call for a process to bring key provider groups and other stakeholders together to collaboratively plan and implement strategies to strengthen the health care safety net.