Access Assured: A Pilot Program to Finance Primary Care for Uninsured Patients Using a Monthly Enrollment Fee

The Journal of the American Board of Family Medicine

Jennifer DeVoe²  David Brown²  Carrie J. Tillotson¹  Danielle Eigner²  John W. Saultz²  Rebecca E. Rdesinski²  Stephen Stenberg² 

[1] Oregon Clinical and Translational Research Institute (CJT), Oregon Health & Science University, Portland;Department of Family Medicine (JWS, DB, SS, RER, DE, JD), Oregon Health & Science University, Portland

关键词: Access to Health Care;    Uninsured;    Health Care Financing;   

DOI  :  10.3122/jabfm.2010.03.090214

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

Background: Access Assured is an experimental program being used by 2 academic family medicine practices to deliver primary care to an uninsured patient population using a monthly retainer payment system in addition to a sliding fee schedule for office visits. This prospective cohort study was designed to determine whether patients would join such a program, to describe the population of people who did so, and to assess the program's financial viability.

Methods: We used data abstracted from our electronic medical record system to describe the demographic characteristics and care utilization patterns of those patients enrolling during the first year of the study, between February 1, 2008, and January 31, 2009. We also compared 2 subpopulations of enrollees defined by their eligibility for office fee discounts based on income.

Results: A total of 600 Access Assured members made 1943 office visits during the study period, receiving a total of 4538.22 relative value units of service. Based on the membership fee, office visit fee collections, and remaining accounts receivable, this resulted in an expected reimbursement rate of $42.88 per relative value units. Three hundred one of the 600 (50.2%) patients had incomes above 400% of the federal poverty level (FPL) at the time of each of their office visits and were therefore not eligible for any visit fee discount. Another 156 patients (26.0%) were eligible for a 100% discount of all visit fees based on their income below 200% of the FPL. Using a multivariable Poisson regression analysis of these 2 groups, we determined that age was a significant determinant of return visit rate, with a 0.7% increase in return visit rate for each additional year of age (P = .006). Women had a 26% higher return visit rate than men (P = .001). After accounting for age, sex, and clinic site, fee discount level based on income was not a significant independent determinant of return visit rate (P = .118).

Conclusions: A retainer-based program to enroll uninsured patients being used in 2 academic family medicine clinics attracted 600 patients during its first year. The program was financially viable and resulted in an expansion of our service to uninsured patients. More than half of the patients had incomes above 400% of the FPL, suggesting that the population of uninsured Oregonians may be economically more diverse than suspected.

• Access to Health Care
• Uninsured
• Health Care Financing

The combined effects of a severe economic recession, continued growth of health care costs, and cuts in Medicaid benefits have contributed to a rapid increase in the number of Americans without health insurance.^1,2 In 2007, health care costs averaged $7421 per person in the United States, with an increasing portion of this cost shifting directly to consumers.³ Access to care among uninsured adults, particularly those with chronic health conditions, deteriorated between 1997 and 2006,⁴ and this trend has probably worsened during the past 2 years. In Oregon, the rate of uninsured reached 16.8% in 2007 and is almost certainly worse in 2010.⁵

Although the lack of health insurance is a substantial barrier to the access of basic health care,⁶ there is good evidence that uninsured people have better self-reported access to care when they are able to receive basic primary care services.⁷ From the perspective of the family physician, providing care to people without health insurance can threaten the financial viability of a practice, placing clinicians in the difficult position of either denying care to people who need it or caring for patients with insufficient revenue to cover the cost of practice.⁸ Under these conditions, physicians often limit the availability of appointments for uninsured people or charge such patients for each service provided, requiring substantial cash payment at the time of service.

On the other end of the economic spectrum, many practices have experimented with retainer or boutique payment models to offer expanded services, usually to insured patients.^9–12 For example, one retainer practice model charges patients a monthly fee in addition to the usual per-visit charges in exchange for services such as house calls, accompanied specialty visits, email access to the physician, and enhanced after-hours access.⁹ This model allows for enhanced revenue to support the expansion of non-office visit services, which are appealing to many consumers. Retainer or boutique practices have been featured in articles in the lay press¹³ and in professional news sources,¹⁴ and these types of practice models have grown to the point that an organization, the Society for Innovative Practice Design, has formed to represent them.¹⁵ In addition, medical professional organizations including the American Medical Association¹⁶ and the American Academy of Family Physicians¹⁷ have published ethical guidelines for such practices.

Providing retainer services to commercially insured patients requires a careful process of compliance with commercial insurance contracts, but there is no such restriction on retainer practice for those without insurance. To our knowledge, the retainer practice model has rarely been used specifically to care for uninsured people and such a model has not been described in the literature. This article describes the first year of a cohort study designed to examine an experimental program using a retainer payment system in addition to a sliding fee schedule for office visits to deliver primary care to a population of uninsured people. The study objectives included (1) to determine whether patients will join such a program, (2) to describe the population of people who enroll, and (3) to determine whether the revenues collected from such a program could cover the costs of providing care in this way.

【 授权许可】

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