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Health Links, an administrative and gatekeeping charity care referral program, provided access to extensive social support, nursing triage, and brief treatment for patients presenting with urgent health problems, resulting in a modest volume of charity care given by the local medical community on an episodic basis. Both the volume of care and the quality of care provided through this program were substandard compared to that available to insured patients with a medical “home” who receive routine preventive and primary medical care.

As the administrative structure could not be sustained without substantial inputs, the project was grant-dependent. Costs to the Rural Health Outreach Program, which funded Health Links over the two-year study period, were between $11 and $12 per patient per month. This is less than many managed care reimbursement rates for full service preventive and primary care (although capitated HMO payments do not cover the costs of specialty and ancillary services). Nevertheless, considering the limited volume and substandard quality of services purchased with these dollars, the cost may still be considered excessive compared to other potential uses for federal and philanthropic funds. A particular irony of the Health Links experience was that many uninsured patients used the program despite their eligibility for Medicaid and the Massachusetts Uncompensated Care Pool, programs that otherwise would have paid for standard-quality medical care services in office and hospital settings and for affordable prescription drugs.

The lack of Health Links protocols for eligibility testing and paperwork completion for public insurance programs was an internal flaw in the project. Therefore federal funding for Health Links actually created a local disincentive for the utilization of available public payment mechanisms.

The Health Links experience raises, without answering, the question of whether in the worst case this kind of charity care program may actually lead to a decrease in the overall volume and quality of available free care—as an unintended consequence of accepting a gatekeeping role, and thereby insulating the local medical community from pressure to serve the working and unemployed poor who make up the medically underserved.

The single nonparticipating internist and his rationale for not participating in Health Links—that he was already subsidizing a significant amount of care for patients within his own practice who could not afford to pay his fees—should not be overlooked if charity care as a model is to be rigorously analyzed. In other words, the volume of care provided through Health Links cannot be compared to zero, but should be compared to some amount of informal, or “old-style” charity care provided as an integral part of medical care, and formerly accepted as a legitimate part of the cost of doing this type of business, prior to the existence of an administrative/gatekeeping entity such as Health Links. It is important to note that the existence of Health Links resulted in most participating practices explicitly terminating any delivery of direct, informal charity care to their patients, requiring any patient unable to pay to seek services through the Health Links system.

Following the study period and up to the present time, some Health Links volunteer physicians maintained and increased their level of effort, agreeing to accept charity care referrals directly from the new community health center as a legitimate referral source. However, some specialty providers have expressed consternation that the health center does not play the gatekeeping role that Health Links once did.

In summary, due to the relatively high cost of providing “free” care under this model, it may not be a sustainable or long-term solution by itself in most communities. Health policymakers and funding bodies should seriously consider whether the costs and benefits of this new style administrative and gate-keeping charity care model offer a truly effective way of extending medical care access to the ever-increasing numbers of the poor and underserved.