The Bureau of Primary Health Cares Rural Health Outreach Program, which funded Health Links from 1994 through 1997, provided $400,800 over the two-year study period. These funds covered personnel costs, reimbursement to the hospital for laboratory and radiology charges resulting from Health Links visits, and some limited prescription assistance for Health Links patients who could not afford to pay for medications ordered by providers.
Table 4 shows the cost of the program, assumed to equal the amount of the federal Rural Health Outreach Grant over the two-year study period, considered in three different ways: cost per individual patient, cost per referral, or cost per contact. Each way of looking at cost is given on a total, annualized, and monthly basis, to allow for gross comparisons with standard insurance premiums and managed care capitation payments.
First, viewing Health Links as a system of care to individuals, the program’s cost was $271.60 per patient over the two-year period, or $135.80 per patient per year or $ 11.32 per patient per month.
Viewing Health Links as a mechanism for screening and referring patients to office-based, standard-quality care, the cost per referral was $264.61 over the two-year period, or $ 132.31 annualized or $ 11.03 per referral per month.
Finally, viewing the Health Links program as a system of labor-intensive supportive social contacts and nurse triage by telephone and at non-medical sites, as well as a system of referrals, the cost can be viewed as $42.23 per contact overall, or $21.11 per contact per year or $1.76 per contact per month. These totals include all contacts recorded in the office telephone log, including calls inquiring about hours and directions, which explains why the cost per medical contact was so much higher.
The hospital provided additional unmeasured resources, including unreimbursed planning and grant-writing time and other indirect costs. However, by and large all Health Links services during the two-year period under analysis were paid for by the federal Rural Health Outreach Program. Due to the seniority of the hospital nursing personnel who successfully “bid” for the Health Links staff positions (among the most highly paid nurses in Franklin County), total costs to the program were probably somewhat higher than might otherwise have been the case.
Additional revenue would have been generated for the hospital had the program not missed an opportunity to pursue insurance reimbursement. Patients were not screened or assisted in completing paperwork for health insurance programs for which they might have been eligible. For example, many Health Links patients would have been eligible for MassHealth, the states Medicaid program, which would have covered provider visits, prescription drugs, and inpatient costs. In addition, Massachusetts has an Uncompensated Care Pool through which hospitals recapture some of their costs for treating patients who cannot pay. For those patients who met the eligibility requirement (total family income at or below 200% of the Federal poverty level), their hospital charges, including laboratory, radiology, inpatient, and emergency department charges, would have been reimbursed in part by the Uncompensated Care Pool.
QUALITY OF CARE
Health care quality is generally understood to be a function of many complex factors including appropriate and timely clinical content, various accessibility and access factors (for example, cultural competence), and continuity of care.
Continuity of care was not one of the original goals of the Health Links program. Continuity was left to the discretion of providers, and was highly variable. When referrals were made to a medical office for standard care, these were usually with the goal of addressing an urgent problem and there was no implied commitment that the patient would be retained by the practice. Although some patients were retained as long-term primary care patients by the providers to whom they were referred, most apparently were not. Health Links staff and volunteers noted that many patients, including many with chronic illness, returned seeking a new referral with each new acute problem or each time they ran out of medication.
Although records were kept of all Health Links contacts and referrals, medical records were of course kept by the practices to which patients were referred. Information concerning the medical content of office visits was not systematically fed back to Health Links staff. Thus, while a kind of social continuity was provided by staff and volunteer nurses at the sites, medical continuity of care was not necessarily achieved. In the longer term, since the Health Links program was not a permanent feature of the local infrastructure, even this social continuity was unfortunately lost.
Clinical preventive services and primary care were not routinely provided through Health Links referrals. As noted above, preventive health services such as cancer screening and cardiovascular risk factor assessment and modification were not routinely offered at Health Links sites. In addition, preventive services were not routinely performed by providers due to the urgent care focus of the program. Low rates of preventive service delivery and lack of continuity of care have recently been noted elsewhere in a similar charity care program.