INDIGENT CARE COLLABORATION
Austin, TX

April 2000

        §       Background

Over the years, healthcare providers and related human service agencies in the region have participated in cooperative efforts to improve the delivery of services to low income and uninsured populations.  Recently, governmental and political entities have shown a willingness to consider groundbreaking approaches to financing and delivery of care.

Despite many efforts, considerable access and financing issues continue to exist and create obstacles for low-income uninsured residents of Central Texas.  Faced with these issues, healthcare safety net providers in Travis County came together in the Spring of 1997 to form the Indigent Care Collaboration (ICC).  The intent of the ICC is to develop joint projects among members to increase access, improve quality and lower the costs of providing care to the region's un-funded population.  Fundamental to the ICC approach is the inclusion of behavioral health as the core service and an understanding that a growing need for behavioral health services is at the base of a substantial proportion of primary care and other visits to healthcare providers.  Similarly, dental health providers have been an integral part of the ICC since its inception.  As a result of the "holistic" approach, we begun initially as an informal forum quickly evolved into a platform to create a more coordinated and integrated system of services for this vulnerable population.

As the ICC began to develop programs, it became necessary to create a more formal structure in which to implement and monitor its efforts.  As a result the ICC was organized as a Texas Uniform Unincorporated Non-profit Association (TUUNA).  members include health and social services providers, payers and purchasers throughout Travis County, including hospitals, healthcare networks, clinics, government agencies, non-profit organizations, individual providers and others.

Care is currently delivered to the uninsured through the following providers, most of whom are charger members of the ICC.  They are:

• Austin/Travis County Health and Human Services Department

• Community Health Centers (FQHC 11 sites)

• David Powell Clinics

• School Based/School Linked Services

• Thurmond Heights

• Austin/Travis County Mental Health Mental Retardation Center

• Blackstock Health Center

• El Buen Smaritano Clinic

• Hays County Health Department

• People's Community Clinic

In addition, healthcare for the indigent is legislatively mandated through the County Indigent Health Care Act.  The act requires counties, public hospitals, and hospital districts to provide a certain level of healthcare to their constituents.  The City of Austin and Travis County have chosen to fulfill this mandate through the Medical Assistance Program (MAP).  Although the State only mandates assistance for those 17% above poverty, the City of Austin and Travis County have opted to provide care to individuals a the 100% above poverty, which is much greater than what is legislatively required.  The MAP Program for the City and the MAP Program for the County are jointly administered by City and County staff within the Austin/Travis County Health and Human Services Department.

The Clinical Assistance Program (CAP), is a City Program.  This program is specific to the homeless, unemancipated minors, and undocumented individuals residing in the City of Austin.  CAP provides access to the same level of healthcare services to MAP.  However, these individuals only qualify for services up to the level of poverty specified under the County Indigent Care Act (22%).  The average enrollment in the City MAP Program for the fiscal year 1999 was 8,158 and the County MAP Program it was 2,011.  Williamson and Hays Counties provide services up to the level of poverty specified in the County Indigent Health Care Act.

The ICC has expanded out to relevant organizations in the surrounding counties to broaden its base and regionalize the project.  Residents of Hays and Williamson Counties, for example, have long relied on Travis County safety net providers and programs.  It is important therefore that leaders in these counties work with the ICC to develop appropriate system-wide solutions to the issues faced by the uninsured.  The ICC has developed several specific ventures, but has not yet formally examined an approach that focuses on care management principles to finance and deliver services to the un-funded population.  The collaborative efforts that have already been established, such as leveraging the ability to the unified call system to establish and tract patients through a medical home.

Several possibilities have been considered for this system redesign, including expansion of MAP, expansion of the ICC call-system and the creation of an indigent care financing district.  One of the major obstacles to developing such a care management system, however, is the lack of objective analysis on how un-funded patients would best be served by such a system and how it could expand into a restructure financing system.

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§       Guiding Principles

The clear goal of the program is to design a delivery and financial system for the uninsured in Central Texas.  Although, we do not know what form it will take, we do know what qualities we would like our ultimate solution to have:

• Sustainability in terms of delivery and financing

• Barrier free

• Offer choice 

• Quality, effective and efficient services

• Cost effective 

• Patient centered

We want to find the best answers for the community recognizing that this will almost certainly require some compromises by each partner in all three counties.

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§       Initial Project Objectives

During Phase I of this project  will utilize this support provided by Medimetrix, and this grant to further examine issues surrounding care to the region's uninsured population.  Our focus will be on access, availability, financing and the influence of cultural and political factors distinctive to our own region.  Through this grant process the ICC will develop appropriate clinical and administrative integrators to support the creation of an adequately financed and organized system.

• Expand ICC participation to include additional representation in Travis County and the surrounding region, including Hays and Williamson Counties

• Assess the size and scope of the uninsured problem and determine the adequacy of the existing system in meeting the needs of this population

• Develop alternative approaches for delivering and financing care to the uninsured

• Analyze the alternatives and create an appropriate model for the ICC service area

• Work with state and local policy makers and legislators to support changes and ensure buy-in 

• Develop indicators for evaluation of this program

The work plan developed includes structure of one Executive Committee, a Steering Committee and three working committees that include Finance, Research and Development and Public Policy.  (See attached Model).  The Committees will be used to enhance the creativity of design, review of vision, assessment and selection of models and assist in development of finance and delivery structure.  The Steering Committee is made up of carefully selected community leaders repreenting all stakeholders from all thre counties including; county judges, mayors, physicians, consumers, major employers, small businesses, behavioral health, dental and local foundations.  The role of the Steering Committee is to enhance actions to fit the vision, use influenece to shape public opinion, review and recommend delivery and financing models, provide public information and coordinate outreach.  This committee has agreed to meet every other months and has a prominent and well-respected physician and CEO of a mjor company as the co-chairs.  Our vision for developing both the delivery and financing models encompasses active communication several times throughout each phase of the process.  This will ensure that stakeholders will be part of each state of our design so that the outcome at the end of the process ensures support and buy-in form each group.  Additional ad hoc stakeholder committees will be formed as part of the Public Policy Committee.  This is anticipated primarily when we reach the model design the "how to finance" states of the selected model and the political advocacy issues required to support implementation of the desired model.

Key components of the work plan include vision, research, education/outreach, assessment, and development of models, implementation and reporting.  Time lines have been assigned and a strategy has been developed within the time line allowing for constant input and feedback to and from the stakeholder committees.

Within the education/outreach tasks we intend to have numerous stakeholder groups and focus group initiatives to enhance not only feedback and participation in the model but also education as to the issues surrounding the reasons for the need to redesign a delivery model.

Outcome measures will be based on producing the ideal model for this community and financing structure that can be supported by the stakeholders involved in this process.  Legislative issues and other broader policy questions will have been identified and selected, as appropriate for possible action during a future legislative session.  A shared vision that is bottom-up focused will continue to drive this initiative and will shape the model selected.  Final outcome to have the model fully developed and supported in time to apply for Phase II.

Central Texas, with its rich ethnic mix and cultural diversity, is among the most rapidly growing area of the United States.  In less than ten years, the population of Travis County, which includes the capitol city of Austin has increased almost 25% to about 712,000 residents.  This rapid growth is fueled by a diversified economy led by the high technology sector.  However, economic disparities between high-income technology workers and low-income workers with limited skills place increased strains on the lcoal healthcare and social services system.

Travis County is located in the South Central part of Texas.  Measured from Austin, the largest metropolitan area in the region.  Dallas is 190 miles northeast, Houston 165 miles southeast and San Antonio 80 miles to the southwest; the Mexican border is 225 miles away.  Austin is the commercial heart of Central Texas, located in a major agricultural area of ranching, poultry, dairy, cotton and grain production.  It is home to the main campus of the University and State Government, Dell Computers, Motorola and IBM are major employers.

Tri-County comprises the initial service area of the project but we are already expanding the participation of this project to include Hays County to the south and Williamson County to the North.  The additional population of these two counties adds another 330,000 to the 712,000 figure.  The region's population is increasing at a higher rate than the State of Texas or the nation as a whole.  The ethnic composition of the area is diverse and Hispanics represent the most rapidly growing proportion of residents.  Hispanics currently make up about 27% of the population up from 15% in 1970 and 21% in 1990.  About 11.5% of the population is African-American and the rest is Anglo and other racial ethnic groups.

Over the past two decades, there have been a decrease in the number of "traditional" family households in Travis County and an increase in the number and proportion of households led by single females.  Today, single females head 17% of family households compared with 10% in 1970.  Children under the age of 18 live in more than six in ten of these households.  This trend is significant because households headed by single females particularly those with children, are associate with adverse economic and social characteristics, such as high poverty rates and reliance on public assistance.

In total over a quarter of Travis County population or more than 190,000 people, are considered "low-income," living below 200% of the federal poverty level.  Of these, more than half (15.4%) of the population or close to 110,000 residents) live below 100% of the poverty level.  These rates are highest among minority groups, the poverty rate for Hispanics and African-American (26%) is about two-and-a-half times that of the Anglo population (10%).  Other measures of community need show that each month, close to 50,000 Travis County residents receive food stamps, more than 7,000 receive emergency rent assistance, and more than 8,000 receive assistance in paying utilities.

A portion of the population living in poverty receives healthcare benefits through the Medicaid program.  The Texas Health and Human Services Commission reports that more than 40,000 Travis County residents were enrolled in Medicaid in November 1998.  Medicaid covers relatively few adults in Texas.  Currently TANF is limited to individuals with incomes at or below 17% of the federal poverty level.  The number enrolled in Medicaid is declining in Travis County.  The proportion of residents insured by Medicaid in the adjoining counties is much smaller.

Because health insurance is associated with life circumstances such as employment, retirement, or participation in government programs, individual health insurance status changes over time.  As a result, it is difficult to pinpoint precise numbers of uninsured residents at any one time.  Nevertheless, attempts have been made to qualify the Travis County uninsured population in order to better develop policy and programs.

Health Partnership 2000, a collaborative of Austin area healthcare providers, conducts periodic community telephone surveys that include questions about health insurance status.  In the most recent survey in 1997, 14% of Travis County respondents reported that not all adult members of their household had health insurance.  Since the 1997 Health Partnership 2000 survey, more than 14,000 small businesses in Texas have dropped employee health insurance coverage.

Representative of Austin/Travis County Health and Human Services Department believe that as much as 25% of the population, three-quarters of which are adults, are now uninsured.  The SETON Healthcare Network estimates that about 151,000 people or more than 21% of the Travis County population are uninsured.  St. David's Healthcare Partnership estimates that 18% of the employed Travis County workforce or about 100,000 workers are uninsured.  This figure rises to 150,000 to 170,000 when workers and their dependents are included.

Using all figures it is estimated that between 100,000 and 135,000 adults in Travis County, representing about 15-20% of the population, are currently uninsured.  These individuals are the target population of this project.  Most of these Travis County residents are considered low-income, living at or below 200% of the federal poverty level.  As many as 30,000 however have incomes above 200% of poverty.

Paul Gionfriddo  
Executive Director
Indigent Care Collaboration
1213 N. IH-35
Austin, TX 78702
Phone: (512) 927-2677
Fax: (512) 927-1350
E-mail:  pgionfriddo@icc-centex.org