BALTIMORE CITY HEALTH DEPARTMENT
Baltimore, MD

April 2000

        §       Background

BCHD chose the Sandtown-Winchester, East Baltimore and Park Heights communities for this initiative since they already-established community level service delivery networks and BCHD had existing relationships with all three communities.  It is a founding member of the Vision for Health Consortium (VFH) since 1994, and BCHD Deputy Commissioner of Operations, Hakim Farrakhan chairs VFH's Board of Directors.  Further, BCHD helped to create PHCHA in 1997.  Elias Dorsey, BCHD Deputy Commissioner for Grants, Research, and Policy was an active HEBCAC Board member.

The Robert Wood Johnson Communities in Charge Initiative provided the impetus to form a coalition of the three existing efforts already underway in the three-targeted areas.

BCHD is working with three innovative consortia within each of the pilot communities:  The table below depicts participants from each community.

In addition to these three organizations, BCHD has received formal commitments of support from the following health systems and institutions:

• The Historic East Baltimore Action Coalition (HEBCAC) - John Hopkins Health System

• The Park Heights Community Health Alliance (PHCHA) - Sinai Hospital of Baltimore

• Vision for Health Consortium (VHC) - Bon Secours Baltimore Health System, Total Health Care, University of Maryland School of Nursing and University of Maryland Medical System.

Primary care is currently available to the uninsured and residents through Baltimore's Federally Qualified Health Centers on a sliding fee scale, emergency rooms, health department clinical sites, and Maryland Primary Care provider sites.  Although, these safety net providers currently have provisions to provide care to the uninsured, there is not an incentive to design a dedicated, or systematic effort in place to use these primary care sites as a vehicle for cost shifting from the acute care setting.  There are minimal if any effort made in outreach to assure that the services are made available.

Financing Strategy

Currently, hospital and other Baltimore healthcare providers are absorbing a large portion of the cost of serving the city's uninsured residents.  Today, much of the care for the underserved is being paid for through uncompensated care resources.  Because of high cost, the underserved generally delay seeking care until it reaches expensive, emergency level proportions.  Under Maryland's All-Payer System, acute care for those that do not have insurance is partially offset through a state funding mechanism established by the Health Service Cost Review Commission (HSCRC).  As levels of uncompensated care rise the overall rates increase for the hospital services.  This is a negative incentive for hospital systems that are struggling to the price competition in today's managed care environment.

Potential sources of ongoing support for serving low-income uninsured residents in the three target neighborhoods include the BCHD, the Maryland Health Services Cost Review Commission (this rate-setting commission controls a pool of money to help hospitals reduce uncompensated care), the Maryland DHMH, private foundations, businesses, and increased sales taxes such as the tobacco tax.  In conjunction with the BCHD, the three consortia will develop a business plan that will project the ongoing cost of delivering care to uninsured residents in these three neighborhoods, identify sources of funding, and develop strategies for securing those funds on a continuing basis.  This plan will also require conducting a cost-benefit analysis to determine whether and how adopting a different, more community-based approach to serving uninsured residents will save much money.

Outreach Strategy

Currently, many uninsured residents do not seek low-cost or free healthcare before their conditions become critical because they do not know such services exist, and are reluctant to interact within the "system" or are too overwhelmed by the psycho-social problems that typically accompany poverty to access care.  Currently, the BCHD is drafting an outreach training curriculum that can serve as a model and help standardize the meaning of "outreach" across programs and services, to include those who are uninsured but eligible for various state or federal healthcare programs.

Delivery System

Although still evolving, each of the three consortia already has a network in place through which healthcare services are being-or-can-be provided to uninsured residents.  This project aims to create a "network of networks" in all three communities that can serve as a model for healthcare delivery citywide.  This aim is not to offer the exact same services in the neighborhood.  

Recognizing that medical problems facing the poor cannot be treated in isolation from educational, housing and employment issues, each consortium includes not only healthcare providers but also representatives from a wide range of social safety net, educational, family support services, church, youth services and housing organizations.

The project's central administrative task will be to create what is called a "shadow managed-care organization."  A shadow MCO is a mock insurance program that can serve both as an instrument for collecting and analyzing data about the uninsured and as a mechanism for proactively managing their healthcare.  In such a system, uninsured residents are assigned an identification number, which healthcare providers and others use to gather basic data, such a number of visits types of diagnostic categories, services rendered, and cost.  This data can be analyzed to gain insight into when, why and how the uninsured seek (or fail to seek) healthcare and the cost effectiveness of current service models.  Armed with such data, healthcare providers, activists, and city officials can identify gaps in services, improve existing services, and design new services in the three target neighborhoods and throughout Baltimore City that ensure better utilization, cost-effectiveness, and health status for uninsured residents.

The initial twelve-month project will target the uninsured residents of Baltimore City's Middle East, Park Heights and Sandtown-Winchester communities.

Nkossi Dambita
Baltimore City Health Department
210 Guilford Avenue
Baltimore, MD 21202
Phone: (410) 396-1420
Fax: (410) 396-1617
E-mail:  ndambita@baltimorecity.gov