COORDINATED HEALTH SYSTEM of JEFFERSON COUNTY
late 1996, the Council for a Coordinated Health Care System was created to
address concerns about charity care in Jefferson County, Alabama. The
Council's members, representing virtually all of the private and public
healthcare providers in the county, agreed that the system of care needed to
refocus on preventive and primary care services rather than predominantly on
inpatient and emergency services. The redesign of the system was seen as
critical both to improve healthcare outcomes and to control costs.
Council activities over the next two years five lessons emerged:
uninsured use a variety of public and private providers for care, but in a
poorly coordinated manner.
is a broad-based willingness to develop public-private partnerships that
facilitate access to care for the uninsured within the limitations of
a coordinated system to work a reimbursement and recognition system for
private providers is crucial to the long-range success of the public-private
those persons with the greatest healthcare needs is the strategy most likely
to garner political and provider support and to show success.
the work and ideals of the Council with the Medicaid program offers a
mechanism to insure additional resources into the system.
Principles which emerged from the Council for a Coordinated Health
Care System and which will govern and design strategy of the Jefferson
County Healthcare Authority are:
healthcare system should improve the health status of the
residents of Jefferson County.
system should integrate Medicaid and the Indigent Care Fund.
public and private healthcare organizations should participate in
the system, but no provider should be financially over-burdened.
system should emphasize community-based preventive and primary
eligible person should have a medical home which coordinates and
manages their care.
with special healthcare needs should have access to services to
meet their needs.
system should ensure adequate primary care capacity.
for developing primary care capacity rests in the public sector.
additional county resources should be required to operate the
system of care.
participating providers should accept appropriate, reasonable and
integrity of the safety net in Jefferson County should be
of the system should reflect a balance of essential community
providers, private providers and consumers.
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in Charge in Jefferson County has the following goals:
the Council to the Jefferson County Health Care Authority with appropriate
administrative structure and representation.
the details of a coordinated delivery system.
a reimbursement system for private providers participating in partnerships.
a unified enrollment and eligibility program.
a methodology to identify from hospital and physician bad debt and charity
records those persons who would benefit from having their care coordinated.
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& Outreach Strategy
is the only county in Alabama that levies a tax specifically to meet
the healthcare needs of "those who afford none or only part of
the costs of their healthcare." The sales tax generates
approximately $84 million a year, approximately $37 million is for the
Indigent Care Fund (ICF) and $14 million in direct subsidy to the
Jefferson County Department of Health (JCDH). The Jefferson
County Commission oversees the ICF as part of the Cooper Green
Hospital budget. The ICF provides half of the operating budget
for Cooper Green and provides specific services at the Jefferson
County Department of Health, Children's Hospital and UAB. Monies
from the ICF are not used to offset uncompensated care costs in the
private sector. The need for a reimbursement system for private
providers, principally specialty physicians was clearly identified
following the opening of the Bessemer Northside Community
Clinic. This primary care practice opened as a partnership
between Bessemer Carraway Medical Center (BCMC) and Jefferson Health
System (JHS) as a direct outgrowth of the Council's activities.
In this partnership agreement, JHS support 1/2 of the family
physician's compensation package so that 1/2 of the practice is
comprised of uninsured persons. BCMC and its medical staff
agreed to provide specialty referral care, diagnostic services,
emergency care and hospitalization as their community charitable
approximately 14 months of operations more than $1.4 million in
physician and hospital charges have accumulated from the Bessemer
Northside practice. The private physicians have become
increasingly vocal about the magnitude of their contributions without
compensation especially when physicians in the public sector are paid
for services rendered. From this tension has come the
realization that a formal reimbursement system must be developed and
adopted if this partnership is to service and others to develop.
In Phase One, the Authority will work with staff at Blue Cross/Blue
Shield of Alabama and actuarial consultants to create an appropriate
and reasonable reimbursement methodology for the private
providers. The initial focus of this work will be outpatient
care, but will subsequently address inpatient services.
A Charity Trust
Fund is proposed to cover a portion of services not directly provided
through the primary care infrastructure of the system. The
Charity Trust Fund will be established through an annual contribution
from the Indigent Care Fund, but could also receive other funds, such
as from a proposed local hospital conversion. Ultimately, the
Authority will secure a Section 1115 waiver that will allow a
completed integration of Medicaid with the County funded
programs. It will be the responsibility of the Authority during
Phase One to develop a formal proposal for the Charity Trust Fund and
ultimately this fund would be administered through the Authority.
A focus on
enrollment will be an essential feature of the system development in
Phase One. Jefferson Health System, the Jefferson County
Department of Health, and Children's Hospital have agreed upon a
unified procedure for determining eligibility and enrollment for
subsidized services. These organizations are foregoing a new
co-payment structure that incorporates a full accounting of services
of each visit or encounter, including the intensity of physician
services. The Authority will implement the procedures that the
co-payment system as well as monitor the effectiveness of the
structural changes in the system. In addition, one of the
important lessons from the Council's work is that "building
it" doesn't mean "they will come." Developing a
system that tries to enroll all the uninsured in Jefferson County is
unrealistic within the limitations of existing resources.
Furthermore, local experience with Jefferson Health System's HMO for
the uninsured (The Community Care Plan) and experience with the
Children's Health Insurance Program suggests that encouraging
uninsured persons to enroll in an insurance program, regardless of its
economic merits is a near fruitless task.
persons with chronic healthcare needs and enrolling them in a
coordinated system of care is locally realistic and politically
desirous to politicians and providers alike. The archeology of
bad debt and charity care is selectively mining bad debt and charity
care records from hospital and physicians to identify persons with
chronic illnesses who without doubt will benefit from enrolling in a
subsidized and coordinated system of care. The Authority will
develop the archeology of bad debt with Blue Cross/Blue Shield
coincident with the development of the reimbursement system discussed
earlier. By using existing provider data to identify the
individuals who are using the system but who are not insured, we will
be able to actively determine likely enrollees into a system of
will be divided into five Network Service Areas reflecting current
utilization patterns. Each Network Service Area (NSA) will
consist of primary care physicians, specialists, support services, and
hospital's. The uninsured will be actively enrolled into the
system, select a primary care provider, and become part of the
NSA. The public sector, i.e. Cooper Green Hospital and the
Jefferson County Department of Health, will be responsible for
developing the primary care infrastructure along with an appropriate
mix of specialty and diagnostic services. Medical management of
persons enrolled in the system will be consistent with managed care
principles, i.e., primary care orientation, health promotion and
pre-approval of referrals. The NSA system will be the key focus
in the initial establishment of networks and strategy for care
delivery by the Authority. In addition, Disease management
Networks, will target conditions that are high cost, require an extensive
specialty management, and/or have the potential for significantly
improving health outcomes for the illnesses. HIV/AIDS, Asthma,
Diabetes and Sickle Cell Disease are the areas that are already in development
and would be enhanced through the Disease Management Network.
The Disease Management Networks will build on the referral and
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Along with the primary
hurdle of financing, an additional hurdle is the maintenance of the working
relationships among providers established by the Council.
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Jefferson County is Alabama's
largest county with a population of 658,000 (1997 Census estimates).
Approximately 70% of the county residents are white, 29% are African American,
0.5% is Hispanic and 0.5% belongs to other ethnic groups. A community wide
evaluation of health insurance status conducted in 1997 showed that
approximately 225,000 Jefferson County residents were uninsured at some time
during the previous year. HealthWatch also revealed that more than 250,000
persons delayed seeking necessary medical care primarily because of lack of
insurance and 48,000 persons were actually denied medical care because they did
not have health insurance or were unable to pay the bill. These remarkable
numbers are in addition to the 43,000 residents who received Medicaid,
approximately 35,000 children and 8,000 adults
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Health System of Jefferson County
8th Avenue North, Suite 200
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