COMMUNITIES in CHARGE—JACKSONVILLE
Jacksonville, FL

April 2000

        §       Background

Planning for Communities in Charge began in March 1999.  The Mayor appointed the Steering Committee in April 1999.  Steering Committee membership includes representatives of:  Shands Jacksonville, City of Jacksonville, Duval County Health department, Health Planning Council of Northeast Florida, Jacksonville Chamber of Commerce, Jacksonville City Council, IM Sulzbacher Center for the Homeless, WE CARE, Duval County Medical Society, and the Florida Department of Children and Families.  The grant was awarded in 1999.

Communities in Charge Jacksonville - is a coalition of public and private entities and individuals working toward a fully coordinated community effort to increase healthcare access for low-income working uninsured in Duval County through a partnership between government and the private sector.  Care is currently delivered to the uninsured through a variety of providers and funding sources:

• The Duval County Health Department and Federally Qualified Health Center have public funds to provide healthcare services to the low-income uninsured.  The Health Department also sponsors specialty services for HIV and tuberculosis.

• The WE CARE Program has a small amount of funding for infrastructure and offers needed medical care provided by volunteers to the low-income uninsured through its 10 donated clinic sites.

• The IM Sulzbacher Center for the Homeless is a public-private initiative that includes a comprehensive health program that provides medical, dental and behavioral health services to the homeless.

• Hospitals provide in-patient emergency care to the uninsured on a regular basis.  Despite targeted interventions, many of the uninsured continue to use the hospitals as urgent care centers and rarely if ever, participate in primary or preventive services.

• The Florida Department of Children and Families funds community agencies that provide mental health counseling and substance abuse treatment.  The City of Jacksonville funds social services such as mental health and housing assistance.  Our community agencies including faith-based organizations offers a variety of social services.

• The City of Jacksonville allocates $18.5 million annually to Shands Jacksonville to subsidize care to the indigent uninsured.  In 1997, a managed care approach was developed to improve cost effectiveness of the funds through proactive management.  The program called FirstCare, emphasizes primary care, disease management and utilization review.  Enrollees are assigned to a primary care provider and given a membership care plan description and provider list.  The benefits include primary care. laboratory, pharmacy services, and specialty services accessible in both the outpatient and inpatient settings.

Financing of services for the uninsured will include three strategies:

• Maximizing participation in available programs

• Improving cost effectiveness of current expenditures for healthcare provided to the uninsured and;

• Increasing funds for healthcare to the target population

Maximizing Participation in Existing Programs

Many individuals currently uninsured are eligible for but not participating in available programs.  The most common example is the Florida Health KidCare Program.  KidCare included Medicaid, the state funded Health Kid Programs, and the CHIP funded expansions of these insurance programs.  Participation is limited due to lack of awareness, cultural barriers, system problems, and legislative requirements.  The State of Florida and The Robert Wood Johnson Foundation have funded an outreach program to increase enrollment in KidCare.  The targets of these efforts are families whose income are at or below 200% of poverty.  The current outreach efforts to this population will be supported and, if necessary expanded and integrated into Communities in Charge.  The CIC Initiative will encourage enrollment in all existing programs and will support or develop additional outreach efforts as needed.

Improving Cost Effectiveness

The current cost of providing healthcare to the uninsured (excluding FirstCare) is estimated to be $56 million.  Funding streams generally unrelated silos that provide categorical services dictated by the immediate condition of the client.  The services are episodic, fragmented and offer little incentive to do outreach.  An initial step of the project will be to analyze current service patterns and provide the opportunity and incentive for the service providers to design and participate in a system of care that improves use of current resources.  Cooperation from organizations will involve retention of their existing funds and will require the system to be developed within the context (and constraint) of the contributions and competencies of each participant.  Enumeration of the services rendered, and a description of conditions being treated should allow for the deification of the intervention strategies that may be effective in transitioning episodes of urgent and emergency care to prospectively managed conditions.

Increase Funding

The Communities in Charge project will develop a funding proposal for expanding healthcare coverage to the low-income uninsured.  This will include an actuarially sound estimate of the cost of providing a benefit package for the targeted low-cost populations.  Data from FirstCare and other providers will be used with standardized databases and projections that include benefits of management.  Improving access to healthcare to the low-income uninsured will require development of long-term, sustainable strategies including an increase in the availability of public funds.  Estimated of the amounts required to cover a variety of options will be made based on:

• Projected cost of the benefit package

• The number of eligible members at full and partial coverage

• Matching dollars available from the Title XXI and other sources such as employer participation in a low premium product.

The resulting estimate of unmet needs will be presented to the Mayor and City Council for discussion for funding alternatives.  The power of the CIC Coalition, bolstered by the data available from FirstCare demonstrating the cost-benefits of managing care will have a major impact on the political process required for expanded funding for the uninsured.

Outreach Strategy

The Outreach Strategy will be based on the use of expansion of existing programs and linkages.  We build on the outreach program for Healthy Kids, which targets the same families that the CIC Initiative has identified as the target group.  Linkages to social service and community agencies will be a key component of the outreach and marketing strategy.  The health and social service community will identify appropriate access points for entry into the system of care.  Functional interrelationships among the helping professions are understanding of the system, its benefits and eligibility process will be the most effective marketing strategy.

Delivery System

It is anticipated that the initial medical provider network will be based on the core of traditional providers of care to low income populations.  The FirstCare Network currently includes Shands Jacksonville and the University of Florida outpatient facilities.  The initial expansion of this network is expected to include the Duval County Health Department Clinics, the Federally Qualified Community Health Center, and others identified above.  Decisions related to expansion of hospital and specialist participation will be made during the planning phase.  The participation of ancillary providers will be based on the composition, location and capacities of the initial network providers.  The priority in network development will be those with a historical commitment to serve the un-funded patient and those who are willing and able to share in the financial risk.

Consideration of the impact of social conditions that present barriers to accessing healthcare services will be an important planning issue.

The current social network is fragmented and incomprehensible for many healthcare providers.  This limits effective referrals from the healthcare system and restricts access and use of needed services.  The inventory of available services conducted during the planning phase will include social services.  It is anticipated that in the operations phase, social service organizations will establish formal linkages with network providers, and the FirstCare staff will be expanded to include a social worker that will provide coordination of services with existing resources.

The services provided in the final implementation phase will include; primary care, specialty care, behavioral health and substance abuse treatment and hospital care.  these services will be provided in a managed care environment, and will include outreach and emphasis on primary care, prevention, screening and early intervention.  Benefits will be designed to be cost effective and emphasize quality, member satisfaction and access to and participation in prevention of services.

Several challenges face the group and the success of the project will depend upon early identification and addressing stakeholder issues and concerns.

The major challenge will be to increase funding for coverage to the uninsured.  We must recruit the active participation of:

• Other hospitals

• Key political and business leaders

• Advocacy groups

The compelling need or the integration of resources and increased funding for services will have to become a generally accepted community concept.

Biases against managed care and the concern about potential conflict of interest by involved parties will impose additional barriers in the development of the business plan.