The Inland Northwest in Charge Initiative
Spokane, WA

April 2000

        §       Background  

Spokane boasts a rich tradition of collaboration around health and human service issues.  Thus, while the official planning activities for Inland Northwest in Charge Initiative did not begin until February 1999, its roots were formed much earlier.  Specifically the Health Improvement Partnership (HIP) and several other unique collaborative venues were established in around 1995.  HIP was launched at the time by Spokane's medical community with a wide array of community partners, as a bold new vision of community improvement, in ways that include but also go beyond traditional healthcare.  Since that time, thousands of individuals and over 500 organizations designed to improve overall community health by acting as a "neutral convener" of "cross-sector" , collaborative community improvement initiatives.  In other words, HIP  has become the ongoing embodiment of Spokane's dedication to work together for the good of the whole.

The coalition specific to planning the Inland Northwest in Charge Initiative began to be formed in February 1999, with the intent to devise a new system of care for the low-income uninsured.  To date, nearly 200 individuals have participated at some level in the process.  An extensive and growing list of partners have been and continue to be involved in this effort, including representatives from the following fields:  Hospitals, Insurance Providers, Medical Clinics, Healthcare Providers and Organizations, Policy Makers, Higher Education, Mental Health, Public Health, Human Services, Education Business Employers, Government Rural Service Providers and Media.  The Steering Committee for the groups consist of 26 individuals from all of these fields.

Care for the Spokane region's uninsured is currently provided through several venues, none of which can serve the needs of the entire population.  As in many communities, the hospital emergency rooms provide a high percentage of uncompensated care, often for conditions that could have been treated in another setting in a more cost-effective manner.  While Spokane County and several of the outlying rural communities have community-based clinics that serve the uninsured, none of them can respond fully to the current demand of services.  Because of their limited capacity, centers regularly must run away individuals seeking care.  Similarly, the Spokane area has Internal Medicine and Family Residency training programs that also provide uncompensated care.  In all of these cases the clinics or services rarely can respond to all of their clients needs, especially in terms of preventive care and ancillary costs such as pharmaceuticals, or specialty services.  As a result, even the uninsured who access care (though only a portion of those who need care actually seek it) are either trying to get care too late - e.g., they are already ill, or are unable to get the very care; e.g., (preventive) when they need to stay healthy.

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  §       Guiding Principles

Inland Northwest in Charge Initiative is a dynamic, open-ended and inclusive planning process working to create a new system of healthcare financing and delivery for Spokane's low-income uninsured.  The Health Improvement Partnership, a non-profit catalyst organization skilled in managing collaborative ventures, facilitates the effort.  This initiative will bring a wide array of partners to the table to design innovative community-specific, fiscally sound, and client-centered approaches for providing healthcare to this target population.  Inland Northwest in Charge will explore effective ways to integrate healthcare and social services to finance service provision in cost-effective ways; to partner with employers and policymakers to be wise healthcare consumers within the new system.

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§       Initial Project Objectives

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§        Financing & Outreach Strategy

As previously mentioned, the Inland Northwest in Charge Initiative involves an inclusive open-minded planning process that will identify community-specific solutions to healthcare financing and delivery for its population.  Therefore, while several promising healthcare models may exist, the ultimate decision as to which model to implement has not yet been made.  The uniqueness of this effort involves building partnerships with finance, delivery and consumer voices to identify options and priorities and to gain buy-in to the planning process and its outcome.  The effort will be guided by an ambitious assessment process to determine the unique needs of our target population, the current healthcare and financing resources we build on, and the gaps in services or access points that we can address more thoroughly.  The program design will win the long run, emerge from the quality of collaboration and the expertise of our assessment, finance and care delivery partners.

Financing Strategy

Over twenty of the partners who control funds related to charity, sliding fee and uncompensated care have indicated that they would consider re-directing a portion of their current funding for these purposes to a new system of healthcare financing and coordination for the low-income uninsured.  In addition to these commitments, local health plans have indicated strong support for innovate approaches to healthcare coverage and have committed to full participation in Phase One activities.

In addition, to leveraging these local resources, the Inland Northwest in Charge Initiative has begun in-depth discussions with local and state government representatives regarding new approaches to financing healthcare for the low-income uninsured.  These partners have agreed to contribute to Spokane region's effort by helping guide policy decisions, pursuing the purposeful redistribution of current financial resources toward creative new healthcare solutions and participating in planning.

The Health Improvement Partnership will coordinate a variety of activities to develop a funding package to finance the ongoing costs of care delivery after implementation.  First and foremost, HIP will continue to build consensus among the above-listed community and state partners regarding the redistribution of current healthcare funds for the uninsured, as well as for the coordination of services and packaging of benefits.  The Assessment Work Group, with professional guidance from Washington State University's Health Policy Administration program and the Spokane Regional Health District's Assessment and Epidemiology Department will research cost-effective benefit plans and healthcare utilization patterns to create a financially sound approach in insuring the low-income population of Spokane.  HIP will also coordinate with existing Washington State Programs such as the Basic Health Plan to determine how the effort might enhance the reach of existing resource while still addressing the identified gaps in services.  It is also clear that Spokane's approach to serving the low-income uninsured will involve pooling of local funds and possible re-channeling of state funds to support a new system of coordinated service and financing.  An exciting extra dimension will be working with the local business community to channel business resources into the funding pool, possibly to design new ways for businesses to offer coverage for their low-income employees.

Preliminary collaborators have emphasize one final design criteria.  Spokane's new system should promote personal responsibility.  Even if people cannot afford to pay very much, they should pay their health and personal destiny.  The emphasis on personal responsibility will blend will with the strong emphasis on prevention.  Spokane's new system will take advantage of the latest research and incorporate the most beneficial mix of preventive interventions.

It is yet unclear whether the new system will function through an existing provider network, safety net facilities, managed care plans, a competitive bid process, or a combination of several such approaches.  The assessment and planning activities in the coming year will determine these outcomes.

Outreach Strategy

From early planning input, it seems likely that Spokane's new system will be involved in some kind of centralized outreach, assessment, and referral mechanism.  This function may be "road tested" via preliminary "Charity Care Network" that could be implemented within the planning year.  Building on HIP's HealthforAll hotline and client support, service seems a likely strategy for launching the referral system.

Outreach and "marketing" of a new system will be conducted through a variety of public awareness activities.  Both the Health Improvement Partnership and the HealthforAll Program have coordinated extensive media campaigns around healthcare issues, including a highly successful effort to reach uninsured individuals to encourage enrollment in state-sponsored health plans.  Given a thorough familiarity with the Inland Northwest in Charge target population and given our knowledge of the most effective tactics for reaching that population; a comprehensive outreach plan will be developed.  Such efforts may include, but will not be limited to:  Television and radio service announcements, print and billboard advertisement, distribution of print materials to key venues frequented by target population; outreach and training service for providers who regularly come into contact with eligible individuals, and perhaps some forms of one-on-one outreach.

Delivery System

To be a neutral convener requires that one enter into a dialogue with no preconceived picture of where it may lead.  HIP will regard this project as a fresh start all ideas welcome.  That said, planning sessions and interviews conducted thus far, as well as existing characteristics of Spokane's development healthcare environment, suggest the following design priorities:

Strengthened/Enriched "Charity Care"

In preliminary brainstorming sessions for this initiative, some early consensus emerged about the feasibility of establishing an interim charity care distribution system as a stop-gap measure during the planning periods for longer-term solutions.  Many local providers experience ongoing requests for charity care.  They indicate that their main reason for denying these requests is fear of becoming disproportionate contributors to the informal pool of such care.  Having an organized system that could field charity care requests and distribute them equitably across the provider community would eliminate that concern.  This expanded system might also involve the "enrichment" of the current system of community health clinics that serve the uninsured; in other words these clinics might develop more options for referrals to specialists and more options for integration with mental health, dental, pharmaceutical, social service, and other forms of support.

Basic Health "Sponsorship"

In a background interview for this project, officials from the Washington State Healthcare Authority suggested another possibility for serving the immediate needs of some of the low-income uninsured.  An organization representing Spokane's Communities in Charge planning effort may be able to contract with the Healthcare Authority to locally subsidize part or all of the client's costs to enroll in the Washington Basic Health Plan.  In other words, if Spokane pools local funds, the State offers the sponsorship program as a vehicle to blend those funds with state subsidies and programs.

Building Upon HealthforAll

Another option will be to explore the prospect of building upon the existing infrastructure created by the HealthforAll Program, a HIP-coordinated program, to enroll the uninsured who are eligible for state-subsidized coverage.  Although HFA is limited now to brokering enrollment, for eligible people, there is no reason why the program could not help coordinate a broader array of service options (like the charity care system mentioned above).  For example, approximately 20% of calls taken by the HealthforAll phone center come from an audience that the program cannot help, low-income working people who are ineligible for state sponsored insurance but unable to secure coverage on their own.  An expansion of the HealthforAll effort will better link the uninsured with resources that currently exist while we seek new solutions for current gaps.

Spokane, Washington the second largest city in Washington State, is the hub of a vast, sparsely populated region that extends west 150 miles to the Cascade Mountains, north several hundred miles into British Columbia, east many hundreds of miles across Idaho and Montana and south across the Palouse wheat fields into eastern Oregon.  Of the approximately 1.3 million people who live in this region, most use Spokane as their hub for serous medical issues.  Spokane County's population is 420,000; approximately half live in the City of Spokane; and the other half live in the rural areas outside of the city.  In adjacent counties within 20-100 miles of downtown live another approximately 100,000 people who consistently use Spokane County healthcare services.  This project involves as a starting point for the approximately 520,000 people who live in or near Spokane County and who regularly participate in Spokane County's healthcare system.

As of 1998, according to Washington State Office Financial Management (OFM), Washington State is home to approximately 600,000 uninsured individuals-about 10.9% of the overall population.  Given an environment of constantly shifting cost and eligibility dynamics for state-sponsored insurances and an almost non-existent private insurance market, these figures are suspect.  Certainly, because of local concentrations of poverty and low-paying jobs that do not offer health insurance, it is reasonable to estimate a much higher percentage of uninsured in the Spokane region compared to the rest of the state, perhaps at least 15% rather than the statewide estimate of 10.9%.  Thus, of the 520,000 people in the Inland Northwest in Charge region, an estimated 78,000 lack health insurance.  Approximately 30% of these are children under the age of nineteen, for whom eligibility guidelines for state-funded health plans are more liberal and less equivocal.  Thus approximately 55,000 local adults fall within the target population of Inland Northwest in Charge.  For the purpose of this project, Spokane's description of "low-income uninsured" includes those living at up to 250% of FPL who are not finding affordable health coverage

Daniel Baumgarten
Executive Director
Health Improvement Partnership
421 West Riverside, Suite 400
Spokane, WA 99201
Phone: (509) 444-3088  
Fax: (509) 444-3077
E-mail:  danb@hipspokane.org