Squeezing the Most from Every Health Care Dollar

Teaching healthy cooking at Health Brigade’s Food Farmacy.

Medicaid expansion in Virginia is forcing Virginia’s free clinics to make a fundamental choice. Should they participate in Medicaid or not?

Accepting Medicaid payments would provide a new source of funding for clinics, which don’t charge for medical services, and would allow them to continue treating patients who qualify for Medicaid and would otherwise need to seek primary care services elsewhere. But Medicaid generates extensive, complex regulations which must be handled by paid administrative staff.

Health Brigade, formerly known as the Fan Free Clinic, has made the strategic decision not to participate. The clinic, which serves the Richmond area, will forego significant revenue and lose many patients. But there will be no lack of patients to take their place, says Wendy Klein, the clinic’s medical director. While Medicaid expansion will provide insurance coverage to up to 400,000 Virginians, an estimated 300,000 still will have none.

“We take care of people with no insurance and no Medicaid,” says Klein. “There are still a lot of poor people who don’t qualify for Medicaid. Even with expansion, people will fall between the cracks.”

The go/no go decision on Medicaid cuts to the heart of the free clinic business model. It determines the populations they serve, and it shapes their organizational structure. Health Brigade, which is run by socially progressive non-profit entrepreneurs, has concluded that it can accomplish more good as a scrappy, low-overhead outfit filling gaps in the safety net rather than as a cog in the bureaucratic healthcare system. While cultural conservatives may feel uncomfortable with some of Health Brigade’s priorities — it serves transgender patients and illegal immigrants — anyone who believes in a strong civil society will find much to admire in the organization. 

A big reason for conservatives to support Health Brigade is its capacity for innovation, as seen, for instance, in the way it incorporates wellness — from yoga to nutrition classes — into the treatment of its patients. While hospitals pay lip service to wellness, their business models are organized almost entirely around treating illness. Hospitals make no profit teaching people meditation, fitness, healthy eating and other forms of prevention.

Health Brigade, a $7 million-a-year nonprofit enterprise, engages in four main activities. One is conventional medical care. Although the emphasis is on primary care,  the enterprise also provides access to specialists. A second is mental health, providing a wide range of psychological and counseling services. The nonprofit also runs outreach programs under contract to combat HIV and STDs, and it operates wellness programs.

“Once you take Medicaid, there are lots of administrative hoops. There are very complex regulations, and you have to invoice for services,” says Klein. “We don’t bill for services. We don’t invoice. We are losing some of our patients to Medicaid, but there are plenty of people to replace them.”

Among the groups not qualifying for Medicaid are undocumented immigrants, legal immigrants who have lived in Virginia fewer than five years, and Virginians without insurance who make more than 200% of the poverty line. The Health Brigade also provides a “safe and inclusive” environment for some 150 to 200 transgendered individuals who feel uncomfortable seeking medical care elsewhere.

In Fiscal 2018, Health Brigade received $850,000 in public sector grants, $275,000 in private sector contracts, and $32,000 in other earned revenue, as well as $870,000 from foundations, and $540,000 in private contributions. The organization values “in-kind” contributions, such as donations from diagnostic labs and pharmaceutical companies. at $4.7 million. The greatest resource, however, is volunteer labor.

The small paid staff at the mental health clinic is supplemented by Virginia Commonwealth University PhD graduate students who donate their time and by volunteer therapists. The clinic focuses mainly on depression, anxiety, and stable bipolar disorder, referring severe cases to Community Service Board Centers better equipped to handle them.

Likewise, the medical clinic relies heavily on volunteers — including endocrinologists, a urologist, a neurologist, a rheumatologist, and gynecologists — to provide both primary and specialty care. For care that the clinic cannot provide, Health Brigade refers patients to Access Now, a collaborative program run by the Richmond Academy of Medicine that bridges the gap to specialty care. Says Klein: “For example, If I need a surgical specialist — say for a hernia repair — I can refer a patient to this system.”

The reliance on volunteers does create challenges providing continuity of care. Health Brigade cannot guarantee that patients will always see the same physician for a particular problem. Consequently, the medical clinic has been an enthusiastic adopter of electronic health records to track the care provided every patient, and Klein spends much of her time reviewing cases to ensure continuity.

Klein sees some transition problems as Virginia’s medical establishment adapts to Medicaid expansion, but she regards them as transitory. Health Brigade applies to pharmaceutical companies for free medications. Because they only provide free pills to indigent patients, the pharmas are asking for proof of Medicaid denial. Unfortunately, says Klein, it can take 90 days to process the paperwork, which leaves hundreds of patients temporarily unable to get their medications. “We’ve been tied up in knots helping our people get care,” she says.

Many of Health Brigade’s patients have low literacy, and they need help making health lifestyle choices. One program, the Food Farmacy, teaches patients who suffer from obesity, hypertension and diabetes about nutrition. Health Brigade partners with another nonprofit, Shalom Farms, to provide fresh vegetables, and a demonstration kitchen teaches people how to prepare and cook them. The program simulates supermarket tours to teach how to shop wisely, avoiding the trap of buying food with empty calories. Says Klein: “We even give them spices and measuring cups.”

Health Brigade can’t do it all. There’s never enough money or resources for Klein to help everyone she’d like to. But the organization has learned how to stretch a healthcare dollar, and it sets an example for the rest of Virgina’s medical establishment to emulate.