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.

There are currently no comments highlighted.

5 responses to “Squeezing the Most from Every Health Care Dollar

  1. I was looking at the Moss Free Clinic in Fredericksburg which their current website indicates that they will not accept people who have MedicAid but my wife who works as a volunteer ACA navigator – at that clinic – advises that they have recently become a “Combined” clinic that does accept MedicAid.

    What I LIKE about charity/low-income services is when the various groups coordinate and integrate their services so that they make the most they can out of limited resources.

    What I dislike is when they operate separately and independently competing against each other for limited resources – like public and private grants and such.

    Yes.. there is going to be paperwork – take a look at the paperwork that folks have to present even if MedicAid is not covered:

    Documents Patients Will Need To Present
    To verify that you meet our eligibility requirements, you must bring the following documents to your eligibility consultation (as applicable):

    Proof of your local address
    Signed Federal Income Tax Return
    One month of all household paystubs
    Social Security Statements and 1099s
    Food Stamp Notice of Action
    Award letter(s) from Disability, Retirement/Pension, and/or Housing Assistance
    Letter of Support
    Documentation of any additional income
    Green Card, Visa or Work Permit
    Medicaid Denial Letter

    Keep in mind when these folks go to other places for assistance, they too are asking for these same documents – which COULD be on ONE database they all would share when determining eligibility.

    I just think it is a mistake and wasting limited resources when these organizations decide to go it alone and choose to do their own separate administrative process.

    We also participate in staffing a local food pantry – that, in turn is part of the Regional Food Bank. Most all of the local stores feed their excess inventory to the food bank which then distributes to the various area pantries. Even then, there are other local groups that also go to the same stores
    asking for excess inventory for their – duplicative efforts.

    Again – we can help more people if we squeeze the most we can out of limited resources by coordination rather than duplicating services and in the process eating up more resources than if we integrated our efforts.

    Cost-effectiveness is always the best path but it is especially so when trying to provide services to people in need. It’s a simple thing – the more cost-effective you are – the more you can help.

  2. From a somewhat different angle: consider the person who seeks assistance. He or she is likely not a professional bureaucrat; likely not an exemplar of patience, likely not well educated; likely not in the best of health, not likely to have a file drawer with relevant papers preserved and sorted. S.O.M.E. in DC (“So Others Might Eat”) serves people who are destitute and often desperate right now. One of the best services they provide is counseling – steering people who come to them, after a decent meal, to those scattered charitable outlets and agencies that no one but a “pro” at this knows how to find – but it’s a bottomless pit of need.

    Health care is an important subset of this array of providers, and one of the most complex; but it’s part of a social safety net of bewildering size for those caught up in it, especially in multi-jurisdictional urban areas like the Washington region. Unlike in a smaller town it’s almost impossible to just open your church’s doors and with volunteer labor from fellow parishioners make a dent in some obvious but amorphous need even right in front of you. But there are so many existing groups out there that are struggling with those problems and need your help and your donations. SOME is masterful at putting inexperienced volunteers to work in rewarding ways, exposing suburbanites who’ve never seen real poverty and mental illness and drug use up close to a relatively approachable sample of homelessness in a relatively safe environment. They serve as a clearinghouse at both ends of the process: both for volunteer placement and for steering those in need to the right assistance.

    Many who come to SOME for a meal are ‘desperate.’ The word literally means “without hope” and they have none. The idea that they can achieve good health may not even be imaginable. The person who seeks medical attention for a specific health problem has, at least, got a goal in mind even if it’s just to be free of pain.

    In this context, try asking for the applicant’s last tax return, or Medicaid denial letter. When was the last time they even received mail at a fixed address, or had a place to store papers, while living in a sleeping bag over a sidewalk steam vent?

    I applaud Health Brigade and their like for dealing with the real need on the ground: motivation, mental health, wellness, as well as basic medical attention to illness, all on a shoestring of public money. “Scrappy” is a good word to describe what they do. And I fully understand why they would feel compelled to turn down Medicaid-eligible patients, who are really an obstacle to what they have set out to accomplish.

  3. Thanks for this article, Jim. I had often heard of the Fan Free Clinic, but had heard any mention of it recently. Now I know why–they changed the name. They apparently do even more good work than I realized.

  4. We do a food pantry at a local church and we vett the clients with a centralized/shared database that is also used by other pantries and other agencies that provide assistance.

    So basically, people put their data in one time and then all subsequent agencies can consult that database rather than collecting the info all over again.

    So it’s like a central clearing house that actually reduces paperwork because it only gets put in once… and not each time someone goes for assistance.

    That reduces wait time (and how much volunteer help is needed) and also ensures that people receiving the food are properly vetted… so
    they fairly quickly get their food and leave and allows others behind them to quickly get their food also.

    But we also check clients for health care status and then direct them to MedicAid or Lloyd Moss Free Clinic or other places that can help them and consult that same database to vett them and reduce paperwork and wait times.

    When someone comes in – and they’re in that database – it smooths the process and gets them help a lot faster than if they have to jump through hoops again.

    That database reduces the amount of administrative resource that is needed to process folks… it allows folks in need to get help fairly quickly instead of waiting for processing.

    it’s a very good thing. I totally believe in it’s value and usefulness.

    I understand that other agencies might want or need to do their own process but as many agencies that can share info – the better.

  5. It’s good to see medical personnel providing free services just like most lawyers do.

Leave a Reply