Case Study 1: Accessing Specialty Care for Community Health Center Patients

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Overview /Summary

The case is about how a health care referral coordinator finds it difficult to find specialty care for her underinsured and uninsured patients. This is because they have no formal agreement with specialty care facilities and professionals who are unwilling to provide charity care to many patients. The specialty facilities administer care to a limited number of underinsured patients per year due to the costs. Heartland can only provide primary and preventative care, so they outsource specialty care to other qualified institutions. Most of the patients admitted for primary care in the heartland eventually require specialty care, and most cannot access it since they are poor and do not have adequate insurance, limiting their care.

Evaluation

The case illustrates that it is difficult to find specialty care for uninsured and underinsured patients. Two-thirds of the patient population in Heartland CHC are recorded to be living below the federal poverty line, with a majority having incomes lower by 200%, which is why they cannot afford good insurance. In addition, the Heartland CHC is only equipped to handle primary and preventive care. This is why they are keen to refer patients requiring specialized care to other qualified healthcare institutions willing to care for them depending on their insurance.

Three issues cause the community health centers problems. Firstly, most of the patients in the facility are either uninsured or underinsured, which makes finding specialty care difficult for Heartland CHC. Secondly, since unfortunate patients cannot afford or access specialty care, they leave their chronic health conditions unmanaged making their lives peaceful to the extent that the conditions become medical emergencies that are terminal (Zuckerman, 2013). Finally, the CHC and EMR systems do not interface, making health care coordination complex, and finding patients requiring urgent specialty care becomes an uphill task.

The consequences for failing to obtain specialty care for uninsured and underinsured CHC patients can be dire. In most cases, the patients opt to live with the condition unmanaged, which deteriorates their health and becomes a health emergency (Timbie, 2019). Such patients return to the community health center when the condition becomes an emergency, putting their life at risk. The worst-case scenario is when the patient succumbs to a condition that can be managed with specialty care if the conditions are treated early.

The above consequences are for the community since the state has not taken advantage of the American Care Act, increasing the cover for the medic and allowing families below the poverty line to access insurance. With the ACA, people above the poverty line can be charged more for medical care since they can afford it to compensate for the unfortunate that cannot pay high premiums (SEO, 2019). Additionally, death from manageable conditions robs people of their loved ones and reduces the health status of the community.

In charity care, all patients should be offered care without discrimination with equal access to resources. For example, it is wrong to restrict appointments with Medicaid patients and deny uninsured patients the care they need because they cannot pay for the services. Instead, charity care should live up to its definition by helping all the community members that require the care regardless of their insurance status. However, equal distribution of care could see some people being denied care in the interest of serving more people.

The executive director or Jenny’s strategy to guarantee an increase in CHC’s patients’ access to specialty care forms a formal relationship with the institutions. By having a formal relationship with the specialty care facilities, Jenny can agree on how many uninsured and underinsured patients they will accept from the CHC. This will allow for the planning and accessibility of specialized care for patients with chronic illnesses.

The state could introduce tax support for charity health care institutions to offset the burden and promote patients’ health in the community. In addition, a reduction in running costs will allow the charity centers to reduce the cost of care, meaning they would increase the number of uninsured and underinsured patients they serve (Ezeonwu, 2018). Furthermore, the state can adopt the ACA policy to allow more people to access affordable health care insurance with more coverage so that more institutions are willing to serve Medicaid patients.

References

Ezeonwu, M. C. (2018). Specialty-care access for community health clinic patients: processes and barriers. Journal of multidisciplinary healthcare, 11, 109.

Seo, V., Baggett, T. P., Thorndike, A. N., Hull, P., Hsu, J., Newhouse, J. P., & Fung, V. (2019). Access to care among Medicaid and uninsured patients in community health centers after the Affordable Care Act. BMC health services research, 19 (1), 1-6.

Timbie, J. W., Kranz, A. M., Mahmud, A., & Damberg, C. L. (2019). Specialty care access for Medicaid enrollees in expansion states. The American Journal of managed care, 25 (3), e83.

Zuckerman, K. E., Perrin, J. M., Hobrecker, K., & Donelan, K. (2013). Barriers to specialty care and specialty referral completion in the community health center setting. The Journal of pediatrics, 162 (2), 409-414.