DC Primary Care Association, Health Justice Alert, May 22, 2001

District of Columbia Primary Care Association
1411 K Street, NW
Suite 400
Washington, DC 20005
202-638-0252
202-638-4637 (fax)
www.dcpca.org - web site

Message: This Health Justice Alert focuses on the momentus transition from the District govenment uninsured care is shifting from the PBC to the Alliance.

PLEASE, please, please.... Get this document into the hands of front line providers: medical providers, social workers, people who make appointments, emergency room providers, soup kitchens, free clothing programs, public lawyers, day care workers, WIC staff, constituent services workers, hotline workers, ministers, NA/AA meeting organizers....

Anyone and everyone who works with and answers questions from people who are uninsured. Please encourage the front line staff to come to the FREE international sessions at the DCPCA on Tuesday morning at the Alliance.

Patients are going to be confused. The more the frontline folks understand, the less fear and confusion for the patients.

"Of all forms of inequality, injustice in health care is the most shocking and inhumane." — Martin Luther King, Jr.

Meet the Alliance on Tuesday mornings at the DCPCA -- 8:30 to 10:30 for five weeks, you can listen, ask questions and learn. . . . JOIN US!

A New Beginning for the Uninsured:
The Alliance Gears Up for a June 24 Start
Learn more at DCPCA Tuesday Morning Meetings

Primary Care and the AIliance: Unity Takes Center Stage

The Alliance Gears Up for an Early Start

The Alliance, or the Washington Healthcare Alliance, is the name of the new integrated network of providers who will be offering comprehensive health care services to the medically vulnerable.

These services will replace those previously offered by tho Public Benefit Corporation.

The contract for the services is with Greater Southeast Community Hospital, which is a for-profit company. Greater SE is legally responsible for the contract services to the District government.

The contract, which is expected to a last a minimum of five years, if contract performance is standards are met, will be the largest health care contract in the District of Columbia. It will replace the previous policy of using an annual subsidy of $45 million to the Public Benefit Corporation, augmented annually for the last five years by loans at the end of the year. The loans were never repaid. The PBC was costing the city between $70 and $100 million annually, with costs increasing as the number of uninsured patients declined.

Learn more at DCPCA Tuesday Morning Meetings

DCPCA is hosting an open meeting on Tuesday mornings, from 8:30 to 10:30, so that providers, social workers, Board members, advocates and others can meet with the Alliance to get a better understanding of how uninsured people will get care under the new plan. Come and join us! Call Kelly Ferrell at 638-0252 for a fax information sheet with details.

Recent Timeline:

Control Board signs legislation autborizing privatization of services: April 30, 2001
Control Board Assumes oversight/management of PBC: April 30, 2001
Court refuses to stay Control Board legislation: May 1, 2001
Department of Health establishes Healthcare Safety Net Administration to oversee contract and keep FEC operating during transition: May 1, 2001
Subcontracts with Alliance partners finalized: Mid-May, 2001

Still to Come:

Mayor will appoint Health Services Reform Commission Oversight Commission to review and comment on transition: Mid-May, 2001
Enrollment process and enrollment sites finalized: June 8, 2001
Court to hear challenge of Control Board legislation: June 8, 2001
Enrollment begins: June 13, 2001
DC General in patient closes: June 24, 2001
Billing begins for Alliance: July 1, 2001

Washington Healthcare Alliance Partnership:

Greater SE Community Hospital
George Washington University Hospital
Children's National Medical Center
Chartered Health Plan
Unity Health Care

What is happening over the next few weeks?

The Alliance, which is lead by Greater Southeast Community Hospital as the contracting agent will be administered by Chartered Health Plan. It was initially set to resume full responsibility for the new uninsured contract on August 1, 2001.

Unfortunately, a resident shortage at the Public Benefit Corporation is causing an early shut down of DC General Hospital's inpatient services. Inpatient care at DC General will cease on June 25, 2001. Currently, patients are being shifted to other hospitals. According to The Post last Saturday, only 80 patients were receiving hospital care at DC General, down from 140 in the fall of 2000.

Please advise all uninsured patients who have been using the PBC for primary care to continue. While eligibility criteria will soon be used for the first time, it will take several months to straighten out who is and isn't qualified, and to shift patients from one system to another. As this change takes place, former PBC patients should keep going to their "medical home".

Overview of How Alliance Will Work:

Patients will enroll at designated enrollment sites. Currently, DC General ambulatory clinic, the six neighborhood clinics, and Greater SE have been identified as enrollment sites.

Patients will sit down with an enrollment worker and complete the application. If they are eligible, and have required documentation, they will be approved immediately. If they need to bring in paperwork, they will be given one-month eligibility.

The Alliance is taking all of the PBC's patient records and "dumping" them into a new data base system for determining eligibility. If all goes well, eligibility should be fairly easy to determine. However, this may prove to be difficult, and may become one of the first major hurdles for the Alliance to overcome.

Patients will also be screened for Medicaid, Healthy Families and other programs. If eligible, applications wilt be completed and the Income Maintenance Administration will certify their applications at the site. Patients will be offered their choice of providers who are paid through the Medicaid system

If patients are not eligible for any government programs, Unity is required by its federal mandate to provide care on a sliding scale. Hopefully, Unity will increase its federal grant to provide this care in the upcoming years.

Qualified patients will receive an Alliance insurance card that will entitle them to the same level of services that was provided by the PBC.

Patients will chose a pnmary care medical home, which will serve as a gatekeeper to specialty and other care.

What isn't included?

During the start up phase: none-Alliance patients will not be able to get medications, specialty visits and hospital visits. Specialty visits and hospitalizations for non-Alliance members will be added in the future (see below).

Medicaid services will be limited to those provided by the PBC. For example, the PBC did not do heart transplants, so therefore, the Alliance is not required to do heart transplants.

Increasing the number of uninsured who are eligible. The PBC, while the largest provider, did not spend the majority of the money on uninsured care. Hospitals, free clinics, specialists, etc have long taken up some of the slack between government funding and need. This will not change. This is called "maintenance of effort" and providers will be required to keep up their free/subsidized care.

The Alliance is only responsible for former PBC patients. If an uninsured low-income patient has been using a free clinic or a sliding scale clinic, and did not use the PBC for specialty care or hospital services, they are NOT eligible currently. Once the Alliance has enrolled previous PBC patients, and some cost projections are possible, there is hope that the number of patients can be increased.

Future possible inclusions:

Snecialtv/Hospitalization Alliance Card Holders; As the Alliance solidifies its administrative capacity; it will add a second category of uninsured cardholders who did not use the PBC over the last two years. These patients, many of whom rely on Unity's current clinics, the Nonprofit Clinic Consortium sites, hospital-affiliated clinics like Perry School and the Children's mobile van, will be able to see specialists and get hospital care.

More patients: Clearly one of the problems with the District's system of care for the uninsured: financing is arbitrary. Patients who are "lucky" enough to get into the PBC system are going to have the government guarantee payment. Those who don't must continue to rely on the good will of the non-profit and provider sectors. This causes dramatic imbalances in quality and quantity. This has been true for years; but only with this transition did the issue crystallize in public discussions. It is true in all but a handful of places in the United States.

More providers: The Alliance is interested in adding more providers to its roster; but this will likely be determined by availability of finding. The more finding, the more providers it can bring in. In other communities, free care pools are used, similar to the Alliance contract, with all providers being able to directly bill the pool for services.

Primarv Care In the Alliance:

Unity Healthcare will acquire management of the six PBC clinics. This will allow Unity to combine five major finding sources for medically vulnerable: federal 330 dollars, health care for the homeless dollars; Medicaid; Medicare and DC appropriated funding. Plus, Unity does charitable fund raising.

Unity, which was formally Healthcare for the Homeless, took over the two troubled federally funded 330 clinics two years, stabilizing the quality of care and finances. By acquiring the former PDC community clinics, Unity's two main clinical sites, and its 13 bealthcare for the homeless site, Unity's central role in the health care system is significantly expanded.

The District plans to use some of the capital money which had been allocated to the PBC to improve the PBC clinical sites, but there are no final decisions on which ones or when. Unity has also applied for a $1 million federal grant to help improve its MIS capacity, and link it to other uninsured primary care sites.

In addition, Unity owns a Medicaid health maintenance organization, making it able to maximize managed care income. This gives Unity a strong combination of funding options to pay for care for the medically vulnerable -- Medicaid, Medicare, federal funding for primary care and homeless services, and DC appropriated contract money. In addition, Unity bills private insurance and raises charitable dollars. As a federal community health center, Unity is also eligible for special federal funding for capital and other improvements. For the medically vulnerable, who often shift from one population to another, this might increase their chances of achieving a stable medical home.

Over the long term, it is also likely Unity will attract increased direct grant money for its care of the uninsured, bringing valuable cash resources to the primary care safety net.

In addition to Unity, Greater SE will manage the DC General ambulatory care site, and add an urgent care center at the campus. Chartered and Children's will offer primary care at their community sites (?)

Chartered has one ambulatory health care clinic for its patients; and former PBC patients will be able to go there as well. In addition, Children's four neighborhood clinics will be included.

There are discussions under way on how to increase the number of primary care sites, but it is unclear how long that would take to work out.

$Cash and the Contract

Annual amount base services:			$66.3 million cap for services
			$54.25 million minimum
Base services include:
	Outreach and application assistance
		no specific details available on money/services
	Primary case, disease management and preventative care
		39,192 encounters
	Dental care
		15,820 visits
	Diagnostic testing and evaluation, specialty physician
		169,668 encounters
	Ambulatory surgery
		2,144 procedures
	Translation
		no specific details available on money/services
	Additional funding:		$7.01 million school health
			$3.7 million corrections
			$1.4 trauma capacity funding
	Year one capital:		$11.8 million
	Start up support:		$1.5

The Alliance must complete cultural competence training, and provide translators, but it is not specified yet anywhere what they are planning to do, nor how Alliance will report on this.

Contract Management:

Shauna Spencer has been named the Director of the new Health Care Safety Net Administration. This Administration is housed in the Medical Assistance Administration, which will manage the money and oversee contract compliance. In addition to the above allocations of money, the Safety Net Administration will receive any monies owed to the PBC when it is dissolved. The Safety Net Administration can adjust the volume of services across categories -- savings in trauma could be shifted to primary care and prevention for example.

Safety Net Administration funds will carry-over from year to year: they will not revert to the general fund.

The contractor will submit monthly, quarterly and annual reports on cost, quality, and access as specified by District. No report format is available.

An oversight committee, appointed by the Mayor, is set to begin its work next week. It is unclear exactly what role they will play, which agency or office will provide the committee with support, or if the committee will have an authority over adjustments in the contract; fines for non-performance etc.

Background, Politics, and Legislation on the Transition from PBC to the Alliance

In the summer of 2000, The Post began reporting that the PBC was illegally operating in the red, and had been doing so for seteral years. It is illegal for any DC agency to operate in the red, because of a Congressional law. Normally, when a DC agency finds itself in the red, special budgetary supplement legislation is passed to cover the deficit. However, the District had been making "loans" to cover the PBC deficit and these loans were never repaid.

Immediately following the publicity of the "loan" prob1em, serious management and financial problems were made public by the Cambio Group, which was hired by the city to complete an assessment of the PBC. In response to the "loans" and the Cambio report, the Mayor overhauled the PBC Board of Directors. The new Board immediately let the PBC Chief Executive Officer go.

This round of PBC/DC General controversy follows more than 20 years of problems with DC General cost overruns and management problems. In 1995, the PBC was created to try and improve integration and efficiency in the District's trotibled public health system. Unfortunately, the PBC was established with a budget deficit and with system problems in the set up. Coupled with a CEO who was to later be fired for fiscal irregularities, the PBC six-year history has been a difficult one.

DC General cost overruns were one of the management problems that prompted Congress to establish the Control Board in 1997. Congressional committee members were unsympathetic to the desires of PBC employees and the Council to keep the PBC going.

From August, 2000 through April 30, 2001; the Council, the Mayor, the Control Board and a wide host of providers, advocates, employees and patients engaged in a long, noisy and public debate, replete with meetings, policy papers, recommendations, hearings, public demonstrations, angry exchanges, and creative thinking.

Some of the major debating points were: 1.) Keeping inpatient services at DC General Hospital, which was loosely translated by proponents of the services into "Save DC General"; 2.) Using money that funded a quasi-public system to fund a private, for profit system; 3.) Loss of an historical African-American institution; 4.) Fear that Greater SE and the other hospitals couldn't handle DC General's trauma and emergency care.

On December 4, 2000, the Control Board directed the Council and the Mayor to come up with a plan to establish a new system of care for the uninsured, and gave them 90 days to do it.

In the Mayor's FY2002 District budget, the Mayor put forward a plan to use $90 million in reserves to fund PBC shut down and transition costs, and requested $70+ million in operating funding for the FY02 fiscal year.

Council voted down both transition funding and future contract money, approving instead direct funding for the PBC This would have required Congressional approval; since Congressional language in the FY2OO1 Budget Act limited the PBC to receive it's $45 million in appropriated funding, money, which was all, spent by the end of March.

In response to the Council's "no" vote to privatization, the Control Board, on April 30, 2001, superceded the authority of the Mayor and the Council, and voted to end the PBC and transition to a privatized contract. A single court challenge remains: on June 8, 2001. Predictions are that the challenge will lose, since the US Court of Appeals for DC Circuit Court upheld the authority of Congress to grant the Control Board the power to Eassume any or all of the [department or agency's] powers" in January of 1998.

The Legislation:

The "Health Care Privatization and Emergency Amendment Act of 2001 Emergency Declaration Resolution of 2001" was signed into law on April 30, 2001. The Resolution was accompanied two Orders and three Acts.

The Resolution approves the expenditure of $90 million to maintain continuity of care for the uninsured by implementing an alternative publicly financed health care delivery system. Or, in non-resolution language, the Resolution approved using the $90 million to fund a privatization contract.

The first order justifies the action of the Control Board, citing the DC 2001 Budget Appropriations Act that limits PBC spending to $45 million in FY01, the PBC reduction in force resolution passed by the PBC Board on August 25, 2001, and the December 4, 2000 Control Board Resolution passed on December 4, 2000 that instructed the Council and Mayor to come up with a plan.

It goes on to repeal the PBC legislation, and authorizes the handing of a "publicly financed health-care delivery system. It authorizes the Health Care Safety Net Administration. It creates an exemption from the Certificate of Need process for developing services to meet the contract obligations, and authorizes the Chief Financial Officer to transfer them money needed.

The second order uses roughly the same justification but also adds a legal precedent to firmly declare the authority of the Control Board. In 1998, someone named Shook took the Control Board to court, questioning its authority to govern, and the courts upheld the Control Board.

This Order transfers control of the PBC's operations to the Control Board, names Dr. George Gilbert as the person to assume leadership in the transition, and names the Department of Health as the regulatory agency responsible. It allows MAA to transfer PBC's disproportionate share allotment to Greater SE.

The ACT. DCFRMAA-1

This docunient outlines the role and responsibility of the Health Care Safety Net Administration, which are to:

It gives the Mayor authority to contract with a private contractor for health care services for the uninsured, and exempts the Mayor from the procurement law.

Further, it defines charity care and gives DOH the charge to measure and monitor charity care.

It defines the role of the Health Care Safety Net Administration in determining Certificate of Need exemptions.

It repeals: the PBC law of 1997, the Comprehenstve Merit Personnel Act of 1978, the Confirmation Act of 1998, and the Procurement Practices Act of 1985.

It is an emergency Act and can be in effect for 90 days, when new legislation will be required. Acts two and three are the temporary and permanent legislation, passed at the same time.

Need more info on this topic? Your best bet is to log on to the Washington Post and do a search on the words, "DC General Hospital". The Post has covered this issue extensively. Old issues of the Health Justice Update are also available, just call Kelly Ferrell at the DCPCA at 638-0252. City Paper also did several articles, but the only ones available on line are the Loose Lips columns.

Meet the DC Healthcare Alliance! Tuesday mornings at DCPCA.

What will the future bring for the uninsured?
Help make the future a healthier one for the uninsured.
Let the Alliance inform you about these services:

A new day, a new system for the uninsured.
How will it work? Who will be eligible?
What services will people receive?

Yes, I would like to join my colleagues in learning about the Alliance, at the DCPCA, 1411 K Street, NW, Suite 400.

PLEASE RSVP -- 30 people each week!
FAX THIS FORM TO 638-4637
Brought to you by the DCPCA and Chartered Health Plan

District of Columbia Primary Care Association Health Justice Alert: The Alliance on a Fast Track May 22, 2001

A New Beginning for the Uninsured: The Alliance Gears Up for a June 24 Start Learn more at DCPCA Tuesday Morning Meetings