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Service Delivery Innovation Profile

Low Overhead Clinic Extends Access to Affordable, Culturally Competent Conventional and Alternative Medicine for Uninsured and Underinsured


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Snapshot

Summary

Casa de Salud offers low-cost, culturally competent medical services—including alternative medicine—to Albuquerque’s uninsured, underinsured, and immigrant populations. The clinic’s low overhead, fueled by work-study students and an electronic medical record, allow it to offer services for a low, fixed price to all patients. The clinic also assists patients in reducing medical debt and in navigating the health care system. The program has increased access to affordable, culturally competent care; built trust with patients; and served as a good training ground for students interested in medicine.

Evidence Rating (What is this?)

Suggestive: Evidence consists of post-implementation data on the number of patients served and a comparison of clinic fees to the average cost of an office visit to other providers in the area.
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Developing Organizations

Casa de Salud; Justice Access Support and Solutions for Health (JAZZ for Health)
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Date First Implemented

2004
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Medically uninsuredend pp

Problem Addressed

A large and growing number of uninsured and underinsured individuals—particularly immigrants—lack access to affordable, culturally competent medical care. As a result, many people in these groups forgo needed care or amass substantial medical debt.
  • Large, growing number of uninsured: An estimated 50 million—1 in 5 people in the U.S.—lacked insurance in 2009. In addition, an estimated 25 million adults did not have adequate insurance, a 60 percent jump from 2003.1 Undocumented immigrants and legal immigrants who have lived in the U.S. for less than 5 years do not qualify for Medicaid and are more likely to lack insurance.2
  • Health care costs on the rise: Health care costs tripled between 1990 and 2008, and currently top $2.3 trillion. Expenditures grew at 4.4 percent in 2008, faster than both inflation and the average income of most U.S. residents.3
  • Leading to forgone care or large medical debts: Inadequate insurance combined with high medical costs lead many people to either forgo care or amass substantial medical debt. In 2009, 45 percent of U.S. adults—and more than 70 percent of those with gaps in insurance—reported that they did not seek needed care because of the high cost of health care.1 Uninsured individuals have even greater difficulty accessing specialty care, such as mental health and substance abuse treatment.4 Those who do seek care often can’t pay the resultant medical bills: 41 percent of working-age adults—and 60 percent of uninsured or underinsured individuals—report problems paying medical bills. More than one-third of uninsured adults carry medical debt of at least $4,000.1
  • Lack of comprehensive, culturally competent care: Many facilities that serve uninsured and underinsured patients do not provide comprehensive, culturally competent care. For example, emergency departments (EDs) and urgent care clinics focus on acute care, not the ongoing management of chronic conditions. Although many facilities offer translation services, most do not employ clinicians who speak patients’ native languages or offer alternative therapies that may be more familiar and acceptable to patients. For example, immigrants from Mexico may be more likely to seek services at a clinic that offers elements of traditional medicina popular, including herbal remedies, massage, acupressure, and homeopathic treatment.

What They Did

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Description of the Innovative Activity

Casa de Salud offers low-cost, culturally competent medical services—including alternative medicine—to Albuquerque’s uninsured, underinsured, and immigrant populations. The clinic’s low overhead, fueled by work-study students and an electronic medical record, allow it to offer services for a low, fixed price to all patients. The clinic also assists patients in reducing medical debt and in navigating the broader health care system. Key elements include the following:
  • Comprehensive, culturally competent services, including alternative medicine: Casa de Salud offers a broad range of conventional and alternative medicine services tailored to the needs of the local population, which includes a large number of Mexican immigrants. To help ensure a high quality of culturally competent care for the patient population, staff members speak and provide services in both English and Spanish. The staff who greet patients speak Spanish as their native language; and telephone services, signs, and printed materials are all in Spanish.
    • Conventional medicine: Medical doctors, physician assistants, and nurse practitioners offer walk-in, primary care and women’s health services. The clinic also offers laboratory services.
    • Alternative medicine: Casa de Salud also offers acupuncture, massage, herbal medicine, and Reiki healing. Many patients feel more comfortable with healing arts that more closely resemble their cultural traditions. For example, Mexican medicina popular (also known as Curanderismo) relies on herbal teas and poultices as well as massage and acupressure to restore harmony and balance to the body. Casa de Salud's nurse practitioner is trained in traditional Mexican healing, and most of the conventional clinicians at the clinic have studied natural therapies to augment their services. Patients may choose to make an appointment for alternative medicine services or a conventional clinician may refer them to the acupuncturist, Reiki master, or massage therapist as appropriate to their illness and their preferences. Clinicians may also refer patients for services not available at the clinic, such as chiropractic care, homeopathy, and sweat lodges.
    • Mental health and substance abuse treatment: Casa de Salud offers substance abuse treatment, including medication, counseling, and other techniques. It also offers a needle exchange program in which drug users can exchange dirty needles for clean ones to prevent the transmission of disease.
  • Low overhead: The clinic uses several strategies to keep costs down, including having premedical and prenursing work-study students serve as medical assistants and taking advantage of a custom-built electronic medical record (EMR).
    • Work-study students: Premedical and prenursing students at a local community college and medical school work at the clinic as part of the school’s work-study program. In collaboration with the schools, the clinic identifies and hires these students on an ongoing basis, requiring at least a 1-year commitment. They perform the traditional duties of a medical assistant, including taking responsibility for the needle exchange program (which gives them direct experience working with difficult patients). Because the students are paid by the work-study program and not the clinic directly, each work-study student saves the clinic the $10,000 in annual salary that a medical assistant typically earns. With 6 work-study students in 2010, the program saved the clinic about $60,000.
    • Volunteer help: In addition to the work-study program, volunteers help in the office. In 2010, the clinic had 20 volunteers who worked about 6 hours a week, saving the clinic approximately $60,000.
    • Custom EMR system reduces administrative burden: The custom EMR developed for the clinic helps document patient encounters and tracks payment for physicians and other practitioners, saving administrative time. The EMR system makes it easy for clinicians to record office notes and observations. This helps clinicians share information and coordinate care among the staff. It also encourages followup and tracking of quality care measures. To save setup costs, clinic staff developed the system themselves using an off-the-shelf database product.
  • Simple, affordable pricing structure: The clinic offers a simple, affordable pricing structure with one price for all patients. While insurance is not required and previously was not accepted, the clinic has recently contracted with one Medicaid provider (Molina) to begin offering insurance-based services.
    • Low, fixed price: Casa de Salud offers a low, fixed price of $40 for any office visit, regardless of whether it is a 20-minute routine appointment or an hour-long massage therapy. (When the program began, the price per visit was $25; the gradual increase has enabled the clinic to cover a small increase in salary for the clinicians and has allowed the program to add a full-time clinic administrator.) Additional services, such as laboratory work, diagnostic tests, stitches, prescriptions, and other procedures, are charged at rates well below the market average. Having this fixed price allows patients without insurance to get the care they need.
    • Working with one Medicaid provider: Prior to 2011, Casa de Salud did not accept any insurance, including Medicaid and Medicare, and all patients paid the same amount. In 2011, the clinic began working with Molina, a Medicaid provider, which has helped bring families together (uninsured or immigrant parents with Medicaid-eligible children), and it has increased health care access for patients struggling with drug addiction. Working with a single form of Medicaid has kept the hassle factor manageable, and the increased revenue from insurance payments helps keep clinic prices low.
  • Additional health care navigation and financial support: Casa de Salud has a staff member who is specially trained to assess patient needs and help guide the individual toward improved health through a series of steps (pathways) that remove barriers to care. (See References section for a related Innovations Exchange profile.) Staff help patients with medical debt to fill out applications for assistance in reducing or forgiving that debt.
  • School-based program for high-risk teens: Based on the success of the clinic, Casa de Salud opened an onsite program at a charter high school to serve students who have been expelled from regular public schools. The program offers an array of services to these students, many of whom have been (or are) victims of drug abuse and violence.

Context of the Innovation

Casa de Salud is a permanent project of Justice Access Support and Solutions for Health (JAZZ for Health), a nonprofit that grew from an identified need for affordable quality health care for Albuquerque’s working poor, including uninsured and undocumented immigrants. New Mexico has one of the highest rates of uninsured patients in the country, with more than 1 in 4 people without coverage in 2009.2

When the local hospital started asking uninsured patients to pay upfront for nonurgent care, a group of health care professionals and community representatives formed to protest what they saw as unfair pricing and billing policies. When the hospital did not change its policy, the group looked for other options for uninsured or underinsured individuals in the community and found that there were few affordable options.

Did It Work?

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Results

The clinic has enhanced access to affordable, culturally competent care for uninsured immigrant populations; built trust with patients; and served as a good training ground for students interested in careers in medicine.
  • Enhanced access: In 2010, Casa de Salud provided medical care for 11,000 patients, 85 percent of whom are uninsured. In the absence of this program, most of these individuals likely would not have access to the types of services offered at the clinic.
  • More affordable care: In 2010, the average office visit at Casa de Salud cost $38.77, well below the $94 to $165 average reported by the Centers for Medicare and Medicaid services for an office visit in the area.5 In some cases, patients received minor treatment (e.g., stitches) for a nominal fee when the same treatment would cost hundreds or even thousands of dollars at a local ED. Ninety percent of patients are able to pay their Casa de Salud bill on time. The clinic has also helped patients reduce their medical debt by more than $700,000.
  • Effective delivery of harm reduction services: Casa de Salud exchanged 116,000 dirty needles for clean ones for 2,371 clients in 2010, reducing the risk of disease transmission for the addicts and for those at risk of an accidental needle stick (law enforcement officers, sanitation workers, family members, children playing in neighborhood parks, etc.).
  • Indirect evidence of enhanced patient trust: Only 16 percent of clinic patients who receive substance abuse treatment lie about their drug use in mandatory self-reports (as confirmed by subsequent mandatory drug testing). At many other facilities offering these services, this “manipulation” rate exceeds 90 percent. In addition, 95 percent of those who receive substance abuse treatment at Casa de Salud actually pay their medical bills from the clinic, a much higher figure than in the typical clinic. Some intravenous drug users who qualify for free services through Medicaid choose to pay for services at Casa de Salud.
  • Good training ground for students: To date, more than 80 percent of premed students who have interned at Casa de Salud have been admitted to medical school.

Evidence Rating (What is this?)

Suggestive: Evidence consists of post-implementation data on the number of patients served and a comparison of clinic fees to the average cost of an office visit to other providers in the area.

How They Did It

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Planning and Development Process

Key steps in the process included the following:
  • Community discussions and meetings to develop goals for clinic: Community representatives met both informally and formally over a year to develop the idea for the clinic and define goals. After that initial period, a core group continued to meet monthly for 6 months before the clinic opened and for the first 2 years of operation.
  • Designing clinic with community input: Community representatives helped to design the clinic, including the pricing structure and the mix of conventional and alternative services. These leaders decided to create an affordable fee structure first and then build sustainable program services that could work within that fee structure. The model took into consideration both the needs of community residents and the needs of clinicians to have a work environment that reflects their ideas and expectations, including reduced administrative hassles.
  • Launching with a small upfront investment: The program launched in 2004. A physician involved in founding the clinic lent a total of $35,000 in the first 3 years to cover rent for office space, initial furnishing, and supplies. Salaries were based on fee for service and grew slowly as the patient base expanded. Clinicians had other jobs to supply their incomes during this time.
  • Spreading the word through "promotoras": Promotoras—members of the local Mexican and Hispanic community who were familiar with the mission of Casa de Salud and the needs of their neighbors—spread the word about the affordable health care services offered at the clinic. As the patient base grew and word spread, office space and services expanded. In 2007, the clinic moved into new space provided at below-market rent by local nonprofit Rio Grande Community Development Corporation.
  • Designing customized EMR: Building their own system based on a low-cost database application allowed staff to customize the EMR specifically for the practitioners involved in the clinic and the different set of services each one offers. This increased acceptability and decreased learning curve for busy clinicians and those who were hesitant to use computers. The system can be accessed from iPhones, iPads, or home computers, which makes charting and patient care easier to manage away from the office.
  • Training work-study students: Each work-study student receives 3 months of onsite training. Students begin with an orientation process, followed by skills-based learning under the supervision of clinicians and advanced staff leaders. Once a clinician has verified their competency with each clinical skill, students may function more independently. Clinicians and advanced staff leaders meet regularly to identify students who need closer supervision and develop individual mentoring plans when appropriate.

    Resources Used and Skills Needed

    • Staffing: Casa de Salud has three clinicians onsite at any time. Staff include 4 physicians, a nurse practitioner, and an acupuncturist, who each work at least 30 hours a week. A Reiki master, 2 massage therapists, and 2 physician assistants work 1 day a week. Six work-study students work 20 hours a week, and 20 student volunteers work about 6 hours per week. The clinic has a full-time (40 hours) clinic administrator and office manager, and 3 paid student interns who provide medical technician services. In 2011, changes to the payment structure allowed the clinic to add a nurse coordinator to the staff.
    • Costs: The annual budget averages roughly $600,000 per year, which covers salary and benefits, medical supplies, and rent.
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    Funding Sources

    Robert Wood Johnson Foundation; Kellogg Foundation; University of New Mexico Health Sciences Center; New Mexico Department of Health; St. Anthony's Foundation; Bernalillo County; New Mexico McCune Foundation; Connie Adler Foundation; Rio Grande Community Development Corporation; McCune Charitable Trust
    • Casa de Salud was started with a $35,000 personal investment from Andru Ziwasimon Zeller, M.D. The clinic has recently started paying that money back with standard interest.
    • The Connie Adler Foundation and individual donations helped fund the purchase of a high-quality ultrasound machine.
    • The New Mexico Department of Health funds the syringe exchange program with $60,000 per year.
    • Rio Grande Community Development Corporation is a supportive partner and landlord, providing below-market rent since January 2007.
    • The New Mexico McCune Foundation and St. Anthony’s Foundation provided annual funding for operations beginning in the clinic’s fifth year of operation.
    • The University of New Mexico Health Sciences Center and Bernalillo County provide a $50,000 grant to cover the services of the onsite health navigator. Bernalillo County also provides $25,000 per year for health literacy services and substance abuse services.
    • The Robert Wood Johnson Foundation provided $105,000 in grant funding in recognition of Dr. Ziwasimon Zeller as a 2010 Community Leader.
    • The Kellogg Foundation contributes funds totaling $100,000 per year.
    • McCune Charitable Trust provided $175,000 in grant funding to be used toward building expansion.
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    Adoption Considerations

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    Getting Started with This Innovation

    • Build a program that meets clinicians’ and patients’ needs: The clinic design and services need to meet the needs of both clinicians and patients. Such considerations should drive decisions about clinic volume (e.g., number of patients served each day), services offered, and length of the work week. Casa de Salud clinicians typically work no more than 4 days a week to encourage proper work-life balance and avoid burnout in an intense work environment.
    • Start small, then build from there: By starting with a modest operation—small space, limited hours, and small staff—the practice could focus on meeting community needs and growing naturally. Beginning with a large operation might have created pressure to over-schedule and diversify, thus reducing the quality of care and the focus on the local community.
    • Transition slowly to the new model, if possible: Physicians who currently have a traditional practice or who work for a larger organization but who want to transition to this type of model can start small, perhaps one-half day a week. Maintaining the other practice can help offset the losses expected in the first years of operation while building a patient base.
    • Have patients pay directly for services: By paying for the physician’s services, the patient is making a direct investment in the delivery of care. This builds the patient–physician relationship and helps ensure patients return to the clinic.

    Sustaining This Innovation

    • Look for strategic partners, including government: Casa de Salud maximizes their reach and increases their income by identifying ways to work with other organizations in the community. In addition to their contracts to provide needle exchange and medical services in a local high school, Casa de Salud is now tapping into an already existing State program to combat the local provider shortage and help recruit physicians and nurses to serve the community.
    • Scrutinize purchases and expenses: Before making a purchase or signing a contract, take time to research the going rate and confirm that you’re getting the best value for the investment. For example, when Casa de Salud decided to add laboratory services for the convenience of its patients, staff carefully researched processing options and didn’t limit themselves to local vendors. They found a National contractor that provides laboratory services at a fraction of the cost of the first offer they received. This enables Casa de Salud to keep laboratory charges affordable while maintaining the bottom line.
    • Plan for growth: Based on current patient load, it's time again for Casa de Salud to expand its facilities to handle more patients. However, such a move takes time, planning, and fundraising. Clinic staff received grant funding ($175,000) to expand the current building and practice in 2012. Information provided in June 2013 indicates that Casa de Salud was able to double the size of the building in anticipation of increasing the number of clinicians within the next two years.

    More Information

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    Contact the Innovator

    Andru Ziwasimon Zeller, M.D.
    Casa de Salud
    1608 Isleta Blvd.
    Albuquerque, NM 87105
    (505) 907-8311
    E-mail: andruziwa@gmail.com

    Innovator Disclosures

    Dr. Ziwasimon Zeller has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

    References/Related Articles

    Collins SR, Kriss JL, Doty MM, et al. Losing Ground: How the Loss of Adequate Health Insurance is Burdening Working Families, August 2008. Available at: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Aug
    /Losing-Ground--How-the-Loss-of-Adequate-Health-Insurance-Is-Burdening-Working-Families--8212-Finding.aspx
    .

    Community Health Navigators Use Pathways Model to Enhance Access to Health and Social Services for Low-Income and At-Risk Residents. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2933.

    The Kaiser Commission on the Uninsured. The Uninsured: A Primer. December 2010. Available at: http://www.kff.org/uninsured/7451.cfm.

    Footnotes

    1 Collins SR, Kriss JL, Doty MM, et al. Losing Ground: How the Loss of Adequate Health Insurance is Burdening Working Families, August 2008. Available at: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Aug
    /Losing-Ground--How-the-Loss-of-Adequate-Health-Insurance-Is-Burdening-Working-Families--8212-Finding.aspx
    .
    2 Kaiser Family Foundation, KaiserEDU.org. US Healthcare costs: Background Brief. Available at: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx.
    3 The Kaiser Commission on the Uninsured. The Uninsured: A Primer. December 2010. Available at: http://www.kff.org/uninsured/7451.cfm.
    4 Cook NL, Hicks LS, O'Malley AJ, et al. Access to specialty care and medical services in community health centers. Health Aff (Millwood). 2007;26(5):1459-68. [PubMed] Available at: http://content.healthaffairs.org/content/26/5/1459.full.pdf#page=1&view=FitH (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
    5 Centers for Medicare & Medicaid Services, Physician Payments: Office Setting, 2009 Data.
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    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: May 25, 2011.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: July 17, 2013.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

    Date verified by innovator: May 24, 2012.
    Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.