How Do Free Clinics Make Money
Cureus. 2016 Feb; 8(two): e500.
Medical Care in a Gratuitous Clinic: A Comprehensive Evaluation of Patient Experience, Incentives, and Barriers to Optimal Medical Care with Consideration of a Facility Fee
Monitoring Editor: Alexander Muacevic and John R Adler
Antoinette Birs
ane University of Primal Florida College of Medicine
Xinwei Liu
1 University of Cardinal Florida College of Medicine
Bee Nash
2 FIRE Module, University of Primal Florida College of Medicine
Sara Sullivan
3 Consulting Section, Sullivan Evaluation Services
Stephanie Garris
4 Grace Medical Home
Marvin Hardy
5 Medical Director, Grace Medical Habitation
Michael Lee
half dozen Pharmacology, Academy of Central Florida College of Medicine
Judith Simms-Cendan
i University of Key Florida College of Medicine
Magdalena Pasarica
7 Medical Education, University of Key Florida College of Medicine
Received 2015 Nov 30; Accepted 2016 Feb 19.
Abstract
Complimentary and charitable clinics are of import contributors to the health of the United States population. Recently, funding for these clinics has been declining, and it is, therefore, useful to identify what qualities patients value the most in clinics in an attempt to classify funding wisely. In order to identify targets and incentives for improvement of patients' health, we performed a comprehensive assay of patients' feel at a gratis dispensary past analyzing a patient survey (N=94). The survey also assessed patient opinions of a modest facility fee, which could be used to offset the subtract in funds. Interestingly, our patients believed it is advisable to be charged a facility fee (78%) because it increases interest in their care (r= 0.69,p< 0.001) and self-respect (r= 0.66,p< 0.001). Incentives to medical care include continuity of care, faith-based care, having a patient medical provider partnership, and charging a facility fee. Barriers include affordable housing, transportation, medication, and accessible information. In order to better medical intendance in the uninsured population, our study suggested that nosotros need to: 1) offer continuity of medical care; 2) offer affordable preventive health screenings; three) support affordable transportation, housing, and medications; and 4) consider including a facility fee.
Keywords: costless clinic, facility fee, barriers to healthcare, uninsured, healthcare improvement
Introduction
With the advent of the Affordable Care Deed (ACA), Medicaid services have expanded to include: (1) adults under the historic period of 65 who earn below 138% of the federal poverty line and (ii) working families who earn between 100% and 400% of the federal poverty line. These individuals will be provided with tax credits to help them purchase health insurance in the newly created wellness care market place [1]. Currently, not all states accept chosen to adopt these new laws. Xx states have refused to aggrandize Medicaid (every bit of September 2015), leaving an estimated three million Americans without coverage [two]. Incomplete country participation in the Medicaid expansion has created a healthcare "gap", which includes Americans who are either eligible for Medicaid, but reside in states not expanding the Medicaid programme or have an income as well loftier to qualify for Medicaid, merely still cannot afford medical insurance despite public subsidies and tax credits.
Gratis and charitable clinics across the U.S. help bridge this gap in health care coverage and provide services to fit the medical needs of these uninsured Americans. According to the National Association of Free and Charitable Clinics (NAFCC), there are approximately 1,200 free and charitable clinics nationwide, all of which are 501(c)(3) tax-exempt organizations that do not receive funding from the federal regime [iii]. With an boilerplate of over 4,000 patient visits and almost 800 new patients per yr, a contempo study surveying over 360 clinics nationwide plant that there is an increasing demand and need for free and charitable clinics [ii, 4]. Without clinics, the uninsured population will not take access to the same standard of medical intendance and preventive services provided to the insured population and may likely experience a filibuster in disease diagnosis equally is described in a study by Ayanian and colleagues who surveyed over 200,000 Americans [5]. A filibuster in diagnosis and preventative care can ultimately lead to negative wellness outcomes and higher healthcare costs for this population [6-7]. Information technology is estimated that patients who have been without insurance for over ane year will pay approximately one-5th of their care out of pocket and typically pay higher fees than the insured [eight-9]. Moreover, fiscal stressors accept been shown to pb to increased levels of depression and feet [10] and tin negatively bear upon or worsen other mental and physical ailments [11]. These clinics have become a vital contributor to the medical and preventative intendance of the uninsured [12].
Today, well-nigh uninsured patients report that they would either not seek medical care or would use the emergency department if complimentary clinics were not available [four]. Free clinics lessen the burden placed on emergency departments while providing care that is comparable to the national standard of care [13-14]. Clinics are reported to have increased staff friendliness and a generalized positive perception of the depth of medical explanation received and the amount of fourth dimension spent with the medical provider [fifteen-19].
Despite their critical role in the medical treat uninsured or underinsured patients, the NAFCC reports that clinics have suffered an overall 20% decrease in funding [two]. This subtract in funding increases the already existing financial arrears faced by these clinics. One solution may be plant in instituting a small facility fee, nether the premise that the fee will not negatively affect patient intendance or patient utilization of free clinics. It has been found that patients are more willing to seek medical intendance from institutions accepting Medicaid/Medicare where they are expected to pay a sliding calibration fee versus facilities where merely private insurance is accepted [nineteen]. Studies accept demonstrated that improvement in patient care is highly dependent on patient appointment and patient return for the recommended office visits [20]. There is a paucity of data validating the reception and effectiveness of a facility fee, and our report aims to delineate whether a fee will serve every bit an incentive or bulwark to medical care. Our goal is to identify targets and incentives to optimize primary medical care in our dispensary by performing a comprehensive evaluation of patient'south feel, concerns, outcomes, and perceptions in a gratuitous dispensary that may be applied to clinics across the Usa.
Materials and methods
Written report clarification
This is a retrospective secondary analysis of a patient survey administered as part of an internal periodic evaluation of patient satisfaction. Patients were recruited between September one-30, 2014 while receiving services at Grace Medical Dwelling, a free clinic in Orlando, Florida. Participation was voluntary. The nature and objectives of the study were explained and informed consent was obtained. To exist eligible to complete the survey, participants were required to meet the following requirements: (i) they must be patients of the dispensary and (2) exist xviii years of historic period or older. If the patient was a minor, a parent was encouraged to fill out the survey on their behalf. The survey was anonymous and was offered in both English and Spanish. A total of 94 surveys were nerveless subsequently existence completed fully.
The clinic offers adult and pediatric medical services in both main care and specialty intendance. The clinic charges a small-scale facility fee ($5, if patients can afford information technology) for the purpose of meeting the patient'due south health intendance needs while taking into business relationship their power to pay the fee. This fee is meant to commencement some of the stock-still operating services, such as rent and utilities, and makes upwardly less than 5% of the clinic budget. No patient volition exist denied medical care if they cannot pay the fee. In that location is no fee for clinical re-checks, preventive screenings, laboratory assessments, X-rays, sample medications, office visits, or care coordination.
The anonymous survey contains 36 items which nerveless information regarding: (1) demographic characteristics; (2) options for medical care earlier joining the clinic; (iii) reasons for not having health insurance; (4) reasons for wanting to be a patient of the clinic; (5) health status, health worries, missed work/school days, information availability earlier and subsequently joining the dispensary; (vi) reasons for missing appointments and not taking prescribed medicine; (7) problems with transportation to clinic; (viii) experience of being a patient in the clinic; and 9) feel with and mental attitude towards the facility fee.
Certain patient demographics were non nerveless; however, the dispensary reports that they serve a various race, sex, and age group. Patients are uninsured residents of Orange Canton, Florida who are at or beneath 200% of the federal poverty level.
The retrospective analysis presented in this written report was reviewed and approved by the Institutional Review Board at the University of Central Florida (blessing #SBE-14-10831).
Statistical assay
Patient characteristics are represented by descriptive statistics (frequencies and valid percentages). Pearson Chi-square or the Binomial test was used to determine significant differences in categorical data. To written report the relationship betwixt the dispensary facility fee and accountability too as self-respect, correlational analyses were conducted. Simply applicative responses were analyzed. All tests were 2-sided, and p-values < 0.05 were considered statistically pregnant. Statistical analyses were conducted in IBM SPSS Statistics 22.0 (SPSS Inc, Chicago, IL).
Results
Patients' financial characteristics and access to healthcare
Xc-four patients answered the survey. Most of the patients participating in this study were unemployed (40.2%), and their living weather were variable with the majority renting or owning an apartment (68.nine%) as can be seen in Table 1. For transportation to the dispensary, nigh used their own automobile (73.5%). Earlier joining the free clinic, most patients (37.1%) would not get care, and thirty.3% would become to emergency room and urgent intendance facilities. The clinic's patients did non have wellness insurance for multiple reasons, including not beingness able to afford the Affordable Care Act Marketplace or individual insurance.
Table 1
Patients' Characteristics and Access to Wellness Care
This table presents patients' characteristics (as determined by employment status, living situations, and mode of transportation) and also their access to wellness intendance (as determined by the self-reported healthcare culling pick if non Grace Medical Home, cognition equally how to admission medical intendance or where to get for help, and concerns related to public health options). Data were generated from 90-4 (94) surveys. Non all questions were answered past all participants. Data are presented here in frequencies and valid percentages.
| Patient Characteristics and Access to Healthcare | Patient Selection: Frequency (Pct) |
|---|---|
| Employment Status | |
| Unemployed | 33 (40.2%) |
| Total-time employment; no benefits | 28 (34.1%) |
| Seasonal work; non a permanent job | v (6.1%) |
| Nether employed (less than xxx hours/week) | 16 (19.five%) |
| Living Situation | |
| Rent or own an flat or house | 60 (68.nine%) |
| Staying with friends/relatives | 23 (26.7%) |
| Shelter | 0 (0%) |
| Transitional housing | 1 (1.ane%) |
| Staying on the street, in motorcar, in wood, etc. | 1 (1.1%) |
| Motel | 2 (two.3%) |
| Modes of Transportation | |
| Drive my own car | 64 (73.5%) |
| Borrow car from friend/family fellow member | 6 (half-dozen.9%) |
| A friend or family member drives me | 12 (13.eight%) |
| Take the charabanc | 8 (ix.4%) |
| Walk or ride bike | 3 (iii.5%) |
| Healthcare Alternative (If not Grace Medical Home) | |
| Health dispensary | eighteen (20.2%) |
| Doctor'south office | 3 (three.iv%) |
| Emergency room | 27 (thirty.iii%) |
| Urgent care clinic | eight (9.0%) |
| Would not get care | 33 (37.1%) |
| Unsure How to Access Medical Care or Where to Go for Help; Concerns almost Enrolling in Public Healthcare Options (Medicaid, Medicare, ACA, etc) | |
| Don't know how to enroll | half-dozen (6.4%) |
| Also complicated or difficult | half-dozen (vi.4%) |
| Won't have specialist I need | xvi (17.0%) |
| Don't want insurance | 26 (27.7%) |
| Can't afford marketplace premium | 55 (58.5%) |
| Can't afford toll of co-pays | 41 (43.half-dozen%) |
| Plans don't cover benefits I'm looking for | viii (8.5%) |
| Express choices | 15 (16.0%) |
Patients' health and financial concerns before joining the free clinic
Earlier joining the free clinic, a large majority of patients were worried about not knowing how to access medical intendance and where to become for help (80.5%) every bit is represented by the information in Tabular array 2. Patients had a variety of medical concerns ranging from morbidities due to chronic diseases to the lack of early detection screenings.
Tabular array 2
Patients' Health and Financial Concerns Before Joining the Free Dispensary
This table presents patients' medical and financial concerns before joining Grace Medical home. Data were generated from ninety-four (94) surveys. Not all questions were answered by all participants. Data are presented here in frequencies and valid percentages. *Participants were able to select multiple responses.
| Health and Financial Concerns Before Joining the Free Clinic | Number of Responses: Frequency (Pct) |
| Medical Concerns | |
| Overweight | 37 (l.0%) |
| Low energy due to illness/status | 46 (62.2%) |
| Chest pain/eye palpitations | 14 (nineteen.vii%) |
| Preventive cancer/early on detection screenings not done | 28 (38.9%) |
| Financial Concerns | |
| Missing work due to illness | 32 (45.vii%) |
| Financial crisis or bankruptcy due to medical issues | 40 (52.six%) |
| Unsure how to access medical care or where to become for help | 62 (80.5%) |
Patients' medical, financial and organized religion outcomes resulting from receiving medical care from the costless dispensary
Data is presented in Figures i- 2. Significantly more patients (94.7%, p < 0.001) reported that their health had improved since joining the gratis clinic, compared to ii.2% who either disagreed or felt neutral. Patients with improved wellness were more likely to feel that they were treated with courtesy and nobility (r =0.61, p < 0001). Patients reported receiving more prevention and screening services (p < 0.05), missing fewer work days due to illnesses (70.6% p < 0.05), and had fewer concerns well-nigh a financial crisis and bankruptcy due to medical illnesses. Patients also learned how to access medical care and where to go for assistance.
Medical Outcomes of Patients Receiving Medical Care in the Free Clinic
This effigy presents the medical outcomes of patients as better, the same, or worse since they joined the free clinic. Patients were asked nigh general health concerns, admission to preventative studies and energy levels. Data were generated from ninety-four (94) surveys. Not all questions were answered by all participants (the range was 85-94 responses). Data is presented here in valid percentages. Participants were able to select multiple responses.
Financial Outcomes of Patients Receiving Medical Care in the Free Dispensary
This effigy presents the financial outcomes of patients as better, the same, or worse since they take joined the complimentary clinic. Patients were asked questions about long term fiscal outcomes and medical care admission. Data were generated from ninety-iv (94) surveys. Not all questions were answered past all participants (the range was 85-94 responses). Information is presented here in valid percentages. Participants were able to select multiple responses.
Incentives and potential barriers to optimal medical care in the free clinic
Information representing potential barriers for medical care: date and treatment noncompliance and paying a fee is presented in Table 3. We found that patients missed their dispensary appointments because of various reasons with transportation problems (22.3%), appointment rescheduling bug (xviii.i%), and inability to get fourth dimension off from work/school (14.9%) existence the most commonly selected.
Table 3
Patient Perceptions of Grace Medical Home'south Qualities
This table presents qualities near valued in free clinics and qualities of Grace Medical Home. Data were generated from ninety-four (94) surveys. Not all questions were answered past all participants. Information are presented here in frequencies and valid percentages. Participants were able to select multiple responses.
| Qualities Most Valued past Patient at Grace Medical Home | Number of Responses: Frequency (Per centum) |
| Master intendance | 69 (73.4%) |
| Specialty care | 48 (51.one%) |
| Affordable medications | 47 (50.0%) |
| Relationships with staff/volunteers | 59 (62.8%) |
| Sets up appt and coordinates referrals | 41 (43.half dozen%) |
Patients valued master care (73.4%) and specialty intendance (51.ane%), but also affordable medications (l.0%) and having coordinated appointments and referrals (43.6%).
Facility fee
Nosotros then studied patients' attitudes towards paying a small sliding scale facility fee (data presented in Figures 3- iv and Table four). Interestingly, significantly more patients agreed or strongly agreed that it is appropriate for the clinic to accuse the facility fee compared to those that disagreed (81.half dozen% vs. 8.i%, p < 0.001). Significantly more than patients felt that by paying a fee they supported the gratuitous dispensary compared to the ones that disagreed (97.viii% vs 2.2%, p < 0.001). In plough, paying the facility fee enhanced patients' level of self-respect (84.iii% vs. 2.iv%, p < 0.001). Further assay showed that patients who reported that paying the facility fee was appropriate, also reported that paying this facility fee encouraged them to exist more than involved in their care (r = 0.69,p < 0.001) and accept more cocky-respect (r = 0.66, p < 0.001).
Positive Patients' Mental attitude Towards Paying a Facility Fee for Medical Care in the Free Dispensary
This effigy presents the response of positive statements towards paying a facility fee in the complimentary clinic. Information were generated from xc-four (94) surveys. Not all questions were answered by all participants (the range was 90-94 responses). All responses were on a i-5 Likert scale. Data is presented here is in valid percentages. Participants were able to select multiple responses.
Negative Patients' Mental attitude Towards Paying a Facility Fee for Medical Care in the Free Clinic
This figure presents the response of negative statements towards paying a facility fee in the free clinic. Data were generated from ninety-four (94) surveys. Non all questions were answered by all participants (the range was ninety-94 responses). All responses were on a 1-5 Likert scale. Data is presented hither is in valid percentages. Participants were able to select multiple responses.
Table four
Correlation Analysis of Patient Willingness to Pay Facility Fee
This table presents correlations (r-values) between questions related to patients' mental attitude towards the facility fee. Correlations which are significant with p < 0.01 level are in assuming.
| Questions | i | 2 | 3 | 4 | v |
| 1. Struggle to pay fee | 1 | ||||
| ii. Can't keep apt due to fee | 0.75 | 1 | |||
| three. Fee encourages me to experience involved in care | 0.63 | 0.61 | ane | ||
| 4. More than self-respect paying something for care | 0.59 | 0.39 | 0.52 | i | |
| five. Information technology is appropriate to accuse a fee | 0.68 | 0.54 | 0.69 | 0.65 | 1 |
But 20.5% of patients reported that they often struggle to pay the facility fee and 12.vii% reported that this resulted in missing appointments. A small percentage of patients (8.0%) felt pressured to pay the fee and more patients felt that the clinic should proceed the facility fee compared to those who idea it should be discontinued (84.0% vs. 2.7%, p <0.001).
Furthermore, even though patients who reported struggling to pay the facility fee were more probable to miss their appointments due to the fee (r = 0.68, p < 0.001), they also reported that paying the facility fee encouraged them to exist more involved in their intendance (r = 0.63, p < 0.001), have more self-respect (r = 0.59, p < 0.001), and ultimately believed that information technology was advisable to be charged a fee (r = 0.68, p < 0.0001).
Discussion
Previous studies evaluating the medical care in free and charitable clinics take focused on tightly defined parameters, such equally patient satisfaction and medical outcomes. While these studies contribute valuable information to our understanding of medical care in gratuitous clinics, our study specifically aims to assess incentives or potential barriers to optimal medical intendance, willingness to contribute a minor fee, and if this fee increases patients' perception of ownership over one's health.
Patient characteristics
Before joining the free clinic, about patients reported seeking care at the emergency department or urgent care facilities, which typically take a high cost for the medical facility also as the patient [21]. This exercise increases the brunt on local emergency departments, turning them into expensive de facto primary care facilities. One reason why emergency room visits may be so costly is that a significant portion of the care provided will get uncompensated. The Centers for Medicare and Medicaid Services guess that nearly 55% of all emergency services nationwide will not be paid for. This fiscal burden is redistributed within the hospital, onto the privately insured, and those who self-pay [22]. Previous reports showed that a tremendous amount of funding allotted for health care could be saved simply past offering better health insurance, encouraging all workplaces to carry affordable health insurance, or supporting more free and charitable clinics [4]. The Agency for Healthcare Enquiry and Quality (AHRQ) found that the average expenses for all people who had one or more visits to the emergency room in 2009 were $1,318 [23]. More than half of the patients surveyed are concerned nigh bankruptcy or financial crunch due to medical issues, which may explicate why a staggering majority of patients would non seek medical care at all if they were unable to admission care from a free clinic. Delays in seeking treatment may not only worsen a patient'southward medical effect, but besides increase the cost of medical care when finally seeking handling.
Expectations of care
Most of the patients surveyed came to the free dispensary for chronic disease management and affordable medications. Approximately one-half of the patients report that they came to the free clinic because they wanted a md to see regularly and who could provide them with continuity of care. One-third of the patients had concerns near non receiving preventive health care and screening services prior to joining the free dispensary. This is consequent with previous reports showing that the uninsured do not have access to like prevention and screening as the insured [5]. Health care costs and suffering from an advanced illness may be decreased by offering screening tests, including pap smears, mammograms, and lipid and diabetes screening.
Barriers to intendance
Transportation may be a barrier to care as 26.five% of the patients did not own a car. Dispensary locations well-nigh double-decker lines or walking distance to subway stations should exist considered when locating new clinics. Other patients would non seek intendance considering they were worried about missing work due to illness, suggesting the importance of offer appointments after working hours.
Previous research supports the fact that medical care in free clinics is of good quality [4, 13-fourteen]. In our written report, almost all patients reported that their health and financial concerns had improved after receiving care at the costless clinic. Interestingly, patients reported that the care at Grace Medical Home likewise encouraged their faith, which was 1 of their about valued experiences. This suggests that offering medical care in a faith-based establishment may increment patient satisfaction and compliance.
Medication compliance dwindled because of either cost or side furnishings, suggesting the importance of patient education nearly medication and importance of adhering to the regimen. More than frequent visits for clinical reassessment and continuity of care will let physicians to evaluate the side outcome profile and ability to tailor the patient's treatment plan. Nosotros do acknowledge that some medications may not be bachelor to our population due to high cost. Thus, developing new models whereby new or enlarged patient aid programs or reduced price plans could exist developed is of paramount importance.
Nosotros know that patients who are more engaged in their care report amend health [20]. Some institutions, including the one studied hither, implemented a sliding scale facility fee, which is believed to improve compliance, accountability, and ultimately medical intendance. This small facility fee may exist a potential bulwark to patient care; nevertheless, there are no studies currently published in the literature addressing this topic. We found that most patients agreed that it is appropriate to pay a sliding scale facility fee and that doing so made them feel more than involved in their own medical care. The data demonstrates that past putting a monetary investment into the visit, patients are more probable to be compliant with medications and physician recommendations and experience more responsible for their medical care. Patients reported comeback in their fiscal concerns and a reduction of missed workdays secondary to illness. If a patient is able to justify a small facility fee in exchange for fewer sick days and involvement in their medical intendance with increased self-respect, then the facility fee becomes an incentive to improving wellness. This study tin be used in other free and charitable clinics to determine if a facility fee is appropriate. The master focus is increased patient care and satisfaction, with the facility fee being an incentive adopted to ameliorate patient care.
This study was conducted in a state that has non expanded Medicaid, so our findings may non be applicable to all states. The survey tool used in this analysis was internally adult and has non been validated at this fourth dimension; therefore, we admit this methodological limitation and encourage usage of a standardized survey that can be applied to all clinics. Future studies should be conducted on a larger scale to include clinics in several geographic locations to substantiate the generalizability of our findings.
Conclusions
As the fiscal support for funding free and charitable clinics decreases [2], there is an acute need to identify the obstacles to optimal medical intendance in an effort to develop targeted strategies to improve care and efficiency in gratuitous and charitable clinics. Most importantly, we explored the patient perception of a facility fee, which we believe will not only improve the patient'southward sense of responsibility for their health care but also shrink the expanding deficit that clinics are facing. Several facets of the free clinic, such every bit continuity of medical care, faith-based care, and charging a facility fee, actually improved patient compliance and engagement. This study is pregnant as it allowed us to draw conclusions that can be used for future evolution of policies to improve the health of the poor and underserved. Our study suggests that critical factors to improve medical care in the uninsured population would 1) offer continuity of medical care; 2) offer affordable and preventive medicine; 3) support affordable transportation, housing, and medicine; and 4) adoption of a facility fee to eternalize patient compliance and ownership of healthcare.
Acknowledgments
We would like to thank the staff at Grace Medical Domicile for their guidance, fourth dimension, and efforts with this project and all the Grace Medical Home patients who participated in this study.
Notes
The content published in Cureus is the result of clinical feel and/or research past independent individuals or organizations. Cureus is non responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the communication of a qualified health care professional. Do non disregard or avoid professional person medical communication due to content published within Cureus.
The authors have alleged that no competing interests exist.
Human Ethics
University of Cardinal Florida Institutional Review Board issued approving SBE-xiv-10831
Creature Ethics
Beast subjects: This study did not involve fauna subjects or tissue.
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