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Strengthening the Health Care Safety Net

Developing Care Systems


Mary Lou Hennrich, R.N., M.S., Executive Director, CareOregon, Portland, OR.

Diana Resnik, Vice President, Community Care, Seton Healthcare Network, Austin, TX.

Douglas Elwell, M.S.A., President and Executive Director, Health and Hospital Corporation, Indianapolis, IN.

This session provided examples of local communities that have sought to more closely integrate various safety net providers (SNPs) into more coordinated systems of care; speakers also discussed the implications of these initiatives for public policy.

Mary Lou Hennrich is Executive Director for CareOregon, a collaboration of traditional SNPs that includes the Multnomah County Health Department, Oregon Health Sciences University, Community and Migrant Health Centers, and other county health departments.

CareOregon evolved as an extension of the Oregon Health Plan, beginning in 1991, through a section 1115 waiver that allowed expanded eligibility, managed care as a basic delivery system, prioritized services and medical treatments, and established capitation based on "reasonable cost." The goal of CareOregon was to increase access and quality while containing costs.

Since becoming a reality in 1994, CareOregon membership has grown from 9,500 enrollees to 45,000 in July 2000. Ms. Hennrich shared several lessons learned thus far in the program, including:

  • Collaboration is not easy, it is difficult to call others to task.
  • Strong leadership is essential.
  • Proceed incrementally, if possible.
  • Begin by agreeing on values, vision, and mission at the start.
  • Build on strengths from sponsoring organizations.
  • Involve members and providers in designing systems to meet their needs.
  • Improved health must be the goal, more than simply access to care.

Ms. Hennrich believes that a strong and effective, fiscally stable network of SNPs is an essential part of the delivery system. She said that a market-based competitive model for organizing safety net services has not proven effective in Oregon, in that it is not a profitable line of business for commercial insurers. She observed that traditional insurers often lack expertise and interest in serving poor and vulnerable populations.

Diana Resnik is Vice President of Community Care for Seton Healthcare Network, a safety net system in Austin, Texas. Ms. Resnik began with a profile of the "good news" about central Texas, which includes Hays, Travis, and Williamson Counties. Central Texas has a rich ethnic mix and is culturally diverse, including Hispanic, African American, and Asian populations. Boasting the highest rate of economic growth of any portion of the State, central Texas has a diversified economy led by the high-technology sector and an unemployment rate of less than 2 percent.

Despite this positive profile, central Texas also faces many challenges. The strong economy has also spurred an increase in the service industry, contributing to the 20-percent uninsured rate, with 600,000 eligible for Medicaid but not enrolled. Central Texas is the only major urban area in Texas without a health care taxing district.

Ms. Resnik discussed a number of precipitating factors involving crisis and leadership that moved central Texas forward in strengthening the health care safety net. On the down side, crisis factors included:

  • Fragmented SNPs.
  • Employers dropping health insurance.
  • Gaps in access to specialty care.
  • Increases in the cost of medications.
  • Increases in chronic illness.
  • Reductions in reimbursement from traditional government payers.

On the up side, leadership factors that helped central Texas include a strong vision of community care, shared services, a bottom-up strategy, and leadership alliances.

One result of these leadership alliances was the development of the Indigent Care Collaboration (ICC), an organization of SNPs with a goal to enhance the accessibility, continuity, and quality of care provided to the indigent and uninsured. Projects include:

  • Uniform means-testing.
  • An after-hours call center.
  • Continuing medical education programs.
  • A dental sealant program.
  • The State Children's Health Insurance Program (SCHIP) outreach.

Ms. Resnik described the emerging model as regional involvement for a regional solution. The ICC model plans to:

  • Reduce the number of uninsured.
  • Enable better management of care.
  • Create a link to physicians.
  • Establish new financing.

Public policy issues encountered by the ICC include:

  • A lack of coherent public policy for the uninsured.
  • Determining where the dollars come from.
  • Physician incentives for safety net participation.
  • Sharing data/privacy issues.
  • Multiple programs creating more overhead and more difficult access to care.

Ms. Resnik presented some lessons learned thus far, including:

  • Commitment of volunteer time is needed for working on collaboration.
  • Building trust is essential.
  • There is limited public awareness of the crisis in indigent health care.
  • Resources are needed to pay for increased needs for care.
  • There is a fear of sharing or pooling resources and savings.
  • There must be a balance of consensus and compromise in decisionmaking.

Douglas Elwell is President and Executive Director of the Health and Hospital Corporation of Marion County, Indiana, which includes Indianapolis. Wishard Advantage is a safety net system in Indianapolis and is part of the Health and Hospital Corporation, whose statutory responsibility is to provide care to those that fall ill or are injured in Marion County. Health and Hospital is a municipal corporation funded by local property tax dollars and operates the Marion County Health Department and Wishard Health Services, comprised of a public hospital, seven community health centers, and a long-term care facility.

The creation of Wishard Advantage was due to several precipitating factors, including:

  • A lack of preventive health care services for indigent patients.
  • A lack of incentives for physicians to serve indigent patients.
  • Delays in treatments.
  • Patients showing up for primary care services in emergency rooms.

Local leaders questioned whether tax dollars could be spent more effectively.

The Wishard Advantage concept is "to encourage the uninsured to proactively seek health care with the purpose of promoting prevention and managing disease before expensive complications present." Although Wishard Advantage resembles an health maintenance organization (HMO), it is actually a managed care medical assistance program modeled after Indiana Medicaid. The program is open to Marion County residents with incomes at or below 200 percent of the Federal Poverty Level (FPL).

Established in 1997, the goals of Wishard Advantage include:

  • Improve quality of care and outcomes.
  • Strengthen doctor/patient relationship and continuity of care.
  • Decrease inappropriate emergency room use.
  • Focus on disease prevention and health promotion.
  • Manage patient care.
  • Improve efficiency.
  • Produce data to guide decisionmaking.

To achieve these goals, Wishard Advantage provides the following services:

  • Choice of primary care physicians.
  • Preventive care.
  • Laboratory and diagnostic testing.
  • Inpatient and ambulatory services.
  • Access to 24-hour nurse triage service.
  • Prescription drugs.

Early results show:

  • An increase in calls to the nurse triage service.
  • An overall increase in ambulatory visits.
  • High patient satisfaction.
  • Increasing enrollment and community awareness.
  • Increasing membership.

Since 1997, membership has increased from 7,000 patients to more than 23,000. Eighty-eight percent of enrollees have incomes below 150 percent of the FPL.

Wishard Advantage is undergoing a local expansion driven by two primary factors: the Health and Hospital Corporation's vision to make Marion County the healthiest community in the United States; and the need to ensure access to a comprehensive system of care for vulnerable populations in the county. Plans for the expansion include all primary care SNPs in Marion County. Currently, other SNPs are referring patients to Wishard for inpatient and specialty care without the benefit of preventive services and patient management. Expected outcomes of the expansion include:

  • The development of a countywide integrated and coordinated system of care.
  • Promotion of local collaboration among SNPs to address community health issues.
  • Compilation of data on indigent patients.

Mr. Elwell shared that Indiana is considering statewide expansion of the program as well.

Policy concerns expressed by Mr. Elwell include crowd-out, the increasing public burden, and the need to perform comprehensive evaluation on health outcomes. Policy lessons include the need to consider all available funding streams, coordinate revenue streams to avoid duplication, and understand who the SNPs are and what services they provide. Mr. Elwell concluded by saying that safety net systems of care should seek to increase the knowledge of the indigent patient population base, improve quality of care and ensure comprehensive services, and improve overall health status.


Gray BH, Rowe C. Safety-net health plans: A status report. Health Aff 2000 Jan/Feb;19(1):185-93.

Scott HD, Bell J, Geller S, Thomas M. Physicians helping the underserved: the reach out program. JAMA 2000 Jan 5;283(1):99-104.

Sparer MS, Brown LD. Uneasy alliances: managed care plans formed by safety-net providers. Health Aff 2000 July/Aug;19(4):23-35.

Wishard Advantage. A managed care program for the low-income uninsured citizens of Marion County. Marion County, IN: Health and Hospital Corporation. 2000.

Current as of August 2001

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Internet Citation:

Strengthening the Health Care Safety Net. Workshop Brief, October 25-27, 2000. User Liaison Program. Agency for Healthcare Research and Quality, Rockville, MD.

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