The clock starts the moment the power goes out in Doralee Carter’s Lexington home.
Carter’s daughter, Catlynn, was paralyzed from the neck down when a drunk driver ran them off the road just before Catlynn turned three. Now 19, she still depends on a ventilator to breathe.
“If the electricity cuts out, she can’t breathe at all on her own,” Carter said. In the event of a power outage, Carter plugs Catlynn’s equipment into a generator. But gas is expensive, and sometimes the local fire department must help provide resources.
The power has been out three times this year, once for five days straight, Carter said. And making ends meet with Catlynn’s medical needs is already hard enough.
Catlynn qualifies for Medicaid with disability benefits, a state and federal assistance program that provides free and low-cost health coverage to more than 60 million individuals nationwide, according to a report by the Henry J. Kaiser Family Foundation.
Still, her mother said, adequate health care for Catlynn is almost impossible to come by in the Rockbridge area because practices will not accept her coverage plan.
Suzanne Sheridan, executive director at the Rockbridge Area Health Center, says doctors are more reluctant to treat Medicaid patients because the reimbursement rate for services is so low. Though it varies depending on service, many practices are compensated about 62 cents on the dollar, she said.
That’s why Catlynn’s mother must drive her daughter at least 40 miles to get to her neurologist, cardiologist, gastroenterologist, pulmonologist— the list goes on— at least every six months. Any complications mean additional frequent visits.
“It’s a big deal having to take her all the way there and back,” Carter said. “It’s expensive, and the traveling is just really hard on her.”
An even bigger problem is that Catlynn’s Medicaid coverage also disqualified her from receiving services at the local free clinic, which required that a patient be uninsured and below the federal poverty level.
That kind of dilemma is what prompted Sheridan and her staff to stop operating as a free clinic and rebrand themselves as a health center.
The Rockbridge Area Free Clinic, which had served low-income and uninsured patients for two decades, became the Rockbridge Area Health Center in January. As the free clinic, the center provided free health care to everyone who qualified. Now, it bases its fees on ability to pay, although the poorest patients still pay nothing. Catlynn Carter still isn’t eligible for most services at the center, but its staff hopes the changes will allow her to do so soon.
The new model mimics what Sheridan hopes the organization will soon become, a federally qualified health center. Sheridan applied for that designation last year and will not hear back until September. Only 25 organizations in the country will be chosen.
But too many people need help now, Sheridan said. Waiting for September to start making changes was not an option.
Even without federal funding, Sheridan has been able to move away from the free clinic model thanks to generous community support and her 150 volunteers. The health center is now open an additional 10 hours during the week. The board of directors hired a new nurse practitioner, a staff-licensed clinical social worker and a psychiatrist.
The health center also expanded eligibility requirements. There are a lot of people who don’t qualify as “low-income” based on federal guidelines but who still really need help, said Katy Datz, development director at the health center.
“People are not longer cut off from receiving our services just based on income guidelines,” Datz said.
Instead, patients are charged a sliding scale administrative fee. People with a higher income just have to pay a little bit more. Medical appointments run up to $40 and dental appointments cost between $20 and $75, while all prescriptions cost $4. The sliding fee enables staff to see more patients and build some revenue, Datz said.
“It was either that or we were going to have to severely cut back on what we were providing,” Sheridan said. “We couldn’t stop doing what the community depended on us to do.”
For those who really can’t pay, the fee is still zero. And if the health center gets the federal qualification, the federal government will reimburse it for providing that free care.
“Our federal funding is what enables us to offer a sliding fee scale for our uninsured patients,” said Peggy Whitehead, Executive Director at the Blue Ridge Medical Center in Arrington, Va., which is a federally qualified health center. About 30 percent of her patients are uninsured, she said.
“For the people whose care we can’t charge, we are totally compensated,” Whitehead said. “This allows us to keep providing services to everyone within our scope of practice.”
The federal designation also opens a number of doors to additional grant funding. Such provisions would enable the local health center to fill some of the gaps for people like Catlynn, whose Medicaid coverage has limitations.
And if Virginia decides to expand Medicaid coverage under the Patient Protection and Affordable Care Act, 75 percent of the health center’s 2,000 patients will be insured by Medicaid within 18 months, Sheridan said. The odds of those people finding doctors, especially when resources are already stretched thin, are slim.
“There are just not enough health care providers to see them,” Sheridan said. “If we don’t serve these people, where else are they going to go?”
According to Whitehead at Blue Ridge Medical Center, that catch is one that makes federal funding so critical in a rural area. Medicaid pays the center full-cost reimbursement, rather than 62 cents on the dollar. That allows for a more sustainable business model and gives those with Medicaid a place to receive care.
“I know a lot of private practices do not accept Medicaid patients, but we love them,” Whitehead said. “We wouldn’t be able to provide health care if we didn’t get the Medicaid compensation.”
Eileen Lepro is the executive director at New Horizons Healthcare in Roanoke, another federally qualified health center. She says her staff scrambles to draw in more patients on Medicaid, as it is one of the organization’s biggest sources of revenue.
Even though the Rockbridge area cannot yet embrace and accommodate Medicaid patients to that extent, the area does boast one major advantage already.
“In a place like Roanoke, there are so many nonprofit organizations looking for donations,” Lepro said. “It’s difficult because we have to compete with them for community support.”
Community support and volunteers make it possible for the Rockbridge Area Health Center to transition into its new model of care. But as the health industry continues to fluctuate, the federal designation would provide something invaluable for the Carter family: convenience.
Partnerships are mandated for federally qualified health centers. So even though the local health center might not have the means to directly provide a particular service, it can send patients to other doctors who do provide those services.
Or, send those doctors to them.
And that, says Doralee Carter, would make everyone breathe a little easier.