AHRQ Innovations Exchange | Multispecialty Practice Uses Time Credit Payments and Other Policies to Enhance Access to Conventional and Alternative Care, Improving Health Status of Low-Income Patients

AHRQ Innovations Exchange | Multispecialty Practice Uses Time Credit Payments and Other Policies to Enhance Access to Conventional and Alternative Care, Improving Health Status of Low-Income Patients

Multispecialty Practice Uses Time Credit Payments and Other Policies to Enhance Access to Conventional and Alternative Care, Improving Health Status of Low-Income Patients

Summary A standalone, practitioner-run, multispecialty center (called the True North Health Center) employs several innovative policies to enhance access to conventional and alternative health care services, particularly for low-income individuals. Key policies include use of an independent contracting model for practitioners, strict credentialing criteria for both conventional and complementary medicine providers associated with the practice, inclusive self-governance through "circles" of practitioners and staff who meet regularly, and a requirement that each practitioner reserve at least 10 percent of appointments for low-income patients who pay either discounted fees or use time credits earned through community service. The program has enhanced access to care and improved the health status of low-income patients, and generated high satisfaction and retention among practitioners and staff. Evidence Rating (What is this?) Suggestive: The evidence consists of post-implementation data on the number of low-income patients served, trends in the health status scores of these patients, and various indicators of practitioner and staff satisfaction and retention.

Developing Organizations

True North Health Center
Falmouth, M

Date First Implemented

2002

Patient Population

Vulnerable Populations > Impoverished; Medically uninsured; Insurance Status > Uninsured; Vulnerable Populations > Urban

Problem Addressed The high costs of care prevent many uninsured and underinsured individuals from seeking needed care. Physicians complain that significant administrative demands created by insurers reduces time available for direct patient care. In addition, both insured and uninsured patients often find it difficult to access high-quality complementary and alternative medicine services from credentialed providers. Inadequate access, especially for uninsured and underinsured: Inadequate insurance combined with high medical costs lead many people to either delay or forgo care. In 2009, 45 percent of U.S. adults—including more than 70 percent of those with gaps in insurance—did not seek needed health care services due to their high cost.1 Insurance paperwork takes time from patient care: According to one study, physicians, nurses, and clerical staff at medical practices spend a combined 50 hours a week per physician on health insurance interactions. This time translates to more than $50,000 a year per physician spent on insurance-driven administrative tasks.2 Many physicians decry the lost time and expense that could be spent providing more comprehensive and effective care to patients. Difficulties finding credentialed providers of alternative medicine: Approximately 4 in 10 U.S. adults accessed complementary and alternative medicine in the past year.3 Often those interested in such services have a hard time determining if a particular practitioner has been adequately trained to provide such services, as licensing requirements vary significantly by type of service and across states.4 Description of the Innovative Activity A stand-alone, practitioner-run, multispecialty center (called the True North Health Center) employs several innovative policies to enhance access to conventional and complementary health care services, particularly for low-income individuals. Key policies include use of an independent contracting model for practitioners, strict credentialing criteria for both conventional and complementary medicine providers associated with the practice, inclusive self-governance through "circles" of practitioners and staff who meet regularly, and a requirement that each practitioner reserve at least 10 percent of appointments for low-income patients who pay either discounted fees or use time credits earned through community service. Key elements of these policies include: Independent contractor model: Each provider operates as a self-employed practitioner, setting his or her own fees, hours, and vacation time, and paying for malpractice and health insurance. Each also pays a separate fee to cover the cost of space and staff salaries and benefits, with three levels of fees depending on the nature of the service offered. For example, physicians pay more than massage therapists. Strict credentialing process, including for alternative medicine modalities: The center uses a strict credentialing process to ensure the quality of traditional and alternative medicine services. In addition to going through a standard credentialing process (e.g., letters of recommendation; proof of medical degree, license, and malpractice insurance; background check), applicants interview with the center's credentialing "circle," a group of practitioners who meet regularly to discuss credentialing issues. (See bullet below for details about this and other circles.) The group assesses whether the practitioner will fit in well with the center's culture and mission. Any practitioner who wants to offer an alternative or complementary medicine service must present to the circle published research on the modality's effectiveness. They must also hold the highest credential available for that modality if they wish to advertise it as part of their practice. For example, a licensed massage therapist who wants to offer craniosacral therapy must have the highest credential available in that service in order to advertise it. Self-governance through "circles": All practitioners and staff participate in governance through various groups (known as "circles") that meet regularly to discuss governance-related issues. Based on the ideas of Christina Baldwin and others and known as the "circle process," this self-governance process emphasizes the need for all voices to be heard and respected. Leadership of a circle rotates, with participants taking turns leading meetings, and all decisions being made by consensus (rather than requiring a unanimous vote). The "full circle," also called the True North circle, includes all practitioners and staff, while other circles include subsets who meet weekly, monthly, or as needed. Staff are paid for time spent in meetings, but practitioners are not. The typical meeting lasts roughly 90 minutes. Each meeting opens with a check-in where each participant can say whatever is on his or her mind; for some meetings with full agendas, the check-in step is limited to one word per participant. More details about some of the circles are provided below: True North circle (full circle): As noted, everyone participates in this group, which meets for roughly 90 minutes each week. The purpose of this circle is to keep all staff and providers up-to-date on current issues. Training in the circle process occurs in this group, as does planning for events and the practice's annual retreat. New practitioners approved in credentialing circle are introduced to the staff at the True North circle. Practitioner circle: This group addresses various issues that pertain to practitioners, including how to deal with difficult patients and challenges related to diagnosing patients. Practitioners are invited to make case presentations to the group once a month. Staff circle: This group discusses staffing issues, including job responsibilities and relationships among staff and between staff and providers. Decision circle: This group deals with difficult relationships and time-sensitive, complex issues related to running the organization. Anyone can join this circle, but those who do must agree to attend weekly meetings. Due to the sensitive nature of the issues and decisions, the content of these meetings is not fully disclosed to other practitioners and staff, unlike other circles. This circle also provides advice to the center's board of directors. Research circle: This group discusses research opportunities and protocols. The center requires all practitioners to participate in research projects, use outcomes measurement tools, and conduct patient satisfaction surveys. Mental health circle: This group meets monthly to mentor each other and discuss specific cases and issues related to patients' mental health. Clinical support circle: This group discusses patient care and charting issues. It also manages the practice's vaccine program and necessary certifications for the practice. Credentialing circle: This group discusses credentialing issues and matters related to interviewing applicants and discussing their qualifications. Direct payment, with required participation in time credits exchange: To eliminate insurance-related administrative burdens, the center does not participate in insurance plans, with most patients paying directly for services. To enhance access for low-income patients, all practitioners reserve at least 10 percent of their time to care for patients who use alternative payment systems, such as discounted fees or participation in the Portland Hour Exchange, which allows patients to earn "time credits" through community service to pay for health care services at the center. Earning time credits: Patients join the Portland Hour Exchange and earn time credit by completing community services such as raking leaves, cleaning, dog walking, and other tasks. These tasks may be completed for individuals or organizations that are members of the Hour Exchange. (For more information on the Hour Exchange program, go to http://www.hourexchangeportland.org.) Using time credits for medical care: Patients inform the scheduler at True North of their desire to use credits or pay a discounted fee when the appointment is set up, and the practitioner and patient come to agreement on the payment specifics during the visit. Patients with urgent needs who do not have "banked" credits can still receive care. Arrangements are made after the visit for the patient to earn credits or have them donated by friends or family members. Practitioners can serve as many patients as they like in this manner, although most aim to meet the 10-percent requirement. The board of directors monitors performance and notifies those not meeting the 10-percent goal. Accessing the exchange: True North practitioners can then exchange the hours they've earned through the program for music lessons, cleaning services, yard work and other tasks. (These tasks are not usually performed by the patients, but by other members of the Hour Exchange program.) References/Related Articles Elliott VS. Using time as currency can help practices care for the uninsured. American Medical News. December 12, 2011. Available at: http://www.ama-assn.org/amednews/2011/12/12/bica1212.htm. Contact the Innovator Bethany M. Hays, MDTrue North Health Center 202 US Route One, Suite 200 Falmouth, ME 04105 (207) 781-4488 E-mail: bhays@truenorthhealthcenter.org Innovator Disclosures Dr. Hays sits on the boards of the Hygeia Foundation, True North, and of the Institute for Functional Medicine. While she does not receive compensation for this board work, she reported receiving payment from the Institute for Functional Medicine for lectures and educational presentations.

Did It Work? Back to Top Results The program has enhanced access to care and improved the health status of low-income patients, and has generated high satisfaction and retention among practitioners and staff. Enhanced access to care: Since opening, the center has treated 674 low-income and/or uninsured patients who collectively received 2,806 visits at discounted fees or through time credits. The monetary value of this care totals nearly $250,000. Many of these patients likely would not have been able to receive this care without this program. Better health: In a 2-year study, three-quarters of patients receiving care through time credits reported an improvement in health status as a result of their treatment. Those who visited more often saw the largest improvements, and patients who visited three or more times improved their health status scores by an average of nearly 50 percent, well above the 33-percent improvement among those with fewer visits. All patients seeing complementary and alternative medicine practitioners reported improvements (by an average of 32 percent), while 70 percent of those seeing a traditional medicine provider (e.g., physician, nurse) reported improvements (by an average of 45 percent). High practitioner satisfaction: A 2009 survey found that 89 percent of practitioners believe the Circle Process represents a good form of governance, with 78 percent being satisfied or very satisfied with it. General practitioners tended to be more enthusiastic about it than others. High retention, enhancing continuity of care: The majority of practitioners (28 of 50) who have been accepted to practice at the center still work there. Eight practitioners have been with the center since its inception, and 14 have been with the practice for at least 5 years. These high levels of retention tend to enhance the continuity of care received by patients. Evidence Rating (What is this?) Suggestive: The evidence consists of post-implementation data on the number of low-income patients served, trends in the health status scores of these patients, and various indicators of practitioner and staff satisfaction and retention.

How They Did It Back to Top Context of the Innovation The True North Health Center grew out of a series of informal meetings by a small group of individuals who wanted to explore how the principles of “holistic nursing” could be applied at Mercy Hospital in Portland, Maine. Originally convened by three nurses who had heard about the concept at a conference, this group caught the attention of hospital leaders, who gave the group a small grant to explore the possibility of establishing an integrative medicine practice at the hospital. (See the Planning and Development Process section for more details.) After the hospital shelved those plans, members of the group decided to pursue the idea on their own. They established a 501(c)3 organization, called the Hygeia Foundation, and raised funds from interested individuals to open the center in January 2002. Planning and Development Process Key steps included the following: Informal meetings at local hospital: After attending a holistic nursing conference in 1996, three nurses at Mercy Hospital wanted to explore how to implement some of the principles at the facility. They called a meeting for staff interested in the topic; 20 people showed up. Over time, the group attracted more staff to its weekly meetings, including nuns, janitors, doctors, administrators, and kitchen staff. The group came to be known as the “Holistic Council.” Decision to use the Circle Process: To consider the full range of ideas from all participants, the group decided to use the Circle Process as described by Christina Baldwin in her book, Calling the Circle (Bantam, 1998). The group felt that this type of emotionally intelligent self-governance places priority on relationships, which they believed would help any program last longer. Research into integrative practices in the community: The group invited practitioners from the local area to make presentations about their healing arts services, including sharing evidence on their effectiveness and information on training, licensing, and credentialing processes. Roughly 10 practitioners made presentations. Development of alternative payment arrangements: While the group decided not to participate in insurance plans, they wanted to make care available to local residents who did not have the means to pay directly for care. Dr. Hays attended a lecture about alternative health care payment systems, including the Japanese system of Hureai Kippu (translated literally as “caring relationship tickets”), established in the 1990s. This system allows volunteers to earn time credits for helping elderly or disabled people. Volunteers may also donate time credits to an elderly relative to help them obtain needed services. While researching similar systems used in the United States, Dr. Hays identified the Portland Hour Exchange, which offers residents the opportunity to trade community service hours for needed services. True North made arrangements to join that program and offer health care in exchange for volunteer service. Resources Used and Skills Needed Staffing: The center has 14 onsite practitioners, including 5 physicians, 2 nurse practitioners, 2 acupuncturists, and 4 mental health practitioners. In addition, 13 credentialed, affiliate practitioners work offsite but still participate in the Circle Process. These offsite affiliates include a chiropractor, a naturopath, a myofacial release specialist, a reflexologist, several mental health practitioners, a life coach, a nutritional coach/fitness trainer, and a formulating pharmacy. Onsite practitioners receive support from 10 administrative staff, some of whom work on a part-time basis. Costs: The center's annual budget totals approximately $800,000, which includes staff salaries and benefits, rent, computers, office supplies, and ancillary costs. begin fsxml Funding Sources True North Health Center; Hygeia Foundation True North was started with the support of private donors.end fs Tools and Other Resources Baldwin C. Calling the Circle: The First and Future Culture. Bantam Books, 1998. Baldwin C, Linnea A. The Circle Way: A Leader in Every Chair. Barrett-Koehler Publishers, Inc., 2010.

Adoption Considerations Back to Top Getting Started with This Innovation Consider merits of being part of hospital: A hospital-based practice may have access to the organization's resources and other support, but also can face more regulations and inspections than a stand-alone facility. While those who created True North were dedicated to providing high-quality, safe care, they feared that the extra regulations would have added costs, and that the center might become vulnerable to funding cuts during the next budget crunch (something that had occurred to integrative medicine centers at other hospitals). Once the group decided not to open as part of the hospital, interest from the local alternative medicine community rose, thus making it even more important to develop a credible and rigorous credentialing process. Learn from others: True North founders regularly advise other organizations on how to develop a credentialing process and other aspects of this type of center. For example, representatives from a large, nearby medical center approached them to learn about credentialing providers for a complementary and alternative medicine center. Keep up recruitment: True North developers based their original projections on expressed interest by practitioners in the area. However, fewer than expected made it through the credentialing process, and the facility has never been used to its full capacity. As a result, program leaders continue to recruit new providers. Sustaining This Innovation Consider payment policies: The time credit policy has been changed several times since originally introduced in 2002. Initially, program developers expressed concern that people who could afford to pay would opt to use credits. Consequently, the original policy included income limits that prohibited use of credits for those above the then Federal poverty level`. This policy was later revised to raise the eligible income level to 225 percent of the Federal poverty level and to require patients to provide documentation to prove their eligibility. That requirement, however, proved too onerous to both patients and staff. In addition, challenges sometimes arose where patients needed care but did not have the necessary time credits, and when patients came for episodic care but did not follow through on their treatment plan for chronic conditions. As a result, program developers further refined the policy to its current iteration, which simplifies the process and enhances access for patients. Use one chart per patient: Although True North still uses paper charts, all practitioners have access to a single chart for each patient, thus allowing them to share information easily. For example, an internist can see the findings of the massage therapist and physical therapist, and all practitioners have access to test results. Keep circles focused: In 2007, True North's new executive director explored the total value of the time spent by staff and providers on various circles, discovering that it added up to nearly $500,000 a year. While staff and practitioners believed strongly in the circles, they reevaluated their organizational structure and the responsibilities of different people within that structure. They also clarified the focus of each circle. These changes reduced the estimated value of time spent in circles significantly, to $355,000 a year. Do not omit “check-in”: As noted, circles include a check-in with each participant. If the agenda is long, the leader may limit the check-in to just one word. Other times, the check-in may be “open,” which means participants can talk as long as they like. While this part of the meeting may seem counterproductive, it often clears the air and allows for more effective work during the rest of the meeting. After a 50-minute check in, the actual work of the meeting may take less than 10 minutes. Without the check-in process, however, the work might take much longer and not get done as well. In essence, the check-in process helps people get to know each other on a personal level, and allows them to work more effectively together. Weigh merits of research requirement: Practitioners have had difficulties in adhering to the contractual requirement to participate in organization-wide research, for several reasons. The day-to-day demands of medical practice often push research down the priority list for many providers. In addition, it can be difficult to compare findings with other practices. For example, True North’s administrative team has been unable to identify another practice willing to compare results from the American College of Physicians questionnaire. Finally, as a small organization, True North faces difficulties securing grants to cover the cost of research projects.

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