Center for Studying Health System Change

are for the poor in Miami is currently being threatened by the weakening tax base that finances indigent care and the vulnerability of many traditional indigent care providers coupled with anticipated growth of the uninsured. There are an estimated 400,000 uninsured and 400,000 Medicaid eligibles in Miami.²¹ These numbers, believed to include a number of the working poor, are expected to increase as a result of falling insurance rates among those employed by small businesses, the constant influx of immigrants into the area and the anticipated impact of welfare reform. Cultural views regarding the role of government may also contribute to the high uninsured rate. Respondents report that within the Central/South American culture, health insurance is viewed as the responsibility of the government; therefore, many Central/ South American employers do not offer health benefits to their employees.

Providers serving these groups include Jackson Memorial Hospital and its network of nine community clinics as well as the federally qualified community health centers. Until recently, the County Health Department also provided clinic services, but Jackson Memorial has taken over these clinics through a competitive bidding process. While there are a large number of clinics, there is considerable conflict and division between the Jackson Memorial system and the federally qualified health centers. The conflict goes back many years: the concentration of the indigent care dollars at Jackson and the more recent competition for Medicaid enrollees are the focus of current concern. Prior concerns that admitting privileges for center physicians limited their ability to keep their patients and provide continuity of care may be abating, but health center respondents continue to report difficulties in specialty referrals and in tracking patients once they are referred to Jackson programs.

The Jackson Memorial clinics are located in several neighborhoods and at the downtown medical campus, where all specialty clinics are based. Of the five community health centers, four are located in the greater Miami area and serve specific ethnic or racial groups. The fifth center, Community Health Initiative of South Dade (CHI) serves the largely rural South Dade area, including the migrant population. Located in their service areas for many years, the five community health centers have strong ties with local leadership. In addition to the JMH and community health center providers, a number of hospitals sponsor clinics, mental health clinics, substance abuse programs and other community-based services generally located in various neighborhoods. A variety of traditional public health and prevention services are sponsored by the County Health Department and community hospitals.

The two major financing mechanisms, the county indigent care fund and Medicaid, are both undergoing changes that may affect support for the delivery of care for the poor. The county indigent care fund, financed by a property tax millage and supplemental funds from the sales tax, primarily supports Jackson Memorial Hospital, its clinics and other services through the Public Health Trust. As a result of centralization of indigent care dollars, Jackson Memorial has been the only place where funds were available to pay for inpatient care as well as many specialty services. The other provider receiving dollars from the fund is one of the federally funded community health centers, Community Health of South Dade, due in part to the lack of JMH clinics in South Dade and the size of the uninsured and underserved population in that area. Other providers have been unable to receive county funds even though they serve indigents in the county.

The community health centers, in particular, report that they are experiencing major financial difficulties because of the lack of support for indigent care and decreased revenues from other sources, particularly Medicaid. In some cases, these facilities have reduced services and closed sites. Medicaid has been a major payer of services for the poor, particularly those provided by community health centers. Centers report that high Medicaid payment rates under the old fee-for- service system helped the centers cross-subsidize services to the indigent. They indicate that as Medicaid has begun to enroll beneficiaries in managed care, they have seen a reduction in the number of Medicaid patients they traditionally served. To retain these patients, centers are being asked to accept various capitated arrangements from plans, which further reduces their Medicaid revenues. At the same time, they report an increase in the number of uninsured patients showing up at their centers. With the new Medicaid efforts to increase enrollment in health plans, they anticipate a further erosion of financial support for center services.

Providers seeing the poor are developing a variety of strategies to be more competitive in Medicaid managed care contracting. The individual centers are joining various plan networks to provide multiple opportunities for their patients to select the center as their provider. Several groups have organized for Medicaid contracting, and Jackson Memorial is trying to strengthen the competitiveness of its plan, the JMH Health Plan.

Health Choice is a provider network involving three Dade County federally qualified health centers, three mental health centers and a health center outside the area. To date, Health Choice has established a number of shared services, hired joint clinical chiefs of services and is developing a management service organization (MSO). It has also developed a primary care network to contract with health plans, and was included in several of the Medicaid proposals during the recent contracting cycle. Aurora is a for-profit provider network of community mental health centers that represents the primary source of mental health services for the indigent. It was organized to contract with health plans for Medicaid patients. To be competitive, it is integrating administrative functions to increase efficiency and lower operating costs. Alpha, a health plan developed by the Florida Association of Community Health Centers on a statewide basis, was successful in the recent Medicaid competition. Only one Dade County federally qualified community health center (FQHC) chose to participate in the plan. The success of these ventures may improve the competitiveness of participating providers in the Medicaid market.

Expanded contracting with-in Medicaid is shifting Medicaid enrollees from obtaining their care almost entirely from the Jackson Memorial Hospital and health center providers to a broader set of providers in the private sector. This may have positive and negative effects on access to care. For the Medicaid population, the broadened provider base may improve access to care. For example, patients who once had to drive two hours from South Dade to Jackson Memorial may be able to make a much shorter trip to a local provider. However, for indigent patients using traditional Medicaid providers, those providers may have reduced capacity to meet indigent care needs if their so-called paying population decreases or the payment for these patients is reduced.

Indigent care capacity in the county therefore faces several challenges, including:

• continued centralization of spending of indigent care dollars;

• incorporation of communities, which has the potential to alter support for county indigent care funding; and

• diminished capacities of other traditional safety net providers.