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Lawrence D. Brown and Beth Stevens Charge Of The Right Brigade? Communities, Coverage, And Care For The Uninsured Health Affairs, May/June 2006; 25(3): w150-w161. [Abstract] [Full Text] [PDF] [Reprints & Permissions]

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Community Approaches to the Uninsured

Richard M. Endress   ( 17 April 2006 )

Right Brigrade, Wrong Seven?

Paul Gionfriddo   ( 16 May 2006 )

Community Approaches to the Uninsured 17 April 2006
Richard M. Endress, President Access DuPage Send comment to journal: Re: Community Approaches to the Uninsured rend{at}accessdupage.org Richard M. Endress	I wish to comment on the recent series of articles on community approaches to care for the uninsured. As background to my comments, I am president of a five-year-old initiative called Access DuPage, which in 2005 delivered a full range of medical services worth approximately $22.2 million to 8,716 low-income, uninsured residents of DuPage County, IL (immediately to the west of Chicago). Let me begin by emphasizing that community-based approaches alone are not a solution to the nation’s uninsured issue. However, in the absence of any apparent national strategy for how to address the issue, community approaches are vitally needed. More importantly, I believe that community involvement in the design and execution of national or statewide programs, when they do eventuate, is crucial to the success of those programs. Based on our experience in Access DuPage, I’d like to suggest nine principles that I believe characterize successful community-based approaches. Perhaps these principles could be considered hypotheses that future research will corroborate or refute. 1. Successful community approaches must engage a critical mass of effective leaders from all sectors of the community required to address the uninsured issue, especially leaders from local physician groups, hospitals, and government. 2. All successful community approaches will necessarily be collaborative; that is, they will be designed not only to share information and coordinate activities, but ultimately to enhance the respective capacities of each participating organization to do what it does best. 3. Successful community approaches must ask and expect all individuals, organizations, and sectors within the local community to do their “fair share” in addressing the uninsured issue. 4. Successful community approaches will probably embody public-private partnerships by which local government and private enterprises work together. 5. Successful community approaches will address the provision of services across the entire continuum of care, not just at the primary care level (this is the Achilles' heel of many federally qualified health center (FQHC) approaches across the country). 6. Successful community approaches will probably incorporate what we term a “Mosaic Strategy”; that is, they will seek to use all models of care available within the community, placing emphasis on coordination and the elimination of duplication rather than on a centralized, one-size-fits-all approach. 7. Successful community approaches will be able to track outcomes across the entire continuum of care, building sustainable commitments through a relentless demonstration of real results. 8. Successful community approaches will develop sustainable funding capabilities, almost necessarily involving some combination of local financial support and ongoing government funding. 9. Community approaches are ultimately sustained by values, and successful community approaches will continually cultivate and reinforce such values. Thank you for the opportunity of adding my two cents' worth to this important conversation.
Right Brigrade, Wrong Seven? 16 May 2006
Paul Gionfriddo, Executive Director Palm Beach County Comm. Health Alliance Send comment to journal: Re: Right Brigrade, Wrong Seven? paul{at}pbccha.org Paul Gionfriddo	While "Charge of the Right Brigade?" by Lawrence Brown and Beth Stevens makes interesting points about seven Communities in Charge programs on which they focused, readers should understand that these were by no means a truly representative sample of either CIC or HCAP programs. In fact, had Brown and Stevens looked as closely at just one other CIC program, they might have come to a different set of conclusions. Specifically, in Austin, TX, the Indigent Care Collaboration (ICC) was sucessful in building a new system of care with shared electronic health records at its foundation, in winning a new countywide tax to support it, in systematically screening hundreds of thousands of uninsured people for scores of benefits and services, and in enrolling thousands of uninsured people in existing coverage programs. Most importantly, it also built a system it could sustain. Since I played a part in it, I'd like to be able to claim that there was something unique about the talents of folks in Austin, but the facts are that many of the attributes present in Austin -- focus, strong community leadership, provider engagement, and the sense of impending crisis -- were just as present in the other CIC communities referenced by the authors. What may have been different was that the ICC settled on two strategic approaches that in hindsight made a lot of sense. First, it attacked the problem with several strategies at once, some of which would offer opportunities for quick wins. The idea was to gain at least some benefit for nearly all of the 300,000 uninsured people in the community, without anyone losing. While there isn't space to go into detail, the shared electronic health record system, common eligibility and enrollment strategies, connecting health and mental health care, and expanding access to primary and specialty care were among the consensus strategies. Second, from the first day it received grant dollars, the ICC began work on the business premise that once grant funds were exhausted, the only ones left to sustain the initiatives would be the providers themselves. Each strategy therefore had to produce some direct bottom-line benefit to safety-net providers, again without anyone losing. While it may seem that circumstances in Austin were unique, I don't think that's the case. A year ago, I accepted the challenge of heading the Palm Beach County Community Health Alliance, where we're actively working to replicate the ICC model in a very different community, using many of the same strategies and some new ones, too. In the meantime, there are many other communities around the country -- many of which have drawn inspiration from the ICC model -- also working to implement multidimensional "virtual system of care" models. When all is said and done, maybe we'll learn that this is what communities can do best. If so, I for one would be happy to leave the major coverage programs to the state and federal governments. I'm just not willing to concede that just because these may not be the right answers for communities, we shouldn't be learning all we can from the ones, like the ICC in Austin, that are left.