Minding the GHAP

Doctors who care about their patients' (expenses)

by Chris Kanaracus

It's about noon in the northern Massachusetts hamlet of Baldwinville, and save for the brittle sound of a jackhammer carving out an abutment near Al's Mini-Mart, the town is a Rockwellian, if slightly weathered, abstract of bucolic Americana.

It's much the same story about a mile up the road at Narragansett Health Care (NHC), a low, brown-shingled, one-story building with a sturdy, sand-and-pebble covered handicapped ramp and a sign above the door that reads: PLEASE RING BEFORE ENTERING.

The level of activity inside NHC, then, comes as a bit of a surprise. Staff members sign patients in and out with rapid but cordial efficiency. Nurses chase down small children hiding near the magazine racks; phones ring incessantly. One patient, thin, with hollow cheeks and wearing a shabby coat, flashes a pearl of a smile as she trots smartly out the door.

According to NHC physician Gretchen Kelley, that sort of goodwill has become common around Baldwinville in the past couple of years, thanks to the Gateway Health Access Program (GHAP), an innovative system meant to provide for the uninsured. And it's been so successful, beginning in January it will expand to hospitals in Leominster and Gardner.

GHAP was formed at Gardner's Heywood Hospital in January 1998 at the urging of a local grassroots coalition, the Greater Gardner Community Coalition, after it conducted a study that found many Gardner-area residents had no health insurance.

The program is partly a screening process for available public assistance, similar to Worcester's successful Healthcare Outreach, and partly a reduced-fee health plan. Under GHAP, patients who arrive at area hospitals without health insurance undergo eligibility screening for programs like MassHealth. If a patient falls short of those requirements, program advisors seek out and present alternative, affordable private plans. Should those two measures fail, GHAP's final option is a reduced-fee care system, based on a sliding scale according to an individual's income. Members choose a primary-care physician from a sizable pool of area doctors who agree to be a GHAP member.

The income requirements are surprisingly generous. Eligible applicants' income can run from approximately 200 to 400 percent above the federal poverty line, or about $15,000 to $42,000 per year. Patients at the low end of the range could pay as little as $15 for an office visit and $40 for a physical, and they can save substantially on surgeries conducted by participating specialists.

But while its sliding scale is what sets GHAP apart from similar programs, it's also a "last ditch option," according to Kelley. For while it might provide clients with affordable, basic care, it's not an insurance plan: there's no inpatient provision, for instance, and medications aren't covered.

"The real goal of this program is in the screening phase, where we try to get people on some type of insurance," says Kelley. "That's where they should be, and that's where we want them to be."

But what this tiny program is proving is that it can help bail out smaller community hospitals that treat a growing number of the area's rural poor.

During its first two years, GHAP's organizers have done just that in a relatively quiet fashion, and in sharp contrast to the growing turmoil in organized health care across the nation. Currently, about 40 million Americans have no health insurance, a number that industry officials estimate will grow to 46 million by 2002. Exacerbating that growing rank, many health-care experts warn, is the troubled health-maintenance organizations, or HMOs. Just last month, Tufts Health Plan of New England, one of the area's largest providers, announced plans to pull out of New Hampshire and Rhode Island, only months after suspending its operations in Maine. And Harvard Pilgrim Health Care of Massachusetts may be the subject of a massive state-government buyout.

Such shakeups haven't, and probably won't, affect GHAP in one way or another, since the bulk of HMO business comes in the form of employee health plans: exactly the opposite of the population GHAP is meant to serve. "People might find their job plan changing over to something else; but the fact is, they'll have something else, whatever company it ends up being. The people that come to us don't have that option," says Lorie Martiska, the GHAP program advisor at Heywood Hospital. Then again, government figures show the number of workers covered by their jobs to be in decline, down to 74 percent in 1998, after holding steady at 78 percent in previous years.

Since its inception, GHAP has enrolled about 750 people into MassHealth (the state's Medicaid program), referred hundreds more to alternative programs, and currently serves about 200 patients with its sliding-scale plan. The result, says Martiska, has been improved health across the region, better doctor-patient relationships, and a considerable reduction in hospital debt.

Other, similar efforts are underway across the state. North Adams's EcuHealthcare continues to operate. In the Holyoke and Springfield areas, there's Hampshire Health Access. In Lynn, Union Hospital sends a "community health van" through residential neighborhoods in an effort to enroll Lynn's large population of poor immigrants in MassHealth. It's a welcome effort, to be sure, when one considers the latest US Census figures concerning health care, that show more than half of the foreign-born poor are uninsured nationwide.

To that end, Beth Buxton, social worker for GHAP's expansion into Health Alliance's hospitals in Fitchburg and Leominster, says the decision to sign on was an easy one. "We have a huge catch-basin of under- and uninsured people around here," says Buxton. That fact isn't surprising, especially in struggling Fitchburg, where factory closings in recent years has nearly crippled the local economy. And Fitchburg, like Lynn, has a sizable number of minority residents, many of whom are children.

Consequently, according to Buxton, the health program of choice for many in Fitchburg and Leominster has been the emergency room. "We've even seen people come in the advanced stages of a disease. Without a primary-care physician, it's hard to know what your health status really is."

Since GHAP was announced among Health Alliance staff earlier this year, says Buxton, 62 physicians and specialists have signed on, and "every day, we hear from two or three more."

Back at Narragansett Health Care, Gretchen Kelley, one of a handful of physicians that makes up NHC's staff, embodies that sort of enthusiasm. She's a sweet-faced woman of about 30, who, at times during a conversation in one of her examination rooms, leans forward out of her seat, almost unknowingly, her eyes alight.

"It's been a huge success," says Kelley, who is perhaps more satisfied than most by that fact, since she was one of the first physicians to sign on with the program, and remains a so-called "physician's champion," basically a liaison between GHAP administrators, participating doctors, and clients.

Kelley saw a need for a GHAP-like program when she joined NHC in July '96, after a residency at a Fitchburg hospital. "[In Fitchburg], you didn't see that many people without insurance . . . they'd be on MassHealth or some other state program, or they'd have coverage through their jobs. Out here, you have a lot of folks who either work part time, or are self-employed, or who just aren't aware of the existing programs available to them." And sometimes, says Kelley, it's not ignorance of the program, but instead reluctance, due to shame.

Prior to GHAP, says Kelley, local doctors would provide such people with care as a "professional courtesy," at a reduced or token cost. Some, in fact, still do.

Though that may have been a common arrangement, it wasn't exactly a comfortable one. "You try to charge people something fair, say $30 for an office visit, as opposed to $65. . . . But who's to say what I should charge people? I don't want to get into everyone's business about what they make, and all that," Kelley says.

Beyond the prying nature of such negotiations, she adds, there were certain unavoidable situations. "You want to take someone at face value when they say that they have no insurance, and say they can't afford to pay the full amount. But I know of at least a few people that have pulled up and said that, [and they] were driving nice cars, nicer than mine."

But Kelley stresses that money isn't an issue for her, or for most other physicians. "I'd rather not get into the financial end of things. That's not what I got into medicine for."

And GHAP, says Kelley, largely removes that issue from her purview.

GHAP helped ease George Crowley's worries, too. About three years ago, the 62-year-old, retired Gardner dog officer found himself without insurance.

The health plan provided by his town job was defunct, and under Crowley's meager income from Social Security, the cost of private coverage was too high. It was a bind, Crowley thought, that he'd be in for three nerve-wracking years, until he reached age 65 and could receive Medicare. "If you've got no insurance, you sweat," Crowley says, in a soft, wheezy voice.

That came to an end when Crowley opened up his local paper and found an ad for the GHAP program. He quickly signed up for the sliding-scale plan, and nearly two years later, he's still on it. "It was a lifesaver. The care and the people have all been excellent." And while Crowley hasn't encountered any major health issues since he's been enrolled in GHAP, he says the sense of security has been reward enough. "If you don't have insurance, it holds you hostage."

Crowley's analogy unwittingly hints at something else -- namely, the reason why Health Alliance is eagerly awaiting the introduction of the GHAP program in their facilities. Thanks to GHAP, Heywood Hospital shaved $400,000 dollars off of its free-care expenditures.

All hospitals in Massachusetts are required to make annual contributions to a pool, the Free Care Pool (FCP), which is then distributed back to hospitals to cover a portion of the costs of caring for the uninsured, such as the homeless. But Massachusetts's larger cities, which contain most of the state's homeless, can easily recoup most of what they pay out. Heywood's Martiska says small hospitals like hers found they weren't receiving enough money.

"You can't charge back to the FCP if someone isn't registered," says Martiska. "Screening them through GHAP lets us do that." According to Martiska, Heywood is now "net even" with the FCP.

But if hospital administrators' primary motive for bringing in GHAP is financial, you can hardly blame them. And, perhaps, as Kelley says, "motives don't really matter" when it comes to insuring the uninsured.