Key Legal & Public Health Issues Impacting the Indian River County Hospital District

1. Key Legal & Public Health Issues Impacting the Indian River County Hospital District Presented by: Jennifer D. Peshke, J.D., M.P.H.

2. What is the role of the Indian River County Hospital District? • Special taxing district entrusted with annual budget of $14,579,423 in tax dollars, created by the Fl. State Legislature to fund public health services in IRC, Fl. • Legal obligation to provide medical care to sick indigent residents of the county under the provisions of section 20 of the Special Act, Laws of the State of Fl. • Residents who meet the standards of being indigent (family income not to exceed 150% of federal poverty guidelines) are eligible to receive medical care at no cost. • Indian River County Hospital District

3. What is the legal relationship between the District and the Hospital? • District owns land upon which hospital sits • Hospital is a public non for profit hospital originally owned, operated and managed by the original Hospital District Board of Trustees put in place by the Governor of the State of Florida in 1958. • In the late 70’s the District board made the determination not to continue management of the day to day operations of the Hospital.

4. Legal Relationship between Hospital and District Continued: • District entered into a lease with a community not for profit corporation, responsible for the day to day operations of the hospital. • District maintains ownership of the land and responsibility for paying for indigent health care which hospital provides. • Indigent Care Agreement also drawn up between District and Hospital re. reimbursement for indigent care paid for by the District to the Hospital. • Amendment of legal documents has occurred over time to meet the changing needs of the community .

5. What Public Health Agencies does the Indian River County Hospital District Fund? • Indigent care delivered by Hospital (IRMC) • Visiting Nurse Association (VNA) • Gifford Health Clinic • Partners in Women’s Health Services • Indian River County Health Department & Dental Clinic • University of Florida Mental Health Clinic, Mental Health Association and Mental Health Collaborative

6. What legal and public health issues impact all of the agencies supported by the District • Funding, budget, and reimbursement for all indigent health care provided • Access to care for indigent residents • Impact of the Patient Protection and Affordable Care Act (PPACA) on funding and Medicaid reimbursement rates • Availability of care for indigent residents beyond the ER, EMTALA implications and formulation of urgent care clinics

7. Funding of all Indigent Health Services in Indian River County: Funding: • Funding for all agencies (including Hospital) seeking reimbursement for Indigent Health Services is requested from District annually in June. • Each agency must come before District and make a detailed presentation as to funds requested, and show needs to be met, as well as outcomes from previous funding. • District Trustees then review budget requests and grant or deny them, taking into account current tax budget for the given year and any other funding agency is receiving.

8. Reimbursement for Indigent Health Services: Funding Continued: BolwellMethod: • The methodology for determination of inpatient, outpatient, and emergency cost reimbursement is documented in the Indigent Care Agreement • Method is based on reimbursement rates Hospital or agency would receive from Medicare for the services rendered, unlike Medicare, District does not limit length of stay for inpatient Care • This methodology is in place as the majority of Hospital’s patient base are on Medicare. Medicaid reimbursement rate is so low, this is most fair method and insures that Hospital or agency neither profits nor loses money from rendering care to District Indigent patients.

9. Partners in Women’s Health Services Program • Originated 1985 at request of District to meet need for obstetrical care (prenatal and delivery) to the underserved women in the county. • Large portion of women were receiving no prenatal care, few physicians were accepting Medicaid payment, and legal liability risks (delivery of a “bad baby”) were considered high. • Results : few women in Indian River County now deliver with little to no prenatal care, lowering legal liability for those delivering these babies. • Partners Program now runs out of free standing clinic through the Health Dept. and practice with privileges at IRMC.

10. Partners in Women’s Health continued: Legal obligation to fund: • Over past 15 years, funding paid by the District to the hospital has ranged from $600,000 to $1.8 million dollars. • Current funding methodology reimburses the Hospital the difference between direct budgeted costs and revenues collected for providing outpatient and inpatient services.

11. Partners in Women’s Health continued: Access to care: • Program provides care to nearly 2/3 of women that deliver at the Hospital, meeting a high public health need in the community, however cost of the program is very high. • Recently District has also begun to reimburse Hospital for a portion of the costs associated with providing Pediatric/Nursery care to newborns.

12. Partners in Women’s Health continued: Due Diligence by District of Partners Program: • Program revisited this past month by the District Trustees to ensure District dollars were being well spent and costs were not escalating to a point beyond reason. • Currently District paying approximately $2,581.86 per birth to an indigent mother, cost was found to have increased less than $100.00 per birth over past 5 years • Board voted unanimously to continue the reimbursement method in effect • Program served over 700 indigent mothers and babies in 2010.

13. Visiting Nurse Association (VNA) Funding: • District currently leases space to the VNA in the District owned Human Services Building at a nominal cost per year. • District also funds several VNA programs which contribute to the legal obligation of District to meet the need of access to care for indigent residents

14. VNA Continued: Access to care: • VNA Home Health Care: • VNA pays for home health care for indigent residents of the county and District agrees to pay for those services at a reduced percentage of usual and customary charges. • VNA Mobile Health Services: • VNA provides mobile health services to indigent residents of the county and District agrees to pay for start up and maintenance funds for the program. Mobile health clinic was purchased and outfitted and presently operates throughout the county. • VNA Hospice House: • District has entered into a lease with VNA to allow VNA to operate a Hospice House on District owned property. • The lease is for a twenty year term with $1 per year rent. The VNA has agreed in the lease to operate the Hospice House in the public interest and for the use and benefit of all residents of Indian River County, including indigent residents.

15. Indian River County Public Health Unit Primary Care, funding and access to care: • In 1987, District began contributing towards the Indian River County Public Health Unit’s Primary Care Program. • Public Health Unit is a hybrid between the county and the Florida Department of Health and Rehabilitative Services. • District contribution to the primary care budget is revisited each year to ensure the contribution is both needed and adequate to meet the needs of the county public health unit.

16. Public Health Unit Continued: We Care, funding and access to care: • In 1992 District agreed to fund the cost of a coordinator of the We Care Program operated by the county public health unit in conjunction with local physicians. • Local physicians have agreed to volunteer their time at the health department however the program was in need of a care coordinator. • District funds the costs of the care coordinator on a yearly basis, which funding is revisited each year.

17. Public Health Unit Continued: Dental Clinic, funding and access to care: • 1992, District agreed to fund the cost of a dental clinic within the Health Department. • Clinic initially designed to be a one time funding, however , developed into an annual funding by District to pay costs associated with dentist to work in clinic. • District funds the costs of the care coordinator on a yearly basis, which funding is revisited each year.

18. Gifford Health Clinic Access to care: • Gifford Demographics • In 1994, District concerned about access to health care polled the residents of Gifford, study showed both the desire and need for access to a neighborhood service delivery site. • District set aside funds to renovate an old school, leased to them by the school district, and with the help of many organizations created a neighborhood clinic. • Two years later, the school district advised the hospital district that the current health center site was slated for demolition and a new location for the health center would be necessary.

19. Gifford Health Clinic Continued: Funding: • Many supportive groups stepped in to build the new $1.5 million clinic, with the effort led by District. • The County Commission donated 3.5 acres of land. • Close to $400,000 of private giving and grants was collected; the remainder of funds came from tax dollars raised over a period of five years.

20. Gifford Health Clinic Before and After photos showing the fruits of the District’s labors: Before After

21. Outpatient mental health services for indigent residents in Indian River County Meeting the legal obligation to provide access and funding for mental health care: • Florida’s mental health system received a “D” in NAMI’s Grading the State Report in 2009, it slipped from a “C” rating in 2006 • Florida ranks 49th in mental health and 35th in substance abuse funding • Florida is one of only 7 states without a mental health parity law • Greater need for mental health services now more than ever due to economy

22. Meeting the need to provide access to outpatient Mental Health Services Formation and support of the Mental Health Association: • 1996, the MHA was formed in IRC to meet the need of providing mental health services to indigent residents at little to no cost. • MHA has been funded by District since 1996 as District recognizes the need to provide these services . • The MHA has grown to include a walk in center with many programs geared towards varying issues related to familial and mental health. • The new program in place meeting the ever increasing needs of the community for mental health services is “Its Okay to Get Help” • It’s Okay to Get Help

23. Mental Health Services Continued: Collaboration to meet the legal need of providing funding and access to care: • Formation of The Mental Health Collaborative, 2004: • Mission: To establish a continuum of care for mental health made up of private and public funders and mental health providers who work in collaboration to increase access, decrease duplication and facilitate community-wide support for mental health issues. • Vision: MHC seeks to provide a seamless delivery of mental health services developed through a collaboration of funders and providers. • Mental Health Collaborative

24. Mental Health Services Continued: Legal obligation to FUND Care: • MHC funded by three groups: The United Way, District, and the McCabe Family Foundation • MHC has been instrumental in obtaining $300,000 in matching funds for the first year for the Mental Health Walk-in Center

25. Mental Health Services Continued: Legal obligation to provide ACCESS to care: • Facilitated the opening and ongoing existence of the Mental Health Walk-in Center • Facilitated the effort that brought the University of Florida Center of Psychiatric and Addictions Medicine to Vero Beach. • Held the first Mental Health Symposium, supports Mission and Vision of the MHC to lessen the stigma and increase access to services.

26. Mental Health Services Continued: Access to Outpatient Care and Collaboration of Hospital, District and University of Florida • Partnership with the University of Florida: In 2008 both Hospital and District recognized need for outpatient mental health services for uninsured or underinsured patients and as a result of this need, District has provided funding to Hospital for outpatient mental health services to be provided to the indigent population in Indian River County

27. Mental Health Services Continued: Legal obligation to Fund care: • Hospital, via funding from the District, is able to assist University with specific resources for establishment and successful operation of the Center • By providing patient care support payments to University with District funds, Hospital derives the benefit of being assured that its outpatient psychiatric indigent patients will receive affordable mental health services.

28. Impact of PPACA on future Funding and Reimbursement • The impact of the Patient Protection and Affordable Care Act (PPACA) on reimbursement methods in the future is one of the biggest legal unknowns facing the District at the present time. • District and agencies are aware that they will all be faced with this issue and are preparing to revise the existing Indigent Care Agreement and funding requests when new reimbursement rates are known.

29. Impact of PPACA on Funding and Reimbursement Continued: • Goal is to ensure proper funding is paid by District to pick up what is predicted to be a looming short fall under the new law • District may have to exercise legal right to raise tax millage rates and hence raise taxes within District’s purview to accomplish meeting legal need of funding indigent health care in future. • Legal and public health policy issues with District exercising legislative authority to raise taxes to fund public health programs

30. Economic state creating additional legal and public health issues for the Hospital District • ER over use due to higher population of uninsured • Impact of Emergency Medical Treatment and Active Labor Act (EMTALA): • Higher rates of uninsured people results in more people using ER for care, presenting with higher rates of “emergency” due to foregoing primary care, a majority of these people are indigent. • EMTALA is a federal law that prohibits a hospital from turning an individual away from an ER for treatment if the person “comes to “ the ER suffering from an “emergency medical condition”

31. District Response to ER over use Access to care: • 2010: creation and funding of two free standing urgent care centers in Indian River County • Funding: • District to reimburse Hospital for indigent patients seen at the clinics at Medicare payment rate • Outcomes: • Goal of reducing use of ER by indigent residents for primary care needs, and in turn reducing overall overhead of ER department and reducing overall cost of indigent emergency care at the Hospital.

32. Conclusion and Questions • Many details presented today are unique to Indian River County, and to Florida’s public health system, however the issues themselves as a whole are quite common within the public health sector of the United States. • I welcome any questions you may have at this time.