A coverage gap between health insurance from the Affordable Care Act and Medicaid has left an estimated 194,000 South Carolinians without health care. They are too poor to qualify for a federal tax credit to lower the cost of private insurance and don't fit the criteria for Medicaid.
But a new statewide initiative called the Healthy Outcomes Plan is providing some of those gap patients free care at hospitals in South Carolina, including those in Beaufort and Jasper counties.
Last fall, every hospital in the state wrote their own Healthy Outcomes Plan to keep uninsured patients with chronic conditions, such as diabetes or hypertension, out of emergency rooms.
These patients, who often can't afford to pay their own bills, cost hospitals and the government the most money. Every year, South Carolina spends nearly $500 million -- a combination of federal and state money -- to reimburse hospitals for providing uncompensated care.
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The state doesn't directly cover the cost of this new free care provided to Healthy Outcomes Plan patients. But each hospital had to develop a plan to preserve their full share of funding distributed by the state Medicaid agency, and they all received a 2.75 percent Medicaid-reimbursement increase as an extra incentive.
Opting out of the Healthy Outcomes Plan would have cost hospitals a 10 percent penalty on their "disproportionate share" funds, which they receive from the state for charity care, according to Access Health Lowcountry director Debbie Slazyk.
In the case of Beaufort Memorial Hospital, which works with Access Health Lowcountry for the program, that would amount to $900,000 of the $9 million it received, Slazyk said.
The S.C. Department of Health and Human Services, which writes the guidelines for the Healthy Outcomes Plan, lists 17 conditions it hopes to target through programs like Access Health.
Beaufort Memorial Hospital offers treatment for seven of them -- congestive heart failure, hypertension, diabetes, kidney infections, chronic urinary tract infections, chronic obstructive pulmonary disease and hypoglycemia. The hospital also attempts to refer patients to partner organizations for treatment of the other conditions, such as dental problems, Slazyk said.
Hilton Head Hospital offers treatment for three conditions -- diabetes, hypertension and chronic obstructive pulmonary disease, hospital spokeswoman Kelly Presnell said.
Coastal Carolina Hospital offers treatment for six conditions -- diabetes, cardiovascular disease, end-stage renal failure, chronic obstructive pulmonary disease, behavioral health conditions, hypertension, sickle cell conditions, and HIV and AIDS, hospital spokeswoman Carolyn Grant said. Grant said the hospital does not offer free care, but looks to send patients to medical homes to receive treatment for those conditions.
This year, hospitals were paid simply for participating regardless of how many patients they enrolled in the Healthy Outcomes Plan. Next year, the rules will change.
"We will tie it more to the actual level of enrollment," said Medicaid director Tony Keck.
The state's Medicaid agency set enrollment goals for each hospital to reach by June 2014, but they weren't judged based on those numbers.
Beaufort Memorial Hospital reached about 50 percent of the 190-person goal the agency set, Slazyk said.
Hilton Head Hospital, which was asked to enroll 57 people, enrolled 29, Presnell said.
Among local hospitals, only Coastal Carolina Hospital exceeded its goal, enrolling 80 people and surpassing its target of 73, Grant said.
Slazyk said the strict criteria made it difficult to find people to enroll. Unlike the Affordable Care Act's Medicaid expansion, which would have made more than 300,000 residents in this state eligible for insurance, the criteria for patients to qualify for the Healthy Outcomes Plan is tougher. They must be uninsured, must have made several trips to the emergency room and must have some chronic condition.
The Medicaid agency expects hospitals to enroll only 8,500 patients statewide. By May 31, about 7,000 had signed up.