Nixa clinic works to improve access, patient care

Daniel Burke, DO, operates three Family Medical Walk-In Clinics, urgent-care clinics designed to give all patients an alternative to the emergency room. The clinics each accept patients with commercial insurance, Medicare, Medicaid, no insurance and workers' compensation patients.

Two of these clinics are in Springfield and the other is in Nixa.

But the Nixa location at 103 Old Wilderness Road is different from those in Springfield.

For the past year, the 5-year-old Nixa clinic has operated with the Rural Health Clinic designation. That means that the Medicare and Medicaid reimbursement rate at the Nixa clinic is higher than it is for clinics without the RHC designation, said Tammy Mallow-Elly, director of business operations for Burke's clinics.

Making room

Burke said that the increased rate is an incentive to encourage health-care providers to make room in their practices for Medicare and, especially, Medicaid patients.

"Because of the reimbursement side of Medicaid, a lot of appointment-based practices really have a hard time setting appointment slots available for folks with Medicaid when they could fill those same slots with people who have commercial insurance," Burke said.

Burke said physicians have two basic charges for patients in clinic situations, one for new patients and one for existing patients.

He said the average office fee for a new patient is $85. Medicaid will reimburse $38 for children under 21, and $30 for all others.

If it is an existing patient, the standard charge is $70. Medicaid would reimburse $31 for a child under 21, and $24 for an adult.

But the RHC-designated Nixa clinics get about $63 per patient in Medicaid reimbursement.

The Medicaid reimbursements vary for each RHC location.

"As a Rural Health Clinic, they don't care what you charge, because they're only going to pay a flat fee that's all-inclusive. And that flat fee (varies) depending on the cost structure of your practice. But for our cost structure, the reimbursement is about $63 per patient," Burke said, noting that that amount is fairly close to commercial reimbursement rates.

Greg Barton, billing supervisor for the Family Walk-In Clinics, said Medicare requires a $100 annual deductible per patient and a coinsurance payment equal to 10 percent of the charges from supplemental insurance or from the patient, if he or she does not have secondary insurance. Medicare pays $46.38 for new patients and $37.75 for existing patients. At the RHC, the Medicare reimbursement also is $63 per visit, Barton said.

Patient volume

Burke attributes the fact that his clinics have always accepted Medicare and Medicaid even prior to the Nixa clinic's RHC status to high patient volume.

"By virtue of our ability to be open seven days a week with extended hours into the evening, our service is not appointment based, and accordingly, it is conducive to seeing larger volumes of patients than in a conventional family practice or other specialty-designated center," Burke said.

Mallow-Elly noted that all patients are charged the same fees only the reimbursement is different. And, she stressed, the quality of service is the same, regardless of payment methods.

"We don't differentiate. We don't take appointments, so we don't know when a person walks in the door, if they're Medicare or Medicaid to begin with," Mallow-Elly said.

She added that while some RHCs designate only specific time slots for Medicare and Medicaid patients, that is not the case with the Nixa clinic.

"We see (Medicare and Medicaid) patients, along with our self-pay and commercial insurance (patients) throughout the day. So what happens for the patient is they have a clinic that (with us) has an unlimited Medicare and Medicaid slots," Mallow-Elly said.

And that un-limited access is a key reason behind the RHC program, she said.

"The whole idea behind it, the original idea, was to get Medicare and Medicaid patients a place to go with quality health care and to get an incentive for providers to come into a health shortage area," she said.

Even with the higher reimbursement rate, Burke, who spent 15 of his 21 medical practice years in emergency rooms, noted that the RHCs are still less expensive for the government than emergency room visits.

"Obviously the state wants to motivate providers to provide access to the Medicaid population. But the reality is that without that incentive, at $30 a patient, it's really hard," Burke said.

RHC requirements

According to Bill Finerfrock, executive director of the National Association of Rural Health Clinics, the RHC program was authorized by federal law in 1977.

"There are a little more than 3,000 clinics nationally. The numbers vary significantly from state to state," Finerfrock said. In Missouri, Mallow-Elly added there are 140.

There are no other RHC-designated clinics in the immediate Springfield area, according to Mallow-Elly. She said the closest one is in Forsyth.

Finerfrock said there are two fundamental criteria for determining the location of RHCs.

"It has to be in an area that is rural. For the purposes of this program, rural is defined as nonurbanized areas by the Census Bureau. An urbanized area is any community with a population under 50,000," Finerfrock said. He noted that contiguous areas with combined populations of less than 50,000 also can be considered a community for RHC-designation purposes.

"The second requirement is that it be an underserved area designated by the federal government as a health provider shortage area or a medically underserved area, or an area designated by the governor as being underserved for the purpose of establishing rural health clinics," Finerfrock said, noting that designation by the governor basically means that states have the option of creating their own methodology to determine whether a shortage exists in a community.

Designating a health-provider shortage area "is essentially a methodology that evaluates the primary care physician-to-population ratio for the service area that's being examined," he said.

For the purposes of determining a health-provider shortage area, Finerfrock said that only primary care physicians are considered: family practice, general internal medicine, pediatrics and OBGYN.

"If the ratio is better or worse, depending on how you choose to look at it, than 3,500 people per one primary care physician and it's all done on a full-time equivalency basis then it is designated as a health-professional shortage area," he added.

That ratio can be affected by the number of doctors who don't see patients who are on Medicare, Medicaid or without insurance.

"Under the (health-provider shortage area), if a physician does not accept certain patients, you can adjust the (full-time equivalent) to reflect that," Finerfrock said.

He added that if it can be documented that a physician won't accept Medicare, Medicaid or the uninsured, the physician can be removed from the ratio.

"The difficulty with that is proving it to the satisfaction of the analyst," Finerfrock said.

"A lot of physicians will not necessarily acknowledge that they won't see certain patients If you were to call up a physician's office that you suspected was not seeing certain types of patients and you simply asked them outright Do you accept Medicare, Medicaid or the uninsured?' nine times out of 10 the physician's probably going to say sure, absolutely.'"

But if the analyst called the same practice to make an appointment as a patient with Medicare, Medicaid or no insurance, they might find that appointments are not available, or are several weeks out, in which case they would likely be seen instead in the emergency room, Finerfrock said.

Greene County shortage

Burke provided a practical example for Greene County's status.

"I know that the entire Greene County is considered a physician-shortage area by Medicaid, even though Greene County has 600-plus doctors in it," Burke said. "The problem is that you might have 600 doctors, but you have relatively few that will provide care to the Medicaid population."

For areas seeking RHC designation for a clinic using the medically underserved criteria, the doctor-to-patient ratio is considered, but not as heavily as other factors that would indicate a medical-care access problem.

"Those calculations are based on points values, but they look at things like infant mortality, low birth weight, socioeconomic characteristics such as unemployment, ethnic characteristics in terms of ethnic backgrounds in terms of English-speaking, age of the population (and) other socioeconomic and demographic characteristics which have traditionally been linked to communities and populations that have demonstrated an access problem," Finerfrock said.

Areas can qualify for RHCs by meeting either the health-provider shortage area or the medically underserved area criteria. He noted, though, that while medically underserved areas can be found in rural areas, they are more common in urbanized areas where the doctor-to-patient ratio is higher, but the socioeconomic and demographic factors would indicate access problems.