The Scituate Health Plan
Organization and Delivery of Health Care Services
The centerpiece of the health care services provided by the Scituate Health Plan is the PrimaryCareFirst Health Center, a community based, multidisciplinary team of health professionals capable of providing 90 to 95 percent of Scituate's health care needs, and charged with the responsibility of knowing about and bringing care to everyone in the community.
The PrimaryCareFirst Health Center role includes primary care and personalized prevention, mental and behavioral health care that is integrated into the primary care process, maternity care, urgent care and emergency transportation for people who need care that is more complex than can be provided locally, home care, health education in community settings and in schools, exercise programs, community health measurement and surveillance, and community wide interventions into environmental or occupational challenges to the community's health.
The PrimaryCareFirst Health Center described here is the also the centerpiece of the first population-based primary care health system in the United States. Population-based primary care attempts to assign every person in a geographic area to a primary care practice, which becomes responsible for the primary and preventive care of every person in that community, and assumes overall responsibility for reducing the incidence and prevalence of disease, and improving the health, of the community as a whole. Because it addressees the community as a whole, population-based primary care provides a mechanism for addressing the incidence and prevalence of disease community by community, and place by place, as it creates health security for individuals.
Although its effect of both cost and quality is unknown, population-based primary care may reduce health care costs, because it provides lower-cost local primary care in place of expensive emergency room care, because it integrates mental and behavioral health into primary care (a process which has been shown to reduce cost) and because it increases the number of primary care physicians per 10,000 population, a process which has been shown to reduce mortality rates from heart disease, cancer and infant mortality, and which should impact on health care costs as well.
The Scituate PrimaryCareFirst Health Center
The Scituate Health Plan will design and construct a comprehensive community
health center, called the PrimaryCareFirst Center, in the town of Scituate.
(Discussions about potential sites are already underway in and by the Scituate
Health Plan committee, the Scituate Health Alliance Committee and the town council.)
Initially, the Center will look like a small to midsized (1-3) physician practice with some expanded services, such as those provided by nurse practitioners, nurse mid-wives, clinical social workers or psychologists (mental/behavioral health), and visiting nurses.
Eventually, when Scituate Health Plan is fully phased in, the Center will be open seven days a week, and will provide physician services, integrated maternity care, integrated mental health care, physical therapy, nutrition, and urgent care and emergency transportation services.
Scituate Health Plan members will visit the Center for scheduled well visits, as well as for same-day sick visits.
The Center will also serve as the base for home health, school health, community health, and health education programs, which will be directed by the Center's professional staff. In this way all the care to the community provided in Scituate will be provided by one multidisciplinary team, so that all Scituate's health activities can be provided in a rational and co-coordinated fashion.
Other Outpatient Services and Procedures
Patients enrolled in the Scituate Health Plan needing or wanting to access
doctors or services outside the PrimaryCareFirst Center will be able to do so,
though co-payment will probably be less for Center services than for those
provided outside (see Financing section of this document for more on funding and
insurance components of plan). In some cases these services will be arranged by
a member's Center-based primary care doctor, in other cases the Scituate Health
Plan member may seek care on their own.
Hospital Care
Center physicians will have admitting privileges at major area hospitals, and
will direct the inpatient care of Scituate Health Plan members who obtain
primary care through the PrimaryCareFirst Center. Center physicians will also
direct planning for care after discharge, which Center personnel will provide or
co-ordinate in the home and during post-hospital recovery.
Population Served
According to the Census 2000, Scituate has a population of 10,324. The median age is 39.7. Approximately 12% of the population is over age 65. 77.5% of total households are family households
The Scituate Health Plan will be capable of serving all Scituate town residents' primary care needs, and will aim at enrolling the entire town's population, in a step-wise fashion.
Initially, the program will focus on three populations:
1. Scituate town employees and teachers (approximately 600 people)
2. Uninsured and self-employed residents (approximately 1,000 people)
3. RIte Care enrollees and state employees who live in the town of Scituate
The first two groups will be offered the option of enrolling, and accessing both the Plan's Patient Savings Account structure and the PrimaryCareFirst Health Center. (see Financing and Insurance) When offered a similar Medical Savings Account option, employers offering these plans found initial adoption rates of 60-80 percent among their employees. As the benefits of MSAs become known among employee groups, adoption rates generally climb to 85 to 95 percent. The Scituate Health Plan expects an initial adoption rate of 50 to 60 percent.
Scituate town residents with Medicare, or whose health insurance is provided by their employers, can use the PrimaryCareFirst Center as a fee-for-service practice if they are not able to enroll in the Scituate Health Plan when the PrimaryCareFirst Health Center opens. With this fee-for service participation, and assuming the integration of at least one of the two primary care practices already serving the town, the initial population served is estimated to be 2500, or about 25 percent of town residents.
The Plan aims to include 90 to 95 percent of town residents over five years, by showing the attractiveness of the Patient Savings account model as it demonstrates the value of the access, quality, and comprehensiveness provided by the PrimaryCareFirst Health Center.
Using a population-based approach to medicine, the Scituate Health Plan hopes to improve the quality and consistency of care for residents with chronic diseases such as high blood pressure, high cholesterol and diabetes, building on the successes of many of today's best disease management programs. The Scituate Health Plan also seeks to improve immunization rates, mammography rates, Pap smear screening rates and breastfeeding rates by studying its defined population, and reaching out to those people who are not reached by traditional preventive technologies. Because it is community based, The Scituate Health Plan can reach these otherwise unscreened people, and those with chronic diseases who might benefit from disease management programs.
Because it will study and know the people it serves, Plan health professionals will be able to bring all the people it serves prevention and disease management, by collaborating with Plan visiting nurses, as well as by staffing a number of community based screening, educational, and exercise programs.
The first measure of the Plan's effectiveness is age and sex matched screening rates for the aforementioned screening modalities. Other, more important measures, include the Plan's ability to impact on the incidence and prevalence of disease in the population served, and the global costs of care incurred by Scituate's population.
A major aim of the Plan, but one more difficult to measure, is the Plan's ability to strengthen community ties in Scituate, as the Plan encourages community residents to care for and about each other.
Financing and Insurance -The Patient Savings Account
There are three tiers to the financing model that will be used to fund the
Scituate Health Plan program and insure enrollees. Funds are provided by a
person's employer, or by the person her/himself, if self-employed. The
per-person, per-year cost of Health Savings Account (a very similar model) is
generally less than the per-person, per-year cost of either membership in health
maintenance organizations or of traditional indemnity insurance.
* High-deductible insurance policy
For hospital care, and other expensive and long-term treatments, a
high-deductible insurance policy will cover the cost of treatments after the
deductible has been paid. The deductible will be drawn from personal health
savings accounts (see next item).
* Patient Health Savings Accounts
Enrollees will have individual savings accounts (or family savings accounts) to cover health care co-pays, deductibles, and other fee-for-service costs not covered by the PrimaryCareFirst health center. These accounts, referred to in state and federal policymaking as Health Savings Accounts(HSAs), will be funded with pre-tax dollars as allowed by federal law, and any funds not expended roll over year to year, earn interest, and can be rolled over into an Individual Retirement Account when the account owner turns 65.
* PrimaryCareFirst Health Center membership fees
The Health Center's basic functioning and overhead will be funded by a per-member charge of $150-300 per enrollee. This funding will also cover the balance (other than co-pays) of primary care and preventive health care services offered by the Center. Health Center membership is a requirement for participation in the rest of the Scituate Health Plan insurance and Patient Savings Account structure.
The marriage of population-based primary care to Health
Savings Accounts
improves both concepts. The HSA structure provides build-in cost controls, as
people become financially responsible for their own health choices.
Population-based primary care insures that people who use HSAs will have access
to prevention, and prevents the creation of a population of people who become
ill because of prevention that did not occur. This community-wide integrated
service delivery and financing system aims to restore community rating, as it
aims to motivate individuals in the community to join a single Plan that serves
the whole community by improving local access, creating local choices, improving
local outcomes, and lowering local costs. But an integrated service delivery and
financing system moves beyond community rating and into community building, as
it gives a community of people a reason to invest in each other, and in each
other's health.
Model Aspects of The Scituate Health Plan
* The Scituate Health Plan converts a patchy health care marketplace to a
comprehensive, population-based primary health care services distribution
system, a system that addresses the entire population served. The Scituate
Health Plan brings prevention and access to the entire community, including
those without health insurance and those who do not or cannot now use the health
insurance they do have.
* The Scituate Health Plan allows the community to learn about and describe
its health needs from a local perspective, and will use the assets and skills in
the community to allow the community to provide care of, by, and for its
members.
* By using a middle-class, semi-rural community to demonstrate the model's
cost-effectiveness, the Scituate Health Plan has the potential to de-stigmatize
community health centers, which are sometimes viewed as only appropriate for
poor, urban or rural populations.
* Because the intervention group is the entire population of the town, the model
allows precise evaluation of the project's success, by assessing the health
status of the population.
* The Scituate Health Plan model addresses economic and social capital building,
as it keeps health dollars in the community while providing access to primary
care and health insurance for all its residents.
* The Scituate Health Plan model preserves choice. Funds from the personal
Health Savings Account can be utilized to obtain care where and when the
patient wishes.