Alamance County aims to improve health with affordable services

Cone Health, a nonprofit health network in Alamance County, spends 20 percent of its budget on care for uninsured patients. But, Cone Health is not getting reimbursed for the costs, and patients are not getting healthier.

“We basically spend way too much money for the outcomes that we get for our uninsured patients because we spend it on inpatient visits and on emergency department visits rather than getting all of those visits to a primary care provider, getting them free medication and helping them manage their care,” said Kathy Colville, healthy communities director at Cone Health.

Identifying the problem

In Alamance County, 12 percent of residents live without health insurance, and 18.5 percent of people live below the poverty line based on Alamance County Health Department’s State of the County Health Report in 2017.

Since uninsured individuals often cannot afford quality care and lack adequate access to a primary care physician, Colville said they tend to dismiss their health concerns until they become too severe. Once these individuals can no longer ignore their health situation, they end up visiting Cone Health Alamance Regional Medical Center emergency department.

When individuals visit the emergency department for chronic conditions, they are spending more money for ineffective care, Colville said. According to Cone Health's website, an emergency department visit costs more than $500 for a patient seeking care.

The emergency department exists to attend to health situations that arise at any time of the day and need an immediate response, not to manage chronic diseases. Since individuals without a doctor visit this department for acute conditions, Colville said treating chronic conditions detracts from the emergency department’s effectiveness and thus the patients’ quality of care.

“When you have an emergency department that is full of chronic back aches, uncontrolled diabetes and anything that is actually better taken care of in a doctor’s office, you’re reducing the efficiency of the emergency department itself,” Colville said.

Because the care is inadequate to patients’ needs, Tracey Grayzer, president of Impact Alamance, a nonprofit organization that invests more than $2 million into Alamance County each year to create healthier outcomes, said emergency department visits are expensive for patients with chronic conditions because they pay for the costs themselves. She said these individuals continue visiting the emergency department and keep spending their money since the treatment does not cure their condition.

“The way our current system is set up is that it’s providing care in the most expensive place, and there has been no preventative measures taken,” Grayzer said. “We have a lot of folks who continue to come to our emergency departments because they don’t have access to care in the community.”

Since the United States does not offer fully government-supported health care, all American citizens have to pay some amount of money for health care, regardless of their financial situation. Colville said the country’s health care system has a cost-sharing component because she said people want to pay for only the health care they need.

“People become better consumers of health care when they have a financial stake in it,” Colville said. “If everything was free all the time, we would have an over-utilization problem.”

Although health care costs money, former President Barack Obama signed a health care law in 2010 to extend health care coverage to uninsured Americans and decrease health care costs, according to HealthCare.gov. For people with plans under the Affordable Care Act, or "Obamacare," North Carolina’s average benchmark premium in 2018 is $627, which is the seventh highest in the country.

Individuals who are not enrolled in health insurance plans under “Obamacare” pay a fee unless they qualify as low income.

“Obamacare” expanded federal funding for Medicaid, but North Carolina is one of 14 states that chose not to accept federal funding to expand Medicaid, according to Healthinsurance.org, a news website that tracks health insurance news and allows visitors to search for health care. Medicaid is a partnership between the federal government and the states, and it helps those with limited income and resources pay for their medical costs.

According to Healthinsurance.org, without Medicaid expansion, 208,000 people have no access to health insurance. If North Carolina accepted the expansion, 626,000 people would gain coverage.

In order to receive Medicaid coverage, Colville said the state determines which groups are eligible. She said North Carolina deems these groups worthy because they are not responsible for their health condition.

“There are some people who have specific circumstances in their lives that make it very difficult for them to pay for their own health care and be employed,” Colville said.

She said the state offers prenatal care to pregnant women who have incomes that are 196 percent of the federal poverty level, which is $20,780 for a family of three, according to HealthCare.gov, so that children are born healthy. Colville said these children are eligible for Medicaid up to one year after their birth so that they continue to develop healthily.

In addition to maternity-related coverage, Colville said parents with dependent children whose household income is up to 45 percent of poverty level have access to health care.

“The rationale is that we want those parents to be healthy enough to care for their kids,” Colville said.

Children with incomes up to 211 percent of the poverty level also have access to Medicaid so that they grow into healthy adults.

In addition to these groups, Medicaid also covers those who are 65 or older and those who are blind or disabled.

Offering low-cost care

Colville said Alamance County health organizations are trying to offer care to low-income people who are not eligible for Medicaid while diverting uninsured patients away from the emergency department so that they have access to affordable and quality care.

Cone Health Alamance Regional Medical Center, a nonprofit community health care organization, partners with Alamance Network for Inclusive Health Care, a coalition of safety net medical providers, to provide access to quality health care for those with limited financial resources.

Cone Health is a nonprofit hospital that strives to serve anyone regardless of financial limitations. Uninsured individuals get a 50 percent discount on hospital charges, but they qualify for additional discounts if they fill out financial assistance forms and score 200 percent below the federal poverty line.

The partnership also offers free clinical services at Open Door Clinic and Al-Aqsa Community Clinic for those who do not qualify for insurance in Alamance County. The Alamance County Health Department is another entity that offers dental care, physical exams and care management for children in addition to maternity care and physical exams for women at a reduced cost. The county likewise provides four federally qualified health centers for low-income individuals.

Alamance Network for Inclusive Health Care published these health care resources in a book called Your Guide to Free and Low Cost Health Care in Alamance County. The book also includes primary care, dental care, behavioral health resources, pharmacies, child health and family planning for uninsured patients or those who do not have full health insurance coverage.

“We can’t print them fast enough for people who need to use them,” Colville said. “We have a lot to offer.”

Maryn Hayward helped create this book when she worked at Alamance Regional Medical Center in the healthy communities department as a part of the Elon-Alamance Health Partner program. She engaged in one year of community health service and focused on increasing access to care for the underinsured and uninsured in the county after graduating from Elon in 2017.

“It’s been a huge help to not only patients seeking care but also community organizations or human service agencies who connect individuals to care,” Hayward said.

In addition to medical services, Colville said Alamance County offers the uninsured a variety of cost-effective health programs that strive to enact lifestyle and behavioral changes rather than prescribing temporary fixes.

Alamance County resident Betty Wooten shops for produce at Harris Teeter.

Alamance County resident Betty Wooten, who is 88 years old, said eating a healthy diet and exercising daily has contributed to her longevity. She said living a healthy lifestyle is an inexpensive preventative measure that has improved her wellbeing and quality of life.

Colville said Cone Health is promoting lifestyle changes to prevent future health issues rather than solely addressing health conditions that patients currently have. One Cone Health initiative is Be Healthy Now, which offers health and fitness activities for free.

Be Healthy Now offers free cooking class.

Enhancing health at the farmers market

The North Park Farmers Market is another initiative that strives to increase access to healthier foods in Alamance County for a more affordable price.

In 2016, Healthy Alamance, a nonprofit organization that works with Cone Health Alamance Regional Medical Center and Alamance County Health Department, established the first permanent farmers market in North Park as an outlet for residents to buy fresh and local produce.

Jared Bishop works as the North Park Farmers Market manager.

Jared Bishop, North Park Farmers Market manager, said the market tries to attract more Alamance County residents by offering affordable options for everyone. North Park Farmers Market is the only market in Alamance County that accepts Supplemental Nutrition Assistance Program and Electronic Benefits Transfer to ensure everyone can afford produce despite their income levels.

SNAP, commonly known as food stamps, is a federal program that provides a monthly supplement to help low-income individuals and families purchase food. The program aims to encourage the promotion of healthy food options as well. EBT is another federal system that allows consumers to transfer their government benefits to retailers in order to pay for products.

“We acknowledge that many of the people that we want to access and who want to shop in North Park do use SNAP and EBT,” Bishop said. “To not prevent anyone from shopping and to really include all types of people, not just people who have the provisions to shop at a farmers market, we wanted to make that program to really encourage and engage the local community.”

For SNAP and EBT users, the market has a Double Bucks program in which consumers can “double their bucks” up to $10. If the customer spends $10, the farmers market can double that and give them $20 worth of tokens. Healthy Alamance implemented this program to encourage consumers to choose healthier options and give farmers the opportunity to sell their produce in the area.

Alamance county residents buy produce at the farmers market.

The farmers market also uses Health Bucks, which are coupons for fresh fruits and vegetables. Bishop said the coupons provide financial incentives that give people the autonomy to buy their own food and make healthy choices.

Because the market provides these payment options, Bishop said the cost-effective produce changes people’s behaviors and contributes to better health outcomes. He said the market teaches residents how to shop more efficiently, healthily and affordably.

North Park has more convenience stores than grocery stores.

Healthy Alamance decided to open a farmers market in North Park because it is part of Alamance County’s food desert, a place with limited access to healthy food and often located in an impoverished area, according to the United States Department of Agriculture.

Bishop said the limited access to grocery stores and the inexpensive price of fast food restaurants contribute to unhealthy eating habits that he said negatively affects residents’ health.

In addition to alleviating food insecurity, Healthy Alamance also established the market as a business, not solely a place where people can buy healthy food.

“We decided to run North Park differently because most farmers markets in the area are run by volunteers,” Bishop said. “We saw in the beginning of the market that this needs to be run as a business, especially to promote growth and keep vendors there and make it affordable to all.”

Executive Director of Healthy Alamance Ann Meletzke said consumers were more interested in economic opportunities than health. She said Healthy Alamance set the market up as a business to positively change more community members’ behaviors.

“Not only do farmers need that to sell their food in Alamance County, but also, consumers need that to feel like they're a part of something,” Meletzke said. “We’re taking the farmers market and turning it into an opportunity for infrastructure development for the food system across the county.”

By making the produce more affordable and by giving more people access to healthier options, Bishop said the farmers market initiative is contributing to better health outcomes.

Preventing diabetes

Hayward is also the minority diabetes prevention program regional coordinator at Alamance County Health Department. She visited the North Park Farmers Market with her diabetes prevention class participants during a class field trip this fall.

As a part of the program, she provides class participants with free farmers market vouchers that offer them $5 worth of produce. Hayward said exposing her class participants to a cost-effective and healthy initiative in their neighborhood teaches them skills to shop and eat healthier for less money.

Diabetes prevention program uses voucher at North Park Farmers Market.

“Only one person out of five knew the market existed and that it was available, so it’s just introducing them to the concept of it and showing them how they can shop cheaply and on a budget,” Hayward said.

Hayward said the farmers market aligns with the purpose of the diabetes prevention class since both programs strive to improve health outcomes without breaking the bank.

The North Carolina Department of Health and Human Services gave Alamance County a $230,000 grant to run the Centers for Disease Control and Prevention’s diabetes prevention program, which aims to decrease adults’ risk of developing type 2 diabetes.

The American Diabetes Association said people diagnosed with diabetes spend an average of $16,752 each year on medical costs, such as treatment and diabetes medication.

Hayward said the diabetes prevention class aims to control the costs of medically treating diabetes by teaching participants about life skills, like healthier diet and exercise habits.

Hayward said with this knowledge, participants may lose weight, increase their physical activity and decrease their average blood glucose levels, which will cut their risk of developing type 2 diabetes in half.

According to the State of the County Health Report in 2017, Alamance County has a diabetes rate of 29.9 per 100,000 people, and North Carolina has a rate of 26.2 per 100,00 people.

Hayward said the program managers do not limit access to this diabetes prevention resource based on ability to pay. The class costs $25 for the year, but Hayward said the instructors offer scholarships up to $20.

“We could offer it for free, but we want to provide something to feel that they are committed and invested in it, but we put that money right back into the program,” Hayward said.

Diabetes prevention class meets to discuss how to stay healthy during the holidays.

Annette Radcliffe is an Alamance County resident who has been taking the diabetes prevention class for 10 weeks. Radcliffe pays $5 for the full year of classes because she qualified for a scholarship. She said the affordability of the class has provided her with knowledge and skills that have helped her lose 7 pounds.

“I’m being held accountable for being active,” Radcliffe said. “I’ve been tracking my activity and what I’m eating. It has made me more aware of what I should be doing to stay healthy.”

Hayward is currently teaching one of two classes in Alamance County to reduce diabetes rates. The class meets every week for 16 weeks and then will follow up on a monthly basis for the rest of the year.

Diabetes prevention class teaches Alamance County residents about healthier food options.

“They ask some questions, learn something new and then take that information home and challenge themselves for the next week,” Hayward said. “We try to mix it up and make it something that they will actually enjoy.”

Hayward said learning about daily habits not only helps participants initially lose weight but also helps them maintain a healthier weight in the future.

“They gain the skills they need for when the program ends,” Hayward said. “This isn’t a diet plan that we prescribe for 30 days. This is a year long commitment, and then you have the skills and the tools to continue making those lifestyle changes.”

Through the medical care and prevention programs that Alamance County offers, Colville said Cone Health Alamance Regional Medical Center and other health care agencies are continuing to provide more quality and cost-effective care that addresses residents’ needs and translates into changed behaviors.

“We’re all working together,” Colville said. “We’re figuring out which patients we share, what frustrations we share and how we can resolve these things together.”

Healthy Alamance group meets to conduct research for future initiatives.