Accrued Cost Savings of a Free Clinic Using Quality-Adjusted Life Years Saved and Return on Investment.

INTRODUCTION: Savings garnered through the provision of preventive services is a form of profit for health systems. Free clinics have been using this logic to demonstrate their cost-savings. The Community-Based Chronic Disease Management (CCDM) clinic treats hypertension using nurse-led teams, clinical protocols, and community-based settings. METHODS: We calculated CCDM's cost-effectiveness from 2007 to 2013 using 2 metrics: Quality-adjusted life years (QALYs) saved and return on investment (ROI). QALYs were calculated using the Clinical Preventive Burden (CPB) score for hypertension care. ROI was calculated by tallying the savings from prevented heart attacks, strokes, and emergency department visits against the total operating costs. RESULTS: Using conservative assumptions for cost estimates, hypertension care resulted in a value of QALYs saved of $711,000 to $2,133,000 and an ROI ratio range of 0.35 to 1.20. Our study shows that when using conservative assumptions to calculate cost-savings, our free clinic did not save money. Cost-savings did occur, but the amount was modest, was less than that of cost-inputs, and was not likely captured by any single health entity. CONCLUSION: Although free clinics remain a vital health care access point for many Americans, it has yet to be demonstrated that they generate a net savings.

Reaching Urban Poor Hypertensive Patients: A Novel Model of Chronic Disease Care Versus a Traditional Fee-for-Service Approach.

BACKGROUND: There is a significant disparity in hypertensive treatment rates between those with and without health insurance. If left untreated, hypertension leads to significant morbidity and mortality. The uninsured face numerous barriers to access chronic disease care. We developed the Community-based Chronic Disease Management (CCDM) clinics specifically for the uninsured with hypertension utilizing nurse-led teams, community-based locations, and evidence-based clinical protocols. All services, including laboratory and medications, are provided on-site and free of charge. METHODS: In order to ascertain if the CCDM model of care was as effective as traditional models of care in achieving blood pressure goals, we compared CCDM clinics' hypertensive care outcomes with 2 traditional fee-for-service physician-led clinics. All the clinics are located near one another in poor urban neighborhoods of Milwaukee, Wisconsin. RESULTS: Patients seen at the CCDM clinics and at 1 of the 2 traditional clinics showed a statistically significant improvement in reaching blood pressure goal at 6 months ( P < .001 and P < .05, respectively). Logistic regression analysis found no difference in attaining blood pressure goal at 6 months for either of the 2 fee-for-service clinics when compared with the CCDM clinics. CONCLUSION: The CCDM model of care is at least as effective in controlling hypertension as more traditional fee-for-service models caring for the same population. The CCDM model of care to treat hypertension may offer another approach for engaging the urban poor in chronic disease care.

Developing a Family Medicine Postgraduate Training Program in Zambia.

BACKGROUND AND OBJECTIVES: The last decade has seen a number of educational programs in family medicine begin throughout the African region as many countries have recognized that family medicine offers an efficient way to meet the growing health demands of their country. Zambia's health situation is similar to many countries in sub-Saharan Africa by having a wide array of compelling health demands and a health sector with a limited capacity to meaningfully respond. This paper describes the efforts to begin Zambia's first post-graduate training program for family medicine. Several different methods were used to assist with the launch of Zambia's first postgraduate training program in family medicine: developing a logistical framework, regional site visits, building consensus among stakeholders, defining family medicine specifically for Zambia, and the development of a curriculum. Significant outputs achieved during the start-up period include: changes to the organizational structure of the medical school, budget reconciliation, and recruitment of the teaching faculty. Challenges that remain for the near-term include identifying appropriate district-level teaching facilities and the recruitment and retention of qualified faculty. Zambia's experience in developing family medicine may prove useful to other academic medical institutions throughout the region or in comparable socioeconomic circumstances as they look to address similar health sector challenges.

Breaking barriers to care: a community of solution for chronic disease management.

For 10 years the Medical College of Wisconsin and Columbia St. Mary's Hospital have joined together in a partnership to work within some of Milwaukee's most impoverished neighborhoods. Beginning simply by providing health care through a free clinic, the partnership soon was confronted with numerous examples of barriers to care being experienced by patients. A community-based participatory action process allowed the local population to give voice to the local realities of barriers to care. Here we combine our anecdotal clinical experience, the neighborhood's input, and an example of a successful program from a low-resource international setting to create a novel approach to treating chronic disease in uninsured populations. This model of care has been successful for 2 reasons. First, the model shows good health outcomes at low cost. Second, solid community partnerships with care providers, churches, and other groups have been formed in support of the model, ensuring its credibility and sustainability.

The new face of refugee resettlement in Wisconsin: what it means for physicians and policy makers.

BACKGROUND: Historically, Wisconsin has received refugees from 3 large geographic areas: Southeast Asia, the Former Soviet Union, and the former Republic of Yugoslavia. However, recent trends demonstrate a dramatic increase in the number of countries from which current refugees originate. Further, state migration patterns show that most counties in Wisconsin have sizable per capita refugee populations and can expect more. OBJECTIVE: This paper describes past and current refugee resettlement trends and their ramifications on health care delivery, health policy, and social development in Wisconsin. METHODS: Statistical data on national, regional, and state refugee resettlement trends was obtained from the US Department of Health and Human Services' Office of Refugee Resettlement and the Wisconsin Department of Workforce Development. Additional data was obtained from Milwaukee-based refugee service agencies. Further, discussions were held with health officials in Barron County and around the Midwest. FINDINGS: Beginning in the 1980s, with the influx of Laotian Hmong refugees, and continuing through the late 1990s with the end of the Balkan Wars, Wisconsin has provided safe refuge for thousands of refugees. Over the last 5 years the diversity of refugees being resettled in Wisconsin has accelerated to include an array of countries. This phenomenon has led to an increase in the range of health behaviors and health needs characteristic of these populations. The new face of refugee immigration has profound implications on Wisconsin's health landscape, not only in terms of clinical disease, but also in health policy, planning, and social development.