“By partnering with our local community health clinics, who already had infrastructure and resources in place for service and delivery of health care, we leveraged both what they can provide and what we can provide into more than either one of us could do our own.” Bell County Judge David Blackburn
The Bell County Indigent Health Care Collaborative received an Achievement Award from the National Association of Counties (NACo) last spring recognizing the collaborative as an “innovative, effective county government program that strengthens services for residents.”
The Bell County initiative, which was launched in 2020, reduced the county’s indigent health care cost to its lowest level in decades while also alleviating stress on hospitals and improving patient care.
“I am so grateful for this recognition from NACo,” shared Ebony Jackson, director of the Bell County Indigent Health Care Program (BCIHC). “It is such an honor to be able to work alongside all of the passionate health care leaders, advocates, and county officials who paved the way to ensure that the Bell County Indigent Health Care Collaborative could be such an immense success.”
Since its inception, the Bell County Indigent Health Care Department had functioned in largely the same way: Residents registered for the program, they received care in area hospitals – often from emergency departments – and the county reimbursed the hospitals. This model of using emergency departments instead of traditional primary care was both more costly and less effective, as patients had no hope for any continuity of care.
Through this collaborative, the county partnered with both the Greater Killeen Community Clinic and the Temple Community Clinic, making them the primary care providers for all BCIHC patients. To receive free care, BCIHC patients now visit one of the two clinics, where they receive both primary and specialty care, as well as prescription medications that the clinics are able to deeply discount through existing grant funds. Area hospitals, Baylor Scott & White, Advent Health, and Seton, also contributed to the effort by making it easier for clinic patients to schedule appointments for specialty care.
The results speak for themselves. Indigent patients now receive more regular and preventive care while costing the county less than half as much as two years ago.
“The Indigent Health Care Collaborative is a great example of the county partnering with local organizations and institutions to better serve our community,” declared Bell County Judge David Blackburn. “This national recognition is a celebration of not just our efforts, but also the efforts of the clinics and hospitals that made this program possible.”
From the Director…
The Bell County Indigent Health Care Program (CIHCP or Program) is a state-mandated program administered by Bell County.
The CIHCP is an eligibility-based health plan that provides medically necessary health care benefits 
for those who meet the income, resource, residency, and household composition criteria and who are not categorically eligible for the Texas Medicaid Program. The Bell County Program pays for covered services. Some services require prior approval, and all services must be medically necessary. The CIHCP is a payor of last resort and not an emergency service.
During my 20-plus year tenure working for our CIHCP, it has always been typical for the department to go above and beyond stepping outside of its comfort zone collaborating with local organizations and institutions to better serve our community. The last two fiscal years have been no exception to the rule of Bell County’s willingness to improve administering its Program while remaining in accordance with department rules adopted under Chapter 61 of the Health and Safety Code, providing medically necessary basic health care services to the under and non-insured.
On Dec. 31, 2018, the Bell County Health Care Collaborative dissolved due to hospital leaders opting out of the 1115 Waiver project. The 1115 Waiver project provided federal funds for several years to Bell County assisting in supplementing its 8 percent budget obligation and providing basic health care services. The county had already finalized its budget and anticipated that federal funding would be made available. With eight months left in FY19, the county funds depleted quickly, and the prior FY19 claims rolled well into the FY20 budget.
In April 2020, our CIHCP exhausted its budget, which resulted in our indigent health care customers no longer having continuity of care and in most cases losing their health care homes. The hospital ER rooms experienced a rise in patients utilizing their facilities for basic health care. Due to the ER influx, it placed a heavy burden on hospital staff serving patients who experienced longer wait times for patients, especially those in need of acute care.
The first red flag identified was the high dollar amount the Program paid for medical prescriptions. It soon became clear that there was a dire need for health care service delivery reform; we knew we could no longer administer services the way we had in the past.
The Bell County Commissioners Court began to intensely examine our CIHCP. Focused discussion between myself as director, members of Commissioners Court, and representatives of each of the three hospitals and community clinics began. We set a goal to cut costs associated with ER visits, prescription drugs, and basic health care while simultaneously increasing both regular and preventive care for our eligible customers.
The scope of the health methodology was to implement a collaborative effort geared toward:
- increasing access to care;
- delivery of services at a lower cost to taxpayers;
- best practice protocol through establishing a primary health care home;
- continuity of care through the community clinics; and
- a referral system between the clinics and hospitals for eligible BCIHC customers to schedule specialty care treatment with hospital providers as deemed necessary.
In September 2020, Bell County and the two community clinics entered a Memorandum of Understanding (MOU) with the delivery method allowing the community clinics to provide a lower cost of basic primary health care treatment in a local setting, which was deemed to be more cost effective. The impact of the initiative was a great success, and the proof is in the pudding.
The Bell County Indigent Health Care Collaborative reduced the county’s indigent health care cost to its lowest level in decades while alleviating stress on hospitals and improving patient care.
The advice I would offer to my fellow directors who would like to improve their programs is as follows:
- Develop a well-trained staff who understands the state guidelines. Provide your staff members with the appropriate software that will assist them with their tasks including case processing, bill payment, reporting, etc.
- Ensure customers meet the eligibility criteria. Strive for cost-effectiveness and efficiency by paying the Medicaid rate, acquiring reimbursement, providing medically necessary basic health services, and being a payor of last resort.
- Get out and into your community to establish relationships and collaborations with your peers who provide services to the similar target populations you serve. This will likely include reaching out to community-based organizations, clinics, and hospitals. Learn what the organizations have to offer that will eliminate duplicating services, and initiate proper customer referrals.
- Be fluid and adaptable, which means counties should move away from “how it’s always been done” if needed. Improve patient care and outcomes by utilizing new and innovative ways to administer your program; this will, in turn, lower your medical costs.
The software providers that support the Bell County Indigent Health Care Program efforts are Indigent Health Care Solutions (IHS) and Integrated Pharmacy Management (IPM).
IHS has played a vital role in our ability to organize and administer the program since 2003. The company’s unique software is set up and specifically structured around the indigent health care program, which makes it highly effective in maintaining case management records, medical claims, reporting, and DRG/Redbook coding. The software is very user-friendly.
IHS played a meaningful role in pinpointing the areas Bell County needed to focus on in lowering health care costs, monitoring reimbursements, and maintaining records across the board. The reporting capability and analytics provided solid data and insights into claims and operational costs. The friendly and helpful staff is available at any time to answer my questions. I highly recommend this software to any county who has an interest in becoming better at administering their IHC program.
One of the initial concerns before the implementation of the collaborative was the percentage of the budget being used for prescription costs. Integrated Pharmacy Management (IPM) was active in helping regulate these expenditures and reducing the current formulary at that time. IPM did not hesitate to promptly travel to Bell County on more than one occasion providing presentations and a report review pinpointing the medications such as analgesics, opioids, over-the-counter drugs, brand name medications, and muscle relaxants, to name a few, that were identified as high dollar meds being prescribed to eligible customers. The medications were promptly removed from the formulary, and Bell County began to see immediate prescription savings. Throughout the two years, our Program has benefited from IPM’s expertise in prescription cost savings. If a county wishes to save taxpayer dollars, have hands-on control of updating prescription eligibility, administer prior authorizations, and have the ability to look up member history and run standard reports, I would recommend IPM.
Why is it important to work with and/or keep your Commissioners Court informed?
Chapter 61 of the Health and Safety Code notes a “statutory obligation” of the local government to provide health care coverage. This chapter is often cited as the Indigent Health Care and Treatment Act. Due to the county’s responsibility, it is pertinent to work with and maintain a well-informed Commissioners Court.
The Bell County Indigent Health Care Collaborative is one of many projects that includes a Commissioners Court presence. This shows the passion and willingness of our Commissioners Court to be involved in better serving the community. It is a win-win to update the Commissioners Court members, who work every day to build vigorous, safe, and flourishing communities.