Since December, clients receiving medical health services from the Lesbian Services Program at Whitman-Walker Clinic have been required to pay a fee for their care, part of a move by the clinic to bring in more revenue while continuing to provide the best services possible.
Ellen Kahn, director of Lesbian Services, says that the change is “not a complete turnaround” in policy, because “the Lesbian Health Center historically has asked clients to contribute to the cost of care,” in the form of donations. Now, however, the program is using a fee schedule based on the client’s income.
Like many service-based organizations in the United States, the clinic has suffered budgetary strain during the past several years. Fluctuations in the stock market, a declining U.S. economy, the after-effects of the terrorist attacks of Sept. 11, 2001, and an increasing joblessness rate have reduced charitable donations to the clinic. To offset these challenges, the clinic is gradually transitioning all of its medical care and mental health services to a fee-for-service system.
Kahn says the new system was piloted with the Lesbian Health Center, where clients can receive a range of gynecological services including pelvic and breast examinations, Pap smears, mammography referrals, screening for sexually transmitted diseases including HIV and pregnancy testing.
The transition to the pilot program has gone smoothly in part because of how the clinic is set up to take appointments ahead of time, says Lesbian Health Center Coordinator Emily O. Smith. “When they call to set up the appointment, it is the ideal time for us to review the changes with them and assess the costs.”
Changes in the fee structure for mental health services will go into effect this spring, Kahn says, while the program evaluates the change-over process at the Lesbian Health Center. Eventually, all clinical and mental health services at Whitman-Walker will charge fees. Since the transition involved updating the computer software to include medical diagnosis billing codes and fees, Kahn says that the clinic wanted to pilot the new system where they could easily gauge how the effectiveness of the changes and assess whether further work needed to be done. Because the Lesbian Health Center has a relatively small overall volume, she adds, changes in patient flow could be easily monitored.
Fees are set on an income-based scale. Clients self-report their incomes and dependents are considered as well. The scale allows for patients whose income falls at $13,470 or less to pay nothing for services they receive. The overall fee scale is lower than market rate for such services, but does increase with the client’s income level. The structure is similar to more traditional health care providers and the clinic will eventually accept insurance for paying clients. Smith says that the clinic is “still in the process of being able to take insurance.”
“This is a very big shift — it doesn’t make sense to have insurance accept you as a free clinic,” she says. “We needed to have a payment system in place in order to develop relationships with these companies.”
A typical visit for many clients of the Lesbian Health Center is an annual exam, which includes a Pap smear, breast exam, urinalysis and testing for gonorrhea and chlamydia. A single woman (defined by the clinic as women claiming no dependents) with incomes between $22,500 and $26,500 will be charged $64 for the annual exam, while a single woman with an income higher than $44,900 will be charged $169. The fee structure becomes more complex depending on the number of dependents a client claims. “Nine times out of ten the women don’t have a problem with the fee,” says Smith. As of yet no clients have opted to pursue a payment plan, although LHC will offer such an option if a client needs it.
Kahn says that clients expressed confusion when the clinic changed the system for Lesbian Health Center payments because information had been released to the community without the full context of the changes. The clinic subsequently tried to clarify the details to ensure that clients had the proper information to understand the changes. “We don’t want to create a barrier to getting health care,” says Kahn, adding that many clients come to the Lesbian Health Center because they feel they cannot get adequate care from mainstream providers.
Â “Most of the changes are things that haven’t had an impact on the client,” says Smith. One such change was to find a new facility to test lab work in order to provide better savings to clients.
To further assure that clients were adjusting to the change, the Lesbian Health Center surveyed clients to get immediate feedback on how the new system affected their service at the LHC. The results of these surveys “illustrate a positive experience,” Kahn says.