Abstract
In the absence of meaningful health reform, Florida implemented a volunteer health care program to strengthen the existing safety net. Since program implementation in 1992, over $1 billion of services have been provided to uninsured and underserved populations. Currently, over 20 000 volunteers participate statewide. Key incentives for provider participation have been an organized framework for volunteering and liability protection through state-sponsored sovereign immunity. Volunteerism, although not a solution to the health care crisis, serves as a valuable adjunct pending full-scale health care reform.
AS THE NUMBER OF uninsured persons continues to increase, patients are relying more on uncompensated care from medical providers through safety nets and volunteer programs to receive needed care.1,2 State and local governments spend an estimated $17.2 billion on care for the uninsured, and physicians donate roughly $7.8 billion in services.3 In communities with higher social capital and in which physicians provide charity care, the uninsured report having less difficulty obtaining needed care.4,5 The Florida Department of Health's Volunteer Health Services Program (VHSP) is a unique safety net program that has been able to leverage public and private resources to obtain health care access for thousands of Floridians while providing substantial return on resources invested.6 We highlight the implementation and successes of the program.
The VHSP was established when the 1992 Florida Legislature passed the Access to Health Care Act7 in an attempt to encourage volunteerism among health care providers. The act allows licensed health care providers to donate their services, either by volunteering in freestanding clinics or seeing patients in their private facilities.8 As an incentive, all participating providers are eligible for sovereign immunity protection—that is, the state is solely liable for any injury or damage suffered by a patient.7 This sovereign immunity protection gives volunteer providers the same liability protection as state employees when they provide health care services to patients who are Medicaid eligible, do not have private insurance and have an income of no more than 200% of the federal poverty level, or are clients of the Florida Department of Health.9
The program is administered within the central office of the Florida Department of Health with an approximate annual state appropriated budget of $755 000. A statewide staff of 10 oversees activities in 11 regions of the state.10 Regional coordinators work within their jurisdiction to support the recruitment of individual providers and organizations to establish a flexible framework for access to care. These partnerships vary within each community: in some places, a physician or county medical society may be the prominent component; in others, religion-based and secular organizations take the lead in coordinating and providing services. In all, the state has approximately 9000 contracts with licensed providers and corporations, including but not limited to physicians, dentists, nurses, pharmacists, laboratory technicians, hospitals, nonprofits, and free clinics.
In a previous study, we reviewed the legal authority of states nationwide to undertake similar programs.6 Of the 46 states who participated in the study, 34 offered sovereign immunity to volunteers, with 25 offering immunity specifically to health care professionals. Although these states offer legal protection, few have a defined volunteer program like VHSP.
For this study, we tabulated the value of services donated, the number of practitioners volunteering, and the number of patients seen from compiled annual reports of VHSP since its inception in 1992. All figures are self-reported by the various volunteer programs, with 3 methods used to report the valuation of services from providers: practitioner hourly rate, actual costs, or standard fees. Data-collection methods have varied over the years, and discounts have not been used for inflation. We also explored all legal cases related to VHSP through the Florida Department of Financial Services.
In the state fiscal year 2006–2007, the value of donated health care services was $147.5 million, an increase from $9.1 million in 1992 (Figure 1).10 For every dollar invested in the program by the state in that year, there was an approximate $195 benefit realized in the form of health care services. Moreover, the program recently reached a milestone achieving a total value of over $1.1 billion in cumulative donated services. The number of health care volunteers has quintupled (Figure 2).10 The total number of patient visits for 2006–2007 was 290 026.
FIGURE 1 Dollars spent on health care services: Volunteer Health Services Program, Florida, 1992–2007.
Source. Florida Department of Health.8
FIGURE 2 Number of volunteers: Volunteer Health Services Program, Florida, 1992–2007.
Source. Florida Department of Health.8
Note. Number of volunteers includes licensed health care providers and non-licensed volunteers.
According to the Florida Department of Financial Services (L.R. Williams, BS, written communication, January 2008), 8 malpractice claims have been filed against individual volunteers participating in the program to date: 5 cases have been adjudicated and 3 are pending. In all cases, the state has assumed full liability. The total cost to the state for the 8 lawsuits filed has been $868 685. For every $1276 donated in goods and services, $1 was spent on legal fees and awards over the life of the program. Most importantly, the courts have upheld the sovereign immunity concept providing coverage for volunteers.
The success of VHSP may be attributed to many factors (see box on page 1169). The presence of the regional coordinators eliminates the need for the direct involvement of the central office of the Florida Department of Health, thus allowing programs to work independently to meet needs identified locally. Collaborative relationships in local communities help to evenly distribute the burden of providing charity care throughout the community and facilitate structure in an otherwise unorganized system. This standardization of processes coupled with the simplicity of the program, which only requires a 3-page contract, self-declaratory patient eligibility, and a standardized referral form, attracts health care providers who want to volunteer while avoiding administrative and legal burdens. Finally, VHSP represents an excellent return on investment for the dollars allocated, exceeding in terms of value even proven public health measures such as immunization.11
Regional coordinators assist in the recruitment of health care providers in their area of responsibility.
Volunteer providers sign a 2-page contract that stipulates the number of patients they are willing to see and the type of services they are willing to provide.
Signing a contract designates the provider as an agent of the state thus making them eligible for sovereign immunity protection.
Patients are determined eligible at the local site by criteria established by the Florida Department of Health. To be eligible, patients must be Medicaid eligible, without private health insurance and have an income that does not exceed 200 percent of the federal poverty level, or a client of the Florida Department of Health.
Once determined eligible, the patient is then referred to a licensed healthcare provider who is a member of the program.
Services available to patients depend upon volunteer resources in the area and the patient's need. General medical care is usual, and procedures as simple as chest X-rays and as complicated as cardiac surgery, physical therapy, or radiation oncology are available.
There is no charge to the patient for services provided.
For the provider to be eligible for sovereign immunity the patient receives no bill, and there is no expectation of a fee for service.
A strong incentive for health care providers to participate in VHSP is the sovereign immunity protection it offers to the providers. Lack of malpractice protection has long been perceived as a barrier to recruiting volunteers, and it affects physicians' willingness to provide care.12,13 Offering sovereign immunity allows volunteers to provide needed services without the fear of malpractice liability.
Literature indicates volunteers benefit from the services they provide as much as those receiving the services.14,15 Providers who volunteer report a renewed sense of camaraderie in the medical profession and commitment to their communities.16 A formal survey could be conducted to validate these findings for VHSP. Conducting routine surveys assessing patient and provider satisfaction will help determine areas for program improvement and document strengths. Results from the surveys can be used for strategic planning and to improve efficiency.
Sustainability has been demonstrated over the 15-year life of VHSP, but maintaining the interest of volunteers has been a challenge. Marketing and recognition of VHSP might serve to encourage those health care providers who have been hesitant to volunteer to do so. Other improvements include hiring more personnel at the regional level to account for the growth of the program, and developing a standardized method for data collection.
Florida's experience and accomplishments with VHSP demonstrate that the extension of state-sponsored immunity can be a realistic and successful component when developing a volunteer program. We believe VHSP can serve as a model for other states wishing to create a similar volunteer program bolstered by state-sponsored immunity. Although volunteer programs alone cannot solve the problem of access to care for the uninsured and underserved, they are a viable and significant part of a comprehensive approach as future health reform unfolds.
Acknowledgments
The authors would like to thank the professional associations, public and private partnerships, and individual volunteers who commit their time and talents to the Volunteer Health Services Program. Their dedication to this endeavor has led to unprecedented success of the program and its impact on local communities.
Human Participant Protection
No protocol approval was needed for this study.
