Formation of the Indianapolis Health and Wellness Center

Running head: FORMATION OF THE INDIANAPOLIS HEALTH 1

Formation of the Indianapolis Health and Wellness Center

Melvin J. Woodard III

Indiana Wesleyan University

Chuck Roome

HCAD-590: Healthcare Administration Capstone

October 20, 2015//October 28, 2015//November 10, 2015//

November 17, 2015//November 24, 2015// December 1, 2015

Version 6

I have read and understand the plagiarism policy as outlined in the syllabus and the sections in

the Student Catalog relating to the IWU Honesty/Cheating Policy. By affixing this statement to

the title page of my paper, I certify that I have not cheated or plagiarized in the process of

completing this assignment. If it is found that cheating and/or plagiarism did take place in the

writing of this paper, I understand the possible consequences of the act/s, which could include

expulsion from Indiana Wesleyan University.

FORMATION OF THE INDIANAPOLIS HEALTH AND WELLNESS 2

Table of Contents

Formation of the Indianapolis Health and Wellness Center 4Problem Statement 5Purpose of the Study 7Significance of the Study 7

Significance to the Writer 9

Significance to Stakeholders 9

Global and National Healthcare Significance 10

Organizational Background 13Mission, Vision and Values 13

Governance Structure14

Demographics 14

Market Position 15

Formal and Informal Mandates 16

The SWOT Analysis 17External Analysis 17

The macro environment 18

The competitive environment 23

Internal Analysis 25

Healthcare organization purpose and mission 25

Healthcare organization culture and leadership 26

Identification and Discussion of Issues 27Information and Literature Review 30

Review of Literature Relevant to the Safety Net System 30

Review of Literature Relevant to the Uninsured and Underinsured 33

Review of Literature Relevant to Direct Primary Care (DPC) Medicine35

Review of Literature Relevant to Racial/Ethnic Disparities 36

Review of Literature Relevant to the Patient Protection and Affordable Care Act (ACA) 39

Analysis of Key Issues 42Recommendations and Conclusions 48Summary 49References 54Appendix A 61


Appendix B 62Appendix C 63Appendix D 64Appendix E 65


Formation of the Indianapolis Health and Wellness Center

Thirty-seven percent of Indiana’s households are struggling to afford the basic necessities

of housing, child care, food, health care and transportation (Indiana Association of United Ways,

2014, Fall). These households have income above the federal poverty level (FPL) but below the

basic cost of living. This population of men, women, children and seniors is known as ALICE,

which stands for Asset Limited, Income Constrained, and Employed. In other words, they are

families of the working poor. In total, there are 922,342 households in Indiana with income

below the real cost of basic necessities as measured by the ALICE threshold – “a level based on

the actual cost of basic household necessities in each county in Indiana” (Indiana Association of

United Ways, 2014, Fall, p. 1). ALICE households are working or have worked, exist in all age

groups, and represent a cross-section of Indiana’s population. All counties in Indiana have some

ALICE (poverty-level) households spread across them. It has been determined that these

households are approximately 23 percent short of the income actually needed to reach the

ALICE threshold (Indiana Association of United Ways, 2014, Fall).

It is believed that helping ease the burden ALICE households face with regard to basic

healthcare would be of great benefit to them and to the community as a whole. A successful

solution would be to develop a medical clinic in the heart of a community of people who fall

beneath the ALICE threshold. The Indianapolis Health and Wellness Center, a 501c3 Indiana

nonprofit organization, is in the process of launching a medical clinic and wellness center in

northeast Marion County where a sizable population of ALICE families exist. Indiana’s

economic productivity is reduced, insurance premiums and taxes are higher, when ALICE

households are forced to make hard choices such as skipping preventative health care and eating

unhealthy food. Future costs are high for both ALICE households and the wider community.


The Indianapolis Health and Wellness Center, an organization dedicated to restoring hope

and healing to the ALICE population, began with an environmental assessment. The need of

uninsured working people and their families in regards to primary health care was an unknown.

The community needs and resource assessment ("Indianapolis Health and Wellness Center:

Community needs and resources assessment," 2015, September) that was produced, with the help

of the Polis Center of Indianapolis, elicited the following information.

There are vulnerable populations in northern Marion County, close to the proposed clinic

site and in the targeted service area.

Twenty-one percent of the households in the targeted service area have income below the

ALICE threshold.

In the targeted service area, 28 percent of African American households and over 31

percent of Hispanic households are below the ALICE threshold.

The importance of providing flexible healthcare hours of operation is an important

feature when serving the working poor, depending on their work schedules.

Problem Statement

Thirty-seven percent of Indiana’s households struggle to afford basic necessities of life.

They struggle with affordable housing, child care, food, transportation, and access to healthcare.

The United Way’s 2014 ALICE Study of Financial Hardship in Indiana (Indiana Association of

United Ways, 2014, Fall) reveals that 352,042 Indiana households live below the federal poverty

level (FPL) and another 570,300 are ALICE households. In total, Indiana has 922,342

households that earn below the ALICE threshold. The average level of income a household

needs to survive is defined by the Household Survival Budget, which is computed separately for

each county in Indiana. More than two-thirds of Indiana’s municipalities have 20 percent or


more of the households in their community living below the ALICE threshold (Indiana

Association of United Ways, 2014, Fall). Public and private assistance is not enough to lift

ALICE households to economic stability.

The cost of basic household expenses in Indiana is more than most jobs can support.

Indiana’s cost of living is beyond what most jobs in the state can provide to working

households. The annual Household Survival Budget for the average Indiana family of

four is $46,495 and for a single adult is $17,026. These numbers highlight how

inadequate the U.S. poverty rate is as a measure of economic viability, at $23,050 for a

family and $11,170 for a single adult. The annual Household Stability Budget – one that

enables not just survival, but self-sufficiency in Indiana – is almost double the cost of the

Household Survival Budget for a family of four ($82,740), and $22,836 for a single adult.

(Indiana Association of United Ways, 2014, Fall, p. 2)

An associated problem focuses on low-income minorities which experience disparities in

health, as well as disparities in healthcare delivery. Within the targeted service area of the

Indianapolis Health and Wellness Center, one in four African American households and one in

three Hispanic households fall beneath the ALICE threshold ("Indianapolis Health and Wellness

Center: Community needs and resources assessment," 2015, September). High priority health

issues exist among minorities. For example, “lack of prenatal care in Medicaid-covered

expectant mothers, high premature birth rates among black mothers, high maternal smoking

rates, obesity, mental health, youth asthma, violence, and hunger” ("Indianapolis Health and

Wellness Center: Community needs and resources assessment," 2015, September, p. 3).

Minorities have historically been negatively impacted by the U.S. healthcare industry,

with issues of quality, access and cost of healthcare (Yancey, Bastani, & Glenn, 2014). Research


shows that “minority individuals have poorer health outcomes, fewer protective health behaviors,

and worse access to and quality of health care, compared to white individuals” (Dubay &

Lebrun, 2012, p. 608). Based upon key indicators, Blacks have worse outcomes than Whites no

matter what level of income and education (Braveman, Cubbin, Egerter, Williams, & Pamuk,

2010). Across all indicators of health, African Americans are the most disadvantaged population

(Yancey et al., 2014).

A successful solution to the problem identified would be to develop a medical clinic and

wellness center in the midst of a community of people who fall below the ALICE Threshold.

Purpose of the Study

The Indianapolis Health and Wellness Center has a single goal, which is to restore hope

and healing to the ALICE population of Marion County and vicinity through accessible

healthcare. Associated with accessibility is the idea that the healthcare model is affordable and

of high quality. Relieving a portion of the burden working people face with their families is a

true ministry of helps, linking faith and health. The work of the Indianapolis Health and

Wellness Center can be replicated wherever a need of this type exists across the country. There

are three objectives associated with the one goal (as shown in Table 1).

Significance of the Study

The Indianapolis Health and Wellness Center, a 501c3 nonprofit organization, is in the

process of launching a medical clinic and wellness center in the northeast part of Marion County.

The center hopes to replicate the health care model used at the Church Health Center in Memphis

(TN), which is the largest faith-based organization of its type in the country serving uninsured

working people and their families. To date, the Church Health Center has served more than

60,000 people in and around Shelby County, TN.


Table 1Goal: Restore hope and healing to the ALICE (Asset Limited, Income Constrained, Employed) population of Marion County, IN and vicinity by providing accessible, affordable, quality healthcare.

Objective 1 Objective 2 Objective 3Direction of change (reduce/increase)

Increase Reduce Increase

Area of change access to personal healthcare services

the percent of income spent for medical services

the level of satisfaction regarding quality of care received

Describe the target population

for the ALICE population of Marion County and vicinity

by the ALICE population of Marion County and vicinity

within the ALICE population of Marion County and vicinity

Degree of change to be measured (quantifiable, such as a percentage, etc.)

20% increase 50% decrease 30% increase

Specific time frame (month, year)

January 2016 to January 2017



Putting it all together Increase access to personal healthcare services for the ALICE population of Marion County and vicinity by 20%, by January 2017.

Reduce the percent of income spent for medical services by the ALICE population of Marion County and vicinity by 50%, by January 2017.

Increase the level of satisfaction regarding quality of care received within the ALICE population of Marion County and vicinity by 30%, by January 2017.

Indianapolis Health and Wellness Center, 2015

Staff members from Empowering Community Healthcare Outreach (ECHO), a ministry

of the Church Health Center, are assisting the Indianapolis Health and Wellness Center with the

replication work. Replicating the work of the Church Health Center in Indianapolis is important.

There are 185,365 uninsured persons in Marion County in 2015 (Franciscan Alliance, 2015).

And one out of five households in the targeted service area of the Indianapolis Health and


Wellness is an ALICE household. This research study can serve as a model for other

organizations that seek to find ways to help the working poor.

Significance to the Writer

The plight of uninsured working families intersected the life of this student in 2009.

After 25 years of anesthesia practice, this student underwent a career change into to fulltime

pastoral ministry. With the change, his family moved from Ohio to Indiana. In the midst of

changing careers and relocating, this student and his family were left without health insurance.

The old plan was allowed to lapse because it had been replaced by the church with a new plan.

But without notice, this student and his family were without health insurance and unable to

access medical care. To add insult to injury, the church where this student pastored, not only

canceled the family’s health insurance but would not provide any extra compensation in its

place. During this period of time, this student’s teenage daughter developed a large (6-7cm)

breast tumor. Surgery was delayed for six months while the family’s health insurance was

restored. Having experienced this time of crisis without health insurance, this student set out to

make a difference for working people and their families who are uninsured or underinsured.

Significance to Stakeholders

Stakeholders are individuals or groups who have a valued interest in an organization’s

success (White & Griffith, 2010). Those persons considered to be stakeholders in the

Indianapolis Health and Wellness Center include: The board of directors, medical director,

executive director, physicians, nurses, employees, creditors, suppliers, patients, potential patients

(who may include the entire community), the Marion County Health Department, the local

healthcare system (core hospitals and safety net facilities), and the donors who support this work.

Although these stakeholders have their personal concerns regarding healthcare in Indiana, all of


them are keenly aware of the high cost of medical services. After all, beyond the patient, the

bottom line with most stakeholders is whether they (or the community) will get paid for goods

and services rendered. Indiana’s healthcare costs are high, as the following information shows.

The average health care cost in Indiana is $130 per month for a single adult (9 percent of

the budget) and $520 per month for a family (13 percent of the budget), which represents

an increase of 26 percent from 2007 to 2012. The health care budget includes the

nominal out-of-pocket health care spending reported in the Consumer Expenditure

Survey. Since it does not include health insurance, such a low health care budget is not

realistic in Indiana, especially if any household member has a serious illness or medical

emergency. Seniors have many additional health care costs beyond what is covered by

Medicare. (Indiana Association of United Ways, 2014, Fall, p. 29)

Tens of thousands of Hoosiers are without insurance. For example, 185,365 (19.7%)

adults in Marion County are currently uninsured (Franciscan Alliance, 2015). The number of

uninsured dramatically affects medical reimbursement rates. Reducing the number of uninsured

Americans and promoting access to healthcare is the focus of the Patient Protection and

Affordable Care Act (ACA) of 2010 (Shi, 2014). Substantial gains in public and private

insurance coverage have been realized since 2014, the first full year of ACA coverage. This has

led to an appreciable decrease in the uninsured rate, which in Indiana fell from 14.6 percent

(2013) to 12.5 percent (2014) – a change of -2.1 percent ("Key facts about the uninsured

population," 2015, October).

Global and National Healthcare Significance

Some might define health as the absence of disease. The World Health Organization

(WHO) goes beyond that and says health is a state of complete physical, mental and social well-


being (Shi, 2014). Quality-adjusted life years are an index that reflects years of life free of

disability and symptoms of illness, which is an outcome of the definition by WHO. It should be

understood that health is the result of personal characteristics and choices (Shi, 2014) But

everything in healthcare is not the peoples’ choice. The United States is not making consistent

progress in reducing the variability of health care quality, and the country is failing to keep pace

with gains in health outcomes achieved by other industrialized countries (Longest Jr, 2010).

Although 17.9 percent of the total economic activity (GDP) in the U.S. is spent on healthcare,

“there is overwhelming evidence of inappropriate care, missed opportunities, and waste within

the U.S. health system” (Longest Jr, 2010, p. 325).

The challenge in the United States is to decide how to reconstruct the health care system

so that money is being spent where it makes sense, and fits the economy, history and culture of

this nation (R. P. Carlson, 2015). Certainly the U.S. health system is being outperformed by

other industrialized countries. Part of the problem is that U.S. health policy must balance the

good of public health with personal liberty, which is often a difficult compromise to make (Shi,

2014). Research must continue on methods to contain U.S. health care costs.

First, the fact those other countries spend so much less per capita raises the possibility

that there may be effective cost control options available. Second, there is an opportunity

cost; more spent on health care means less money available to spend on other societal

needs. Third, and related to this, there are strong reasons to believe that the availability

of new and effective medical technologies such as gene therapy will result in an even

greater jump in spending. (Rice & Kominski, 2014, p. 263)

The cost of healthcare in the United States is a significant factor in the number of

Americans without any form of health insurance (Stephens & Ledlow, 2010). Many working


Americans do not have health insurance coverage and feel the daily pressure of being uninsured

(Stephens & Ledlow, 2010). The debate rages on whether health insurance is a right or privilege.

Providing full medical coverage to all uninsured Americans may be cost-prohibitive. But a

realistic incremental step would be to provide basic, primary health benefits (Stephens &

Ledlow, 2010). The lack of adequate health insurance coverage creates a plethora of problems.

Stephens and Ledlow (2010) help with understanding the magnitude of the problem.

Emergency departments across the nation are in crisis mode because of the immense,

uncompensated burden of the uninsured, lower reimbursements, and government

regulation.

Uninsured Americans with chronic diseases significantly add to the overuse and abuse of

hospital emergency departments.

The financial burden of uncompensated care is severe for hospitals and physicians.

Loss productivity of the uninsured due to illness or injury is of concern to any business.

It decreases national productivity as well. And for the uninsured, time away from work

further complicates family financial issues.

The cardinal principles of medical ethics include autonomy, beneficence, and justice.

Rosenau, Roemer and Zimmerman (2104) believe these principles apply in public health as well.

As America transitions from a society that once could pay for efficacious healthcare to one that

now struggles politically and economically to do so, a question begs to be answered: “How

should scarce resources be allocated and used?” (Rosenau, Roemer, & Zimmerman, 2014, p.

728) Some things that need to be determined going forward are:

Determining the balance between expenditures and quality of life in the case of chronic

and terminal illness;


Determining the appropriate limits on using expensive medical technology;

Determining the government’s obligation to protect the most vulnerable sectors of

society;

Determining the responsibility of the young to finance healthcare for older persons;

Determining fully what obligations health care insurers and providers have in meeting the

right to know of patients as consumers.

America has to do a new thing with its health care system because the past is no longer a reality.

Organizational Background

Thoughts of the Indianapolis Health and Wellness Center began with a site visit in

August 2014 to the Church Health Center in Memphis (TN). The Church Health Center is the

largest faith-based healthcare organization of its type in the country serving uninsured working

people and their families. A group of persons from New Salem Missionary Baptist Church in

Indianapolis (IN) traveled to Memphis to participate in a Replication Workshop. At the

conclusion of the three-day workshop, the group agreed to proceed with the replication process.

The Indianapolis Health and Wellness Center formally began on October 29, 2014 with a

community meeting at New Salem MBC. With an ECHO consultant present to facilitate the

meeting, community members in attendance were assigned to various committees within the

Planning Team structure set by ECHO. The Indianapolis Health and Wellness Center was now

under development.

Mission, Vision and Values

The Indianapolis Health and Wellness Center is a faith-based nonprofit organization

“dedicated to restoring hope and healing to the ALICE population through accessible, affordable,

quality healthcare.” The mission emphasizes providing access to medical care for struggling,

working-class Indiana residents and their families. The vision for the center is “to be a


significant provider of compassionate care and wellness services for vulnerable populations in

our community.” The Indianapolis Health and Wellness Center adheres to the following five

values: Hope, Trust, Commitment, Integrity and Wellness.

Governance Structure

The Indianapolis Health and Wellness Center is to be governed by the Board of Directors

of the Corporation. The Board, which consists of seven members, is to maintain the specific

purpose of the Corporation which is to provide charitable medical assistance to uninsured and

underinsured people residing in Marion County (IN) and vicinity. And subject to the provisions

of law, of the Certificate of Incorporation and of the By-Laws, the Board is to have the control

and management of the affairs and operations of the Corporation and is to exercise all the powers

that may be exercised by the Corporation.

During development, the Planning Team Leader is to be responsible for aligning the

operations of working committees and their individual chairs. Committees operating under the

Planning Team include: Environmental Scan, Legal, Operations, Site, Communications, and

Finance. Before the Corporation opens to business, a Medical Director and Executive Director

shall be chosen and have responsibility over daily operations of the facility and staff.

Demographics

Indiana has 352,042 households with income below the federal poverty level (FPL),

which is $11,770 for a single adult, $15,930 for a couple, and $24,250 for a family of four. But

there are another 570,300 ALICE households, which have income above the FPL but below the

ALICE threshold (a level based on the actual cost of basic household necessities). In total, there

are 922,342 households (37 percent) in Indiana struggling to afford the basic necessities of

housing, child care, food, health care, and transportation. There are serious consequences for


both ALICE households and their communities when these families cannot afford the basics.

When struggling with choices, skipping preventative healthcare occurs very frequently. In turn,

many low-income persons, often belonging to racial/ethnic minority groups, experience

disparities in health and disparities in health care delivery. Shi (2014) states, “Racial and ethnic

minorities experience disparities in health status perception, causes of death, and high risk

behaviors when compared to non-Hispanic whites” (p. 123). The ALICE Report (Indiana

Association of United Ways, 2014, Fall) presents the following statistics for Marion County:

Forty-five percent of the households in Marion County are struggling.

There are 69,924 households at the FPL and another 93,566 households below the

ALICE threshold.

In total, 162,490 (out of 363,157) households in Marion County need help acquiring the

basic necessities of housing, child care, food, health care, and transportation.

Indiana’s real cost of living exceeds what most jobs in the state can provide to working

families.

Market Position

The cost of healthcare in Indiana is much like it is across the U.S. It is a major problem.

Hundreds of thousands of Indiana Hoosiers are without health insurance coverage because they

cannot afford to buy it. Fewer and fewer employers are offering the benefit to their employees.

Since 2014, full implementation of the ACA has shrunk the number of Hoosiers without

insurance. But there is a need to do more and the Indianapolis Health and Wellness Center is

poised to help. In an attempt to provide accessible, affordable, quality healthcare for working

people and their families, the center plans to offer direct primary care (DPC) – of which the

defining element is an enduring and trusting relationship between patient and provider.


MedLion, for example, is a successful DPC model affiliated with 41 practices in 13 states and

was created “specifically to take care of underinsured and uninsured populations, to give them

access to affordable and high-quality basic primary care” (R. P. Carlson, 2015, p. 21).

Proponents of DPC claim the model incentivizes physicians to keep patients healthy and out of

costly hospitals and specialty care (R. P. Carlson, 2015).

Primary care coverage for the uninsured is a major step to reforming the United States

health system, and it is more cost effective than performing a complete overhaul (Stephens &

Ledlow, 2010). DPC is providing quality, affordable medical care at a price the uninsured and

underinsured can pay. The health of uninsured working people increases as does their

productivity, while inappropriate emergency room visits are reduced. Uninsured persons in the

target service area of Marion County, who do not have a physician or medical home, can get

primary care service at the Indianapolis Health and Wellness Center.

The DPC model offered by the Indianapolis Health and Wellness Center is an age-based

subscription plan. In other words, any person seeking to join the center’s primary care plan can

do so by paying a monthly subscription fee, based upon their current age. Any and all services

offered by the center are fully covered for patients as long as they are paid up in the subscription

plan. The age-based subscription plan is established like this:

0-18 yrs. $10/mo.

19-29 yrs. $35/mo.

30-49 yrs. $50/mo.

50-69 yrs. $75/mo.

Formal and Informal Mandates


The Indianapolis Health and Wellness Center embraces the following formal and

informal mandates in its operations:

Replicate the good work of the Church Health Center in Memphis, TN.

Link faith and health, hope and healing for vulnerable populations of citizens.

Facilitate the work of the safety net system in Indianapolis by positively impacting

healthcare problems within ALICE households.

Determine our own identity based upon the needs in our community.

Recruit friends in the community who will embrace the mission, vision and work of the

Indianapolis Health and Wellness Center.

Help ALICE households survive.

Provide a wellness center with initiatives that make a difference in minority health

outcomes for African Americans, Hispanic/Latinos, Native Americans, Asian Americans,

Pacific Islanders, and Alaskan Natives. Wellness initiatives include infant mortality,

breast cancer, sickle cell anemia, obesity, diabetes, and mental health.

Reduce, if not eliminate, disparities in health and in health care delivery for vulnerable

populations in Indianapolis.

Provide unique medical opportunities for ALICE households, such as primary care,

podiatry, ophthalmology, dentistry, x-ray services, and pharmacy services on a sliding

scale fee basis.

Provide a medical home, if necessary, for ALICE households.

The SWOT Analysis

External Analysis


The External Analysis section of this paper analyzes some of the external factors that

affect healthcare organizations. Many environmental factors influence the work and stability of

U.S. healthcare organizations. Changes that occur in external conditions can be viewed as

threats or opportunities. While healthcare organizations cannot control these factors, they must

be prepared to respond in order to survive. There are two subsections under the heading: The

macro environment and the competitive environment.

The macro environment. In an environmental scan, the macro environment refers to

global forces that affect all organizations alike and includes industries, markets, companies,

clients and competitors. When changes occur in the macro environment new opportunities or

threats are created for organizations. Firms, even entire industries, will change their business

model and adopt new strategies to engage (or avoid) the changing environment. The healthcare

industry is in great flux today due to many unknowns circling about (Bristol & Joshi, 2014). The

business model that has existed for decades between hospitals and clinicians is being threatened

by macro environmental issues (G. Carlson & Greeley, 2010). Several factors within the macro

environment will be discussed below.

Economic factors. Economic trends, coupled with inferior clinical outcomes, in the U.S.

healthcare system suggest that the present medical system is not sustainable (G. Carlson &

Greeley, 2010). America spends more money on health related business than any nation on

earth. Annual healthcare expenditures top $2.7 trillion, consuming more than 17.3 percent of the

U.S. GDP (Bristol & Joshi, 2014). Health care spending has been increasing for decades at an

unsustainable rate, outstripping inflation and jeopardizing the competitiveness of American

businesses (Bristol & Joshi, 2014, p. 541). The nation is losing its competitive edge, as the high

cost of U.S. healthcare is wiping out any productivity advantage American businesses have


(Scott, 2006). Quality, cost and appropriateness of services are forces within healthcare that

must be reconciled. Efficiency (how well resources are used to achieve a given result) and cost-

effectiveness (comparing the cost-benefit of an intervention) are increasingly more important in

light of the changes that are occurring in healthcare (Wyszewianski, 2014).

Demographics. Franciscan Alliance’s Community Health Needs Assessment (Franciscan

Alliance, 2015) provides some current demographics for the State of Indiana. The population in

2015 is 6,613,067; which consists of 2,556,127 households and 1,710,950 families. Within the

2,556,127 households, the median income is $49,030 and the average income is $64,249. Based

on household income, Asians fair-better-than Whites, who fair-better-than Hispanic/Latinos, who

fair-better-than African Americans. The average household size is 2.51 members. Families

living below poverty equal 192,651 (11.26%), and families with children living below poverty

equal 153,783 (8.99%). The populace by ethnicity/race: Whites (83.33%), African Americans

(9.33%), Hispanic/Latinos (6.73%), Asian (1.88%), American Indian/Alaskan Native (0.3%),

Native Hawaiian/Pacific Islander (0.04%), other (2.97%), and 2+ races (2.24%). The median

age in Indiana is 37.6 years; those <18 (23.95%) and 18+ (76.05%); those over 65 (14.52%).

The civil labor force that is unemployed is 9.3% percent.

Legal, political, and social conditions. The Patient Protection and Affordable Care Act

(ACA) of 2010 is the most significant piece of U.S. healthcare legislation since 1965, when

national legislation established the Medicare and Medicaid programs. At the passing of the

ACA, more than 40 million Americans were uninsured and the U.S. healthcare system was

struggling because of it. The federal government was compelled to do something on a national

level to help vulnerable populations get the medical attention they needed. Since the ACA, the

legal and political landscape continues to change for the sake of parody. But the onus of caring


for low-income, minority individuals disproportionately falls upon core safety net providers.

And America’s healthcare safety net is not comprehensive, nor is it well integrated; which makes

it neither secure or uniform (Lewin & Altman, 2000).

It is difficult to generalize about the overall state of the nation’s health care safety net

given its local nature and attributes….In many underserved inner-city and rural

communities, core safety net providers may be the only available source of primary

health care services for the vulnerable populations residing in these areas….Rising

numbers of uninsured patients, coupled with changes in Medicaid policies and cutbacks

in public and other subsidies, are beginning to place America’s health care safety net in a

state of serious jeopardy. (Lewin & Altman, 2000, p. 4)

The solvency of safety net providers is often dependent upon state and local government

support. This means that care for uninsured persons and other vulnerable populations is usually

resolved at the local level. The level of support for local safety net providers, like the

Indianapolis Health and Wellness Center, depends greatly on the political will of the community,

attitudes toward vulnerable populations, and attitudes towards the providers who serve them

(Lewin & Altman, 2000). There will always be a group of Americans whose needs exceed the

services that can be purchased with a health insurance card alone (Lewin & Altman, 2000).

Technological changes. Within the United States’ health care system, new diagnostic

equipment and advanced treatment technology are essential tools. Right or wrong, the U.S.

healthcare system relies on expensive devices to stand at the top of the global medical world.

The down-side is that with newer and newer operational technology, the price of medical

treatment in America will continue to skyrocket over that found in other industrialized countries.


Out of the Health Information Technology for Economic and Clinical Health (HITECH)

Act of 2009, billions of dollars in incentives were used to promote the adoption and meaningful

use (MU) of certified electronic health records (EHRs) among eligible hospitals (Diana, Harle,

Huerta, Ford, & Menachemi, 2014). EHRs are expected to bring a variety of health benefits,

including the reduction of disparities in healthcare access and improving the overall quality of

healthcare in the U.S. (Anthony & Campos-Castillo, 2015). EHRs facilitate information

exchange and enable better coordination of care. At the present time, hospital adoption of EHR

technology remains low across America which limits the realization of benefits from having such

a tool. Despite what negativity exists about EHRs, the future of medicine is geared toward data

analytics because of the benefit they bring in quality of care, cost, and access.

In today’s healthcare market, administrative decisions surrounding new technology go

beyond budgeting and capital improvement discussions. Hofmann (2000, March/April) notes

that healthcare executives are often asked to approve capital expenditures in excess of available

funds. And given the unrelenting economic pressures to provide more services with less

reimbursement, this situation seems like it will continue. In order to meet the needs of various

constituencies, improve the cost-effectiveness of service, comply with legal, licensing, regulatory

and JCAHO requirements, as well as satisfy financial viability measures, a more defensible

framework must be established. And relevant to discussions on capital budget decisions are

matters such as beneficence (actively promoting behaviors that benefit others), nonmaleficence

(do no harm to others, including the community), fidelity (covenant responsibilities), and justice

(acting with fairness and impartiality) (Hofmann, 2000, March/April). In other words, there are

economic and noneconomic criteria to consider before purchasing new technology.


Natural forces. For most of the twentieth century, according to Dranove (2000), the U.S.

healthcare system traditionally operated in the following manner:

Patients relied on autonomous physicians to act as their agents;

Patients received complex care from independent, nonprofit hospitals; and

Insurers did not intervene in medical decision making and reimbursed physicians,

hospitals, and other providers on a fee-for-service basis.

Trust was a major factor in the traditional healthcare system of the last century. Patients

trusted that providers would act unselfishly, putting the patient’s interests above their own.

Patients trusted that their providers were well trained and had the technical competence to

properly diagnose and treat the patient. And patients trusted their providers to control costs and

coordinate other resources to deliver the best quality of care. The traditional way in the U.S.

healthcare system is no longer because of forces that have brought about rapid and significant

growth. Conklin (2002, Fall) identifies a variety of “wild cards” that will force change within

the U.S. healthcare system going forward:

Growth in the U.S. population, including an increase of elderly people in the population;

Increase in healthcare technology and related costs;

Reimbursement rates in the future;

Growth in the number of allied health care professionals;

Increased dependence of the U.S. population on drugs and related pharmaceutical costs;

Skyrocketing cost of health insurance for individuals and families;

Increased cost for malpractice insurance, case settlements, and jury awards;

Universal health insurance legislation and its evolvement;

Economic recessions or expansions.


The competitive environment. There are external factors affecting the competitive

environment within the health care industry and its service markets. Three competing factors are

rising administrative costs, the complexity of the U.S. healthcare financing system, and the

deteriorating hospital-physician relationship (G. Carlson & Greeley, 2010). A fourth competitive

factor focuses on new models of healthcare delivery.

Rising administrative costs. Thirty-one percent of the healthcare costs in the United

States fall under the category of administrative costs (G. Carlson & Greeley, 2010). That is high

compared to 16.7 percent in Canada (G. Carlson & Greeley, 2010). High administrative costs in

the U.S. are the result of dealing with insurance companies (G. Carlson & Greeley, 2010). The

U.S. health sector has long been partial to health providers and insurers, but that is changing.

The complexity of the U.S. healthcare financing system. Healthcare financing is a very

complex and politically charged issue. But it is the system that society uses to pay for healthcare

services essentially (Gapenski, 2013). The U.S. healthcare system relies on third-party payers to

pay for a majority of medical services rendered to patients. The manner of healthcare financing

affects how hospitals and physicians are eventually reimbursed for their services. The insurance-

driven U.S. system tends to disenfranchise those of low socioeconomic status.

The association between the quality of healthcare and health insurance type has been well

documented, as has the impact of insurance status on how much of specific recommended

services an individual receives….uninsured individuals experienced deficits in the receipt

of preventative care and the likelihood of receiving care decreased as the length of time

without health insurance increased. (Shi, 2014, p. 125)

Gorey et al. reason that people of low socioeconomic status are likely to be more affected

by health care financing issues than their more affluent counterparts. In a system with


substantial barriers to care, the affluent may be better able to maneuver their way to early

diagnosis and high-quality oncologic treatment. (Schatzkin, 1997, p. 1095)

Hospital-physician relationships. Traditional relationships within healthcare, such as that

between hospital and physician, are being challenged as a fundamental rethinking of the health

system takes place (G. Carlson & Greeley, 2010). Strategies to preserve and strengthen the all-

important relationship between hospital and physician are a major priority of administrators.

Physicians’ general dissatisfaction with the practice of medicine contributes to the breakdown in

these relationships (G. Carlson & Greeley, 2010). Economic, regulatory, and financial pressures,

added to medical malpractice, are straining physician services.

Rising healthcare costs, deteriorating relationships, unexplained variations in clinical

outcomes, transparency in healthcare outcomes, medical tourism, competition between

hospitals and physicians, and reluctance by hospitals and physicians to change are among

the issues challenging the sustainability of the current business model. (G. Carlson &

Greeley, 2010, p. 158)

New models of healthcare delivery. Two basic types of systematic change are reactive

change and fundamental change. Reactive change reacts to an isolated process within a system

and does not change the other parts of the system (Maccoby, Norman, Norman, & Margolies,

2013, p. 97). Fundamental change transforms the entire system (Maccoby et al., 2013). A

fundamental change must take place in the U.S. healthcare system. Establishing primary care

coverage for the uninsured is the first necessary step in transforming the current system

(Stephens & Ledlow, 2010). A lack of focus on primary care in the recent past has contributed

to the present economic situation in healthcare, leaving a large group of uninsured and

underinsured in this country to over-utilize more expensive modes of treatment.


One new healthcare model is direct primary care, which drops insurance in exchange for

better provider-consumer relationships. A subscription fee associated with DPC is not to be

confused with concierge medicine, which is based on large retainer fees. By eliminating

insurance, 30 million uninsured (includes working Americans and legal aliens) could have a

medical home at the cost of roughly $36 per month (Stephens & Ledlow, 2010).

Replacing insurance reimbursements with a predictable monthly cash flow of

subscription fees can double or triple annual per-patient revenue. Eliminating the coding,

claims submissions, prior authorizations and telephone time on hold with multiple

insurance companies can also dramatically change the way direct primary care physicians

practice. (R. P. Carlson, 2015)

Internal Analysis

The Internal Analysis section of this paper analyzes factors specific to the internal

strengths and weaknesses of an organization; specifically here, the Indianapolis Health and

Wellness Center. Although this organization is under design and will be constructed after this

writing project is concluded, it is believed that certain elements of the business can be forecasted

with a reason of certainty. There are two subsections under the heading: Healthcare organization

purpose and mission, and healthcare organization culture and leadership.

Healthcare organization purpose and mission. The Indianapolis Health and Wellness

Center is a faith-based, nonprofit organization that seeks to restore hope and healing to the

ALICE (Asset Limited, Income Constrained, and Employed) population of Marion County, IN

and vicinity through accessible, affordable, quality healthcare. The purpose and mission of the

organization is very clear to those involved in the formulation of it. Thousands of Indiana

working people and their families need help accessing healthcare. Despite efforts through the


ACA to make health insurance available to everyone, need still exists for accessible healthcare.

Providing opportunity for uninsured and underinsured working persons to receive affordable

primary care, and establish a medical home, will be of tremendous benefit both to the patient and

the community.

Brinckerhoff’s Risk Decision Tree (2004) is a very helpful tool for social entrepreneurs

(people who take risks on behalf of their organization to maximize its mission-effectiveness).

The Risk Decision Tree has five questions to keep a social entrepreneur focused. The following

questions are asked (Brinckerhoff, 2004, p. 175):

Does this action support our mission?

Does this action keep us focused on our priorities?

Do we have adequate information to decide?

Have we applied appropriate business analyses?

Have we consulted appropriately with our stakeholders?

Persons working on the formulation and construction of the Indianapolis Health and

Wellness Center are continuously prodded by external support staff to focus on the priorities of

the mission – access to affordable, quality health care. Stakeholder input has been good. And

although there has been a desire at times to go farther than expected, the founder of the center

(this student) has been repeatedly guided throughout this educational program to stay on mission.

The Risk Decision Tree has helped this student stay focused.

Healthcare organization culture and leadership. This section analyzes the behavior,

structure, and leadership of the organization. Are the values and priorities of the organization

reflected in the behavior that is exhibited? Does the structure of the organization support the

stated mission and strategy? Is the leadership promoting diversity and facilitating change? All


of these questions are good to ask and need to be answered. But they cannot be fully addressed

at this time in the development of the Indianapolis Health and Wellness Center. What can be

stated securely is that the organization’s drafted mission, vision, and values are evidence of a

stewardship mindset. Brinckerhoff’s (2004) picture of a mission-based steward is a person who

consistently leads the organization to manage the community’s resources in a manner that

maximizes its mission-effectiveness. A stewardship culture is developed over time as shown

below.

The culture of a group can now be defined as a pattern of shared basic assumptions that

was learned by a group as it solved its problems of external adaptation and internal

integration, that has worked well enough to be considered valid and, therefore, to be

taught to new members as the correct way to perceive, think, and feel in relation to those

problems. (Schein, 2004, p. 17)

Current members of the Indianapolis Health and Wellness Center have not been together

long enough to talk about the patterns of learned behavior that exist within the organization. But

it is good to be fully aware that the things which are being done now may well become the

standard by which they are done in the future, and passed on to new members. It behooves

current members to formulate culture wisely so others may embrace it later.

Identification and Discussion of Issues

There are key research issues within this body of work, though it is conceived of as a

formation project. These foundation issues will be briefly stated below and then analyzed in

greater detail later in the paper. The research issues concern: The presence of a healthcare safety

net; the plight of uninsured and underinsured working-class persons, after full implementation of


the Affordable Care Act; direct primary care, a new way to access affordable, quality healthcare;

ending racial/ethnic disparities in healthcare through accessible, affordable healthcare.

How does the core safety net system support the U.S. healthcare system to abate

problems facing vulnerable populations of people? The relationship between health insurance

and access to care and medical outcomes is a well-documented issue (Lewin & Altman, 2000).

Large numbers of low-income minorities and persons of immigrant status are uninsured or

underinsured, Medicaid beneficiaries, with special healthcare needs, and live in geographically

or economically disadvantaged communities. They are the vulnerable populations often spoke of

in this paper. In the absence of universal health care, the core safety net system serves as the

default system in caring for many of these types of persons. In many inner-city and rural

communities, the safety net system may be the only available source of primary health care

(Lewin & Altman, 2000). A committee from the Institute of Medicine made the following

comment:

The committee concludes that the safety net system is a distinct delivery system, however

imperfect, that addresses the needs of the nation’s most vulnerable populations. In the

absence of total reform of the health care system and while the new market paradigms are

unfolding, it seems likely that the nation will continue to rely on safety net providers to

care for its most vulnerable and disadvantaged populations. (Lewin & Altman, 2000, p.

75)

After full implementation of the Affordable Care Act, will there be a significant

population of uninsured and underinsured persons? Healthcare reform officially began with

the signing of the Patient Protection and Affordable Care Act on 23 March 2010. Based upon

information from the Gallup-Healthways Well-Being Index, which conducts a nationwide


telephone survey annually, “the overall rate of uninsured Americans fell from 17.3% to 13.8%

from 2013 through 2014, when the individual requirement to obtain health insurance took effect”

(Nix, 2015, p. 17). Despite a reduction in the nation’s uninsured population, there is still strong

concern over long-term economic outcomes and the cost of expanded coverage (Nix, 2015).

Focusing on affordability is crucial, because millions of low-income, uninsured Americans face

challenges assessing appropriate and affordable resources for preventive and primary care

("Meeting the healthcare needs of underserved communities," 2014, May). Those persons who

are disenfranchised by the American healthcare system and choose to drop out of the insurance

marketplace, along with undocumented immigrants, will continue to represent a substantial

number of people that will need a medical home.

Can direct primary care (DPC) provide accessible, affordable, quality healthcare to

the uninsured and underinsured? The cost of healthcare in the United States is a major

problem. The U.S. has struggled mightily to control healthcare costs over the past two decades.

That is why the following makes sense: “We suggest that although providing full medical

coverage to all uninsured Americans may be cost-prohibitive, a very realistic incremental step

would be to provide basic, primary health benefits” (Stephens & Ledlow, 2010, p. 98). DPC

eliminates costly insurance for the patient, and replaces insurance reimbursements for the

physician with a predictable monthly cash flow from subscription fees. Proponents of DPC

claim their model incentivizes physicians to provide better care that keeps patients healthy and

out of costly specialty and hospital care (R. P. Carlson, 2015).

What impact does accessible, affordable, quality healthcare have on racial/ethnic

disparities? Healthcare disparities exist and they matter. They matter to millions of Americans

who put their health on hold until they can afford to be sick. While cost is crucial, fixing it is not


sufficient to heal the entire U.S. healthcare system. Another issue must be addressed – the

elimination of health disparities. Zuvekas and Taliaferro (2003) report that disparities in access

persist, across racial and ethnic groups, despite marked improvements in the nation’s overall

health. Members of racial/ethnic groups continue to have poorer access to high-quality health

care services and different patterns of use versus whites (Zuvekas & Taliaferro, 2003). Society

must begin to affect the broader factors that underlie racial and ethnic disparities in health.

Information and Literature Review

This research study sought to formulate a medical clinic and wellness center for the

ALICE (Asset Limited, Income Constrained, and Employed) population of Marion County, IN

and vicinity. This work follows a community needs and resources assessment conducted by the

Polis Center of Indianapolis (2015), on behalf of the Indianapolis Health and Wellness Center.

Although a safety net system exists, there are no known facilities in Indianapolis dedicated to the

care of working people and their families who are uninsured or underinsured. The Indianapolis

Health and Wellness Center is dedicated to restoring hope and healing to the working uninsured

and underinsured (ALICE) by providing accessible, affordable, quality healthcare.

A review of related literature was necessary to better understand the problem being

proposed in the present research study. The problem is a large number of Indianapolis

households with working families (ALICE) lack access to affordable, quality primary care. A

successful solution to the problem would be to develop a medical clinic and wellness center in

the midst of a community of people who fall below the ALICE Threshold. This information and

literature review examines information regarding the safety net system, the plight of working

uninsured and underinsured families, Direct Primary Care medicine, and racial/ethnic disparities.

Review of Literature Relevant to the Safety Net System


The importance of the America’s healthcare safety net system cannot be overemphasized.

The healthcare safety net lacks a consistent definition, and the concept of such “conjures up the

image of a tightly woven fabric of federal, state, and local programs stretched across the nation

ready to catch those who slip through the health insurance system” (Lewin & Altman, 2000, p.

47). The share of care offered by the country’s safety net to poor and uninsured populations is

difficult to precisely measure.

Roby (2014) claims that the term safety net is used to describe a loosely defined set of

providers, which includes community health centers, local health departments and public

hospitals. The safety net system developed over time, in piecemeal fashion, as opportunities

arose to help meet the needs of persons who could not afford or obtain care due to geography,

poverty, language needs, disabilities, and other factors (Redlener & Grant, 2009).

In broader and potentially more accurate terms, the safety net represents…providers in

private practice, privately and publicly owned rural and urban community clinics, free

clinics, federally supported community and migrant health centers, acute care hospitals,

mental health clinics, psychiatric hospitals, and public health departments that deliver

direct services to low-income or vulnerable patients with and without insurance coverage.

(Roby, 2014, p. 704)

It is important to understand the impact disparate providers make within the safety net

community. Disparate providers refers to all those who can “by examining the magnitude of

their contribution, the level of their involvement, and the unique ways that they may enhance

access to care, improve the quality of health care, and change the underlying trends in health care

spending” (Roby, 2014, p. 705). Their contribution to the care of vulnerable populations is not


always evident, but it is of tremendous benefit to the millions of people who are medically

disenfranchised because of physician shortages in their communities (Roby, 2014).

With full implementation of the ACA, more than 40 million Americans currently

uninsured will enroll in coverage through Medicaid and commercial insurance products.

However, undocumented immigrants and persons who still cannot afford to purchase insurance

coverage will become further disenfranchised by the U.S. healthcare system (Roby, 2014).

The safety net system in the U.S. will be in flux for the next decade or two (Roby, 2014).

The role the safety net can play in caring for the low-income, uninsured, or underserved

population in their areas will be defined and redefined (Roby, 2014). But before long, safety net

providers will be better integrated into the U. S. health care system.

Safety-net providers have historically been successful in delivering high-quality care to

their patient population while also managing their spending effectively. Efficiency will

be a key component of strengthening the safety net after ACA implementation, along

with continuing to develop systems and strategies that will allow the disparate providers

that make up the safety net to change roles and adapt to the new markets for health

insurance and the remaining uninsured who are left out of the reforms. (Roby, 2014, p.

716)

A disproportionate number of minority groups depend on America’s safety net system for

their health care needs (Lewin & Altman, 2000). African Americans, Hispanics, Native

Americans, and Asians appear in large concentrations at urban safety net hospitals versus other

urban hospitals. Fortunately, the core safety net serves a wide range of persons and vulnerable

populations: Uninsured and underinsured, Medicaid beneficiaries, chronically ill individuals,

people with disabilities, mentally ill individuals, people with communicable diseases, legal and


undocumented immigrants, minorities, Native Americans, veterans, homeless people, substance

abusers, and prisoners (Lewin & Altman, 2000).

Review of Literature Relevant to the Uninsured and Underinsured

Healthcare in the United States is too expensive! Stephens and Ledlow(2010) agree that

higher costs are a problem and “a major factor in another very serious conundrum: the number of

Americans without any form of health insurance coverage” (pp. 98-99). Millions of Americans

face weekly challenges of accessing affordable, quality care (preventive and primary care) –

either because they are without insurance or they don’t have enough insurance (Stephens &

Ledlow, 2010). One study estimates that 44 percent (81 million) of US adults ages 19-64 were

either underinsured or uninsured in 2010 – up from 75 million in 2007 and 61 million in 2003

(Schoen, Doty, Robertson, & Collins, 2011). The same study claims that adults with incomes

below 250 percent of the federal poverty level are continually at risk of becoming uninsured or

underinsured (Schoen et al., 2011). It’s now estimated that 16.3 percent of people ages 18 to 64

years remain uninsured (Bias, Agarwal, & Fitzgerald, 2015).

The majority of uninsured Americans are nonelderly (below age 65), low-income adults;

and more than half of these are people of color (Majerol, Newkirk, & Garfield, 2014, December

5). The risk of being underinsured appears greater for young, Hispanic, low-income persons

(Cardinali et al., 2014, November-December). Underinsurance exists “when patients have to

forego or delay needed health care or when out-of-pocket medical costs exceed 10% of

household income (5% for low-income families)” (Cardinali et al., 2014, November-December,

p. 855). Added to the total problem, Medicaid beneficiaries and low-income workers with

unstable employment regularly move on and off of insurance (Lewin & Altman, 2000).


Our 2013 survey of the general population in eleven countries – Australia, Canada,

France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the

United Kingdom, and the United States – found that US adults were significantly more

likely than their counterparts in other countries to forgo care because of cost, to have

difficulty paying for care even when insured, and to encounter time-consuming insurance

complexity.(Schoen, Osborn, Squires, & Doty, 2013, p. 2205)

The growing number of uninsured within medically underserved populations is a major

factor driving health insurance reform debates (Shi, 2014). The medically underserved

continually experience undiagnosed and/or untreated health conditions that put them at risk for

serious illnesses and acute episodes, which must be treated in intensive, high-cost settings

("Meeting the healthcare needs of underserved communities," 2014, May). If reforms succeed in

increasing the affordability of care, a 70 percent drop in the number of underinsured people and a

steep drop in the number of uninsured people is expected (Schoen et al., 2011). That is good

news because the current picture of the uninsured and underinsured is unacceptable.

In the year 2001, an estimated 14.6% of the American population, or 41.2 million people,

were uninsured. By 2004, this number grew to 48.1 million uninsured individuals…In

2009, the number of uninsured individuals ranged from 45 to 48.1 million. Young adults

(18-24 years old), American Indians, Alaskan Natives, and residents of New Mexico and

Texas were most likely to not have health insurance as compared to other groups. It is

important to emphasize that many working Americans lack health insurance coverage as

well. Among Americans aged 18-64 years, more than 17% lack health insurance and

nearly 20% of uninsured are children. Nearly 40% of uninsured children live in poverty.

Hispanics are most likely to be uninsured. In 2007, nearly 34% of the uninsured were


Hispanic. Other minority groups also suffer disproportionately. Even more surprising is

the fact that over two-thirds of the uninsured hold full-time jobs. (Stephens & Ledlow,

2010, p. 100)

The most sweeping health insurance expansion and market reform, since the enactment

of Medicare and Medicaid in 1965, was initiated with the signing of the Affordable Care Act on

23 March 2010. From the Gallup-Healthways Well-Being Index, which conducts a nationwide

telephone survey annually, the rate of uninsured Americans fell from 17.3% (2013) to 13.8%

(2014), when the individual requirement to obtain health insurance took effect (Nix, 2015).

Despite a reduction in the nation’s uninsured population, there is still strong concern over long

term economic outcomes and the cost of expanded coverage (Nix, 2015). Focusing on

affordability going forward is crucial ("Meeting the healthcare needs of underserved

communities," 2014, May).

Review of Literature Relevant to Direct Primary Care (DPC) Medicine

Reforming the U.S. healthcare system should begin with providing primary care coverage

for the uninsured and underinsured patient populations (Stephens & Ledlow, 2010). Preventive

and primary care are the least costly ways to treat patients and keep them healthy("Meeting the

healthcare needs of underserved communities," 2014, May). “Changing the physician payment

system to encourage more primary and preventive care and less specialty care is clearly

essential” (J. G. Atkinson & T. N. Giovanis, 2015, p. S630). Taking this approach would be

better than performing a major system overhaul. Educating patients to the importance of primary

care is smarter for the bottom line, and will help patients better manage their own care for the

long term ("Meeting the healthcare needs of underserved communities," 2014, May).


Direct primary care, as defined by the Direct Primary Care Coalition (DPCC), is “an

innovative alternative payment model for primary care being embraced by patients, physicians,

employers, payers and policymakers across the United States. The defining element of DPC is

an enduring and trusting relationship between a patient and his or her primary care provider”

("What is Direct Primary Care (DPC)? The official definition(s)," 2014, June 13). Direct

primary care is often confused with concierge medicine lately. But DPC practices do not bill

insurance and do not receive reimbursement from insurance companies. Subscription fees (aka,

membership fees) from the patient typically cover the full range of comprehensive primary care

services ("Concierge medicine vs. direct primary care," 2015).

Replacing insurance reimbursements with a predictable monthly cash flow of

subscription fees can double or triple annual per-patient revenue. Eliminating the coding,

claims submissions, prior authorizations and telephone time on hold with multiple

insurance companies can also dramatically change the way direct primary care physicians

practice. (R. P. Carlson, 2015, p. 20)

Direct primary care is empowered to achieve superior health outcomes, lower costs, and

an enhanced patient experience ("What is Direct Primary Care (DPC)? The official

definition(s)," 2014, June 13). Five tenets of DPC practice include service, elimination of fee-

for-service, patient choice, advocacy, and stewardship. The best aspect of doing medicine this

way is that physicians communicate with patients in the most appropriate and convenient way

(R. P. Carlson, 2015). DPC will be the standard way primary care is practiced in the next 10

years (R. P. Carlson, 2015).

Review of Literature Relevant to Racial/Ethnic Disparities


Health care disparities exist and they matter. They matter to millions of Americans who

put their health on hold until they can afford to be sick. While focus on affordability in health

care is crucial, it is not sufficient to heal the U.S. healthcare system. The issue of eliminating

health disparities must also be addressed. Zuvekas and Taliaferro (2003) report, “Despite

marked improvements in the nation’s overall health, disparities in access persist across racial and

ethnic groups….Members of these groups continue to have poorer access to high-quality health

care services and different patterns of use than those of whites” (p. 139). Two findings from

Serban’s (2015) dissertation are important here: First, individuals living in counties with income

levels below poverty, and a higher percentage of persons without a high school education, had

lower odds of reporting a personal doctor; and secondly, black residents living in black isolated

neighborhoods or Hispanic residents living in Hispanic isolated neighborhoods had lower than

average potential accessing primary care services. Society must begin to affect the broader

factors that underlie racial and ethnic disparities in health. Ponce and Ko (2014) report that areas

with a higher percentage of black and Hispanic residents have fewer physicians per capita.

The distinction between disparity in health and disparity in healthcare should be

underscored. Disparity in health refers to racial/ethnic differences in morbidity and mortality

which are influenced by a variety of factors (only one of which is health care) (Bustamante,

Morales, & Ortega, 2014). In contrast, a disparity in health care is “a difference in care that is

not accounted for by a difference in access to care, personal preference, clinical need, or clinical

appropriateness” (Bustamante et al., 2014, p. 105).

Commenting on the substantial amount of racial disparities in the American health

system, Williams and Jackson (2005) report that the “overall death rate for blacks today is

comparable to the rate for whites thirty years ago, with about 100,000 blacks dying each year


who would not die if the death rates were equivalent” (p. 325). A number of factors (e.g., patient

factors, provider factors, and system factors) are associated with access to and utilization of

health care. Patient factors are influenced by patients’ attitudes toward providers and the health

care system, their perception of health and views of specific diseases, and their ability to accept

and cope with illness (Bustamante et al., 2014).

These attitudes in turn determine whether a patient will seek care, adhere to providers’

recommendations, and successfully achieve desired outcomes. Patient trust, level of

comfort with medical providers, and satisfaction with care are important factors for entry

into the health care system as well as its continued use. (Bustamante et al., 2014, p. 107)

Provider factors come from discordance between patient and provider demographics.

Within the medical community, there is an overrepresentation of White males from affluent

socioeconomic backgrounds. Balanced against that is the vast number of racial and ethnic

minorities in the U.S. that come from socioeconomically disadvantaged communities and

families with lower education and income levels. Such discordance fuels stereotyping,

unconscious bias, inability to comprehend language, misunderstanding, differences in

beliefs/religious beliefs, personal mistrust, lack of empathy, and so forth, which ultimately lead

to inappropriate or ineffective clinical decision making (Bustamante et al., 2014).

System factors impact healthcare disparities as well. The cardinal principles of medical

ethics – autonomy, beneficence, and justice – are not always held up in public health. In

particular, justice appears to be missing. Rosenau, Roemer, and Zimmerman (2014) state, “In

the United States, virtually all health care is very inexpensive (at the margin) to those with health

insurance, while virtually all health care is extremely expensive to consumers without insurance”

(p. 732). This creates a rationing of medical care. “Rationing medical care is not always


ethically dubious”; in other words, “too much medical care is counterproductive and may

produce more harm than good” (Rosenau et al., 2014, p. 732). Medical care is often rationed in

underprivileged and economically blighted areas.

Review of Literature Relevant to the Patient Protection and Affordable Care Act (ACA)

The Affordable Care Act of 2010 is not the typical kind of federal legislation because it

really is two bills combined into one law – the Patient Protection and Affordable Care Act

(ACA) and the Health Care and Reconciliation Act of 2010 (HCERA) (Cannan, 2013). The

legislative process behind this historic piece of U.S. healthcare governance was conducted more

ad hoc and less systematically (Cannan, 2013, p. 133). Legislation was incorporated into the

ACA that bonded it with multiple legislative histories, creating a sort of legislative umbrella.

Cannan (2013) states, “The history of health care legislation could be seen as taking place over

the course of an entire century, from Theodore Roosevelt’s advocacy for a health care system to

Bill Clinton’s failed effort in 1993” (p. 136). Actions of the 111th Congress, documented in the

Library of Congress’s legislative database known as THOMAS, figured significantly upon the

work of the ACA. The new healthcare legislation even underwent judicial review by the U.S.

Supreme Court. In June 2012, the high court upheld the ACA’s individual mandate but struck

down its expansion of Medicaid. In conclusion, though the legislative process was convoluted

and twisted, universal health coverage is becoming a reality in America.

The ACA contains eight parts: Industry standards, patient guarantees, individual

mandates, healthcare exchange, subsidies, Medicaid expansion, Medicare payments, and

employer mandates (D. Sabotin, personal communication, 3 March 2015). Each section of the

new healthcare law seems to engender or enrage a particular subset of people. Yet it resembles

the universal health plans found in Massachusetts and Oregon.


The U.S health care system is 37th amongst the nations of the world (D. Sabotin, personal

communication, 3 March 2015). Nearly 50 million Americans were without health insurance

(prior to the ACA), which created a burden on the rest of the populace to keeping the national

health system vibrant. The White House ("Fact sheet: The Affordable Care Act: Secure health

coverage for the middle class," 2012, June 28) released this fact sheet in support of the ACA.

Insurance companies no longer have unchecked power to cancel policies, deny children

coverage due to a pre-existing condition, or charge women more than men.

Over 86 million Americans gain preventive care coverage free of charge, like

mammograms for women and wellness visits for seniors.

Nearly 13 million Americans will receive some rebate because their insurance company

spent too much of their premium dollars on administrative costs or CEO bonuses.

The law helps 5.3 million seniors and people with disabilities save an average of over

$600 on prescription drugs in the “donut hole” in Medicare coverage.

The law has provisions to strengthen and protect Medicare by continuing to fight fraud.

The law helps 6.6 million young adults stay on their parents’ plans until the age of 26,

which includes 3.1 million young people who are newly insured.

The ACA has achieved its major goals of expanding enrollment and reducing the number

of people without health insurance. In 2014, more than 8 million Americans purchased coverage

in the Health Insurance Marketplace (PPACA), with an estimated 40 percent of them previously

uninsured (Bias et al., 2015). Furthermore, individuals with existing health problems have been

protected. “However, issues still exist, particularly with the affordability of health insurance” (J.

G. Atkinson & T. N. Giovanis, 2015, p. S630). The ACA lacks meaningful cost containment

language. Affordability and access issues are created by limited provider networks and high


deductible policies. These insurance policies are very expensive and the cost is continuing to

rise (J. G. Atkinson & T. N. Giovanis, 2015).

The original design of the ACA assumed Medicaid expansions would be mandatory.

However the Supreme Court disallowed that provision, leaving opportunity for some states to

refuse the expansion. This has left gaps to be filled. Interestingly enough, “states not expanding

Medicaid are home to the highest uninsured and poverty rates across the country” (Adepoju,

Preston, & Gonzales, 2015, p. S665). Other states, like Indiana, were slow to expand. Medicaid

is a need-based program for low-income and high risk populations, such as low-income child and

family services, persons with developmental disabilities, and low-income nursing home

residents. Administration of the Medicaid program occurs at the state level, whereby each state

determines its own mixture of federal and state funding. Some states may experience setbacks as

a result of failing to expand their program:

Choi et al. examined historical cancer screening rates and mortality-to-incidence ratios in

states that have not expanded Medicaid and conclude that historical disparities in cancer

screening that existed prior to the enactment of the ACA are likely to be exacerbated. (G.

Atkinson & T. Giovanis, 2015, p. S631)

In the post-ACA era, there are many issues that still must be addressed. With the help of

a few resources (Adepoju et al., 2015; J. G. Atkinson & T. N. Giovanis, 2015; Call et al., 2015) a

list is provided. The list is certainly not complete.

Fill the gaps created by states not expanding their Medicaid programs;

Address affordability and access issues created by high deductible plans and limited

provider panels;

Restructure the physician payment system;


Restructure physician ordering and referral patterns;

Simplify the enrollment process;

Eliminate differential access to care;

Consider underlying social elements that make medical homes and ACOs robust;

Close knowledge gaps in preventative health services utilization;

Physicians and providers should advocate for a stronger safety net and resources to

provide patient-centered care, including communication across health systems.

Analysis of Key Issues

The research study under investigation in this paper pertains to the formation of the

Indianapolis Health and Wellness Center in Marion County, IN. This study is in response to an

identified problem, the lack of accessible healthcare for the ALICE (Asset Limited, Income

Constrained, and Employed) population in Indianapolis and vicinity. There are four research

issues in this body of work that were briefly introduced earlier in this paper. Following the

Information and Literature Review, the four issues will now be analyzed by this student.

How does the core safety net system support the U.S. healthcare system to abate

problems facing vulnerable populations of people? The safety net system in the United States

is a distinct system that addresses the needs of the nation’s most vulnerable and disadvantaged

populations (Lewin & Altman, 2000). Millions of uninsured and underinsured persons rely on

the safety net system for their healthcare needs because they cannot afford to matriculate through

more expensive healthcare systems requiring insurance. The Kaiser Family Foundation’s

continuing analysis of health reform “points to the ongoing degradation of health insurance in the

United States” (Rosenbaum, 2015, p. 463). Degradation of health insurance means greater direct

financial exposure for patients. Insurers and employers are shifting premium costs to employees


through strategies like shrinking coverage, hiking deductibles, tightening provider networks,

increasing cost-sharing for more costly services, and denying treatments (Rosenbaum, 2015).

Hence, the importance of the safety net system cannot be overemphasized.

America’s health care safety net is not easily defined, as it has developed over time in a

piecemeal fashion. The safety net represents a myriad of “disparate providers” in “private

practice, privately and publicly owned rural and urban community clinics, free clinics, federally

supported community and migrant health centers, acute care hospitals, mental health clinics,

psychiatric hospitals, and public health departments” (Roby, 2014, p. 704). The contribution of

these service providers to the care of vulnerable populations is of tremendous benefit, both to the

medically disenfranchised who receive services and to the wider community which must often

absorb the cost of indigent care. Vulnerable populations include: Uninsured, underinsured,

Medicaid beneficiaries, chronically ill, people with disabilities, mentally ill, people with

communicable diseases, immigrants – legal and undocumented, minority groups, veterans,

homeless, prisoners, and substance abusers (Lewin & Altman, 2000).

The Indianapolis Health and Wellness Center seeks to address the problem outlined by

becoming a member of the core safety net community in Marion County. Appendix A displays a

picture of the targeted service area the center will serve, which touches five different counties:

Boone, Hamilton, Hancock, Madison, and Marion. Appendix B displays a number of safety net

clinics that currently exist within the targeted service area but serve different populations. It is

anticipated that the most frequent clients of the center will be working low-income minorities,

legal and undocumented immigrants, and persons with high deductible health insurance plans.

After full implementation of the Affordable Care Act, will there be a significant

population of uninsured and underinsured persons? U.S. healthcare reform officially began


on 23 March 2010 with President Barack Obama’s signature on the Patient Protection and

Affordable Care Act (ACA). Millions of low-income, uninsured Americans continued to face

the challenge of accessing healthcare – affordable, quality primary care ("Meeting the healthcare

needs of underserved communities," 2014, May). Medicare patients roll on-and-off the program,

undocumented immigrants, and chronically ill minorities need a medical home. The cost of

health care in the U.S. keeps many individuals uninsured. An even more intriguing question is:

Will there be a significant number of underinsured working adults once the ACA has been fully

implemented?

Based upon information from the Gallup-Healthways Well-Being Index, “the overall rate

of uninsured Americans fell from 17.3% to 13.8% from 2013 through 2014, when the individual

requirement to obtain health insurance took effect” (Nix, 2015, p. 17). In 2014, 24 million adults

met the definition of underinsured; i.e., they spent 10% or more (5% in the case of low-income

people) of their household income on out-of-pocket healthcare expenses (excluding premiums)

(Rosenbaum, 2015). It seems reasonable to believe that in 2015 and beyond, Americans without

sufficient health insurance coverage will abound.

The ACA is said to be a contributor to the ongoing decline in insurance coverage and to

greater exposure of the cost of health insurance for the underinsured (Rosenbaum, 2015). Three

fundamental policy choices embodied in the legislation are responsible for creating such a

phenomenon. Hastening the problem is the following.

The first is the law’s failure to take on underlying healthcare costs directly. The second

is the decision to significantly limit the size and scope of premium subsidies and cost-

sharing reduction assistance available for health plans purchased in the Marketplace, even

though the buyers would be low- and moderate-income families….Finally, the third is the


so-called Cadillac tax, which imposes a 40% excise tax on employer plans that exceed a

certain threshold, and has triggered an employer land-rush to reduce the actuarial value of

their plans (most easily through high deductibles) in order to avoid the tax. (Rosenbaum,

2015, p. 464)

The Indianapolis Health and Wellness Center is to be situated in the northeast corner of

Marion County. Within the five counties located inside the targeted service area, 21.4 percent of

the families are considered ALICE households with income above the Federal Poverty Level but

below the basic cost of living (see Appendix C). There are pockets of vulnerable populations

with no health insurance in the service area. The population age 0-65 with no health insurance is

displayed in Appendix D. Noteworthy is a large area of deprivation located immediately east of

the center (< 20 mi.) all within the service area (see Appendix E). These families find it difficult

to afford the costs of basic necessities (housing, child care, food, health care, and transportation).

Bringing hope and healing to this large population of underinsured by providing accessible

healthcare is both a blessing and a benefit to the community.

Can direct primary care (DPC) provide accessible, affordable, quality healthcare to

the uninsured and underinsured? Providing full medical coverage to all uninsured Americans

appears to be cost prohibitive. But a viable alternative would be to provide basic, primary health

benefits to the uninsured and underinsured as a first step in the right direction (Stephens &

Ledlow, 2010). Direct primary care is defined as “an innovative alternative payment model for

primary care being embraced by patients, physicians, employers, payers, and policymakers

across the United States ("What is Direct Primary Care (DPC)? The official definition(s)," 2014,

June 13, p. 1). DPC eliminates costly insurance for the patient, and replaces insurance

reimbursements for the physician with a predictable monthly cash flow from subscription fees


(R. P. Carlson, 2015). DPC is empowered to achieve better outcomes, lower costs, and a more

fulfilling patient experience ("What is Direct Primary Care (DPC)? The official definition(s),"

2014, June 13). Best of all, this arrangement incentivizes physicians to keep patients healthy and

out of more costly specialty and hospital care (R. P. Carlson, 2015). Educating patients to this

way of medicine would be very important.

The Indianapolis Health and Wellness Center has been developed to provide a DPC

subscription plan to working persons and their families, using a fee schedule that is extremely

affordable. The model is an age-based subscription plan and works very simply. Any person

seeking to join the center’s DPC plan can do so by paying a monthly subscription fee, based on

their current age. All services offered by the center, from its various caregivers, are fully

covered as long as patients are enrolled in the plan. The age-based subscription plan is this:

0-18 yrs. $10/mo.

19-29 yrs. $35/mo.

30-49 yrs. $50/mo.

50-69 yrs. $75/mo.

The Indianapolis Health and Wellness Center will offer direct primary care medicine,

podiatry, ophthalmology, immunizations, and limited dental services. All services are currently

covered under the subscription plan. The center is expected to be open 250 days a year with an

average of 20 patients per day, making the plan very sustainable.

What impact does accessible, affordable, quality healthcare have on racial/ethnic

disparities? Millions of Americans cannot afford to get sick because they lack health insurance.

Therefore, they play Russian roulette with needed health care – avoiding doctors and hospitals

until they no longer can because their health has reached a critical level. But fixing the U.S.


healthcare system is not all about providing insurance for everyone or making medical services

affordable. They also need to be equitable. Meaning, disparities in healthcare delivery must also

be eliminated. Healthcare disparities exist and they matter. Zuvekas and Taliaferro (2003)

report that disparities in access persist, across racial and ethnic groups, despite marked

improvements in the nation’s overall health. Members of racial/ethnic groups continue to have

poorer access to high-quality healthcare services and different patterns of use versus whites

(Zuvekas & Taliaferro, 2003). Society must begin to affect the broad factors that underlie racial

and ethnic disparities in health.

The impact of accessible healthcare amongst minority populations can be profound.

Low-income minorities have little opportunity now to receive affordable, quality healthcare but

that issue can be eliminated causing racial/ethnic disparities to disappear. However, there is

needful work to be done. Stereotyping, unconscious bias, inability to comprehend medical

language, misunderstanding of diagnosis, differences in religious beliefs, mistrust, lack of

empathy, and so forth, can be diminished if the physician-patient relationship is enhanced

(Bustamante et al., 2014). Direct primary care is a game-changer for all of these reasons.

The Indianapolis Health and Wellness Center seeks to eliminate racial/ethnic barriers that

exist in Marion County (IN) by providing accessible, quality primary care. The age-based

subscription plan in the DPC model eliminates the need for insurance and provides opportunity

for a quality physician-patient interaction. Patients go away feeling helped through a medical

encounter in their best interest. Unlike previous trips to the doctor, this one was meant to get

them back to good health and keep them that way. Various pilot practices of DPC providers

“showed improved patient satisfaction and clinical outcomes, reduced racial disparities and

absenteeism, and better functional status” (R. P. Carlson, 2015, p. 23). As one DPC physician


stated, “Our job is to help people improve their health, and if we improve their health, a side

effect will be lower health care costs” (R. P. Carlson, 2015, p. 24).

Recommendations and Conclusions

In response to the problem presented in this study, a group of faith-based persons in

Indianapolis, IN are in process of launching a medical clinic and wellness center in the Northeast

sector of Marion County (IN). The project, known as the Indianapolis Health and Wellness

Center (IHWC), is dedicated to providing accessible, affordable, quality healthcare to uninsured

and underinsured working persons and their families. These families are known as ALICE

(Asset Limited, Income Constrained, and Employed) households. Formulation of IHWC is

being supported by Empowering Community Healthcare Outreach (ECHO), a ministry of the

Church Health Center (CHC) in Memphis, TN. CHC is the largest faith-based healthcare

organization of its type in the country serving uninsured working people and their families.

ECHO was founded by the Nancy and John Snyder Foundation, a faith-based nonprofit

organization in Fort Worth, TX.

In the formation of IHWC, important leadership positions and committees will assume

responsibility for the bulk of the work. ECHO has identified the following key leadership

positions in the development process:

Visionary: Gives voice to the clinic in the community in the earliest stages.

Medical Champion: Gives voice to the clinic in the medical community.

Planning Team Leader: Designs, implements and leads the Planning Team process.

Data Champion: Asserts and manages the power of valid data to document the initial and

on-going need for the clinic in the community.


Governance Ally: Ensures the role of governance is held in high esteem and receives

energy and effort equal to that of the efforts toward operations.

One of the most rewarding and pivotal roles in the development of an ECHO clinic is that

of the Planning Team Leader (PTL). This position assumes central control on behalf of the

developing clinic. The PTL is truly responsible for the getting the job done as they collectively

work with various other committee chairpersons on the Planning Team (PT). The PT, which is

invaluable to the success of the development effort, is comprised of six committees:

Environmental Scan, Legal, Operations, Site, Communications and Finance. The PT is:

Responsible for developing and approving organizational values, mission, and for

producing the Environmental Scan and Business Plans. Members are chairs of

committees who attend this monthly meeting to coordinate efforts. In addition,

Committee Chairs are responsible for monthly meetings of their respective committees.

(Empowering community healthcare outreach: A guide for starting a charitable

community healthcare clinic, n.d., p. 14)

In regards to the development of the Indianapolis Health and Wellness Center, Table 1

(below) displays a timeline of activity; Table 2 (below) displays planning methods of various

committees; and Table 3 (below) displays projected budget expectations.

Summary

The Indianapolis Health and Wellness Center (IHWC), a 501c3 Indiana faith-based non-

profit organization, is attempting to launch a medical clinic and wellness center modeled after

the Church Health Center (CHC) of Memphis, TN. CHC is the largest faith-based healthcare

organization of its type in the country serving uninsured working people and their families. To

date, CHC has served more than 60,000 people in and around Shelby County (TN). Empowering

Community Healthcare Outreach (ECHO) – a ministry of CHC – is working with IHWC to


replicate the work of CHC in Marion County (IN). In serving the most vulnerable members of

society, the work of IHWC is a ministry of hope and healing to working families in need of help.

The capstone project written of herein serves as the developmental ideas in the formation of the

IHWC. While attempting to replicate CHC’s work, IHWC addresses very unique circumstances

in Indianapolis.

Table 1Timeline of ActivityActivity Month

1Month

3Mont

h6

Month9

Month12

Month18

Initial meeting w/ ECHO Consultant & Planning Team XValues, Mission and Vision XBoard members recruited XLegal structure determined XClinic goals determined XBusiness Plan completed XBegin Board training XApply for federal 501(c)3 XResearch clinic locations XDevelop budget for years 1&2 of clinic operations

X

Develop funding plan for year 1 of operations

X

Explore partnerships w/ existing providers

X

Board reviews, revises, approves first year budget, creates funding plan

X

Develop Personnel P&P XDevelop plan for hiring Ex Dir/Clinic Director

X

Ex Dir and Med Dir in place XEHR purchased XGrand Opening Celebration! X



Table 2Methods Planning

Tasks and Subtasks

Person(s) Responsible Resources Needed Start and Finish Dates

Environmental Scan

Planning Team Leader and Environmental Scan Committee

SAVI Information Months 1-3

Mission, Vision, Values

Visionary andPlanning Team

Passionate Mission Months 1-3

Board members recruited

Visionary and Governance Ally Knowledge people w/ connections

Months 1-3

Clinic goals determined

Planning Team Leader and Operations Committee

Environmental Scan Months 3-6

Apply for federal 501c3 status

Planning Team Leader and Legal Committee

By-Laws and legal advice

Months 3-6

Develop budget and funding plan

Planning Team Leader and Finance Committee

Examples of budgets and plans from other groups

Months 3-6

Develop personnel P&P

Planning Team Leader and Operations Committee

Examples of personnel P&P from other groups

Months 7-12

Hire Ex. Dir. and Clinic Dir.

Board of Directors and Legal Committee

Criteria, Resumes, References, and Credentials

Months 7-12

EHR purchased Planning Team Leader and Operations Committee

Information and references

Months 7-12

Dry run conducted Planning Team, Ex. Dir, Clinical Dir, Operations comm., providers, staff, and volunteers

Fully operational medical clinic

Months 13-18

Grand Opening Celebration!

All stakeholders in the clinic!! Fully operational medical clinic

Months 13-18

Review clinic data Ex. Dir, Clinic Dir, Staff, and Board of Directors

Clinical data and outcome measures

Months 13-18


Table 3Projected Budget for IHWC

Projected Revenue for

ClinicRevenue Description Transition Transition Operations Operations

Year 1 Year 2 Year 3 Year 4Gifts, grants, and contributions received 250,000Gross Receipts from services performed 492,000Total Revenue $742,000

Projected Expense for

ClinicExpense Description Transition Transition Operations Operations

Year 1 Year 2 Year 3 Year 4Construction/Up fit 10,000 2,500 5,000 10,000Education/Training 4,000 4,000 6,000 6,000EMR Software 6,600 3,600 7,200 7,200($3000 setup plus 300/month/provider)Equipment Repair 1,000 3,000 3,000 4,000Fund Raising/Marketing 10,000 10,000 10,000 12,000Insurance (liability, malpractice, board) 20,000 20,000 35,000 35,000Lab Fees 10,000 12,000 20,000 24,000Medical Equipment 20,950 8,000 20,950 24,500Medical Supplies 10,507 12,000 15,800 18,500Linen Service ($228.40 for 1, $428.80 for

2)

2,741 2,741 5,146 5,146Occupancy (Rent, Water, Utilities)Water $40 per month 480 480 490 490Telephone, internet $330 per month 3,960 3,960 4,039 4,039Rent $500 per month 6,000 6,000 6,120 6,120Electricity $250 per month 3,000 3,000 3,060 3,060Cleaning $525 per month 6,300 6,300 6,426 6,426Cell PhoneOffice Equipment 16,804 4,000 16,804 8,000Office Supplies 3,272 3,500 7,500 7,500Salary and Fringe BenefitsFront office (1, 3 in year 3) 23,520 23,520 70,560 70,560Navigator (determines ACA or orange

card)

23,520Office Administrator (1) 68,600 68,600 68,600 68,600Assistant office administrator (1) 39,200LCSW (1 in year 2, 2 in year 3) 35,000 70,000 100,000 100,000CMA (1) 27,440 27,440 27,440 27,440Physicians $120,000 annual (1, 2 in year

3)

120,000 120,000 240,000 240,000Benefits and taxes @ 25% 66,140 72,390 126,650 142,330Nurse on call $150/mo. X3 mos. Then

$219/mo.

2,421 2,628 4,032 4,032Website


Total Expense $478,735 $489,659 $809,817 $897,663

Occupancy (2% increase in year 3) 19,740 19,740 20,135 20,135Salaries and fringe benefits 340,700 381,950 633,250 711,650


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FORMATION OF THE INDIANAPOLIS HEALTH AND WELLNESS 62Appendix A: Description of Targeted Service Area


Appendix B: Safety Net Clinics in Targeted Service Area


Appendix C: Populations under the ALICE Threshold


Appendix D: Vulnerable Populations


Appendix E: Area Deprivation Index

Documents

Formation of the Indianapolis Health and Wellness Center