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Four Years of CHEER: Cost and QALY Savings of a Free Nurse-run Walk-in Clinic Serving an Uninsured, Predominantly Spanish-speaking Immigrant Population in Providence



Non-emergent visits to emergency departments by uninsured patients impose unnecessary costs on both patients and safety-net institutions. We evaluated the health and economic impacts of providing free, walk-in care to low-income, uninsured adults-most of them Hispanic-at a free clinic between January 2013 and December 2016. Providing access to health care services for uninsured patients at Clínica Esperanza/Hope Clinic reduced emergency department expenditures in Rhode Island by approximately $448,876 (range: $410,377-$487,375) annually and may have also reduced future healthcare costs for this population by more than $48 million ($12,034,469 annually) over the four-year evaluation period. For every $1 in funding for walk-in clinic operation, delivering free care provided a return on investment of $71.18 (range: $70.95-71.40) in healthcare value. Providing access to non-emergent walk-in care at the more than 12,000 free healthcare clinics nationwide may save billions in ED costs while improving the health of uninsured individuals.
© Meharry Medical College Journal of Health Care for the Poor and Underserved 30 (2019): 856–869.
Four Years of CHEER: Cost and QALY Savings
of a Free Nurse- run Walk-in Clinic Serving an
Uninsured Predominantly Spanish- speaking
Immigrant Population in Providence
Katherine Barry
Meghan McCarthy
Jacob Buckley
Sandra Jacques, RN
Heather Johnson, BA, MLIS
Valerie Almeida- Monroe, RN
Anne De Groot, MD
Abstract: Non- emergent visits to emergency departments by uninsured patients impose
unnecessary costs on both patients and safety- net institutions. We evaluated the health and
economic impacts of providing free, walk-in care to low- income, uninsured adults—most of
them Hispanic—at a free clinic between January 2013 and December 2016. Providing access
to health care services for uninsured patients at Clínica Esperanza/ Hope Clinic reduced
emergency department expenditures in Rhode Island by approximately $448,875 (range:
$410,377– $487,375) annually and may have also reduced future health care costs for this
population by more than $48 million ($12,034,469 annually) over the four- year evaluation
period. For every $1 in funding for walk-in clinic operation, delivering free care provided a
return on investment of $71.18 (range: $70.95– 71.40) in health care value. Providing access
to non- emergent walk-in care at the more than 12,000 free health care clinics nationwide
may save billions in ED costs while improving the health of uninsured individuals.
Key words: Medically uninsured; models, nursing; health care disparities; emergency room
diversion; cost- bene t analysis; health equity.
Clínica Esperanza/ Hope Clinic (CEHC) serves a low- income, predominantly His-
panic neighborhood of Providence, Rhode Island (Olneyville), providing free
and JACOB BUCKLEY are Project Managers and volunteers at Clínica Esperanza/ Hope Clinic.
HEATHER JOHNSON is a Research and Education Librarian at the Dartmouth College Geisel School
of Medicine and Clínica Esperanza/ Hope Clinic volunteer. VALERIE ALMEIDA MUNROE is the
Nurse Manager at Clínica Esperanza/ Hope Clinic. ANNE DE GROOT is Volunteer Medical Director
at Clínica Esperanza/ Hope Clinic, CEO/ CSO at EpiVax, Inc., and Research Professor at University of
Rhode Island and Director of the Institute for Immunology and Informatics at University of Rhode
Island. Please address all correspondence to Anne De Groot, Clínica Esperanza/ Hope Clinic, 60 Valley
Street, Suite 104, Providence, RI 02909. Phone: (401) 347-9093; Email: dr.annie.degroot@gmail
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Barry, McCarthy, Buckley, Jacques, Johnson, Almeida-Monroe, and De Groot
culturally and linguistically attuned health care services to the uninsured. Around the
time that CEHC was established, the rate of uninsurance for non- elderly adults (ages
18– 64) in Rhode Island was estimated to be 11.8%.1 Despite the net positive impact of
the Patient Protection and A ordable Care Act (ACA), thanks to which an estimated 20
million non- elderly adults (ages 18– 64) gained health insurance,2 nearly 50,000 Rhode
Islanders3 and more than 27 million individuals in the U.S. remained uninsured a er
its enactment. A signi cant proportion (20%) of these individuals remain ineligible
for ACA coverage because of their immigration status.4
Numerous studies have established that uninsured individuals in urban settings, who
have limited access to primary health care providers, use the emergency department
(ED) for non- urgent health needs.5– 7 One consequence of limited access to care is that
an estimated 13.7 to 27.1 percent of all ED visits in the United States are non- emergent
and could be su ciently addressed at an alternative ambulatory care center. Unnecessary
ED visits are also a problem for insured patients. Nationally, diverting non- emergent
patient visits from the ED to ambulatory care centers could save $4.4 billion in annual
health care spending.8 Locally, the Rhode Island Department of Health (RIDOH) has
estimated that $90 million in avoidable health care expenditures can be attributed to
unnecessary ED visits.9
Nurse- run walk-in clinics in free health care settings that are sta ed by volunteer
health care providers and administrators may provide one potential model to reduce
the impact of this problem.  ere are more than 1,000 free clinics in the U.S., of which
approximately 50% provide some type of urgent care to uninsured individuals.10 e
Clínica Esperanza/ Hope Clinic Emergency Room Diversion (CHEER) clinic is a nurse-
run ambulatory care center for (only) uninsured patients, featuring walk-in appoint-
ments and short wait times. It has served as an alternative to the ED for a low- income,
predominantly Hispanic population in Providence since 2012.
e CHEER clinic is a valuable source of ambulatory health care for adult uninsured
patients experiencing non- emergent medical conditions. An evaluation of the CHEER
program during a pilot period demonstrated a positive return on investment in terms
of ED visits avoided and in terms of the value of chronic disease diagnosis, prevention,
and treatment (measured in Quality Adjusted Life Years [QALY]).11
Free clinics expand access to non- emergent ambulatory health care for the uninsured
at the national level and, while they reduce ED-related health care spending, they also
improve the health of the uninsured. We seek to evaluate the economic impact of the
CHEER model to support the current literature of free clinics as valuable sources of
safety- net care across the country.  is report calculates the impact of free, walk-in
health care in the context of out- of-pocket costs, ED visits, and QALYs for the pre-
dominantly Spanish- speaking, low- income uninsured patient population served by the
CHEER of Clínica Esperanza/ Hope Clinic in Rhode Island, between 2013 and 2016.
e CHEER model. All services o ered at CHEER are provided free- of-charge, regard-
less of income level. Detailed information on the development of the CHEER model and
operating procedures can be found in the in a previous report published by Bicki etal.11
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858 Cost and QALY savings of a free clinic
CHEER clinic eligibility. Potential patients are eligible for CHEER if they are: (1)age
18 or over (or emancipated), (2) lack health insurance or cannot a ord to access care,
(3) lack a primary care provider, and (4) not experiencing a medical emergency (such
as trauma, deep tissue lacerations, drug or alcohol intoxication, heart attack, stroke).
Navegantes and volunteers help refer clients that do not meet these criteria to other
sources of care, including the ED if necessary.  e number of CHEER visits is capped
at eight total patients per day, and patients who cannot be accommodated are held
over and included in the evening clinic if openings are available, or asked to return
the following day.
Sta ng the walk-in clinic. Nurses and clinical volunteers (international medical gradu-
ates and local specialty clinicians) operating under established clinical care protocols
form the sta of CHEER. Under the direction of the Nurse Manager (a registered nurse),
volunteer clinicians provide treatments for non- emergent medical conditions, such as
urinary tract infections and sexually transmitted diseases and initiate treatment for
diabetes and hypertension.  e Medical Director (a locally licensed, volunteer medi-
cal doctor) reviews all patient encounters by CHEER clinicians, abnormal laboratory
reports, and diagnostic imaging reports using the electronic medical record (EMR)
system.  e clinic is also sta ed by Navegantes, who are bilingual advanced commu-
nity health workers and medical interpreters who provide peer education on healthy
lifestyles and chronic disease management.  e combined e orts of no more than 12
sta members, a core group of approximately 20 volunteer clinicians and founders
and approximately 250 active volunteers, have maintained clinic operations for more
than 10 years, demonstrating the sustainability of the CHEER clinic and its parent Free
Clinic over a signi cant period of time.
Return on investment. To determine the relative impact of CHEER on the health
and economic well- being of the patient population, we quanti ed the relative value
of CHEER services in terms of out- of-pocket patient costs avoided through diverted
ED visits and in terms of QALY saved by providing access to preventative, diagnostic,
and treatment services at CHEER. We calculated the return on investment (ROI) of
CHEER using the same methodology previously used by Bicki etal. for CHEER clinic.11
e ROI calculation re ects the health care value returned for each dollar invested in
CHEER, based on QALY saved and ED visits diverted.
QALY saved. Using the method previously described by Bicki etal.,11 which was
derived from a similar study conducted by the Boston Family Van,7 we assigned a
Clinically Preventable Burden score (CPB) (range: 1– 5) to selected preventative services
provided by the CHEER clinic.  e CPB score indicates an estimated range of QALY
saved by the service.  e QALY is a measure used to determine both the quality and
quantity of life lost to a disease; one QALY is equivalent to one year of life in perfect
health.12 erefore, higher CPB scores re ect services which are more cost- e ective in
their impact on patient mortality and morbidity. Clinically Preventable Burden scores
were originally de ned in 2001 by the National Commission on Prevention Priorities
and were updated in 2017 by the HealthPartners Institute.13 Each score corresponds to
a range of QALY saved for a cohort of four million individuals. We adjusted the scores
for this analysis by determining the average of each range and calculating the QALY
savings for an individual subject. Since the upper bound of QALYs was not provided
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Barry, McCarthy, Buckley, Jacques, Johnson, Almeida-Monroe, and De Groot
for a CPB score of 5, we used the lower bound as our estimate. We de ned codes for
each service in the electronic health record system used by CEHC (eClinicalWorks)
and used these codes to aggregate the number of CHEER patients receiving each ser-
vice during the four- year study period (2013– 2016). We multiplied this number by
the QALY value associated with the CPB score of the intervention. While there is no
universally accepted dollar value of a QALY, we conservatively estimated the value of
each QALY to be $50,000, based on similar evaluations published in the literature.14
ED diversion. To estimate the number of CHEER patient encounters that may have
resulted in ED visits if patients had not obtained care at CHEER, the CHEER nurse
reviewed each CHEER visit and determined whether the patients chief complaint
when reporting to CHEER could be classi ed among the top  een causes of poten-
tially preventable ED visits reported by the RIDOH for R.I. patients in 2014.9 ese
causes included: upper respiratory infection, low back pain, abdominal pain, urinary
tract infection, headache, neck sprain, fever, alcohol abuse, teeth problems, face injury,
dizziness, anxiety, sore throat, backache, and chest pain. We counted the number of
CHEER visits that included any of the above except for alcohol abuse, facial injury,
and anxiety (which were not common causes of CHEER visits).
A 2013 study demonstrated that the average cost of an ED visit associated with one
of the top ten outpatient conditions for an uninsured patient was $1,178.15 e operat-
ing cost of CHEER clinic is $170,602.50 per year, based on average annual costs during
the period 2013 to 2016.  ese costs represent roughly 35% of the costs of operating
the parent clinic, since the parent clinic performs a range of services (nutrition classes,
outreach in the community) that are not provided at CHEER. During the four- year time
frame, there were an average of 995 visits to CHEER each year (a total of 3,978).  e
average CHEER clinic cost for a single patient visit is therefore calculated to be $172.
We can infer that CHEER reduces the potential ED costs by approximately $1,006. Since
we have no means of knowing whether patients or hospitals cover the cost of this care
(hospitals may o set potential pro ts by claiming the full cost of uninsured patient ED
visits as charitable care), these savings can only be described as $1,061 in “health care
costs saved” for each patient diverted from the ED to the lower- cost CHEER clinic.
In a recent Patient Satisfaction Survey, 41% of CHEER patients responded “yes” and
20% responded “maybe” when asked if they would have gone to the ED if the CHEER
clinic had not been an option that day. To de ne a conservative estimate of the health
care costs saved due to CHEER visits, we made the assumption that 41% of all CHEER
visits would otherwise have been ED visits.
During the study period (January 2013 through December 2016), 2,312 unique patients
were treated at CHEER, of whom 1,234 (53%) were female and 1,078 (47%) were
male. Patients attending CHEER clinic predominantly were immigrants from Central
and South American countries and the Caribbean and were younger, on average, than
patients seen in the parent Continuity of Care Clinic (CCC).  ey listed one of 20
di erent countries as their country of origin, the top 10 of which are shown in Figure
1A.  e comparative age distributions of CHEER patients, CCC patients, and the R.I.
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860 Cost and QALY savings of a free clinic
population are shown in Figure 1B.16 More than 75% of CHEER patients indicated that
their primary language was not English; approximately 60% of patients spoke Spanish
as their primary language. Additional primary languages commonly listed by CHEER
patients included Haitian Creole, Arabic, and Portuguese.
Providers routinely screen for chronic illnesses during CHEER walk-in appointments.
As shown in Figure 2, the prevalence of diabetes, hypertension, and hyperlipidemia
was higher among the 799 patients seen in CCC during 2016 than among the 1,116
patients seen in CHEER during that time, likely because CCC patients tend to be older
than CHEER patients. Patients from both clinics had a lower prevalence of hyperten-
sion and hyperlipidemia than the general R.I. population, but had a higher prevalence
of diabetes, which is consistent with the predominantly Hispanic population at CEHC
and CHEER.17 Patients who are diagnosed with a chronic illness during a CHEER visit
are enrolled in the clinics continuity of care clinic (CCC)—a separate program, with a
budget that can be di erentiated from the CHEER costs described in this article.  e
CCC provides patients with chronic illness with access to regular, quarterly visits and
health/ nutrition education programs.
QALY saved. Preventative services provided at CHEER saved nearly 1,000 QALY over
the four- year study period, for an average of $12,034,469 in QALY- related cost savings
per year. Detailed calculations for each of the interventions that are associated with a
CPB score and included in the QALY calculation are provided in Table 1.
Based on these  ndings, we estimate that CHEER services returned $69.54 in
QALY value per dollar invested by providing diagnosis, treatment and prevention to
Figure 1A. Countries of origin of the CHEER patient population.  e category “other”
includes patients from less common countries such as Chile, Panama, Senegal, Egypt,
and Costa Rica, as well as those who refused to report their country of origin.
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Barry, McCarthy, Buckley, Jacques, Johnson, Almeida-Monroe, and De Groot
walk-in patients, regardless of their chief complaint.  ese are real savings, as patients
who are identi ed as having obesity are referred to Vida Sana, the CEHC- based
program for healthy lifestyles, or to the DPP program at CEHC (these programs are
funded separately). Patients who have non- speci c complaints are frequently identi ed
as having one or more signi cant chronic diseases, such as diabetes or hypertension,
of which they were frequently previously unaware.  us, access to CHEER and routine
health screening in the walk-in context identi es undiagnosed chronic diseases and
opens a door to continuity of care.
Figure 1B. Age distributions of CHEER patients, CCC patients, and RI population.
Figure 2. Prevalence of chronic diseases among CHEER patients CCC patients, and RI
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862 Cost and QALY savings of a free clinic
ED diversion. For the study period, we identi ed 1,937 CHEER visits that may
have resulted in potentially preventable ED visits if patients had not been able to visit
CHEER (see Table 2). Forty- nine percent of CHEER visits fall under this classi ca-
tion, which remains proportional to the number of CHEER patients who would have
used the ED had CHEER not been able to address their non- urgent health care need
(49%) reported in a previous survey of CHEER patients, conducted by Bicki etal.,
and similar to the 41% of patients reporting that they would have used the ED in our
more recent internal survey.11
By multiplying the number of visits by the average costs saved per ED visit diverted
to CHEER clinic, we estimate that an average of $410,377 (conservative estimate) to
$487,375 (liberal estimate) in health care costs were avoided per year by diverting
patients from the ED.  ese costs may have been waived by the local ED and claimed
Table 1.
saved per
2013– 2016
saved per
Ave ra ge
costs saved
per year
Obesity screening
and counseling
5 0.17500 2274 397.95 99.49 $4,974,375
Diet and physical
5 0.17500 253 44.28 11.07 $553,438
4 0.11125 2219 246.86 61.72 $3,085,797
In uenza vaccine
4 0.11125 496 55.18 13.80 $689,750
4 0.11125 955 106.24 26.56 $1,328,047
4 0.11125 630 70.09 17.52 $876,094
Alcohol misuse
3 0.03250 885 28.76 7.19 $359,531
3 0.03250 122 3.97 0.99 $49,563
Breast cancer
3 0.03250 290 9.43 2.36 $117,813
Total 240.69 $12,034,406
QALY= Quality Adjusted Life Years
CHEER= Clínica Esperanza/ Hope Clinic Emergency Room Diversion
CPB= Clinically Preventable Burden
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Barry, McCarthy, Buckley, Jacques, Johnson, Almeida-Monroe, and De Groot
as uncompensated care, an expense that may have been reimbursed by the state or
federal government. While the total amount of uncompensated care is only a fraction
of the overall uncompensated care budget, these savings resulted from an investment
of approximately $170,000 per year in free health care at CEHC.  e return on invest-
ment, in terms of ED costs saved, is considerable: $1.64 (range: $1.46 to $1.81) saved
per dollar invested.
Total ROI. When ED diversion and QALY value savings are combined, CHEER
services saved a total of $12,548,478 per year (or more than $48M over the four- year
study period) and returned an average of $71.18 per $1 of funding (range: $70.95– 71.40)
from January 2013 through December 2016.
e Clínica Esperanza/ Hope Clinic Emergency Room Diversion clinic has continued
to reduce ED visits by uninsured patients using the clinic, while connecting these
patients to continuity of care and health education programs.  is is particularly
Table 2.
CHEER visits for common preventable ED complaints per year 484
Upper respiratory infection 85
Back pain 66
Abdominal pain 50
Urinary tract infection 111
Head/ neck pain 45
Chest pain 65
Teeth problems 6
Dizziness 58
Cost of an outpatient ER visit $1,178
CHEER expenses per year $170,603
Personnel $129,211
Utilities/ operational $36,797
Supplies $4,595
Number of CHEER visits per year 995
Cost of a CHEER visit $172
Costs saved per diverted ED visit $1,006
Average ED diversion cost savings per year $448,876
Conservative estimate $410,377
Liberal estimate $487,375
Ed= Emergency Department
CHEER= Clínica Esperanza/ Hope Clinic Emergency Room Diversion
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864 Cost and QALY savings of a free clinic
important for the population of patients served by CEHC, most of whom are Hispanic
and who have high rates of undiagnosed diabetes and other chronic diseases.  us the
value of CHEER to the city of Providence and the state of Rhode Island is likely to
be signi cant (although di cult to estimate in terms of actual cost savings), since the
clinic serves a population that has limited access to care and a high burden of chronic
disease.  erefore our estimate of “ER costs saved” is likely to be an underestimate
for the actual value of the CHEER intervention, as it does not include the impact of
lost wages and economic instability that may be attributed to chronic illness in this
low- income population.
Although we are not able to track the behaviors of non- CEHC patients, we can
compare ED usage of CEHC patients with a comparable group of patients who do have
access to insurance. In a parallel study (not yet published), we have obtained ED data
for 2016 from the Executive O ce of Health and Human Services of Rhode Island
and found that the rate of ED visits for Medicaid patients was 602 per 1,000 patients,
with 239 of these visits de ned as “potentially preventable.” A comprehensive chart
review of CEHC charts for the same time period, revealed the rate of ED use for CEHC
patients to be 239 per 1,000, with 147 per 1,000 being “potentially preventable.”  is
62% reduction in preventable ED visits is likely to be attributable to the availability of
free walk-in care for CEHC patients at the CHEER clinic.
Uninsured adults of all racial and ethnic backgrounds are 1.40 times more likely to
experience premature mortality when compared to those who have insurance,18 and are
more likely to experience long- term adverse outcomes known as health disparities.19
Hispanic and African- American minority groups have not experienced the same degree
of improvement in health care access since the ACA was enacted as non- Hispanic
Uncertainty in the U.S. health care industry has created a growing need for health
care providers and community leaders to provide sustainable, accessible options for
non- emergent health care needs. While uninsured, low- income patients may not be
required to pay the full cost of an ED visit themselves, the provision of uncompensated
care creates a  nancial burden for safety- net hospitals.21 Furthermore, a patient who
visits the ED but does not follow up with a primary care physician does not experience
the bene ts of primary care, such as proactive prevention and diagnosis of medical
conditions.22 Spanish- language interpreters are o en underutilized in EDs.23– 24 e avail-
ability of linguistically appropriate care at the volunteer- run CHEER clinic is another
advantage provided by CHEER.
A study by Dranove etal. demonstrated that the burden of uncompensated hospital
care decreased a er the implementation of the ACA in states that expanded Medic-
aid.25 e authors of this study later suggested that if Medicaid expansion ceases or is
rolled back by the passage of new health care legislation, there will be a considerable
increase in the  nancial burden of uncompensated care on hospitals due to an increase
in the number of patients lacking health insurance.26 Should adjustments to the ACA
result in higher numbers of uninsured patients, the CHEER clinic model is one that
could be expanded to other free clinics as a means of reducing cost of health care for
uninsured and underinsured individuals while improving their connection to a source
of health care.
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Barry, McCarthy, Buckley, Jacques, Johnson, Almeida-Monroe, and De Groot
is paper joins a body of literature describing analyses of the provision of primary
care at free clinics in an e ort to reduce ED usage among uninsured patients. A study
in North Carolina found that, for counties with an established free clinic, an emergency
department visit for an uninsured individual was 2.5% less likely to be a ‘preventable ED
visit’ than would be found in a county that did not have a free clinic.27 Furthermore, a
2012 study by Fertig etal. found that the costs of non- emergent ED and in-patient care
decreased by an estimated $170 per patient enrolled in a large free clinic in northern
Georgia.28 Hwang etal. provided evidence that showed that patients engaging in care
at a free clinic in Virginia showed reduced unnecessary usage of the ED, compared
with uninsured patients not enrolled at a free clinic.29
Only a few studies have estimated the ROI of free clinics in terms of both ED diver-
sion and QALYs. Whitley etal. found that outreach by Community Health Workers in
the Mens Health Initiative had a positive  nancial impact through increased engage-
ment with primary care, system navigation, and case management.30 However, previous
studies that have conducted ROI analyses of providing preventive health care services
to uninsured patients in the setting of free clinics have shown lower cost savings than
reported here.31– 32 Sanders et al. reported that providing hypertension care at a free
community- based clinic resulted in a ROI ratio range of 0.35 to 1.20; Oriol etal. dem-
onstrated a ROI ratio of 36:1 in the context of the provision of care in a mobile health
clinic.31– 32 e unique model at CHEER of o ering a “clinic within a clinic” devoted
to walk-in treatment of non- emergent conditions rather than on- going primary care
provides an opportunity for the provision of a wider range of clinical interventions for
a larger number of patients while leveraging existing facilities. In addition, the nurse-
run model, operating under physician- approved protocols, signi cantly reduces the
operational costs of CHEER, enabling the Nurse Manager to be the primary provider
in lieu of a full- time physician.
Strengths and limitations. A strength of our study is that we were able to evalu-
ate the impact of free, walk-in health care over four years for a sample of over 2,000
patients. In addition, because our analysis was based on a wide range of primary care
services, we were able to analyze the cost savings for more than acute services.
A limitation of our analysis is that the ROI calculation does not include the long- term
value of health education services such as Vida Sana and Diabetes Prevention Programs,
or of transition to long- term primary care in the parent clinic. It is di cult to quantify
the value of this follow-up care on the economic stability of this population of patients,
and therefore our calculated return on investments may be lower than the true value.
An additional limitation of our study is that we cannot directly measure the impact
of these services per patient. We assume that the impact of the service is equal across
individuals, whereas some patients may be more likely to bene t than others due to
greater participation in the programs or better understanding of the materials provided.
Next steps.  e initial goal of CHEER was to o er non- emergent care services in
order to prevent overutilization of the ED by providing an alternative treatment facility
that provided high- quality, low- cost care for non- emergent concerns. In o ering this
service, CHEER provided a point of entry into all of the services o ered at CEHC,
providing an added bene t to patients presenting to CHEER rather than to the local
ED.  e Clínica Esperanza/ Hope Clinic is in the process of advocating for a ‘pay for
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866 Cost and QALY savings of a free clinic
success’ social equity investment by local hospitals and the state, to provide long- term
sustaining support to the CHEER program.
We have shown that this model is cost- e ective and that it improves health care
delivery while being adapted to meet the needs of an uninsured immigrant population.
e present study did not track long- term e ects on ED use by patients who have visited
the CHEER clinic, so future studies by CEHC may consider investigating behavioral
change.  ese savings were more easily estimated than other savings, such as future
health care costs avoided by future insurers of CHEER patients due to identi cation
and treatment of chronic diseases in the pre- insured (patients who will be eligible for
Medicaid under the ACA when they complete the  ve- year waiting period required for
new citizens of the United States). We are currently tracking the ROI of our primary
care services, health education classes, and the impact of access to free pre- insured
care at CEHC and will report on the substantial savings that can be attributed to these
services in separate studies.
e CHEER clinic is supported by grants from foundations and insurers (60% of
income), contracts with the local health department and city (30% of income) and dona-
tions (10% of income); local hospitals provide in-kind support (free electronic medical
record). As demonstrated in this report, the return on this investment is substantial in
terms of costs saved, and health care provided to populations a ected by health dispari-
ties. Support for the expansion of non- urgent care services at the more than 1,000 free
clinics that are operating in the U.S. has the potential to reduce health care costs and
could have signi cant impact on the well- being of low- income patients nationwide.
We are grateful to the Rhode Island Department of Health, the Rhode Island Legislature
(Senator Paul Jabour), Blue Cross Blue Shield of Rhode Island, the Rhode Island Foun-
dation, CVS Health, the City of Providence (Community Development Block Grant),
BankRI and our generous individual donors, including John and Letitia Carter and the
Carter Family Foundation, for their generous support of the CHEER clinic. With the
support of these funds and our altruistic volunteers, CEHC is striving to make Rhode
Island “a place to be healthy” for our entire community.
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age by sex. Washington, DC: U. S. Census Bureau, 2015.
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868 Cost and QALY savings of a free clinic
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27. Hutchison JH. North Carolina free clinics: e ective primary care provider for the
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uninsured. (Doctoral dissertation). Charlotte, NC: University of North Carolina at
Charlotte, 2016.
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... CEHC's serves a vulnerable, low-income Spanish-speaking population and its work and mission has been described previously. [6][7][8] CEHC is open six days per week, offering both walk-in and scheduled visits in primary care and specialty clinics. Some of these clinics are organized by local medical and physician assistant students, which bring selected specialty clinics and resources to CEHC's patients. ...
... Regarding Pap screening, ACOG guidelines were adhered to at 92.3% of visits and USPSTF mammogram guidelines were adhered to at 94.1% of visits. Reasons for non-adherence to the guidelines included patient requesting exam deferral (6) or inability to tolerate due to pain (2). In 16 instances, the reason for not performing a Pap was not documented. ...
Background: Uninsured, low-income, Spanish-speaking patients face barriers to obtaining gynecologic care in the United States. Clínica Esperanza/Hope Clinic, a free clinic in Rhode Island, hosts a biweekly Women's Clinic (WC) established and run by local medical students. Methods: A retrospective chart review identified gyne- cologic services provided, needs met and adherence to screening guidelines at WC between June 2017 and May 2021. Results: During 80 clinics, 278 patients were seen. 362 encounters occurred, with 288 missed appointments. Women primarily attended WC for routine care (159, 43.9%) or abnormal uterine bleeding (41, 11.3%). Common services provided include gynecologic exams (302, 27.0%), Pap smears (221, 19.7%), and STI screening (166, 14.8%). Pap smear and mammography guidelines were adhered to during 92.3% and 94.1% of visits, respectively. Conclusions: Accessible gynecologic care is a significant unmet need for uninsured, Spanish-speaking patients. These findings demonstrate the importance of gynecologic care at free clinics and warrant their expansion.
... CEHC's innovative programs and comprehensive healthcare metrics have been described in several publications. [3][4][5][6][7] ...
Full-text available
The COVID-19 pandemic disproportionately impacted uninsured and minority populations, contributing to and reinforcing long-lasting health inequities. Clínica Esperanza/Hope Clinic (CEHC), a free clinic serving uninsured individuals, is one ‘safety-net’ clinic that improved access to COVID-19 testing and vaccinations for an at-risk population during the pandemic. A retrospective review was performed to quantify COVID-19 testing and vaccination rates for clinic participants, which were compared to rates in the general population. 51.7% of patients seeking COVID-related care at CEHC were uninsured, compared to 8% in Providence and 4.8% in Rhode Island. CEHC performed 5,623 COVID-19 tests for 4,498 unique individuals, a total of 15,783 vaccines were administered, and 10 to 20% of COVID-care participants reported food insecurity during the study period. The prevalence of COVID-19 in the uninsured population and the high demand for vaccines highlight the important role that free clinics can play in the pandemic setting.
Full-text available
Non-urgent healthcare problems are responsible for more than 9 million visits to the emergency department (ED) in US hospitals each year, largely due to patients' lack of access to a primary care physician. To avoid costly and unnecessary ED usage for non-urgent health problems, a walk-in clinic run by nurses (CHEER Clinic) was developed as an extension of the services provided by an existing free clinic in a low-income neighborhood of Providence, RI, with the goal of providing uninsured patients with a convenient, no-cost means of accessing healthcare. An evaluation and cost-effectiveness analysis of the clinic's first 5 months of operation were performed. During this pilot period, 256 patients were seen. When incorporating the quality-adjusted-life-year value of preventive services rendered, an estimated $1.28 million in future healthcare costs was avoided. Dividing these cost-savings by the clinic's operational cost yielded a mean return on investment of $34 per $1 invested. Adding nurse-run walk-in hours at a free clinic significantly expanded access to healthcare for uninsured patients and was cost-effective for both the clinic and the patient. Ultimately, replication of this model in community clinics serving the uninsured could reduce ED burden by treating a substantial number of non-urgent medical concerns at a lower cost than would be incurred for treatment of the same problems in EDs.
Full-text available
We examined the charges, their variability, and respective payer group for diagnosis and treatment of the ten most common outpatient conditions presenting to the Emergency department (ED). We conducted a cross-sectional study of the 2006-2008 Medical Expenditure Panel Survey. Analysis was limited to outpatient visits with non-elderly, adult (years 18-64) patients with a single discharge diagnosis. We studied 8,303 ED encounters, representing 76.6 million visits. Median charges ranged from $740 (95% CI $651-$817) for an upper respiratory infection to $3437 (95% CI $2917-$3877) for a kidney stone. The median charge for all ten outpatient conditions in the ED was $1233 (95% CI $1199- $1268), with a high degree of charge variability. All diagnoses had an interquartile range (IQR) greater than $800 with 60% of IQRs greater than $1550. Emergency department charges for common conditions are expensive with high charge variability. Greater acute care charge transparency will at least allow patients and providers to be aware of the emergency department charges patients may face in the current health care system.
Full-text available
This study estimates the benefits and costs of a free clinic providing primary care services. Using matched data from a free clinic and its corresponding regional hospital on a sample of newly enrolled clinic patients, patients' non-urgent emergency department (ED) and inpatient hospital costs in the year prior to clinic enrollment were compared to those in the year following enrollment to obtain financial benefits. We compare these to annual estimates of the costs associated with the delivery of primary care to these patients. For our sample (n = 207), the annual non-urgent ED and inpatient costs at the hospital fell by $170 per patient after clinic enrollment. However, the cost associated with delivering primary care in the first year after clinic enrollment cost $505 per patient. The presence of a free primary care clinic reduces hospital costs associated with non-urgent ED use and inpatient care. These reductions in costs need to be sustained for at least 3 years to offset the costs associated with the initially high diagnostic and treatment costs involved in the delivery of primary care to an uninsured population.
Introduction: Savings garnered through the provision of preventive services is a form of profit for health systems. Free clinics have been using this logic to demonstrate their cost-savings. The Community-Based Chronic Disease Management (CCDM) clinic treats hypertension using nurse-led teams, clinical protocols, and community-based settings. Methods: We calculated CCDM's cost-effectiveness from 2007 to 2013 using 2 metrics: Quality-adjusted life years (QALYs) saved and return on investment (ROI). QALYs were calculated using the Clinical Preventive Burden (CPB) score for hypertension care. ROI was calculated by tallying the savings from prevented heart attacks, strokes, and emergency department visits against the total operating costs. Results: Using conservative assumptions for cost estimates, hypertension care resulted in a value of QALYs saved of $711,000 to $2,133,000 and an ROI ratio range of 0.35 to 1.20. Our study shows that when using conservative assumptions to calculate cost-savings, our free clinic did not save money. Cost-savings did occur, but the amount was modest, was less than that of cost-inputs, and was not likely captured by any single health entity. Conclusion: Although free clinics remain a vital health care access point for many Americans, it has yet to be demonstrated that they generate a net savings.
Objective. To document racial/ethnic and gender differences in health service use and access after the Affordable Care Act went into effect. Data Source. Secondary data from the 2006-2014 National Health Interview Survey. Study Design. Linear probability models were used to estimate changes in health service use and access (i.e., unmet medical need) in two separate analyses using data from 2006-2014 and 2012-2014. Data Extraction. Adult respondents aged 18 years and older (N=257,560). Principal Findings. Results from the 2006-2014 and 2012-2014 analyses show differential patterns in health service use and access by race/ethnicity and gender. Non-Hispanic Whites had the greatest gains in health service use and access across both analyses. While there was significant progress among Hispanic respondents from 2012-2014, no significant changes were found pre-post health care reform, suggesting access may have worsened before improving for this group. Asian men had the largest increase in office visits between 2006-2014, and, although not statistically significant the increase continued 2012-2014. Black women and men fared the worst with respect to changes in health care access. Conclusions. Ongoing research is needed to track patterns of health service use and access, especially among vulnerable racial/ethnic and gender groups, to determine whether existing efforts under health care reform reduce long-standing disparities.
Purpose: The Patient Protection and Affordable Care Act's provisions for first-dollar coverage of evidence-based preventive services have reduced an important barrier to receipt of preventive care. Safety-net providers, however, still serve a substantial uninsured population, and clinician and patient time remain limited in all primary care settings. As a consequence, decision makers continue to set priorities to help focus their efforts. This report updates estimates of relative health impact and cost-effectiveness for evidence-based preventive services. Methods: We assessed the potential impact of 28 evidence-based clinical preventive services in terms of their cost-effectiveness and clinically preventable burden, as measured by quality-adjusted life years (QALYs) saved. Each service received 1 to 5 points on each of the 2 measures-cost-effectiveness and clinically preventable burden-for a total score ranging from 2 to 10. New microsimulation models were used to provide updated estimates of 12 of these services. Priorities for improving delivery rates were established by comparing the ranking with what is known of current delivery rates nationally. Results: The 3 highest-ranking services, each with a total score of 10, are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults. Greatest population health improvement could be obtained from increasing utilization of clinical preventive services that address tobacco use, obesity-related behaviors, and alcohol misuse, as well as colorectal cancer screening and influenza vaccinations. Conclusions: This study identifies high-priority preventive services and should help decision makers select which services to emphasize in quality-improvement initiatives.
One pillar of the Affordable Care Act (ACA) was its expected impact on the growing burden of uncompensated care costs for the uninsured at hospitals. However, little is known about how this burden changed as a result of the ACA’s enactment. We examine how the Affordable Care Act (ACA)’s coverage expansions affected uncompensated care costs at a large, diverse sample of hospitals. We estimate that in states that expanded Medicaid under the ACA, uncompensated care costs decreased from 4.1 percentage points to 3.1 percentage points of operating costs. The reductions in Medicaid expansion states were larger at hospitals that had higher pre-ACA uncompensated care burdens and in markets where we predicted larger gains in coverage through expanded eligibility for Medicaid. Our estimates suggest that uncompensated care costs would have decreased from 5.7 percentage points to 4.0 percentage points of operating costs in nonexpansion states if they had expanded Medicaid. Thus, while the ACA decreased the variation in uncompensated care costs across hospitals within Medicaid expansion states, the difference between expansion and nonexpansion states increased substantially. Policy makers and researchers should consider how the shifting uncompensated care burden affects other hospital decisions as well as the distribution of supplemental public funding to hospitals.
Medicaid disproportionate-share hospital (DSH) payments are expected to decline by $35.1 billion between fiscal years 2017 and 2024, a reduction brought about by the Affordable Care Act (ACA) and recent congressional action. DSH payments have long been a feature of the Medicaid program, intended to partially offset uncompensated care costs incurred by hospitals that treat uninsured and Medicaid populations. The DSH payment cuts were predicated on the expectation that the ACA's expansion of health insurance to millions of Americans would bring about a decline in many hospitals' uncompensated care costs. However, the decision of twenty-five states not to expand their Medicaid programs, combined with residual coverage gaps, may leave as many as thirty million people uninsured, and hospitals will bear the burden of their uncompensated care costs. We sought to identify the hospitals that may be the most financially vulnerable to reductions in Medicaid DSH payments. We found that of the 529 acute care hospitals that will be particularly affected by the cuts, 225 (42.5 percent) are in weak financial condition. Policy makers should recognize that decreases in revenue may affect these hospitals' ability to give vulnerable populations access to care.
As part of the safety net, free clinics (FCs) increase access to preventive and primary care for the uninsured. This study compared a group of uninsured FC users and a group of uninsured non-FC users to explore the impact of FC enrollment on the pattern of ED visits, as characterized by (1) level of complexity of care received at the ED, and (2) avoidable vs. unavoidable as classified by an existing clinical algorithm. Emergency department visits by FC users were less likely to be low-level-of-care than visits by non-FC users (OR 0.89, 95% CI 0.84-0.93). Free clinic enrollment was not a statistically significant predictor of avoidable visits (p=.6465). We found that the group of individuals who had access to primary care at the local FCs were significantly less likely than the group of uninsured individuals who were not enrolled in a FC to use the ED for care with lower levels of clinical complexity. Thus, the cost of increasing the primary care workforce as the Medicaid population expands may be worth it in the long run. Further exploration into what characterizes an effective FC is needed.