The foundation of Gov. Nikki Haley's alternative to the "Obamacare" Medicaid expansion has been much more successful in some parts of South Carolina than others, according to early enrollment data released last week by the S.C. Department of Health and Human Services.

While Charleston-area hospitals are making month-over-month gains signing up patients for the new project, other hospitals in the state have made little or no progress.

"There is wide variation of how this thing is getting implemented throughout the state," said DHHS Director Tony Keck. "There's a group of people who get it and who are actively investing in this effort, and there's a group of hospitals that don't get it and are doing the least possible. That's exactly what we expected."

This project - formally called the Healthy Outcomes Plan - is part of the Haley administration's broader alternative to Medicaid expansion. It is intended to target uninsured patients with chronic conditions, like diabetes, who have used the emergency room at least five times.

Hospital staff are responsible for enrolling these patients in the Healthy Outcomes Plan and directing them to other providers, including primary care practices and free clinics, to better manage their care at a significantly lower cost. Each hospital was allowed to tailor the Healthy Outcomes Plan to meet its community's needs.

Not a requirement

The Healthy Outcomes Plan is free for patients, but it does not provide them with private health insurance or Medicaid cards, like Medicaid expansion under the Affordable Care Act would have done. South Carolina is one of about half of all states that decided against expanding its Medicaid program with federal dollars made available by the health care law.

Hospitals in South Carolina were not required to participate in the Healthy Outcomes Plan after the General Assembly approved the initiative last year, but all of them are. The alternative meant hospitals would have been docked millions of dollars that the government uses to reimburse them for some of the uncompensated care they deliver to the uninsured.

Keck said a 2.75 percent Medicaid rate increase last year - equal to nearly $35 million - was used to encourage hospitals to participate and to offset the expense of implementing the Healthy Outcomes Plan.

"So they actually had strong incentives to participate, but weren't 'harmed' if they didn't," he said.

Enrollment goals

Hospitals will be paid for participation no matter how many patients they enroll in the Healthy Outcomes Plan this fiscal year.

For example, five months into the project, Bon Secours St. Francis Health System in Greenville had not enrolled any patients, but will still be paid its share for simply developing a plan and meeting the agency's minimum reporting requirements, Keck said. Five other hospitals in South Carolina, including Hilton Head Hospital and Carolinas Hospital System in Florence, enrolled fewer than five patients between Oct. 1 and Feb. 28.

Meanwhile, a handful of rural hospitals have already exceeded their enrollment goal set by the state agency.

"Next year, it's going to be much more tied to actual participation," Keck said. "You're not going to get paid if you don't have people enrolled."

Each hospital's enrollment goal is different. The enrollment goals for rural hospitals are obviously much lower than hospitals in urban areas like Charleston because they treat fewer patients.

Anne Sass, grants director for Roper St. Francis Healthcare, who is managing the system's Healthy Outcomes Plan, said that's one of the reasons why it has been much harder for large hospitals to enroll patients in the project. Even trying to contact them about the Healthy Outcomes Plan is a challenge, she said. Initially, the hospital tried mailing patients letters, but that didn't work very well.

'Hard to reach'

"One month they're living with their aunt. The next month they're living with their step-cousin. You know, the next month they might be living on the street," Sass said. "They're using the throw-away phones, the temporary phones. They're living paycheck to paycheck. I just don't think (DHHS) had any realization about how difficult this population was going to be."

Barney Osborne, vice president for finance and reimbursement at the South Carolina Hospital Association, said other hospitals have reported similar challenges enrolling frequent ER patients into the program.

"Once that person walks out of the door of your hospital, it can be almost impossible to reach them," Osborne said. "They think it's about a bill, so they just won't answer the phone. You name it - these are just a hard group of people to reach."

Roper St. Francis Healthcare is collaborating with the Medical University Hospital and East Cooper Medical Center on the project. Between Oct. 1 and March 18, the three systems had enrolled 726 patients, or 58 percent of their target population, in the Healthy Outcomes Plan. The Charleston hospitals have the largest target population in the state, Sass said.

Deer stand

Data provided by the state agency to The Post and Courier on Friday shows that 3,028 patients in South Carolina, or 36 percent of the statewide target population, had been enrolled in the Healthy Outcomes Plan between Oct. 1 and Feb. 28.

Moving forward, DHHS will also require hospitals to share a "story to tell" when they submit their monthly enrollment updates.

These stories aren't meant to gloss over the obstacles that some hospitals are facing as they try to enroll patients in the Healthy Outcomes Plan, Keck said. In fact, some of the stories highlight how difficult the process has been.

For example, one Healthy Outcomes Plan patient still visited the hospital ER 15 times in January and February.

Keck shared another story about a hospital caseworker who tried to enroll a patient in the Healthy Outcomes Plan by driving to the patient's house. The listed address turned out to be a deer stand down a dirt road, he said.

"She knocked on the tree and called out the individual's name. No one was home," he said, quoting one of the stories directly. "What it points out is how difficult is it to reach people and engage them meaningfully."

Even more challenging, Sass said, is actually crafting a health care plan for these patients within 60 days of their enrollment in the Healthy Outcomes Plan. That's one of the requirements that the agency set for hospitals.

It's too ambitious, Sass said. "The numbers are really high that they're asking us to achieve and the timeline is too narrow."

Reach Lauren Sausser at 937-5598.