“We have patients who are working 40 or 50 hours a week and still can’t afford health insurance,” says Allison Williams, Executive Director of Tulip Tree Family Health Care. “Or, if they can afford it, they have an $8,000 deductible, so they can’t actually use it. Those are a large portion of the people we serve.”
Tulip Tree, a health care center and an IFF loan recipient based in Fort Branch, Indiana, strives to fill the gap between the care people need to stay healthy and the care they can pay for – to the benefit of everyone in the region.
“Healthy people make a healthy community,” Williams says. “And that’s what we’re here for.”
In 2018, the small but highly productive center served 2,988 individuals from 33 zipcodes spanning Southern Indiana and Illinois. Nearly 80% of those patients qualified to receive Medicaid and/or Medicare.
The region is mainly rural, and resources can be scarce; Fort Branch, for example, does not have a grocery store. Many patients travel 20 miles or more to visit Tulip Tree. Plus, the center offers three types of care at a single site: primary medical care, dental care, and behavioral health care.
“The fact that such a large geographic area relies on Tulip Tree – and that they offer one-stop services for people who don’t have the time or money to travel to multiple centers – makes them a tremendous asset to the region,” says Torrence Moore, IFF’s Managing Director of Lending.
Tulip Tree’s inclusion of behavioral health has been particularly well-received. The center added a full-time psychiatric nurse practitioner after conducting a 2017 community survey and patient focus group that overwhelmingly pointed to an acute need for more mental health services. “It wasn’t a surprise – it’s a nationwide issue and something we’d already experienced,” Williams noted.
Healthy people make a healthy community,” Williams says. “And that’s what we’re here for.”
She recalled one of many instances when a patient had announced, “I’m finally ready for help.” But because of limitations to the person’s insurance and the dearth of mental health providers in the area, it would have been six months before a psychiatrist could see her.
Determined to address this recurring problem, Tulip Tree revised its strategic plan and, through a partnership with the University of Southern Indiana, focused on ways to better integrate primary care and mental health. That ultimately led to the recruitment of a full-time psychiatric mental health nurse practitioner who completed her degree at Southern Indiana.
Now, Tulip Tree’s primary care physicians can take patients who also need mental health services right over to the on-site counselor. Similarly, dental patients with high blood pressure – the center takes every patient’s blood pressure, regardless of the services they’re seeking – can easily access primary medical care if needed.
Covering the true cost of service
No matter how well-managed and vital a center like Tulip Tree may be to the region, sustaining the services it provides can be a daunting challenge.
Those who work in health care are acutely aware of why that is, but others sometimes are not: Medicaid rarely covers the full cost of a patient’s visit. For example, the government may pay a provider $100 for a $140 visit. That’s why private medical providers take only a limited number of Medicaid patients – and why some health care centers must supplement reimbursements with other sources of revenue, such as grants and donations.
That can be especially tricky for smaller centers like Tulip Tree, which has limited capacity for fundraising and grant administration.
“People hear ‘health center,’ and they picture a big, multi-site provider,” Williams says. “We are not that. We are small – under 30 staff, many of whom are part-time – and we all wear a lot of hats.”
Tulip Tree has historically pieced together funding from a state grant, community members, foundations, and local employers. But given the low-income population it serves and the high-quality care it provides, the center’s leadership decided in 2018 to pursue another option: Become a Federally Qualified Health Center (FQHC). Doing so would allow the center to shore up its business model and live its mission on a larger scale.
An FQHC designation means that a center must meet 19 strict requirements, including being a nonprofit and providing services on a sliding fee scale. In return, it receives enhanced government reimbursements that cover the full cost of caring for Medicare and Medicaid populations. FQHCs also receive federal grants to help them serve entire areas and/or certain populations that are uninsured.
The first step for Tulip Tree was to become what is known as an “FQHC Look-Alike.” Look-Alikes are well-positioned to eventually transition into full-blown FQHCs because they must meet the same requirements. They are also reimbursed for the full cost of Medicare and Medicaid payments.
However, Look-Alikes do not receive federal grants to cover patients who are uninsured, even though in Williams’ experience, most find themselves in that position for legitimate reasons. In Tulip Tree’s case, those patients constitute about 13% of visitors.
Tulip Tree’s leaders also knew that the changes it had to make to become a Look-Alike – including upgrades to its facilities and additions to its staff – would be costly, and that Look-Alikes typically experience a lag of up to six months before they begin seeing their first Medicare and Medicaid reimbursements.
Enter IFF, which specializes in helping nonprofits take calculated risks that bring opportunities to strengthen communities. IFF provided a $350,000 loan to refinance an existing line of credit Tulip Tree held on its building. That enabled the health center to recapitalize cash that had been used to make building improvements and purchases (e.g., furniture, fixtures, equipment), leading up to its Look-Alike application and inspections.
“IFF sustained us through the application process,” Williams said. “We were in a financial crunch – which is common given the nature of what we do and our size – and IFF totally understood that. They processed the loan very quickly and were very helpful along the way.”
That extra boost contributed to Tulip Tree receiving its Look-Alike designation in July 2018. And in 2019, the organization completed its application to become an FQHC; the awards will be announced in September.
“We often talk at IFF about how a single nonprofit client of ours is doing the work of five organizations,” Managing Director of Lending Torrence Moore says. “Tulip Tree is a classic example of that, always going above and beyond to meet people where they are. We’re excited to see what they do next.”