Q: Mr. Keane, could you please share with us a little bit about your background and about Unity Health Care, the organization you lead?
A: Unity Health Care is a §501(c)(3) federally qualified health center (FQHC) located in the District of Columbia. Unity Health Care originally started as a health care program for the homeless in 1985 and was funded by private grants. I began working as the CEO of Unity Health Care in 1990. In 1992, we were asked by the D.C. government to convert Unity to FQHC status and greatly expand the services we provided. We quickly expanded from a 50-employee center for the homeless with a $4,000,000 annual budget to now serving as a 1,000-employee center with 25 locations and a $100,000,000 budget.
My background is not entirely consistent with the position description for CEO of a large urban FQHC. I came to the United States from Ireland in 1969 as an ordained Catholic Priest. I was assigned to the Diocese of Richmond and worked mostly in the Northern Virginia area. In 1987, I left the priesthood, and married in 1988. I joined Unity two years later, and it has been a delightful run ever since. "
Our programs care for the homeless, provide shelters, address school issues, provide 24-hour a day service to the D.C. prison system and facilitate health care and related programs for the underserved in the District.
Q: As the largest federally qualified health plan in the District of Columbia, how do you work with other not-for-profit and other governmental agencies in the region to foster better access and care?
A: We are fortunate to have excellent partners who work with us in areas where they have greater focus and expertise. For example, we work with a number of agencies to address the severe housing problem which exists in the District. We provide access to pantries and shelters to those who leave a hospital with an injury, but we also work with housing “specialists” to attempt to locate affordable housing for working families whose hourly wages simply will not meet the cost of housing in the District. We also work with groups like Catholic Charities who complement the medical services which are our focus with the social and spiritual services which they are skilled at addressing.
While we are the largest of D.C.’s FQHCs by far, several of the smaller FQHCs provide focused services in a number of areas such as HIV treatment and prevention, immigrant centered issues, etc. We take advantage of those resources and that expertise where it will benefit the population we serve. Our constituents primarily are members of the underserved communities whose incomes are below the federal poverty line. They are often in fragile positions economically and socially. We care for all clients regardless of their ability to pay.
Among our greatest resources are the “case managers” which we employ to coordinate care and social access among all of these systems and to help address our clients’ culinary, educational, transportation, work force training or medical concerns.
Q: Discuss briefly your financial success in caring for the underserved in the District of Columbia.
A: The District of Columbia has been very generous in its expansion of Medicaid coverage. As a result, over 96% of the D.C. population has some level of coverage. While we have weathered hard times in the past, we are currently fiscally able to expand our services and improve access as a result of this increased funding and coverage.
However, our recent financial success is a mixed blessing. As a result of the improved economic climate for health care for the poor in the District, a number of other players, including hospitals and national firms, are attempting to enter the market. While we welcome healthy competition, we are concerned that the new entrants may be tempted to “cherry pick” the patients based on fiscal or ease of service considerations, and leave us at a fiscal disadvantage because of our commitment to serve everyone regardless of their circumstances. Still, we welcome the opportunity for competition, and we will “up our game” to become an even more value driven organization focused on excellent outcomes.
Q: Describe briefly five of the most important components of the services you provide.
A: First, access to health care for our citizens is key. With 25 facilities, we try to facilitate access wherever possible, initially by being embedded in the very communities we serve.
Second, continuity of care is critical. You can buy some groceries on occasion at a 7-11, but you typically do not use a convenience store for your weekly household needs. We want to provide comprehensive care with the whole array of necessary items and services. We want to steer our patients seamlessly through the entire health care system. Soup to nuts. That is what I mean by continuity of care. We go beyond simply being an urgent care center. We provide everything from primary care to trying to address indirect social and health care needs that are a by-product of poverty.
Third, our practitioners focus on the diagnosis, treatment and resolution of specific diseases which appear in significantly greater numbers in the population which we serve. For example, diabetes, hypertension, HIV and Hepatitis C are all important focuses of our care.
Fourth, as I mentioned earlier, our commitment goes beyond direct health care. People in poverty do not just lack direct health care. They also have needs in areas which are sometimes referred to as the “social determinants of health.” For example, we assist with transportation, language barriers (particularly for our Asian, Ethiopian and Hispanic populations), hunger and nutritional issues (addressing the “food deserts” which are common in the inner city), and other similar barriers.
Finally, we try to make accessing health care on a regular basis a priority for the people we serve. Some are suspicious of the health care industry, and we work hard to make it not just a “one off” service. We want them to come back and obtain follow up care. To do this successfully, compassion and trust are critical.
Q: What changes in federal policy would be helpful to you in meeting your mission?
A: This is a very uncertain time with our federal government. We have been lucky so far. Uncertainty in funding and a lack of commitment at the federal level for basic things like the full range of prevention is of concern. At the federal level, they tend to focus on aspects of an overall problem which received the greatest attention in the media. For example, the new concern for the opioid crisis is very important, but you should not address that at the expense of continued growth in the treatment of mental health and substance abuse issues. We need to see more “linkage” among all relevant aspects of a health care problem.
We are also concerned, particularly from a Medicaid perspective, that the tendency seems to be moving towards state grants and competition which can lead to arbitrary budgets for care that did not meet the needs of the population. We are, however, amenable to exploring new compensation systems which reward outcomes rather than the number of procedures. If you can teach a patient not to smoke or drink, the value to the system is much greater than treating the patient with a series of visits to address the conditions that result from those bad habits.
We are also concerned about the “work requirements” being imposed on Medicaid. We are certainly in favor of everyone working who is capable of working. A problem with our population is that many are unable to work. The large incidence of mentally ill patients is an important consideration. Additionally, the high unemployment rate in urban areas such as DC is not primarily a function of people being lazy or wanting to take advantage of the system. Instead, there is simply a lack of meaningful entry-level jobs in an urban environment like much of the District. No one objects to Medicaid recipients working if they can; however, we should not create an arbitrary barrier simply because it may be politically expedient.
