Using time as currency can help practices care for the uninsured

A column about keeping your practice in good health

By Victoria Stagg Elliottis a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009. Posted Dec. 12, 2011.

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Time banking, a system that turns hours into a currency, is being tested in a few places as a way for practices to treat uninsured patients and improve access to care.

"It helps people be engaged in care and helps physicians really control the amount of care they give away," said Bethany Hays, MD, medical director of True North, a nonprofit clinic in Falmouth, Maine. "I think it makes people feel better about themselves to know they are paying for care. It's not charity care. Patients who cannot afford to pay with money are paying in time credits."

Time banks are local networks in which participating businesses and individuals give and receive credits that can be used for "purchasing" goods and services elsewhere. People can earn credits for volunteering in their community. TimeBanks USA has a registry of nearly 300 time banks nationwide.

Though practices have bartered with patients -- say, trading care for maintenance work at the practice and other nonmonetary compensation -- time banks formalize the arrangement so that patients and physicians aren't negotiating a trade of services at the time of care. Before the patient comes in, the physician would know whether time credits will pay for the visit. Practices paid in time credits could then use them to pay for other services within the network or donate them. None of the "income" from time credits is taxed.

The few medical organizations that have participated in time banking say it's not a way to eliminate unpaid charity care. However, they say time credits represent a chance for practices to receive some form of compensation when they might not otherwise get it. They say the credits can provide patients with better access to care and improve the practice's standing in the community.

That can happen even if -- in the case of Lehigh Valley Hospital & Health Network -- a medical organization elects not to accept time credits for care. Lehigh Valley helps support the Community Network bank in Allentown, Pa., and has published research showing that the participation of individuals in a time-banking network, especially those who live alone, helps promote better mental health and connections with others. Some Lehigh Valley patients who have transportation problems are driven to clinics by people earning credits for their service through the time bank.

"Time banks provide a complementary currency. Hours are not intended to replace dollars," said Ed Collom, PhD, associate professor of sociology at the University of Southern Maine in Portland, who has written several papers on time banking, including one looking at Lehigh Valley's experience.

True North has been notable for receiving plenty of national media attention for its participation in time banking. It signed up with Exchange Portland, a local time bank. Through its participation, True North allows some patients to pay for a doctor visit with time credits earned by volunteering in the community.

For example, a patient may respond to a request for two hours of yard work from a member of the time bank. The hours worked are recorded by the bank. The patient may use the hours to pay for care at True North, whether or not the yard work was done at the practice's facility.

The amount of time bank hours required for care is preset. Patients at True North, which has seven affiliated physicians, receive one visit for every two hours of service provided to other time bank members.

"We thought it was reasonable to have a two-credit exchange," Dr. Hays said. "That was a complex negotiation, but they really wanted us to participate. And we really wanted to participate."

A medical practice interested in participating in a time bank would need to negotiate how much care doctors would provide to participants. True North physicians agree to spend 10% of their time caring for patients who pay in time credits.

"It would have to be up to the physician to decide the number of hours per month they feel most comfortable with so that they are not overwhelmed," Collom said.

Time banks have their limits. Participants say they're not intended to cover co-pays or deductibles for insured patients. Federal law prohibits their use for Medicare or Medicaid patients. True North generally uses time credits with uninsured patients.

In addition, a True North patient using time credits still would need to pay cash for any services outside the practice, such as lab work.

Time banking is not a bartering system, Dr. Hays said. "It's an alternative monetary system. And it's not charity care. The patient is exchanging something for care. It helps people be engaged in care and helps physicians really control the amount of care they give away."

Lehigh Valley's time-banking program originally launched to link patients needing transportation, but it has expanded. It now supplies some services vital to the health network, such as medical interpreting.

The hospital provides 46 hours of training to medical interpreters, who then are required to provide 46 hours of language services to the hospital as part of the time bank program. After the commitment is fulfilled, hours earned interpreting can be used for other services in the time bank. Some interpreters have used the training to get jobs in and out of the hospital system.

"Our clinical partners will get their patients to use the time bank," said Laura Gutierrez, a manager of Allentown's Community Exchange, which receives funding for operations from Lehigh Valley. "It's a reciprocal model. The focus is to both give and receive."

Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009.

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