Posts Tagged ‘community benefit’

Hospital Emergency Rooms: Last Resort or Failsafe?

Friday, October 5th, 2012

Recently, old arguments about the appropriate role of the hospital emergency room (ER) in our health care system have resurfaced as the nation considers its next President. Given the high profile of the issue and the wide array of public opinions on the matter, now’s a good time to unpack the arguments by investigating what federal protections patients have in the ER, the policy questions this issue raises, and—spoiler alert!—why we think the ER makes a better backstop than it does a coverage program.

While it’s certainly true that the ER has become the default option for many people to receive health services, equating ER usage to comprehensive health coverage ignores routine pitfalls patients face when attempting to get care in the ER. The mantra that “anyone can get free care in the ER” is easy to dish out when one is a card-carrying member of the insured class, but—as we point out below—it’s full of misconceptions.

Misconception #1: ERs Have to Treat All Comers, All the Time
The Emergency Medical Treatment and Labor Act (EMTALA), passed in 1985, requires hospitals to provide emergency care to all patients regardless of ability to pay. This qualification is key. While it provides certain protections to patients with emergency medical conditions or in active labor, “emergency” care isn’t synonymous with “medically necessary” care. Simply put, hospitals are not required to treat non-emergencies.

For example, The New York Times reported health care giant HCA has implemented a policy of turning away patients with “minor illnesses like the flu” to cut down on costs. The trouble with this approach is that one patient’s “minor illness” might be the next public health crisis; and, it assumes that the patient in question has somewhere else to go for care. And, “minor” issues aren’t always so minor. In another chilling excerpt, “[o]ne doctor, who…still works as an emergency physician, recalled one episode in which he was told to turn away a young boy with a deep cut in his arm because it was not bleeding profusely and he therefore did not meet the criteria.” Stitches, chemotherapy, diabetes and asthma treatments, preventive screenings – many forms of care may be medically necessary but still outside the EMTALA definition of an emergency, depending on the circumstances.

Misconception #2: If You Can’t Pay, You Won’t Be Asked To
While EMTALA requires hospitals to treat patients regardless of ability to pay, it doesn’t prevent hospitals from sending bills; require them to offer any help to patients who may be low-income, uninsured or underinsured or direct them to public programs like Medicaid; or limit the steps they take to collect on outstanding debts. Nothing in EMTALA requires hospitals to provide free care. In fact, patients who are treated in the ER often go home with big bills that have lasting, sometimes devastating, effects on their family’s financial stability. Many studies show a link between medical debt and foreclosure, poor credit ratings and bankruptcy.

Misconception #3: Hospitals Are an Ideal Place to Get Health Care
Claiming that people can rely on the ER as a “provider of first resort” sidesteps the real limitations that come with the territory. First, ER patients don’t always have access to ongoing primary, specialty or preventive services, or to coordinated care they would receive in a primary care setting that would help them avoid acute episodes from chronic illnesses like asthma and ear infections. These and other chronic episodes need ongoing attention and can be better managed through good primary care (the Affordable Care Act [ACA] has a provision for that – see more on medical homes). Second, inappropriate use of the ER contributes to overcrowding, which can lead to deadly delays in care (see this New England Journal of Medicine piece in which a doctor reflects on losing his mother to stroke as she waited for a bed in an overcrowded ER).

Closing the Holes in the Hospital Safety Net
The hospital ER has its role in our health care system, but it is no substitute for comprehensive health care and coverage. It often fails to offer cost-effective, comprehensive care. But until everyone has affordable coverage and meaningful access to quality care, millions will continue to lean on hospital ERs for care. That’s why Community Catalyst and dozens of other consumer advocates recently weighed in on another ACA provision that helps patients address the financial toll hospital bills can take.

This summer, the IRS issued proposed rules that further define how hospitals should treat patients, in the ER or otherwise, who can’t afford to pay the bill. Recall that earlier this spring it was widely reported that a non-profit hospital in Minnesota was using a third-party billing agent that embedded agents in ER waiting rooms. These agents allegedly pressured patients to pay before seeing a doctor. Taking a no-nonsense approach in rulemaking, the IRS proposed rules would ban hospitals and third-party contractors from demanding payment in areas where emergency care is provided and hold hospitals responsible for most actions performed by third-party billing and collection contractors. (For a more detailed summary of the proposed rules, go here.)

These rules won’t address all of the problems that arise from our system’s over-reliance on ER care. But, they are an important step to protecting patients who have to rely on the hospital safety net. These resources help explain how the IRS proposed regulations will help cushion the landing.

- Jessica Curtis, Hospital Accountability Project Director
& Eva Marie Stahl, Policy Analyst

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Posted in affordability, Hospital Accountability/Charity Care | No Comments »

The Changing Nature of Public Health: National Public Health Week and the County Health Rankings

Friday, April 6th, 2012

It has been an interesting couple of weeks for those of us concerned with improving the health of our communities. The last half of March had us celebrating the second anniversary of the Affordable Care Act and listening to the oral arguments before the U.S. Supreme Court about its future. And this week the focus shifts to yet another critical aspect of our goals for better health: the expanding definition of public health. April 2-8 marks the American Public Health Association’s annual National Public Health Week, focused on the theme of “A Healthier America Begins Today: Join the Movement.” And on April 3rd, the University of Wisconsin Population Health Institute released the 2012 County Health Rankings, which show us in detail that where we live matters to our health.

So even though they don’t involve chanting crowds on the National Mall and intense questioning from Justice Kennedy, National Public Health Week and the County Health Rankings send a clear message: acting to improve health involves multiple sectors and the way we measure health must be expanded. This year, National Public Health Week highlights the importance of prevention and wellness, including the contribution made by the Affordable Care Act (ACA). The ACA is not just about the health care system; it also supports public health and includes several initiatives aimed at breaking down the siloes between our health care “system” and public health by creating incentives and policy tools to drive collaboration. The law includes the National Prevention Strategy, which is a prevention framework that tackles issues such as health disparities, encouraging healthier behaviors, and creating healthy environments for work and play. And, the ACA requires non-profit hospitals to collaborate with public health partners and communities in identifying and addressing pressing community health needs, as part of their core community benefit requirements.

With National Public Health Week, the County Health Rankings, and the National Prevention Strategy all in the mix, the next question is, “what should be done to improve a community’s health?” The County Health Rankings model shows that there are a multitude of things we should all be doing to make our communities healthier. Some actions are clearly identified with health, like programs to help people quit smoking or outreach to increase the number of people getting screened for cancer or heart disease. However, the County Health Rankings model also includes a variety of other issues rarely discussed as part of health, like strengthening our education system or creating stable jobs in our community. Both research and experience show that these issues contribute to community health, and community advocacy is essential in taking action to address them.

For example, New Mexico Voices for Children is using funding from the Robert Wood Johnson Foundation’s Roadmaps to Health Community Grants to help communities and decision makers understand and support public policies and practices that promote both early education and health. In Springfield, Massachusetts, Partners For a Healthier Community is using also using a Roadmaps to Health Community Grant to create the Wellspring Initiative, which is engaging large local institutions, like insurance companies and hospitals, to support a new community-owned business that can create new jobs for local residents.

These organizations and others supported by the Roadmaps to Health Community Grant are hard at work on issues like education, income and employment, family and social supports, and community safety, knowing full well that addressing those issues will ultimately improve the health of their communities. They are a part of the changing definition of public health, like many other organizations across the country. The County Health Rankings, National Public Health Week, and the National Prevention Strategy are pieces of the larger movement to improve health in our communities, and we are seeing their impact every day.

– Phillip Gonzalez,  Program Director
Roadmaps to Health Community Grants 

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On Billing and Collections, Some Hospital Groups Out of Tune

Tuesday, February 21st, 2012

Close readers of the Health Policy Hub will note that most of our blogs on hospital issues tend to sound a common refrain: transparency, transparency, transparency. If what’s coming over our wires is any indication, transparency—or the lack thereof—about hospital pricing, financial assistance, and bill collection is resonating these days in many corners of the country.

Why? Why does transparency matter so much—and why is it so hard to come by?

Let’s look at the story that played out in New York last week. Last Monday’s New York Times covered a major report by our partners at the Community Service Society of New York (CSSNY) that investigated how hospitals receiving $1.2 billion in public subsidies from the state’s Indigent Care Pool handle bills for low- and middle-income patients. The findings were alarming: many New York hospitals are using Pool funds to write off patient “bad debt.” Hospitals that tag patient accounts as “bad debt” can, and often will, send the accounts to collections—a decision that can have long-term financial implications for patients. For example, New York hospitals receiving $250 million in Pool funds had collectively placed 4,000 liens on patients’ homes in 2010 in attempts to collect on bad debt. Furthermore, many New York hospitals are falling short of state requirements that they inform patients about financial assistance and other programs before collecting on outstanding bills. Yet, public funds have continued to flow to hospitals flouting these rules.

While New York hospitals may not be feeling the impact of these practices, their patients certainly are. Hope Rubel, a self-described “typical middle-class American,” found herself on the wrong side of one New York hospital’s accounting ledger. Uninsured due to prohibitively high costs, she received emergency hospital services after a stroke—closely followed by an $88,000 hospital bill she couldn’t afford. On Wednesday, Ms. Rubel (along with CSSNY and Community Catalyst staff) talked about her experience with Democracy Now! hosts Amy Goodman and Nermeen Shaikh.

AMY GOODMAN: Did you understand you could get some kind of financial aid?

HOPE RUBEL: No, absolutely not. [...] I had one brief conversation with a social worker while I was in the hospital that was fruitless for me, and then I was on my own. And then the bills started coming from the hospital, and then the phone calls, and then a collection agency, and then the lawyer. I spoke with the lawyers, and I explained to them my situation and that I did not have the money to pay this bill. And they said that we could work out a monthly payment of about $2,000 a month—would be, you know good—

AMY GOODMAN: To the hospital. [...] For how many years?

HOPE RUBEL: —an $88,000—well, ’til the $88,000 was paid off. I said, “Well, I am in no position to pay that kind of money. I cannot do it. I don’t know what to tell you. I can’t do it.” Then the paperwork came: they were suing me.

This is why consumer advocates stress the importance of hospital transparency. Far too often, the burden of navigating the complex maze of hospital pricing, or of asking the right questions about financial assistance or a fair payment plan, falls to patients who do not know such programs exist. For these patients, any miscommunication or misstep carries long-term financial consequences with little possibility for relief. And if this happens in New York—where, it bears noting, the laws around hospital transparency are comparatively robust—consider the burden that falls on patients in states without any such laws at all.

The policy solutions to the problem are pretty simple, actually, but they’re all rooted in one thing: transparency. We need hospitals to provide patients and the public with information about financial assistance and billing programs. We need policymakers to gather and share this data in a way that enables comparisons of hospitals’ policies. That’s how we’ll know where the trouble spots are.

Yet some hospital groups are adamant that things are working fine the way they are, thankyouverymuch. But for whom? When trade associations block national initiatives to make information about financial assistance programs publicly available, or frame Coloradans’ efforts to limit charges to low-income uninsured patients as “unnecessary administrative requirements, which would in turn increase the cost of health care and impede access,” we have to wonder who they’ve been talking to.

Because it certainly isn’t Hope Rubel, or the millions of Americans who are in her shoes.

If it were, hospitals would be singing a different tune.

 – Jessica Curtis, Director
Hospital Accountability Project 

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Fuzzy Math from the AHA: Another Reason for Strong IRS Reporting Requirements

Thursday, February 9th, 2012

The American Hospital Association (AHA) last Thursday released a report stating that non-profit U.S. hospitals provided 11.3 percent of total annual hospital expenses toward community benefit. The AHA contracted with consulting firm Ernst & Young LLP to evaluate data from tax year 2009, the first year that federal reporting on hospital community benefit programs became mandatory. The report, “Results of the 2009 Schedule H Project,” represented about 30 percent of all hospitals required to file Schedule H with the IRS. Footnote: The 30 percent of hospitals analyzed in the report represents those who voluntarily submitted their Schedule H reports to the AHA or Ernst & Young for evaluation.

Unfortunately, in addition to the potential bias from self-selected reporting, creative accounting helps paint a rosy picture in this report that’s a bit far from reality.

We’ll start with where we agree with the AHA: Communities are unique, with local problems demanding local solutions, and we’re supportive of any efforts that shed light on all the good things non-profit hospitals are doing to improve access to care and health.

But, we have a problem with some of the ways that AHA has classified community benefit in this document.

First, the AHA report counts “bad debt expense attributable to charity care” as community benefit. The AHA is taking a few too many liberties with semantics here. Consider this: You’re uninsured and low income, and I send you a $20,000 bill for emergency care you received at my hospital when you broke your leg, and you haven’t paid that bill because you can’t afford it, but I have sent the bill to a collections agency (cut to: notice to appear in court, wage garnishment, etc.), even though I don’t really expect you ever to pay. Do you think you’ve received a “benefit”? Probably not. A “benefit” would be if I told you, based on your income level and insurance status, I understand you can’t afford the bill, and you don’t have to pay it, or I will work with you to come up with an amount you can pay. (After all, I’m a non-profit hospital and my mission likely includes caring for all who need care, regardless of ability to pay.)

Unfortunately, the AHA counts the first situation, “bad debt,” as a community benefit. The IRS, the Catholic Health Association (which is recognized for setting the bar on community benefit standards), and most consumer advocates we’ve talked to, do not count “bad debt” towards the community benefit calculation.

(There’s actually a simple solution that could benefit everyone – make more efforts to find out if patients qualify for the hospital’s financial assistance policy, and whatever part of the bill is reduced can be counted as community benefit. Hospitals make pennies on the dollar for bills sent to collections. And most importantly, that unaffordable bill isn’t hanging over the head of the unlucky patient who needed care they couldn’t afford.)

Similarly, the AHA report counts shortfall from Medicare reimbursements as community benefit. We disagree with that characterization (as does the IRS). The Medicare Payment Advisory Commission (MedPac), the independent Congressional agency that advises Congress on issues affecting the Medicare program, finds in their March 2011 report that Medicare payments are adequate for efficient providers. If a hospital has a Medicare shortfall, it most likely either is inefficient or exists in a market where they can charge fairly high private rates, which reduces pressures to be efficient and can be used to subsidize Medicare patients.

Counting bad debt and Medicare shortfall as community benefit are controversial moves that contradict current IRS policy and the recommendations of other hospital and consumer groups. It’s precisely for these reasons that we need mandatory, complete community benefit reporting on Schedule H. The 2011 Schedule H form, recently released by the IRS, requires consistent reporting of community benefit expenditures as well as the new financial assistance and debt collection provisions that were included in the Affordable Care Act in 2010. We applaud the IRS for recognizing the need to require true reporting rather than questionable accounting on a self-selected sample. Non-profit hospitals, which are accountable to the taxpayers, must present a true picture of how much they are giving back to their communities, not just PR spin.

– Anna Dunbar-Hester, Policy Analyst

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Posted in Hospital Accountability/Charity Care | 1 Comment »

Following the Leaders: How Some Hospitals Use Community Benefit Programs to Address Health Equity

Monday, September 26th, 2011

We’ve used this space to talk at some length about the shortcomings that follow from our “patchwork quilt” of state and federal standards for community benefit. Today, we’re taking a detour to talk about what’s right with community benefit—specifically, steps some hospitals are taking to address disparities in health through community benefit programs.

Naming the Problem
The face and voice of America is changing. Racial and ethnic minorities currently comprise one-third of the U.S. population; nearly 47 million people—18 percent of the population—speak a language other than English at home. With this change in demography, the health of the United States as a whole is becoming increasingly dependent on the health of minority populations. Yet disparities in health are widespread, well-documented, and present in every factor that impacts how long and how well people live: from healthy behaviors to clinical care access and quality, and from social and economic factors (like income, housing, and education) to physical factors such as environmental quality. Each year, an estimated 83,000 deaths are attributable to racial and ethnic health disparities.

Fortunately, some hospitals are responding to factors contributing to disparities in health by creating community benefit programs that address all of the factors impacting health in their communities, including access.

Creating Solutions through Community Benefit
Last week, hospital community benefit officers and consumer advocates shared their experiences with partnering to address health disparities.

First, we shared Community Catalyst’s vision for “community benefit” as goods, services and resources provided without reimbursement (or with partial reimbursement) to address community-identified needs and concerns, particularly those of groups who are underserved. Community benefit implies a partnership—a social contract, of sorts—between hospitals and their communities. This vision sees an active role for community partners in identifying community needs and assets and shaping the priorities hospitals choose to address. These programs can focus on a variety of issues impacting health equity—health care access through financial assistance or funding for free clinics, for example, or programs to increase access to healthy foods.

Then, hospital community benefit officers shared how hospitals are addressing health disparities:

• Vondie Woodbury of Trinity Health System, Mercy Health Partners and the Muskegon Community Health Project in Michigan shared how initial community efforts to increase access to care for the uninsured led to the creation of the Access Health Program, a community-based, non-profit cooperative that now partners with Mercy Health to provide access to a full range of services for small business employees who were previously priced out of the commercial insurance market. The program focuses significantly on educating members about healthy living and prevention. “First and foremost, we learned we had to democratize the [community benefit] system so that all of the voices in the community have a chance to shape what is happening. That’s been key to our success,” she said. Trinity hospitals also use a common enrollment form that asks questions to determine if patients are presumptively eligible for financial assistance, prescription drug help, food stamps, and a free vision program offered by a community partner. Trinity also sends outreach workers to visit patients who are behind on their bills and enroll them in financials assistance or Medicaid, rather than allowing their accounts to proceed to collections erroneously.

• In Sonoma County, California, the community benefit arm of Saint Joseph Health System takes a broad, comprehensive approach to address the social determinants of health, according to Dory Magasis Escobar. It deploys health promoters from the communities it serves to educate their friends and neighbors about healthy behaviors and available services, as well as sponsoring free services through community clinics. But it also teaches community members how to relate to systems of power in order to effect change. For example, the health system trains community leaders to respond to neighborhood concerns; participates in community coalitions; and engages in advocacy at the local, state, and federal level on issues that impact vulnerable members of its community.

While these hospitals are stellar examples, advocates can still make progress when local hospitals aren’t as inclined to partner with the community. “Be persistent,” said Claudia Lennhoff of Champaign County Health Care Consumers, an Illinois organization that first approached hospitals about improving financial assistance and debt collection policies. “We started out as adversaries because they wouldn’t meet with us. We were able to move that to a very different place and recently worked together to increase dental access in our community.”

Good News Is (Potentially) on the Way
While hospital leadership plays a major role in determining community benefit programs, the Affordable Care Act also includes some new requirements that can help public health and community advocates raise their concerns. Starting in 2012, all tax-exempt hospitals will have to engage in a “community health needs assessment” and plan implementation strategies that take input from public health experts and community representatives. And while the final rules are still being written, the most recent document put out for comment by the IRS includes a substantial role for grassroots leaders and community members. (Community Catalyst submitted comments on this document.)

While it pays to understand the issues policymakers will be wrestling with in the coming months, community benefit planning processes should be underway in most hospitals. Health equity advocates should ask for a seat at the table, no matter where their hospitals are in the planning process. After all, we share a common vision for communities that promote the health of everyone.

- Jessica Curtis, Project Director, Hospital Accountability Project

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Posted in Affordable Care Act implementation, Health disparities, Hospital Accountability/Charity Care | 2 Comments »