Here to be seen: ten practical lessons in cultural consciousness in primary health care

Providing health care for culturally diverse individuals and members of underserved groups can be challenging but also rewarding if a few simple yet important lessons are followed. Taking time to get to know patients; using preferred names; looking at patients' photographs; learning patients' languages; showing respect; being open to messages in the media; listening to patients' stories; prescribing culturally appropriate and practical regimens; and remaining aware of the interrelationship of culture, illness, and health care are steps toward cultural consciousness and competence in primary care. This article is based on a keynote address at the 11th Annual Primary Care for the Underserved Conference held May 2003 in Boston, Massachusetts.

Unsure about the uninsured. With the nation's uninsured population up another 3.2%, politicians spin the news, while hospitals wait for solutions

As the latest statistics surfaced showing the uninsured population has hit 45 million, politicians added spin and healthcare providers were still hoping for some solutions. Census official Daniel Weinberg, left, said the data don't reveal what caused a drop in employer-sponsored coverage.

Hospital provision of uncompensated care and public program enrollment

Hospital provision of uncompensated care is partly a function of insurance coverage of state populations. As states expand insurance coverage options and reduce the number of uninsured, hospital provision of uncompensated care should also decrease. Controlling for hospital characteristics and market factors, the authors estimate that increases in MinnesotaCare (a state-subsidized health insurance program for the working poor) enrollment resulted in a 5-year cumulative savings of $58.6 million in hospital uncompensated care costs. Efforts to evaluate access expansions should take into account the costs of the program and the savings associated with reductions in hospital uncompensated care.

The health care safety net: money matters but savvy leadership counts

The nation's health care safety net--heavily reliant on external funding and support--is uniquely vulnerable to shifting and often adverse market and policy conditions. While adequate funding is essential to ensuring safety net providers can care for low-income people, the Center for Studying Health System Change (HSC) has identified a number of other factors key to building and maintaining viable community safety nets. Throughout the four rounds of HSC's Community Tracking Study (CTS) site visits, researchers have found that strong political and organizational leadership, community support, collaboration and business acumen have helped safety net providers build capacity and improve care coordination for low-income and uninsured people. These characteristics and business strategies have strengthened many community safety nets, better preparing them to weather current economic problems and providing a road map for the potentially tougher times ahead.

Medicaid and indigent care issue brief: Medicaid: provider reimbursement: year end report-2002

Medicaid provider reimbursement rates have been a hot topic for the last several years. Twenty-eight states including California, Hawaii, Indiana, Maryland, Mississippi, New York, and Wisconsin addressed the issue in the 2000 legislative session while 30 states enacted legislation dealing with provider reimbursement in 2001.

Medicaid and indigent care issue brief: Medicaid: services covered: year end report-2002

Medicaid provides health care insurance for low-income children, some parents who meet income thresholds, pregnant women, the elderly and the disabled. In order to receive federal funds for Medicaid, each state must offer coverage for the following health care services: inpatient and outpatient hospital services; physician services; medical and surgical dental services; nursing facility services; home health care services; family planning services; rural health clinic services; laboratory and x-ray services; pediatric and family nurse practitioner services; federally qualified health center services; nurse-midwife services; and early and periodic screening, diagnosis and treatment (EPSDT) services for individuals under age 21. States can also choose to cover certain additional services under their Medicaid plans, and these often include prescription drugs, dental services (nonmedical or surgical), clinic services, and vision and hearing services. It is up to each state to decide what optional services to include with the mandated services to create their Medicaid benefit package.

Medicaid and indigent care issue brief: Medicaid: access to health services: year end report-2002

Medicaid provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. In 1999, Medicaid provided health care insurance to approximately 32 million low-income Americans. However, in that same year, 42 million Americans had no health insurance at all. In order to reduce the number of people without health insurance, states have expanded or clarified their eligibility standards to allow more people to enroll in Medicaid and other medical assistance programs.

Mounting pressures: physicians serving Medicaid patients and the uninsured, 1997-2001

The proportion of doctors providing any charity care decreased from 76.3 percent in 1997 to 71.5 percent in 2001, according to a new study by the Center for Studying Health System Change (HSC). The proportion of physicians serving Medicaid patients also decreased from 87.1 percent in 1997 to 85.4 percent in 2001. The small decrease in physicians serving Medicaid patients does not appear to have had any negative effects on access to physicians among Medicaid beneficiaries. On the other hand, the more sizable decrease in physicians providing charity care is consistent with other evidence showing decreased access to physicians by uninsured persons. New budget pressures could lead states to freeze or cut Medicaid provider payment rates, which could then trigger access problems.

Uncompensated care and emergency department utilization: a local study having national implications

This article provides a comprehensive picture of the manner in which uncompensated care patients utilize the emergency departments (EDs) of two Central Florida hospitals. Specifically, this study assesses the impact of treating uncompensated and primary care patients in ED settings on scarce hospital and community resources. Recommendations are being offered to manage a troubling situation that is occurring with alarming frequency in today's health care system throughout the United States. Special emphasis is placed on recommendations addressing alternative triage and financing models that are considered to be both socially responsible and economically viable. The results of this study suggest strongly that health care organizations must find an alternative to the current trend in ED utilization, in order to meet the primary care needs of patients and not compromise the care provided to those with emergent conditions. The recommendations emanating from this study outline a mechanism that can improve the timeliness of emergency care to those in need, while at the same time, making available primary care resources to those seeking services through an emergency department.

Nowhere else to turn. As the ax falls on mental health funding, hospital EDs fill the gap--reluctantly

As the ax falls on mental health funding, state mental hospitals are closing and investor-owned psychiatric organizations are filing for bankruptcy or shifting their focus to more lucrative general acute care services. That leaves patients--many of them uninsured--with nowhere to seek help except hospital emergency departments.

Valuing charity

Arrow asserted that a variety of institutional arrangements and observable mores of the medical profession were functional responses to the failure of the market to insure against uncertainties. But one of these norms--the ethic to provide treatment without regard to ability to pay--was also a response to the failure of the political system to assure the elderly and poor would not suffer more than others when they got sick. This ethic is strikingly different from the norm in most other areas of the economy. Automobile dealers and department stores are not expected to give away their products to the poor; neither are grocery stores or farmers. Public education is a closer analogy, reflecting the norm that all children deserve a good education. In education, however, unlike in medicine, we collectively support this norm by providing public funds to accomplish this goal rather than by relying on the private market. In 1963, physicians argued that a combination of the market and private philanthropy (including the obligations of physicians) would be sufficient to guarantee high-quality care for the elderly and the poor. Government financing, they argued, would lead to socialized medicine, impairing relationships between physicians and patients and between physicians and society. Based on his article, Arrow would not have agreed. Neither, apparently, did the public. The enactment of Medicare indicated, in part, that many people understood, even in 1965, the extent to which treatment choices and outcomes were affected by ability to pay. Events since 1965 suggest that there is some tension between insurance and ethical responses to uncertainty despite Arrow's endorsement of both. I have argued here that Medicare and Medicaid further eroded the ethic that treatment should be available without regard to ability to pay by reducing physician willingness to provide charity care and by reducing the resources available to public hospitals and the interest of private teaching hospitals in providing care to the uninsured poor. Largely independent of Medicare and Medicaid, the increasing importance of pharmaceuticals and other services delivered outside of the hospital further strengthened the connection between treatment choices and ability to pay, and the growth of capitated payment systems made this connection salient to many insured patients and their physicians. In part, then, the AMA was correct: Medicare and Medicaid have contributed to the erosion of trust in physicians as incorruptible agents for patients. Some of this trust undoubtedly was misplaced, even in 1965, and trust alone was not sufficient to guarantee widespread access to medical care or to assure that treatment provided would take true social benefits and costs into account. Medicare and Medicaid, as well as the growth of prepayment insurance plans, represent institutional responses to the failure of the 1963 norms to accomplish societal goals. Still, as we have seen, these responses create their own challenges, and we continue to search for institutions that will allow widespread insurance to coexist with the physician-patient trust that Arrow correctly identified as an important response to uncertainties and information asymmetries in the medical care market.

Physicians pulling back from charity care

Physicians have long provided care to the medically indigent for free or at reduced rates. However, recent findings from the Center for Studying Health System Change (HSC) indicate that the proportion of physicians providing charity care dropped from 76 percent to 72 percent between 1997 and 1999. In the short term, most medically indigent people are still getting care. But policy makers should take note that reduced physician participation in charity care will hurt the poor if-as projected-growth in physician supply slows and the number of uninsured rises along with escalating health care costs. This Issue Brief discusses the extent of the decline in physician provision of charity care, the reasons for the decline and implications for the future of the safety net.

The impact of HMOs on hospital-based uncompensated care

Managed care in general and HMOs in particular have become the vehicle of choice for controlling health care spending in the private sector. By several accounts, managed care has achieved its cost-containment objectives. At the same time, the percentage of Americans without health insurance coverage continues to rise. For-profit and not-for-profit hospitals have traditionally financed care for the uninsured from profits derived from patients with insurance. Thus the relationship between growth in managed care and HMOs, hospital "profits," and care for the uninsured represent an important policy question. Using national data over an eight-year period, we find that a ten-percentage point increase in managed care penetration is associated with a two-percentage point reduction in hospital total profit margin and a 0.6 percentage point decrease in uncompensated care.

No easy answers

Illegal immigration is on the rise and Congress has restricted access to health coverage for legal immigrants. Those factors combine to create a large pool of uninsured patients, and hospitals once again are left to foot the bill--to the tune of millions of dollars a year. And the problem is no longer restricted to border states and big cities.