Helping patients receive medical benefits. Collaboration between hospitals and legal services assists providers and low-income Kansans

In Kansas, legal services lawyers have teamed up with Catholic healthcare administrators to help uninsured and underinsured hospital patients receive healthcare benefits from programs for which they may be eligible. The project--Hospital Patient Assistance Program--provides comprehensive assistance in establishing a patient's eligibility for medical benefits. Hospital participation in the program is simple. When business office or admissions staff discover that a self-pay patient has been registered with the program, they refer the patient to Kansas Legal Services; Inc. (KLS). KLS staff members try to determine if the patient is eligible for benefits from any of a number of programs, including Medicaid, Medicare, and Crime Victims Assistance. If KLS finds no programs for which the patient is eligible, it does not accept the case and notifies the hospital. Hospitals participating in the program have found that many accounts they previously wrote off as not collectible can be paid. Since the program began in 1990, participating hospitals have realized almost $8 million in payments from various benefit sources.

Structural adjustment and health policy in Africa

World Bank/International Monetary Fund Structural Adjustment Programs (SAPs) have been introduced in over 40 countries of Africa. This article outlines their economic policy measures and the experience of the countries that have introduced them, in terms of nutrition, health status, and health services. The evidence indicates that SAPs have been associated with increasing food insecurity and undernutrition, rising ill-health, and decreasing access to health care in the two-thirds or more of the population of African countries that already lives below poverty levels. SAPs have also affected health policy, with loss of a proactive health policy framework, a widening gap between the affected communities and policy makers, and the replacement of the underlying principle of equity in and social responsibility for health care by a policy in which health is marketed commodity and access to health care becomes an individual responsibility. The author argues that there is a deep contradiction between SAPs and policies aimed at building the health of the population. Those in the health sector need to contribute to the development and advocacy of economic policies in which growth is based on human resource development, and to the development of a civic environment in Africa that can ensure the implementation of such policies.

Is reasonable access what we want? Implications of, and challenges to, current Canadian policy on equity in health care

Considerations of equity in the context of health care systems are often related closely to the presence or level of prices incurred by users of health care services. Some politicians and commentators have suggested that the removal of user charges under the Canadian health care system has led to equal access to care. But it is not clear that the equity principle inferred from these claims corresponds to the equity goals of current Canadian health policy. In this article the authors identify the precise equity principle that lies behind current health policy in Canada and consider the extent to which that principle is reflected in the performance of the system. They then consider other approaches to equity in health care in the context of the stated objectives of Canadian health policy and identify the implications of pursuing reasonable access in future health policy. The authors suggest that the implications of the current equity goals have not been recognized by policy makers, and if they were to be recognized it is not clear that they would be acceptable to Canadian populations and/or policy makers. Moreover, some of the implications would appear to be incompatible with other stated objectives of public policy.

Have procompetitive changes altered hospital provision of indigent care?

In the past decade alone there have been numerous changes in the financial and competitive environment of hospitals in the United States. Some examples include the advent of Medicare's Prospective Payment System, growth in managed care options, relaxation of states' Certificate of Need (CON) regulations, and court cases questioning the tax-exempt status of nonprofit hospitals. In this paper we attempt to reveal how hospitals alter their provision of care to the poor in a more cost conscious and competitive environment. Using hospital data from the State of California for the fiscal years ending in 1983 and 1987, estimates explaining uncompensated care commitments are presented. In particular, this study illustrates how hospitals under different ownership control varied their provision of uncompensated care over the period studied on average and by profitability level. Other factors, such as hospital location, teaching status, medicare patient load, and contractual adjustments, are also included in the analysis. A number of interesting trends are detected. Moreover, the results are found to be compatible with a quid pro quo hypothesis which states that hospital regulators reward large uncompensated care providers with profitable CON licenses.

Maternal and infant care: comparisons between Western Europe and the United States

A series of studies between 1986 and 1990 gathered data on maternal and infant care in ten Western European countries with lower infant mortality rates than the United States and compared the findings both within the European countries and in aggregate with the United States. Results from these studies reveal great variation among the study countries in how perinatal care is financed, staffed by professional and nonprofessional health workers, and provided by public clinics or private offices, and in the number of and locale of the recommended number of prenatal visits. Invariably consistent among the study countries is the nearly complete enrollment of childbearing women in early and continuous prenatal care, and the strong linkage of that care to a generous spectrum of social supports and financial benefits. None of the benefits generally pertains in the United States. The relevance of these observations for the United States suggests that current policies intended to lower economic barriers to a highly medicalized version of maternity care may yield disappointing results unless the perinatal sequence is linked to a more generous set of maternity-related social supports and financial benefits than is now contemplated.

Medicaid program; limitations on aggregate payments to disproportionate share hospitals; Federal Fiscal Year 1993--HCFA. Notice

This notice announces the final Federal fiscal year (FFY) 1993 individual State allotments for Medicaid payments made to hospitals that serve a disproportionate number of Medicaid recipients and low-income patients with special needs. The final FFY 1993 State DSH allotments published in this notice supersede the preliminary FFY 1993 DSH allotments that were published in the Federal Register (57 FR 55261) on November 24, 1992.

Medicaid program; limitations on provider-related donations and health care-related taxes; limitations on payments to disproportionate share hospitals--HCFA. Final rule

This final rule clarifies HCFA's policies concerning provider related donations and health care related taxes. In addition, this final rule revises regulations with regard to disproportionate share hospital spending limitations. This final rule amends an interim final rule that was published in the Federal Register on November 24, 1992. The interim final rule established in Medicaid regulations limitations on Federal financial participation (FFP) in State medical assistance expenditures when States receive funds from provider-related donations and revenues generated by certain health care-related taxes. The interim final rule also added provisions that establish limits on the aggregate amount of payments a State may make to disproportionate share hospitals for which FFP is available. The provisions of the interim final rule were required by the Medicaid Voluntary Contribution and Provider Specific Tax Amendments of 1991.

Government purchasers see value in managed care

The County of San Diego and the Massachusetts Department of Mental Health are providing access to the indigent--and cutting their costs through managed care programs.

Health care. Way ahead of Bill

Unable to wait any longer for federal reform, states and companies are launching their own programs to cut costs and extend coverage to more of those now uninsured.

Valuing the community benefits provided by nonprofit hospitals

Nurse executives need to be aware of the changing legislative climate in which nonprofit hospitals operate. Adopting an aggressive stance to protect an institution's tax-exempt status has become increasingly important. One way to provide protection from governmental challenges is to demonstrate the extent of charitable benefits provided by the hospital. The authors identify areas that hospital personnel should analyze to determine the nature and value of these benefits. Nurse executives are a valuable resource for identifying and communicating this information. They can also exert influence on their respective administrations to reassert the charitable nature of their mission.

Going off the dole: a prudential and ethical critique of the healthfare state

The present 'healthfare' state in the United States is neither practically nor morally justified. The nation currently fails to provide adequate access to health care for tens of millions of uninsured citizens. To suggest that the United States' half-million physicians should provide their care as charity is an inadequate solution. The transfer of assets from the 'haves' to the 'have-nots' through taxation in a 'healthfare state' undermines human compassion, and fails to respect minimal moral requirements. However, alternative strategies are possible. During the next 20 years health care could come to be financed on the basis of sound quasi-libertarian moral and prudential principles. In the interim deliberate political action is required to achieve novel health policy, available and affordable job and career training, and universal employment. It is possible to achieve universal access to adequate health care while sustaining individual choice, and at the same time to reduce or virtually eliminate taxpayer-subsidized health care. This approach would, in time, eliminate the healthfare state and eventually encourage and even require citizens to go off the healthfare dole.

A study on financial viability of clinics and physician practices in under-served areas of Wisconsin: the primary care physician shortage problem and collection issues

A survey of 21 physicians and clinic managers in Health Professional Shortage Areas (HPSAs) and other under-served areas in Wisconsin found that to combat increasing costs, low reimbursement rates and increasing charity care demands, several practices rely on outside sources of funding. Also, the financial viability of physician practices in underserved areas of Wisconsin is threatened more by the low reimbursement rates of Medicaid and Medicare than by the provision of charity care. Though few are limiting the number of Medicare and uninsured patients they will treat, many have begun implementing cost containment measures, including more strict collection policies. There are also indications of restricted access for Medicaid patients.

Hospital bad debt in France: who does not pay?

Hospital bad debt commonly represents 4-5% of total patient revenue. We examined bad debts accrued by our hospital over a 10-year period from both a medical and sociodemographic perspective. We found that true medical emergencies represent 90% of 'bad debtors' admitted, and that, despite generalized medical insurance in France, a quarter of unpaid bills belong to French residents. We conclude with a proposal to limit individual hospitals' accountability for bad debt.

Healthcare Financial Management Association, Principles and Practices Board. Statement No. 16. Classifying, valuing, and analyzing accounts receivable related to patient services

This Principles and Practices Board project was undertaken in response to the frequent requests from HFMA members for a standard calculation of "days of revenue in receivables." The board's work on this project indicated that every element of the calculation required standards, which is what this statement provides. Since there have been few standards for accounts receivable related to patient services, the industry follows a variety of practices, which often differ from each other. This statement is intended to provide a framework for enhanced external comparison of accounts receivable related to patient services, and thereby improve management information related to this very important asset. Thus, the standards described in this statement represent long-term goals for gradual transition of recordkeeping practices and not a sudden or revolutionary change. The standards described in this statement will provide the necessary framework for the most meaningful external comparisons. Furthermore, management's understanding of deviations from these standards will immediately assist in analysis of differences in data between providers.

Changing characteristics of schizophrenic patients admitted to state hospitals

OBJECTIVE

Characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 were studied to examine changes in the demographic profile of the patient population and in principal sources of payment for hospitalization over the study period.

METHODS

Information on patients' demographic characteristics and principal payment sources was obtained from a nationally representative data base compiled about every five years by the National Institute of Mental Health.

RESULTS

Among schizophrenic patients admitted between 1970 and 1986, the proportion of African-American males increased. By 1986 patients were less likely to pay for care through private insurance or their own resources. They were more likely to receive Medicare and to lack medical insurance. Medicare use increased largely among white patients, and medical indigency largely among African-American patients.

CONCLUSIONS

Changes in the characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 may be related to changes in nosology, in the prevalence of schizophrenia, and in the types of patients likely to be admitted to state hospitals. The increase in the number of medically indigent patients accentuates the need for more adequate finding of state hospitals.

Primary care program improves reimbursement. The Federally Qualified Health Center program helps hospitals improve services to the medically indigent

Under a program created by Congress in 1989, certain primary care treatment centers serving the medically and economically indigent can become Federally Qualified Health Centers (FQHCs). Recently enacted rules and regulations allow participants in the FQHC program to receive 100 percent reasonable cost reimbursement for Medicaid services and 80 percent for Medicare services. An all-inclusive annual cost report is the basis for determining reimbursement rates. The report factors in such expenses as physician and other healthcare and professional salaries and benefits, medical supplies, certain equipment depreciation, and overhead for facility and administrative costs. Both Medicaid and Medicare reimbursement is based on an encounter rate, and states employ various methodologies to determine the reimbursement level. In Illinois, for example, typical reimbursement for a qualified encounter ranges from $70 to $88. To obtain FQHC status, an organization must demonstrate community need, deliver the appropriate range of healthcare services, satisfy management and finance requirements, and function under a community-based governing board. In addition, an FQHC must provide primary healthcare by physicians and (where appropriate) midlevel practitioners; it must also offer its community diagnostic laboratory and x-ray services, preventive healthcare and dental care, case management, pharmacy services, and arrangements for emergency services. Because FQHCs must be freestanding facilities, establishing them can trigger a number of ancillary legal issues, such as those involved in forming a new corporation, complying with not-for-profit corporation regulations, applying for tax-exempt status, and applying for various property and sales tax exemptions. Hospitals that establish FQHCs must also be prepared to relinquish direct control over the delivery of primary care services.

Why nonprofits? Hospitals and the future of American health care

The future of the nonprofit hospital depends on its relationship to the for-profit and governmental sectors of our economy. A decade ago, the primary challenge came from the growing investor-owned hospital companies. Nonprofit hospitals' responses--both competitive and imitative--led to new challenges from government regarding tax-exempt status. The reasons underlying this challenge include the growing commercialism of health care, the nation's failure to deal directly with the problem of the uninsured, and the lack of a coherent theory of tax exemption. Although hospitals are likely to retain exemptions from federal taxation, challenges to local tax exemptions are likely to continue. Strategies that hospitals pursue for competitive purposes may undercut their legitimacy as tax-exempt institutions, but several groups are working to address the issue.

The advantages and risks of being a tax-exempt, nonprofit organization

Most nonprofit hospitals enjoy exemptions from income, property, sales, and other taxes. The advantages of the tax exemption generally outweigh any disadvantages. Recent legislative and judicial challenges, however, have reduced the tax benefits of nonprofit hospitals. The authors review tax exemptions as they relate to hospitals, identify the primary advantages and risks, and highlight areas where nurse executives can further the exempt purpose of their institutions.

Healthcare Financial Management Association, Principles and Practices Board. Statement no. 15: Valuation and financial statement presentation of charity service and bad debts by institutional healthcare providers

Principles and Practices Board (P&P Board) Statement No. 2, issued in 1978, provided a basis for differentiating between charity service and bad debts. The statement acknowledged that, while the differentiation was helpful, the financial accounting and reporting of charity service and bad debts were the same. In 1990, the American Institute of Certified Public Accountants (AICPA) published (after review and approval by the Financial Accounting Standards Board and the Governmental Accounting Standards Board) an extensive revision of the guide titled "Audits of Providers of Health Care Services." The revised guide substantially changed the reporting of bad debts and eliminated charity service from revenue. Disclosure of the entity's policy for providing charity service and the level of charity service provided is required by the revised guide. The P&P Board decided that a substantive revision of its Statement No. 2 was required to bring it into conformity with the revised guide and to provide direction on implementation of the revised guide's requirements. This statement supersedes Statement No. 2 and deals with the same issues, including bad debts.

Selling cost containment

Health care expenditures in the United States have continued to grow despite efforts to control them. This Article discusses the need for health care reform, outlines the model that reform should follow, and considers why the United States has not progressed toward a workable solution. It introduces a single-payer approach to cost containment and explains how such an approach could be "sold" in the United States. Finally, the Article examines various ways to mobilize support for such health care reform.

Principles of health care reform: an African-American perspective

To protect the interests of underserved Americans, fair and rational health care reform must embrace 10 principles. These include universal and comprehensive coverage; mandatory cost containment; equity; freedom to change jobs or to relocate; high quality; reduced paperwork; primary care; help for the underserved; consumer-oriented care; and fair financing.