Diagnostic patterns in hospital use by an urban homeless population

Because patterns of disease and health care system usage by the homeless constitute a neglected area of research in the medical literature, we undertook a retrospective analysis of inpatient records on medically indigent adults, controlling for housing status, to add to the growing body of research in the area of homeless health care. Data on all 4,243 indigent patients admitted over 2 fiscal years (1985 and 1986) under the county medical services program of San Diego County, California, revealed 5.3% (226) to be homeless. The commonest major diagnostic category among the homeless discharges was "diseases and disorders of the skin, subcutaneous tissue, and breast," constituting 21.2% as compared with only 8.7% of the discharge diagnoses for housed indigent persons. Within this major diagnostic category, the predominant diagnosis-related group was cellulitis, accounting for 12.8% of diagnoses in the homeless and only 4.0% of discharge diagnoses in other medically indigent persons. A homeless housing status was also correlated with a higher percentage of discharges with the major diagnostic category of "substance use and substance-induced organic mental disorders" but was negatively correlated with that of "diseases and disorders of the circulatory system."

The search for solutions to the indigent care crisis

Providing care to the medically indigent is draining the financial resources of many hospitals. While a unified plan has yet to emerge from Congress, several proposals are being considered. These range from expanding Medicaid to requiring that employers provide a minimum level of healthcare benefits to employees. Meanwhile, states have begun to cope with the problem on their own. Special taxes, lotteries, supplements, and universal insurance plans are among the solutions being tested. Despite these efforts, the question of who will pay for those who cannot remains largely unanswered.

General pediatric clinic practice management: results of a survey of academic departments

The purpose of this survey is to provide an overview of hospital-based general pediatric clinics (GPCs) from the perspective of the practice manager. Academic pediatric departments located in the United States were surveyed to gather information regarding a number of issues relevant to the operation of their GPCs. These issues include educational efforts related to practice management, personnel allocation, financial performance, organizational formats, administrative arrangements, and access to primary care services for children of poor families. Of 131 surveys, 94 were returned (72% response rate). There were an average of 15,486 visits per year to GPCs, and the number of visits overall has increased by 11.9% during the past 5 years. Educational efforts related to practice management vary greatly within GPCs; less than half report any. The overall staff ratios per faculty physician are similar to those in nonteaching practices but differ in composition because of training activities inherent to GPCs. There is an average loss of $250,000 per clinic at GPCs. Organizational formats vary considerably; the majority of physician directors have no line-management authority for nursing and clerical staff. Survey results confirm that GPCs serve a large number of poor children with 41.3% funded by Medicaid and 16.0% unable to pay out-of-pocket expenses. GPCs are generally not used to teach practice management, tend to lose money, and have little faculty involvement in their management.

Access to medical care in a medically indigent population

OBJECTIVE

To study nature and extent of barriers to access to medical care in a single county and to define the nature of the illnesses in a population affected by those barriers.

DESIGN

Descriptive study of consecutive patients not able to obtain medical care because of financial or other barriers. Financial barriers and medical diagnoses were categorized and the severity of illness and impact of unavailability of medical services were judged by a panel of internists using consensus analysis. The likelihood of obtaining care after refusal of assistance was also evaluated.

SETTING

A social services eligibility office on the grounds of an urban, university teaching hospital that serves a largely medically indigent population.

PATIENTS

200 patients who presented to eligibility workers seeking financial assistance.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Sixty percent could not obtain care because they were illegal aliens, 40% could not obtain care because they did not meet the strict criteria of the assistance programs. Sixty percent of patients had a moderate to high likelihood of long-term disability from their illnesses; 38% of a subgroup were not able to find care four weeks after entering the study, and these patients appeared to have more severe disease than those who were able to find care.

CONCLUSIONS

Many medically indigent persons with significant illnesses face serious financial barriers to access to medical care.

Uncompensated emergency care in hospital markets in Los Angeles County

A survey of hospital emergency rooms in Los Angeles County was conducted in March 1987. Analysis of the distribution of uninsured emergency care patients revealed that private hospitals play a significant frontline role in terms of entry into the hospital system for patients who are unable to pay--almost one-half of such patients were treated in the emergency rooms of private hospitals. Hospitals serving markets in which a higher proportion of residents had incomes below the poverty level provided a greater share of uncompensated emergency room services.

Financial barriers to medical care: a prospective study in a university-affiliated community clinic

Access to medical care in the United States is deteriorating, particularly for the poor. The authors evaluated patients who could not afford medical care recommended by physicians in a university-affiliated clinic that serves a predominantly indigent population. The authors determined the patients' demographic characteristics, their medical problems, and the types of care for which financial barriers existed. In addition, the authors compared the patients' demographic characteristics and medical illnesses with those of a control group of patients from the clinic who did not experience financial barriers to medical care. Of the 1,950 patients evaluated, 94 (4.8%) were unable to afford care recommended by their physicians. Sixty-seven percent were US citizens, 73% were unemployed, 63% had monthly family incomes of less than $500, and only 33% had health insurance. The patients had a variety of medical problems, ranging from hearing loss, for which they could not obtain hearing aids, to breast masses, for which they could not obtain mammographies or biopsies. When compared to patients who did not experience financial barriers to recommended care, the study patients tended to be poorer, more likely to be undocumented, more likely to be uninsured, and less likely to have acute, self-limited illnesses. Our findings support the argument that the nation's current piecemeal approach to providing indigent health care may lead to serious financial barriers to access in some localities.

Outreach as case finding. The process of locating low-income pregnant women

This article documents the process of an outreach program for locating disadvantaged women who, as a group, do not receive prenatal care early and have adverse pregnancy outcomes. Three full-time community residents searched for pregnant women for a year, being paid a commission for each woman that they found who enrolled for antenatal care. Outreach workers spent more than half of their time in the field, contacted 20 to 25 people per day, and used a variety of strategies to locate women. Fifty-two women entered the Harlem Hospital Medical Center health care system through the outreach process, with 104 pregnant women not already receiving antenatal care being identified by the outreach workers. Their effort, conversion rate, and yield were comparable to private sector salespeople. The cost per enrollee was high (although not higher than the cost of additional low-birthweight births). Alternatives for locating pregnant women are suggested.

A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (1)

America's health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses. To an increasing degree, the present financing system is inflationary, unfair, and wasteful. In its place we need a strategy that addresses the whole system, offers financial protection from health care expenses to all, and promotes the development of economical financing and delivery arrangements. Such a strategy must be designed to be broadly acceptable in our society. To remedy the deprivation, we propose that everyone not covered by Medicare, Medicaid, or some other public program be enabled to buy affordable coverage, either through their employers or through a "public sponsor." To attack the excess, we propose a strategy of managed competition in which collective agents, called sponsors, such as the Health Care Financing Administration and large employers, contract with competing health plans and manage a process of informed cost-conscious consumer choice that rewards providers who deliver high-quality care economically.

The fruits of empire rot on the vine: United States health policy in the austerity era

Since 1970--with the decline in the hegemonic empire--the U.S. economy has entered a period of lower profitability, producing a major shift in the economic behavior of corporate capital. In contrast to the demand stimulation (New Deal) programs of the earlier period of prosperity capitalism, capital has moved toward a profit stimulation strategy in the current era of austerity capitalism. Fundamental to this austerity strategy is the drive to reduce costs of production. Both governmental and employee health benefits represent a cost of production. Thus in the health field, austerity strategy signifies a reduction in the provision of health benefits to employees and cuts in governmental health programs. An effect of austerity capitalism may be that health patterns now mainly confined to the underdeveloped world will become more prominent among the low-wage and unemployed sectors of the working class in the United States.

Primary prevention with the poor: structural conflicts between the health and welfare systems

Arizona has developed a Medicaid program under the waiver provisions of Title XIX of the Social Security Act. This paper examines how well a managed care system for Medicaid recipients works in delivering prevention services. The conflicts between the welfare system and the delivery of prevention services are explored.

Public hospitals: an assessment and plan for the future

We are currently living in very difficult times for most health care providers. Even though we have always known it, the fact that resources for health care are limited is now abundantly apparent to consumers, health care providers, fiscal intermediaries, government (local, state, and federal), health care planners, and policy makers. Hospitals, especially, are being severely pressured to reduce resource consumption and costs. Conditions that are difficult for nonpublic hospitals are critical for public hospitals in general and nearly fatal for rural public hospitals. Fortunately, nonpublic hospitals are beginning to realize for the first time that their future depends, to a significant degree, on a strong and financially healthy public hospital system. If the public hospital, the hospital of last resort, closes, medically indigent patients will have to be treated in nonpublic hospitals, with the resultant medical, financial, economic, political, and social consequences. Therefore, the importance of public hospitals has to be even better recognized and appreciated and these institutions actively supported in order for the private and total health care systems to be successful.

Decentralized services for public hospital patients: a cost analysis

Dr. Sharfstein's introduction: In this era of cost containment and fiscal constraint, it is critical to consider alternative methods of delivering public psychiatric care that emphasize decentralized approaches, shortened lengths of stay, and innovative clinical interventions. This month's report dramatically illustrates the cost savings that can be achieved in a decentralized treatment program, particularly costs associated with the judicial process and involuntary commitment. The need for high-quality services at the local level is greater than ever.

The financial condition of New York City voluntary hospitals: the first year of NYPHRM (New York Prospective Hospital Reimbursement Methodology)

HIGHLIGHTS OF THE STUDY. In 1983, for the first time since 1977, the average voluntary hospital in New York City did not incur a deficit. Nevertheless, voluntary hospitals in New York City continued to have a lower return on their assets than voluntary hospitals in the rest of the state, in the Mid-Atlantic region, and in the nation. New York City voluntary hospitals would need 85 percent of their total assets to repay their debt, while the comparison groups would use less than 60 percent. The annual rate of growth in hospital expenses among New York City voluntary hospitals declined from almost 12 percent between 1981 and 1982 to less than 9.5 percent between 1982 and 1983, which also was almost a full percentage point below the national rate of increase. Between 1982 and 1983, the value of uncompensated care provided by New York City voluntary hospitals increased from 3.4 percent to 3.7 percent of total operating expenses. Fourteen of the 49 New York City voluntary hospitals studied were financially stressed in 1983, compared to 18 in 1982. Without the additional revenues received from the NYPHRM pools, 10 more New York City voluntary hospitals would have had bottom-line deficits. More details on the financial condition of New York City voluntary hospitals in 1983, and first year of NYPHRM, follow. Definitions, data sources, and methods are described in an appendix to the report, which also includes a glossary of financial terms.