Charity at the Deathbed: Impacts of Public Funding Changes on Hospice Care

A core hospice value is caring for dying individuals regardless of their ability to pay. Historically, a stable source of government funding has provided the financial cushion necessary to extend care to indigent patients. Recently however, 2 factors have challenged the charitable-care value. First, financial reserves have been constrained by regulatory actions limiting admissions, lengths of stay, and reimbursement levels. Second, the number of uninsured individuals has increased. This study of hospices in 17 states found that hospices (1) remain committed to indigent care despite deep concerns about inadequate financial resources, (2) are encountering increased demand for services from indigent patients, (3) are currently covering indigent-care costs, but are pessimistic about their future ability to do so, and (4) are pursuing alternative funding with mixed results.

Fund helps CMs find resources for patients

Tampa General Hospital has created a fund that case managers can use to pay for post-discharge services for unfunded patients when there is no other option. Case managers can use the fund to pay for home health services, a short stay in a skilled nursing facility, or other post-discharge services to free beds for other patients. Case managers and social workers huddle with the treatment team every day and identify challenging patients early in the stay. The case management and social work team tries to identify family or other community support that can help care for undocumented patients after discharge.

Financial hardship in settling medical bills among households in a Semi-Urban Community in Northwest Nigeria

BACKGROUND

An equitable health care system that responds to the needs of its people is important to break the cycle of poverty and ill-health. However, rising health care cost, and the preponderance of user fees to finance health care have often limited access to needed health services.

STUDY DESIGN

A cross-sectional descriptive study design was employed, using a pretested, semi-structured, interviewer-administered questionnaire.

RESULTS

The study was carried out among 188 respondents. Majority (88.2%) of the respondents were within the age-group 20-49 years, about two-thirds 63.8% were married and about half (42.8%) had family size between 5 and 9. The study revealed that about a quarter (26.1%) experienced hardship in settling their medical bills. While one-third (31.1%) had to sell their assets, about half (45.2%) had to secure loan while 16.6% had to resort to begging because of hardship encountered in settling the medical bills. Furthermore, of those who sold theirs asset; 46.2% sold their farmlands, 38.5% sold a piece of land, while 16.3% sold their vehicles.

CONCLUSION

This study has revealed that inhabitants of Samaru community experience hardship in settling their medical bills. Consequently, innovative strategies like deferment of payment and fee exemption, enrolling into community-based health insurance schemes as well as voluntary contributory health insurance schemes etc need to be considered, in order to alleviate the hardship in settling the medical bills.

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.

Transforming revenue cycle processes in an indigent care setting

Steps that Grady Health System in Atlanta undertook in transforming its revenue cycle include: Conducting a complete revenue cycle assessment. Enhancing staff skill levels and customer service techniques--and holding staff. accountable for errors. Automating processes that previously were performed manually. Validating applications for financial assistance electronically. Screening for Medicare/Medicaid eligibility among self-pays.

Financial and health burdens of chronic conditions grow

Almost 72 million working-age Americans--18-64 years old--live with chronic conditions, such as diabetes, asthma or depression. In 2007, almost three in 10, or more than 20 million people with chronic conditions, lived in families with problems paying medical bills--a significant increase from 21 percent in 2003, according to a new national study by the Center for Studying Health System Change (HSC). While problems paying medical bills are especially acute and still rising for uninsured people with chronic conditions (62%), medical-bill problems also are significant and growing among people with private insurance and higher incomes. For the more than 20 million chronically ill adults with medical bill problems in 2007, one in four went without needed medical care, half put off care and more than half went without a prescription medication because of cost concerns.

Is access sufficient? An examination of the effects of the MedShare program to expand access to prescription drugs for indigent populations

We conduct an evaluation of MedShare, a program designed to enhance access to prescription drugs for indigent patients in the Greater Cincinnati area. The program expands access to drugs by providing subsidies to reduce the costs paid by patients for their prescriptions. The assumption is that by expanding access to prescription drugs, participant health outcomes as measured by quality of life improve. Although the program appears outwardly successful, we found little difference between program participants and comparison groups. We feel that these findings point to a major flaw with existing health policy: access alone is not sufficient to improve health outcomes. Too often programs are created and, provided they show outwards signs of success (e.g., enrollment and utilization), are assumed to be improving the health of the community. Our findings indicate that one must look beyond just expanding access to ensure that programs are indeed achieving their overall objectives.

Use of a diagnosis-based risk adjustment model to estimate costs of indigent care in a community at Medicaid reimbursement rates

OBJECTIVES

This study used a diagnosis-based risk adjustment model to estimate the annual costs of uninsured patients in Austin, Texas, and describe the prevalence and costs of their chronic conditions. The data were supplied by the Indigent Care Collaboration, a partnership of local safety-net hospitals and clinics.

METHODS

This study used the Diagnostic Cost Groups prospective Medicaid All-Encounters model, which uses diagnoses, age and gender to assign relative risk scores to patients. The relative risk scores were multiplied by the per capita Texas Medicaid expenditure to obtain estimated annual costs. Chronic diseases were described in terms of prevalence and total estimated annual cost.

RESULTS

A total of 471,194 encounters were recorded for 163,729 patients meeting the study inclusion criteria between the 1st March 2004 and the 28th February 2005. The mean estimated patient yearly cost was US $1,307, and the total estimated yearly population cost was $228,909,529. The most common chronic conditions included hypertension, diabetes, depression, substance abuse, pregnancy, asthma, chronic obstructive pulmonary disease and congestive heart failure.

CONCLUSIONS

This study demonstrates how the unknown costs associated with caring for indigent uninsured patients in a community can be estimated at Medicaid reimbursement rates using the Diagnostic Cost Group model on aggregated patient encounter data.

Which single intervention would do the most to improve the health of those living on less than $1 per day? Interview by Gavin Yamey

Background to the debate: PLoS Medicine is participating in the Council of Science Editors' global theme issue on poverty and human development on October 22, 2007 (http://www.councilscienceeditors.org/globalthemeissue.cfm). Over 200 scientific and medical journals are taking part. For our theme issue, we asked a wide variety of commentators worldwide—including clinicians, medical researchers, health reporters, policy makers, health activists, and development experts—to name the single intervention that they think would improve the health of those living in poverty. We also asked four individuals living in poor, rural agricultural communities in the Santillana district, province of Huanta, Ayacucho, Peru to give us their response to the question, “What do you think would do the most to improve your health and the health of your family?” (The four community members were Severino Rojas Poma, Mercedes Vargas Soto, Julián De La Cruz Chahua, and Martín Rojas Poma). Our October 2007 Editorial discusses this debate further.

Einkommensverluste durch den Empfang von Krankengeld - Wann macht Krankheit arm?

PURPOSE

When absent from work due to sickness, most employees in Germany receive continued pay from their employer for six weeks. After this period, sick employees receive sickness benefits from their Statutory Sickness Fund. These sickness benefits are calculated in a rather complicated way as a percentage of gross and net salary. The paper focuses on two questions that have rarely been studied: which income groups show a particularly large difference between net salary and net sickness benefits? Which income groups move below the poverty line after receiving sickness benefits?

METHODS

We calculated how much sickness benefit is actually paid to the insured, for different income and tax groups. The definition for the poverty line is outlined as well. Due to methodological difficulties, the comparison between sickness benefits and poverty must be confined to single-person households.

RESULTS

In the income groups chosen here (gross salary up to 4000 Euro per month), net sickness benefits amount to about 77 % of net salary, for all insured. Financial problems can mainly be expected for the lower and the upper income groups. Expressed in absolute terms, the upper income groups experience a large reduction in net income. The lower income groups come close to the poverty line or fall below it.

CONCLUSIONS

Sickness benefits provide income in case of sickness; this is an important achievement of social policy. However, we should study the financial burden which sickness benefits could have for the insured. More in-depth analyses would require data that are not yet available (e. g. on the number of insured per income group and the income of other household members). The analyses presented here already show that sickness benefits could lead to severe financial problems for at least some insured. They point to the need for more studies in this neglected field.

Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital

CONTEXT

There are up to 1 million patients treated in acute-care hospitals for community-acquired pneumonia (CAP), with an estimated annual cost > 8 billion dollars. A newly validated CAP outcomes prediction rule developed by Fine and colleagues has been advocated as a guide to hospitalization decisions.

OBJECTIVE

To evaluate the clinical characteristics, costs of care, and resource utilization of patients with low-risk CAP at an urban public hospital serving an indigent population.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study from June 1, 1994 to May 31, 1996.

MAIN OUTCOME MEASURES

Clinical characteristics and costs of care of patients with low-risk CAP and features associated with low-risk CAP in this population.

RESULTS

A total of 522 patients were identified at the time of hospital admission as having CAP; 97 patients (19%) were HIV positive on hospital admission and excluded. Of the remaining 425 patients, 253 patients (60%) were classified as pneumonia severity index (PSI) class I-III (low risk). Of the patients with low-risk CAP, only four patients (1.6%; 95% confidence interval, 0.4 to 4.0%) died during hospitalization. Low-risk CAP was both costly and accounted for significant resource use (35.4% of total CAP costs, and 45% of all CAP bed days). Of the patients with low-risk CAP, there were 138 patients (55%) who could potentially have been treated as outpatients (absence of altered mental status, hypotension, hypoxia on hospital admission, or direct ICU admission). However, 49% of these patients had a history of alcoholism, 20% had a blood alcohol level > 50 mg/dL, and 44% were homeless.

CONCLUSIONS

A significant proportion of the patients admitted with CAP to a public hospital had low-risk CAP and accounted for a significant proportion of the CAP bed days and costs. The use of the PSI accurately predicted which patients would be at low risk for death; however, the utility of using the PSI to reduce low-risk CAP hospital admissions would have been of limited benefit. High rates of homelessness, substance abuse, and medical needs not captured in the PSI would preclude many of these patients from unsupervised outpatient treatment.

[The free delivery of drugs during hospital consultations]

INTRODUCTION

In France, the access to treatment has become a priority and a right. Hence, the supply of care has been reorganised in order to improve the management of the health scourges for all the patients, whether they can pay for what they need or not. The free delivery of drugs (FDD) is part of the services offered by the public hospitals for the low income patients or those who do not yet benefit from social security coverage. As such, it is inscribed within the context of the right to treatment and is a corner stone to a new mission of the public hospital services and care networks.

METHOD

The polyclinic of the Max Fourestier hospital is one of hospitals in the Paris area that supplies medical and surgical consultations to the population and provides drugs free of charge. From April 1, 1999 to the end of June 2000, all the FDD were studied for all the non-hospitalised outpatients who came to the consultations with a prescription for drugs, which could not be supplied in a pharmacy because of lack of revenues or social security coverage.

RESULTS

The diseases encountered in the context of FDD were the same as those of the general population. No specificity was revealed in the prescriptions related to vulnerability. If it were necessary, this would confirm the fact that the management of persons in difficulty should be integrated in the provisions of common rights. The treatments concerned were essential, and for some persons life saving, and justifying the interest of FDD without which the health of these individuals would rapidly decline. Furthermore, this study shows the need for careful management of FDD in order to avoid the anarchical and uncontrolled delivery of several prescriptions, source of deleterious drug interactions and iatrogenia. This is the reason for the recommendation to all the staff delivering free drugs that they systematically ask the patients to meet a referring physician and contact the hospital pharmacist when necessary.

COMMENTS

The FDD request is an ideal occasion for a physician to meet the patient and, because of the professional secrecy, to learn more of the patient's life style, and reveal, other than the diseases, the patients risk factors or elements of vulnerability that interact with the general state of health. The access to rights, on the occasion of FDD, is a fundamental public health strategy, since it provides the patient with access to preventive and primary care health measures. This is why we propose that FDD, other than the medical consultation, become systematically coupled with a consultation with a social care worker, to permit the rapid return of the patients to their common rights.

CONCLUSION

Free drug delivery should not be conceived as a traditional pharmaceutical delivery, it should be the pretext for the reintegration of persons to their social rights and with a strategy of improved medical care. Organised in this manner, FDD is a precious tool for access to care and prevention, but also to the construction of a social relationship.

Statistical comparison of consumer drug expenditures and discretionary purchases to assess drug affordability

BACKGROUND

Affordability may be defined as the absence of economic barriers to a good or service. There are 2 frequently observed measures of affordability: a consumer's ability to pay and his or her physical access to a good or service. Thus, most programs designed to subsidize consumers' health care costs, especially state programs that address prescription drug expenditures for people aged > or =65 years, base eligibility on measures of income as a proxy for a consumer's ability to pay. These measures do not explicitly include a consumer's willingness to pay for medications. For example, it is possible that some Medicare beneficiaries may be resistant to paying for medication because other major health care expenditures are typically covered by insurance. This resistance could be exacerbated by the keen awareness among the general population of the rising costs of medications. Because medications are considered a necessity, expenditure levels are usually compared with expenditures for other necessities, such as housing and medical services.

OBJECTIVE

In an attempt to assess consumers' potential willingness to pay for medications, this article draws on data from the US Bureau of Labor Statistics' Consumer Expenditure Surveys to compare pharmaceutical expenditures with out-of-pocket expenditures for discretionary purchases, such as dining outside the home.

RESULTS

Personal out-of-pocket expenditures for medications have ranged from 0.8% to 1.0% of consumer unit income since 1985. These expenditures are relatively small compared with those for necessities, such as housing (33%) and food (13.5%). They are also less than the share of income dedicated to many nonessentials.

CONCLUSION

Assessing inability versus unwillingness to pay for medication remains a problem for both researchers and health care policy makers attempting to determine the affordability of medications.

Effect of the Vaccines for Children program on physician referral of children to public vaccine clinics: a pre-post comparison

OBJECTIVE

Started in late 1994, the Vaccines for Children (VFC) program is a major entitlement program that provides states with free vaccines for disadvantaged children. Some evaluation studies have been conducted, but they do not include individually matched pre-post comparisons of physician responses. This project studied the effect of the VFC on the physician likelihood of referring children to public vaccine clinics for immunizations.

DESIGN

In 1999, trained personnel conducted a survey of a cohort of physicians who previously participated in surveys on barriers to childhood vaccination conducted before VFC implementation. Responses were matched, and pre- versus post-VFC comparisons were made.

SETTING AND PARTICIPANTS

Minnesota and Pennsylvania primary care physicians selected by stratified random sampling and initially studied in 1990 to 1991 and 1993, respectively.

MAIN OUTCOME MEASURES

Likelihood of referral of a child to a public vaccine clinic.

RESULTS

On a scale of 0 to 10, physician likelihood of referring an uninsured child decreased by a mean of 1.9 (95% confidence interval: 1.2-2.5) from pre- to post-VFC. Two fifths (45%) of physicians reported that the VFC decreased the number of referrals from their practice to public vaccine clinics and 50% gave intermediate responses. Among physicians who participate in VFC, only 9% were likely to refer a Medicaid-insured child in contrast to 44% of those not participating.

CONCLUSIONS

Physicians' reported referral and likelihood of referring Medicaid-insured and uninsured children has decreased because of VFC in Minnesota and Pennsylvania.vaccination/economics, vaccination/legislation and jurisprudence, immunization programs/economics, immunization programs/utilization, vaccines/economics, Medicaid/economics, national health programs United States, child health services.

"I can't afford that!": dilemmas in the care of the uninsured and underinsured

When patients lack sufficient health care insurance, financial matters become integrally intertwined with biomedical considerations in the process of clinical decision making. With a growing medically indigent population, clinicians may be compelled to bend billing or reimbursement rules, lower standards, or turn patients away when they cannot afford the costs of care. This article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (1) whether to refer the individual to a safety net provider, such as a public clinic; (2) whether to forgo indicated tests and therapies because of cost; and (3) whether to reduce fees by fee waivers or other adjustments in billing. Clinicians' responses to these dilemmas impact on quality of care, continuity, safety net providers, and the liability risk of committing billing violations or offering nonstandard care. Caring for the underinsured in the current health care climate requires an understanding of billing regulations, a commitment to informed consent, and a beneficent approach to finding individualized solutions to each patient care/financial dilemma. To effect change, however, physicians must address issues of social justice outside of the office through political and social activism.

Heart failure disease management in an indigent population

BACKGROUND

Multidisciplinary disease management programs (MDMP) have demonstrated reduced hospitalizations in motivated pretransplant heart failure populations, but little is known about their effectiveness in largely indigent patients who are not transplant candidates.

METHODS AND RESULTS

We studied 35 patients with heart failure with left ventricular ejection fraction (EF) </=45% enrolled in an MDMP who were either indigent or funded by Medicaid/Medicare. This nonrandomized sample consisted of 14 patients identified because they had hospital readmission rates of >/=2 per year (group A) and 21 patients referred by their primary care physicians because they were difficult to manage (group B). Group A patients were New York Heart Association (NYHA) class III or IV, aged 25 to 87 years (mean 57 +/- 17 SD) and had an EF of 15% to 45% (29% +/- 11%). Group B patients were NYHA class II or III, aged 35 to 86 (57 +/- 16) years and had an EF of 20% to 45% (28% +/- 10%). Data were compared for the year before enrollment in the MDMP and the year afterward. In group A hospital admissions decreased from 33 to 3, a 91% reduction, and NYHA class improved to class II-III (P <.001). In group B hospital admissions decreased from 9 to 0, and NYHA class improved to class I-II (P <.001). When hospital and clinic charges were assessed for both groups, the net savings were $162,000 per year or $4600 per patient.

CONCLUSIONS

A multidisciplinary heart failure program can improve functional status and reduce hospitalization and net costs compared with conventional care in indigent non-transplant candidate patients.

Financial status does not predict weight loss after bariatric surgery

BACKGROUND

Lower socioeconomic status and poor funding are thought to be associated with suboptimal outcome after bariatric surgery. We undertook this study to determine if funding status is a predictor of outcome in patients undergoing bariatric surgery.

METHODS

The medical records of 131 consecutive patients who underwent vertical banded gastroplasty (VBG) for clinically severe obesity (BMI >40 kg/m2) were reviewed. Patients were divided into three groups based on insurance status: (1) commercially insured/traditional indemnity programs; (2) entitlement programs (Medicare), and (3) medically indigent (Medicaid or no funding). Data is mean +/- SD. Data was analyzed using ANOVA and Student t-test.

RESULTS

The three groups had similar preoperative weight. Mean BMI was 39 +/- 13, 42 +/- 15, 41 +/- 11 at 1 year, and 40 +/- 13, 43 +/- 16, 45 +/- 16 at 2 years postoperatively for the insured, entitlement, and indigent groups, respectively.

CONCLUSION

After standard preoperative evaluation and screening, patients loss weight following VBG independent of insurance status. Source of funding should, therefore, not preclude patients from undergoing bariatric surgery. Patients with limited financial resources can expect similar outcomes as patients with commercial insurance.

The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States

OBJECTIVES

To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data.

DESIGN

Survey of a nationally representative sample of 2,864 adults receiving HIV care.

MAIN INDEPENDENT VARIABLES

Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick.

MAIN OUTCOME MEASURES

Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale.

RESULTS

More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access.

CONCLUSIONS

Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Medication nonadherence and its relation to financial restriction

The question of patient nonadherence has always been an important factor in determining candidate suitability for organ transplantation. Data that explore the association of financial problems and posttransplant medication nonadherence are limited. Findings suggest that medication nonadherence was more likely to occur when recipients did not have insurance coverage and had to rely on Medicaid or indigent drug programs. Our center developed a formalized program within the outpatient pharmacy, including a full-time medication counselor who helped recipients secure resources to pay for pre- and posttransplant medications. To determine whether the availability of posttransplant medications could reduce medication nonadherence, we conducted a survey with 50 consecutive liver transplant recipients in the outpatient clinic. Nonadherence rates were significantly reduced from 25% to 10% (P < .01) compared with recipients who had been transplanted before the development of our drug program. These results suggest that optimum medication adherence can be obtained when recipients are provided guidance in securing their necessary medications without financial restriction.

Income levels of bad-debt and free-care patients in Massachusetts hospitals

This study disputes the common notion that many hospitalized patients whose expenses are written off to bad debt are able to pay their bills. By matching 1996 state tax returns to more than 350,000 bad-debt and free-care claims at seven Massachusetts hospitals, we found that most patients involved had incomes below the federal poverty level and thus were presumably eligible for either public programs or hospital-based free care. This suggests that hospitals and public officials need to investigate further why low-income, uninsured patients are not receiving benefits for which they are eligible. Our results also suggest that measurements of indigent care levels in hospitals for purposes of research or regulation should include some portion of bad debt.

Painful medicine: managed care and the fate of America's major teaching hospitals

Healthcare spending in the United States has risen steadily throughout the post-World War II period as the American healthcare system has been transformed from cottage industry to big business. The increasing rate of social investment in healthcare also transformed America's major teaching hospitals. As a case in point, the University of Iowa Hospitals and Clinics saw annual operating revenues rise from $1 million in 1945 to more than $350 million in 1995, which was accompanied by an extraordinary expansion in its physical facilities and in its multifaceted operations. In the 1970s and even more so in the 1980s, however, the unceasing climb in healthcare spending fueled concern among policy experts, politicians, employers, and insurers alike. In turn, the search for effective cost controls led to the current managed care revolution. While the end of that revolution is not yet in sight, managed care has, it appears, effected significant cost savings, but at no small cost to America's major teaching hospitals and their social missions of teaching, research, and patient care. Whether those missions can survive--and, if so, in what form--in a healthcare system dominated by the managed care ethos is an increasingly important concern.