Monday, August 11, 2008

What happens when the safety net gets a hole?

Interesting story in the Cleveland Plain Dealer today about MetroHealth System's new policy of restricting care to poor patients of Cuyahoga county only. MetroHealth is basically the charity hospital of the Cleveland area, serving the needs of the poor and underprivileged in the metropolitan area, and it has been hemorrhaging cash for years. Previously, the residency requirement was only loosely enforced; patients living in nearby Lorain or Lake counties were processed as if they were Cuyahoga residents and received all the benefits of being poor and uninsured in the "proper" zip code.

The new policy cleaves hundreds of patients with chronic medical conditons (diabetes, hypertension, etc) from the appointment schedule. Unless, of course, they can suddenly come up with $150 to pay for the visit. This also doesn't include the untold numbers of patients who won't be eligible for elective or semi-urgent surgical procedures (cholecystectomies, gyne procedures, and colon cancer surgery).

So what is a patient supposed to do? The options are rather lean. You can go to a local "free clinic" in the surrounding counties. But free clinics don't pretend to be a suitable alternative for the all-encompassing health care needs of a family. For example, here's a listing of the "medical services" provided by the Lake County Free Clinic:

Diagnosis and treatment of short-term illnesses and basic medical needs

Physicals for work, school, sports, Headstart
People with more serious medical problems will be referred to other providers, including the emergency room, urgent care & private doctors. Services not available include treatment for chronic conditions (diabetes, hypertension etc.), serious injuries, STD testing, family planning or mental health.

Laboratory Assistance
The clinic will perform reduced cost laboratory work on an outpatient basis for those who have a requisition order from their physician, but cannot pay for the lab order.

Prescription Assistance
The clinic will provide financial assistance once per calendar year for Lake County residents who do not have insurance and cannot afford to pay for a prescription. Income guidelines apply.

Not too impressive. Sounds like the medical repertoire of a typical stay at home mom. As long as your chief complaint is "scraped knees" or "ouchy finger", the Free Clinic is a marvelous option. So for the ER's of Lorain and Geauga and Lake and Ashtabula counties, get ready to be deluged by a flood of uninsured patients seeking basic medical treatments.

And I'm sure it will effect general surgeons who take ER call. Inevitably we will see more patients with symptomatic hernias and worsening biliary colic that may have previously been cared for at Metro. This isn't a revolutionary development. We take care of uninsured patients all the time. A lot of times, the patient will qualify for HCAP (hospital care assurance program) funding to help with the costs of hospitalization/operating room time. But the individual surgeon gets nothing. I usually tell patients to pay what they can (to the chagrin of our billing people). If it's a self employed contractor who doesn't have insurance because "it's too expensive" even though he drives a Ford F-250 and just got back from a Myrtle Beach vacation, we may pursue payment a little more strenuously, even sending him to collections. If it's a single mother working two jobs, I usually end up operating pro bono. Not a big deal. But it will be interesting to see what happens to the numbers of uninsured patients I deal with in the coming years given the new policy of MetroHealth.


Kelley said...

Any ideas on how to fix the system? I'm not asking this sarcastically, either. I find it such a frustrating situation, I mean we can't expect hospitals and physicians to continue to operate for free, or no one will be able to afford to stay in business anymore, yet at the same time, how can healthcare providers, in good conscience turn away patients in desperate need of care due to ability to pay? It seems like such a vicious circle, with no real answers ( I personally don't see how universal healthcare is a feasible solution, unless they DRAMATICALLY lower the cost of medical education ). I was just wondering what your opinion is, as a surgeon in the field, facing already dwindling reimbursements.

Kelley said...
This comment has been removed by the author.
Anonymous said...

All they have to do is move to North Carolina and claim Illegal Alien Status. Duke will even put you on the Transplant List, and if something goes wrong, John Edwards will handle your case, he's got plenty of spare time now a days.

Anonymous said...

I am amazed at your reading list...Daily Kos? Thats reading?
you'll be more relaxed and better enlightened.
from one surgeon to another

Anonymous said...

A review found nearly 900 out-of-county residents in 2007, said Sarah Stamp, vice president of medical operations.

"We see a lot of patients who are seen at hospitals in the outlying counties. The patients will go to the ER and the doctors will tell them to get follow-up care at MetroHealth," said Barbara West, administrator of emergency and ambulatory services. "The doctors will state that."

And West said she knows why. The emergency-room doctors know the community doctors at out-of-county hospitals will not forgive their medical fees for the uninsured patients, she said.

An uninsured patient can walk into almost any emergency department and be seen. Federal law requires hospitals that receive Medicare funds -- which is nearly all of them -- to see all emergency-room patients and, at the very least, stabilize them.

And in Ohio, a program called the Hospital Care Assurance Program assesses hospitals and pools money collected from the hospitals with federal matching funds. The money is then redistributed to help hospitals cover the costs of treating the indigent.

But doctors aren't involved in this program and are under no federal obligation to take indigent patients. Uninsured patients have a difficult time getting an appointment with a private physician.

MetroHealth officials said most patients they're calling have chronic medical conditions that require frequent doctors' visits. Stamp said MetroHealth's free and reduced-cost care is a significant part of the bad debt the hospital writes off each year.

But the county-owned facility, which is partially supported by taxes from Cuyahoga County residents, can't be the hospital of last resort for all of Northeast Ohio. MetroHealth received $40 million this year from the county to help pay for care for the poor.

"We really want to support our mission and be here for the people of Cuyahoga County who are truly unable to pay, not just those unwilling to pay," West said.

A study published last week in the Annals of Internal Medicine reported that millions of uninsured Americans with chronic diseases get little or no medical treatment unless they show up at emergency departments.