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CARING FOR THE UNINSURED AMID FINANCIAL PRESSURES USING TARGETED MARKETING METHODS TO INFLUENCE PATIENT BEHAVIOR

JEFFREY S. BARKOFF DENNIS DUNN, PHDKENT FRANCISLINDA MACCRACKEN, MBAGARY PICKENS, PHDLEAH H. RAY, MBAMICHAEL SHIPLEYMEREDITH A. WELLS, MS

APRIL 2010

TABLE OF CONTENTSINTRODUCTION .......................................................................................................................................... 1

THE UNINSURED POPULATION: NOT HOMOGENOUS ..................................................................... 1

UNINSURED HEALTH SERVICES UTILIZATION .................................................................................. 2

OUTPATIENT SERVICE USE DIFFERS BY PAYER GROUP ................................................................. 3

INPATIENT SERVICE USE DIFFERS BY UNINSURED PATIENTS ..................................................... 3

USING MARKETING TO INFLUENCE BEHAVIOR OF THE UNINSURED ........................................ 4

STRIVING FOR BALANCE: TACTICS FOR CONSIDERATION ............................................................ 6

MARKETING TACTICS ............................................................................................................................... 6

FRONTLINE TACTICS .................................................................................................................................7

CONCLUSION ...............................................................................................................................................7

APPENDIX ................................................................................................................................................... 8

REFERENCES .............................................................................................................................................. 9

Caring for the Uninsured Amid Financial Pressures 1

INTRODUCTION Across all political affiliations, industries, and socioeconomic backgrounds, healthcare reform ranks among today’s most discussed topics. But in the midst of the debate, one fact remains clear: providing care to the uninsured segment of the population is a monumental task of paramount importance.

The total uninsured population now includes one out of every six Americans. Estimates of the total number of uninsured individuals ranges from roughly 46.31 to 49.72 million. The uninsured population now exceeds the total number of Medicare beneficiaries by roughly 22 percent. Furthermore, forecasts indicate that the number of uninsured will reach 58 million Americans by 2014.3

The cost of continuing to provide care as we do today will translate into billions of dollars in unpaid medical bills for patients with little or no coverage. But the more hospitals and healthcare providers know about their patients – notably the uninsured – the better equipped they will be to meet their missions, maintain a robust community benefit, and contain costs as components of financial viability. Regardless of the future of healthcare reform, hospitals and healthcare providers are well served to assess utilization and care patterns, examine their patient rosters, and develop strategies to lower expenses without sacrificing quality of care.

In supporting this need, Thomson Reuters experts explored the topic of caring for the uninsured by examining national hospital data and consumer healthcare information to articulate the unique characteristics and behaviors of this growing population. This paper identifies distinct segments with different utilization trends/behaviors, as well as channels and receptiveness to marketing. In addition, Thomson Reuters developed recommendations to hospital leadership on how to provide the right care at the right site of service to help better manage the rising costs of serving the uninsured.

The research presented here draws upon multiple sources, including the Thomson Reuters Outpatient Procedure Estimates and consumer research from the annual Thomson Reuters PULSE™ Healthcare Survey.

THE UNINSURED POPULATION: NOT HOMOGENOUS

Uninsured – Not Necessarily Low Income or UnemployedFor many Americans, the “uninsured” – when viewed as a single group – often means those without employment or those who cannot afford individual healthcare coverage. The uninsured are not a homogenous group and include both unemployed and employed individuals, at various income levels, as well as their children and other dependents. Thomson Reuters experts have found significant differences among the various subgroups of the uninsured, including site of service preferences and health conditions.

Thomson Reuters defined four mutually exclusive segments for the uninsured, based on employment status and income level. Key differences in behaviors of the various segments are described as follows.

• Uninsured, employed with incomes under 300 percent of the Federal Poverty Level• Uninsured, employed with incomes above 300 percent of the Federal Poverty Level• Uninsured, unemployed with incomes under 300 percent of the Federal Poverty Level• Uninsured, unemployed with incomes above 300 percent of the Federal Poverty Level

2 Caring for the Uninsured Amid Financial Pressures

Uninsured – Low Income, not Medicaid Not all low-income individuals qualify for government coverage through Medicaid.4 Medicaid eligibility is based on considerations of income as well as other characteristics. Among the population groups that generally qualify for Medicaid are children, parents of dependent children, pregnant women, the disabled, and the elderly. The income levels at which these groups qualify differ from state to state, and group to group. Generally, coverage for children and pregnant women is available at higher income levels, followed by the disabled and elderly, and lastly, parents of dependent children. Childless adults who are not disabled or elderly do not qualify for Medicaid, even at the lowest income levels.5

Uninsured Workers Across All Industries – Variations Within The uninsured are present and working across nearly all segments of American business, even at moderate income levels. There is a significant presence of uninsured/employed at greater than 300 percent of the Federal Poverty Line (FPL), with high concentrations in the financial services, information technology, transportation, and utilities industries. These individuals are often the recipients of direct marketing targeted toward the purchasing individual for self-pay insurance plans.

The construction industry, and the leisure and hospitality services industry, have the highest percentage of uninsured/unemployed individuals below 300 percent of the poverty level. While these industries have lower employee retention rates and may have higher incidences of on-the-job injuries, this group of individuals also moves between employed and unemployed status more frequently. This group is often unable to access quality health insurance given the number of workplace-related injuries that occur in these lines of work.

Table 1: Uninsured Workers by Industry

INDUSTRY

EMPLOYED UNINSURED PERSONS: 0-FPL300

EMPLOYED UNINSURED PERSONS: FPL300+

UNEMPLOYED UNINSURED PERSONS: 0-FPL300

UNEMPLOYED UNINSURED PERSONS: FPL300+

GRAND TOTAL

Financial Activities 43% 35% 17% 6% 1,098,728

Information 41% 30% 20% 9% 456,213

Transportation and Utilities

44% 29% 22% 5% 1,340,292

Educational and Health Services

46% 28% 22% 4% 3,576,886

Professional and Business

40% 26% 28% 6% 3,149,590

Wholesale and Retail Trade

46% 24% 25% 4% 4,499,978

Manufacturing 49% 23% 24% 5% 2,264,383

Construction 41% 22% 33% 5% 3,950,430

Agriculture, Forestry

56% 18% 24% 3% 626,562

Leisure and Hospitality

50% 18% 28% 4% 4,756,268

Source: Bureau of Labor Statistics, Current Population Survey, March 2008 Supplement

UNINSURED HEALTH SERVICES UTILIZATION

Physician Office Visits Lower; Self-Reported Conditions Higher For the employed and unemployed uninsured, office visits occur infrequently. Regardless of employment status, the uninsured average 2.5 physician office visits per year – approximately half the rate of those with insurance.

However, despite a lower number of visits to physicians’ offices, the uninsured population has below-average health status and experiences complicating factors that negatively impact health. Unemployed, uninsured individuals self-report heart problems, hypertension, and lung cancer at extremely high rates, and show a high prevalence of chronic conditions. Risk factors among unemployed, uninsured patients include: obesity, poor diet, extreme stress, depression, and anxiety.

Caring for the Uninsured Amid Financial Pressures 3

As a result, it’s not surprising that the uninsured often seek other locations and venues of care, including inpatient and hospital emergency department settings.

OUTPATIENT SERVICE USE DIFFERS BY PAYER GROUP

Medicaid Usage Higher Than Uninsured Medicaid outpatient utilization across all delivery settings, including high-cost surgical procedures, invasive procedures, and deliveries, ranges from two to three times greater than that of the uninsured. Uninsured Patients Seek Lower Cost Medical Therapies, Minor Procedures, and VisitsThe uninsured population frequently accesses lower cost medical therapies, minor invasive procedures, and visits (often paid directly by the patient) at hospital outpatient or non-hospital clinic settings. In this case, the uninsured take advantage of the various charity care and community benefits provided by area hospitals that treat patients of all payer coverage categories or those without coverage at all. It’s also common for the uninsured to use the Emergency Department for non-emergent visits at a much higher rate than those with private insurance. But the use of Urgent Care centers, a lower cost-of-service site, shows below average usage rates for the uninsured population.

To have an impact on this cycle of high-cost behavior across payer groups, hospital providers and their marketing teams could benefit from developing and delivering targeted messaging regarding the various sites of services, and clarifying the key situations for use.

Further insights on how frequently the uninsured population accesses healthcare services are revealed in the chart below. For all outpatient services, the uninsured access care through a physician office at a rate 67 percent lower than the Medicaid population and 53 percent below the privately insured population.

Table 2: Outpatient Visit Use Rates

DIFFERENCE IN USE RATE FOR OUTPATIENT VISITS

Visit Type % Difference - Uninsured vs. Medicaid % Difference - Uninsured vs. Private

Emergency department visit, emergent -25 -22

Emergency department visit, urgent -4 26

Office medical visit, established patient -52 -32

Office medical visit, new patient -55 -44

Source: Thomson Reuters Outpatient Procedure Estimates, 2009

INPATIENT SERVICE USE DIFFERS BY UNINSURED PATIENTS

Postponement of Care a Factor The uninsured that are unemployed with incomes above 300 percent of the Federal Poverty Level use hospital inpatient services at a rate of nearly three-to-one, compared to other uninsured segments. The difference between the inpatient usage rates of these groups likely stems from the fact that the unemployed are more likely experiencing either chronic or disabling illnesses that prevent them from working or pursuing employment.

In addition, this segment of the uninsured is the most likely to delay or postpone care for at least 12 months, creating a vicious cycle that further exacerbates chronic conditions and leads to increased inpatient visit rates.

The situation is complicated by the fact that the uninsured, and in particular this segment of the uninsured, are more likely to avoid receiving the recommended screening services to maintain health. In short, the segment that needs the most care is the one most likely to use the costliest form of care delivery (inpatient services) rather than accessing other, less-costly sites of services capable of managing conditions.

4 Caring for the Uninsured Amid Financial Pressures

Chart 1: Physician Office vs. Inpatient Encounters

USING MARKETING TO INFLUENCE BEHAVIOR OF THE UNINSURED

A hospital’s marketing programs and targeted messages can be an effective means of directing the various uninsured segments to appropriate and cost-effective settings of care. In fact, well-executed marketing and communications campaigns can positively impact the overall profitability of the entire healthcare organization.

However, there are significant differences in preferred communication channels and messages to reach the targeted uninsured audience. In comparing the uninsured with the insured population, the uninsured segment, on average, has less information at hand when selecting a hospital. This information disparity suggests that concerted efforts to direct and channel care for the uninsured to specific services or sites must be precisely designed for the intended audience.

A look at distinct marketing messaging opportunities, patient segmentation and clustering techniques, and marketing vehicles will help illustrate how these unique groups can be best reached.

For example, the uninsured audience with incomes under 300 percent of the Federal Poverty Level, without differentiation to employment status6, is more likely to respond to traditional methods of communication about pursuit of services (e.g., radio, direct mail) than to Internet campaigns or information from employers.

Chart 2: Preferred Communication Channel Compared to the Average

60

50

40

30

20

10

0Physician Visits Inpatient Discharges Inpatient Nights

n Employed UninsuredPersons: 0-FPL300

n Employed UninsuredPersons: FPL300+

n Unemployed UninsuredPersons: 0-FPL300

n Unemployed UninsuredPersons: FPL300+

Enco

unte

rs

-18% -12% -6% 0 6% 12% 18%Percent Difference from Average

n Less Than $50k

n Greater Than $50k

Preferred Info Channel: Word of Mouth

Preferred Info Channel: Employer

Preferred Info Channel: Physician Office

Preferred Info Channel: Internet

Preferred Info Channel: Phone

Preferred Info Channel: Direct Mail

Preferred Info Channel: Newspaper

Preferred Info Channel: Radio

Preferred Info Channel: TV

Heard/Saw Healthcare Advertising

Use Internet For Health Info Lookup

Have Internet Access

Source: Thomson Reuters PULSE™ Healthcare Survey, 2009

Source: Bureau of Labor Statistics, Current Population Survey, March 2008 Supplement

Caring for the Uninsured Amid Financial Pressures 5

While hospitals have shifted their budget allocations to create a host of scalable, efficient, online health resources (e.g., hospital Web sites, health content) that serve as patient education materials, they may miss the targeted audiences that need these resources most. A traditional target audience analysis, based on the HouseholdView® segmentation system, provides a window into the need to craft specific messages for the uninsured market.

The chart below demonstrates that within the uninsured population, there are additional differences driven by demographic details, such as age, that may be leveraged for marketing success and cost containment.

Chart 3: Likelihood to Postpone Care

Messaging to Uninsured Greatest/Silent Generation – Get the Doctors on BoardThe Greatest/Silent Generation segment of the uninsured population, is more likely than their younger counterparts to have a primary care physician (PCP). And despite being concerned about the cost of medical services, they are more likely to seek care.

In the Thomson Reuters PULSE™ Healthcare Survey, the age 55+ generations reveal strong physician alignment and consider “Physician Referral” and “Physician Affiliation” as the most important drivers in selecting a hospital for care. Correspondingly, strengthening physician relationships, rather than increasing direct-to-consumer outreach, may ultimately be more advantageous in influencing individuals’ hospital selection process. Stronger physician relationships can foster paths of communication, with the intent of shifting use of healthcare services to the appropriate settings and thereby improving care management. The behavior of the over-55 uninsured population is consistent across the segment and can be messaged accordingly.

Messaging to Uninsured Baby Boomers and Gen Xers – Use Direct Mail or Phone CampaignsCrafting effective messaging for the under-55 populations is a more difficult task, even for those with significant health issues, including younger uninsured segments that are at risk for hypertension, depression, and diabetes. As the chart Likelihood to Postpone Care indicates, these individuals are less apt to have a PCP and therefore are unable to be directed by their physician to appropriate sites of care. Even within the under-55 uninsured population, the Baby Boomer and Gen Xer groups prove to be two distinct populations:

• Those who would act on healthcare advertising, but do not often see it (These segments make up the majority of the uninsured population.)

• Those who are aware of healthcare advertising, but would not act on it

HEALTHCARE ATTITUDES OF FOUR GENERATIONS7

Greatest/Silent Generation (born before 1942)

Baby Boomers (born 1943–1960)

Generation X (born 1961–1981)

Millennials (adults born since 1982)

29. No Frill

s

20.0%

15.0%

10.0%

5.0%

0.0%

-5.0%

-10.0%

-15.0%

-20.0%

-25.0%

-30.0%

55. Restf

ul Retir

ement

54. Month

ly Check

s

47. Golden G

irl

46. Playin

g Bingo

38. Outle

t Shoppers

33. Sim

ple Living

17. Flyi

ng Solo

37. Penny S

avers

n Postponed Care: 1 year

n Have PCP

Perc

ent D

iffer

ence

from

Ave

rage

Over-55 Segments Under-55 Segments

Source: Thomson Reuters PULSE™ Healthcare Survey, 2009

6 Caring for the Uninsured Amid Financial Pressures

Focusing on the former, those who would act on healthcare advertising, helps marketers to connect with a willing and receptive population. The dilemma comes in deciding which media and messages are most important and effective. The goal in developing a strategy that best suits this audience is to identify the most appropriate media to reach them, avenues that will draw upon their penchant to respond positively to any form of healthcare advertising.

The two strongest media formats for this population are standard direct mail and telemarketing. Of these two mediums, direct mail is usually the most cost-effective communication channel to connect with the uninsured, under-55 population. In order to impact site of service selection, the goal of these mailings should be to direct individuals to a primary care physician and encourage them to pursue necessary care. Another tactic that has been effective with this audience is to develop a health lecture on a topic relevant to their lives. Since many uninsured individuals in this segment struggle with chronic stress and anxiety, health lectures on these topics are likely to resonate.

Directing this population could utilize a strategy such as:Table 3: Potential Outreach Strategy

CALL TO ACTION MEDIA HOSPITAL GOAL

Attend a health lecture Direct mail Help establish relationship with PCP

Potential Topics: Anxiety, Depression, Stress Management

Phone number provided for follow-up questions

Provide reason to see a PCP

Follow-up call after attending to make an appointment with a primary care physician (PCP)

Identify critical health conditions that require treatment and management

Source: Thomson Reuters crmView™ Marketing Solutions, 2010

Successful efforts require consistent messaging through preferred media channels to help achieve the goals of identifying the most appropriate site of service and disease management program.

STRIVING FOR BALANCE: TACTICS FOR CONSIDERATION

While everyone from Washington to your hometown critiques and debates the tactics for healthcare improvement, hospitals continue to face the critical onus of delivering uncompensated care.8 There is an immediate need to identify and achieve real solutions. Regardless of the system-wide healthcare changes that may be on the horizon, most individual hospitals and healthcare systems face faltering business models that are forcing reductions in services and staff.

This research raises plausible considerations for achieving a balance between meeting the mission of serving the uninsured, benefitting the community, and also addressing healthcare budgetary constraints while delivering a significant return to the board and other key stakeholders. Simple solutions may not exist. However, by guiding and transferring care to more appropriate care settings, healthcare providers have an opportunity to address the cost of care, while concurrently increasing quality of care, patient throughput, efficiency, and ultimately reimbursable care.

To chart the roadmap toward these achievements, consider the following tactics:

MARKETING TACTICS

Focus on Patients Who Drive the CostsA small number of patients usually drive the majority of costs. Target these patients at the right time with the right message. Then, measure the impact of your efforts through response rate analysis and reporting, and support continuous improvement based on your successes.

Mine the Customer Information to Gain Key InsightsMining, modeling, and measurement are vital steps in understanding your current and anticipated patient populations. Organizations without the internal talent or tools to achieve a comprehensive analysis can consider partnering with healthcare-focused strategic intelligence and consulting firms and/or purchasing market intelligence tools.

Caring for the Uninsured Amid Financial Pressures 7

Periodically Reevaluate Tactical PlansThe tactics provided above are recommended as ongoing efforts, in lieu of one-time, evaluation processes. Though characteristics and utilization behaviors of patients continually change, patterns emerge and measurement will provide key insights in determining the effectiveness of the aforementioned tactics.

These marketing tactics can help your organization gain a greater understanding of your audience, the best way to reach them, and how their behavior changes over time. The frontline tactics below offer additional suggestions for providers to consider.

FRONTLINE TACTICS

Partner With Physicians for Continued Patient Education and DirectionEnsure information is shared with patients on appropriate care settings. For example, emergency department (ED) physicians may be able to share literature on other facility resources, including primary physicians, urgent care locations, and clinics.

Review Increased Collection Efforts (at the Time of Service)Increased collection efforts may discourage the uninsured from seeking care at expensive sites of service when less expensive sites provide equally appropriate care. Yet it is important to study both the short-term and longer-term effects of such an effort. While the target audience may seek care at your ED much less frequently, a patient’s disease or condition may worsen, and require acute inpatient services.9

Examine Success StoriesIdentifying organizations that have successfully addressed the right care at the right site helps generate ideas on what to do and who to leverage for support.

CONCLUSION

The challenges the medical community faces in meeting the needs of the uninsured while also remaining fiscally responsible to their own organizations are great. Although the landscape of healthcare politics remains in flux and is likely to continue so for the foreseeable future, healthcare organizations can take a number of practical steps to alleviate some of their most vexing financial challenges while improving their ability to care for the uninsured.

Table 4: HouseholdView® Segments

SEGMENT NAME AGE MARITAL STATUS GENERATION

55. Restful Retirement 75+ Married/Married with Kids Greatest/Silent

54. Monthly Checks 75+ Married/Married with Kids Greatest/Silent

47. Golden Girl 65+ Single Female/Single Female with Kids Greatest/Silent

46. Playing Bingo 65+ Single Female/Single Female with Kids Greatest/Silent

38. Outlet Shoppers 55-64 Single Female/Single Female with Kids Boomers

37. Penny Savers 55-64 Single Female/Single Female with Kids Boomers

29. No Frills 45-54 Married with Kids Boomers

33. Simple Living 45-54 Married Boomers

17. Flying Solo 35-54 Single Female Gen X/Boomer

Source: Thomson Reuters HouseholdView®

Oakwood Annapolis Hospital, part of the Oakwood Healthcare System in Wayne, Michigan, receives over 70 percent of its admitted patients from the emergency department (ED). The facility identified patterns of its ED “frequent fliers” through the use of Thomson Reuters crmView™ Marketing Solutions and employed direct mail to generate awareness within their target audiences.

They stressed the importance of seeing a primary care physician for non-life threatening conditions and shared information regarding federally qualified care centers. Among their achievements, cost of care decreased by $35 per ED visit; improper utilization declined by 72 percent; physician referrals for patients to more appropriate health centers increased by 12 percent; and the ordering and prescribing of narcotics in the ED declined by 10 percent. 10

8 Caring for the Uninsured Amid Financial Pressures

APPENDIX

THOMSON REUTERS PULSE HEALTHCARE SURVEY Thomson Reuters delivers unique insights into consumer healthcare behavior and attitudes with the proprietary PULSE™ Healthcare Survey – the largest ongoing, privately funded telephone healthcare survey in the United States. Through the PULSE Healthcare Survey, Thomson Reuters has compiled more than 100,000 household interviews annually since 1988. The survey is conducted by telephone throughout the entire year to account for seasonality. Each year, Thomson Reuters clients help to determine the PULSE Healthcare Survey topics, ensuring the questions asked reflect the most important industry topics. The questions are both behavioral and attitudinal in nature and are modeled to reflect the larger population. The PULSE Healthcare Survey is unique in that it ties results to two proven lifestyle segmentation systems: PRIZM® by Nielsen and HouseholdView®, a Thomson Reuters methodology. The use of lifestyle segmentation gives healthcare clients better insights into who is using which services and where similar households are located within their markets.

HOUSEHOLDVIEWHouseholdView® is a dynamic, proprietary segmentation system for the next generation of healthcare consumer insights. The 56 segments paint a comprehensive picture of how healthcare consumers use health services, select providers, define quality, obtain healthcare information, and respond to healthcare advertising. With a high level of sophistication for today’s complex healthcare market place, each of the customer segments within HouseholdView is a unique combination of the variables determined to be the most predictive of consumer healthcare behavior. HouseholdView segments align with the strategic planning and marketing challenges that face the healthcare industry today.

THOMSON REUTERS OUTPATIENT PROCEDURE ESTIMATESThomson Reuters Outpatient Procedure Estimates predicts the total annual volume of ambulatory procedures performed by ZIP code, age group, sex, site of service, and payer for every market in the United States. Procedures are defined and reported by 591 categories of CPT® and HCPCS codes, which are further grouped into clinical service lines as well as broad technical groups. To construct population-based use rates for all payers and all ambulatory care settings, Thomson Reuters uses proprietary and public claims, as well as Federal surveys. The rates are adjusted to reflect local utilization patterns and are then applied to demographic and insurance coverage projections by ZIP code to estimate outpatient utilization for 2009 and 2014.

HEALTHCARE ATTITUDES OF FOUR GENERATIONS7

GREATEST/SILENT GENERATION (BORN BEFORE 1942): Attitude toward gathering healthcare information: Physician Directs Me

• Rely on personal doctors, defer to physicians’ preferences

• Rigid definitions of good service: the customer is always right

• Consider only physicians and nurses as health professionals

BABY BOOMERS (BORN 1943–1960):Attitude toward gathering healthcare information: Engage Me

• Prefer individual engagement in healthcare

• Seek counsel from and bring information to the physician, and then research physician recommendations

• Consider only physicians and nurses as health professionals

• Often involved in decision-making for their aging parents, while also informing the health needs of their own children

GENERATION X (BORN 1961–1981):Attitude toward gathering healthcare information: Educate Me

• Desire to be educated and involved

• Relatively healthy compared to older generations

• Curious and actively seek information

• Assume physicians and staff are knowledgeable

• Strong interest in amenities

• Likely to switch physicians and hospitals based on recent experience

• More in common with the Millennial adults than with the Boomers

• Definition of health professionals is broad and includes nurse practitioners, physician assistants, insurance companies, and pharmacies

MILLENNIALS (ADULTS BORN SINCE 1982): Attitude toward gathering healthcare information: Connect with Me

• Access healthcare system through primary care providers (PCP), urgent care centers, and Ob/Gyns with a higher likelihood to use Ob/Gyns as PCPs

• Relatively low utilization of inpatient and outpatient services

• When using inpatient services, most come through maternity and emergency departments

• Enjoy and use technology

• Maintain positive, personal relationship with physician

• Seek health information from multiple sources

• More likely to switch providers if confidence in care lost based on recent experience

Caring for the Uninsured Amid Financial Pressures 9

REFERENCES

1 DeNavas-Walt, Carmen, Bernadette D. Proctor, Jessica C. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2008.

2 2009 Thomson Reuters, Insurance Coverage Estimates.

3 Abelson, Reed. Bills Stalled, Hospitals Fear Rising Unpaid Care, February 8, 2010.(http://www.nytimes.com/2010/02/09/health/policy/09hospital.html)

4 (http://www.ache.org/Pubs/Releases/2010/TopIssues_2010.pdf) Retrieved on March 2, 2010.

5 (http://www.cms.hhs.gov/MedicaidEligibility/) Retrieved on March 2, 2010.

6 For the purposes of the following analysis, Thomson Reuters is comparing and contrasting the behaviors of the below $50,000 and above $50,000 income households. The $50,000 line is close, but not exactly comparable to 300 percent of the Federal Poverty Line for a family of three in the contiguous 48 states. As such, we are using household income for approximating behavior of the uninsured population 300 percent FPL compared to the above $50,000 household population as an approximation for the insured segment.

7 Matching the Market: Using Generational Segments to Attract and Retain Consumers.Thomson Reuters, 2009. pgs. 2-3.

8 Guggenheim, Ricardo, MD. Uncompensated Care is a $31 Billion Problem Waiting to be Solved. HealthLeaders News. September 26, 2008.

9 Ibid, Guggenheim.

10 Patient Marketing Addresses E.D. Over-Utilization and Lowers Cost of Care. Thomson Reuters, 2009.

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