Health care for the Health care for the uninsured in St. uninsured in St. Joseph’s CountyJoseph’s CountyEcon 30500 – Economics of Econ 30500 – Economics of

PovertyPovertyProfessor WarlickProfessor Warlick

Claire Anderberg, Jaime Dennig, George Claire Anderberg, Jaime Dennig, George Fisher, Eileen Offer, Oscar Padilla, Fisher, Eileen Offer, Oscar Padilla,

Sharon ZhuSharon Zhu

ObjectivesObjectives

How do Indiana State programs help How do Indiana State programs help alleviate financial stresses?alleviate financial stresses?

Economic burden to Memorial Economic burden to Memorial HospitalHospital

How are hospitals reaching out to How are hospitals reaching out to the community?the community?

Health care for extreme povertyHealth care for extreme poverty Health care on campusHealth care on campus

StatisticsStatistics Non-elderly Americans (65 and under) w/o Non-elderly Americans (65 and under) w/o health insurance increased 10% from 2000-health insurance increased 10% from 2000-2002 to over 44 million (17% of population)2002 to over 44 million (17% of population)

Over 49,500 uninsured in St. Joseph CountyOver 49,500 uninsured in St. Joseph County Increases in uninsured have been linked Increases in uninsured have been linked to employers dropping health care to employers dropping health care coverage and increasing costs of health coverage and increasing costs of health care coveragecare coverage

The uninsured do not come from one social, The uninsured do not come from one social, economic, or racial classeconomic, or racial class They come from all walks of life They come from all walks of life “Cover the Uninsured Week” – report by Ann Thompson athompso@co.st-joseph.in.us

Uninsured of St. Joseph County

“Only questions with more than 50 respondents are included in the county profile, as a sample less than 50 would not provide statistically stable results. Due to the relatively small size of the SJC sample (236 respondents), analysis based on age, race and sex could not be completed”.http://www.stjosephcountyindiana.com/sjchd/PDFs/St.%20Joseph%20County%20Health%20Department%20-%20Health%20Assessment.pdf

Hoosier HealthwiseHoosier Healthwise

http://www.stjosephcountyindiana.com/sjchd/PDFs/2006AnnualReport.pdf

Assistance for low income Assistance for low income familiesfamilies

CKF (CKF (Covering Kids and Families of St. Joseph Covering Kids and Families of St. Joseph

CountyCounty) helps families in the process ) helps families in the process of applying for health care aid of applying for health care aid through “Hoosier Healthwise”through “Hoosier Healthwise”

Goal of CFK is “to ensure that all Goal of CFK is “to ensure that all eligible families have access to eligible families have access to affordable healthcare”affordable healthcare”

There are many different places There are many different places around South Bend that to go for around South Bend that to go for help in enrolling for Hoosier help in enrolling for Hoosier HealthwiseHealthwise

http://www.ckfindiana.org/index.htmlhttp://www.ckfindiana.org/st_joseph/enrollment.html

Hoosier HealthwiseHoosier HealthwiseSCHIP and Medicaid of Indiana SCHIP and Medicaid of Indiana

Who’s EligibleWho’s Eligible - “children, pregnant women, and - “children, pregnant women, and low-income working families” – Must meet income low-income working families” – Must meet income requirements (150% of poverty level)requirements (150% of poverty level)

How do they receive health care?How do they receive health care? – Each family – Each family is assigned a PMP (primary medical physicians). is assigned a PMP (primary medical physicians). The program provides you with a list of The program provides you with a list of doctors to choose from in your areadoctors to choose from in your area- PMP must be picked within 30 days of - PMP must be picked within 30 days of beginning the program, and you must maintain a beginning the program, and you must maintain a PMP for 12 months unless you supply “good PMP for 12 months unless you supply “good cause” cause” - Choose a Managed Care Organization - Choose a Managed Care Organization

- You can only receive care from within - You can only receive care from within your MCOyour MCOhttp://www.in.gov/fssa/maternal/hoosier_healthwise/whoiselig.htmlhttp://www.in.gov/fssa/maternal/hoosier_healthwise/getcare.htmlInterview with David Roos (Vice President St. Joseph County Health Interview with David Roos (Vice President St. Joseph County Health Department Department droos@ckfindiana.org))

Benefits CoveredBenefits Covered - Emphasis on preventative care and check-ups- Emphasis on preventative care and check-ups- There are different packages available There are different packages available

- Ex. Package A includes – hospital care, doctor visits, Ex. Package A includes – hospital care, doctor visits, check ups, prescription drugs, lab services, substance check ups, prescription drugs, lab services, substance abuse services, mental health care, dental care, vision abuse services, mental health care, dental care, vision care, transportation, chiropractors, etc. at NO COST care, transportation, chiropractors, etc. at NO COST

- Package C offers the same services but with co-payments Package C offers the same services but with co-payments for prescription drugs and limited other services for prescription drugs and limited other services (151%-200% of the poverty level – not the poorest)(151%-200% of the poverty level – not the poorest)

All payment goes directly to the health care All payment goes directly to the health care providers and not to the families enrolledproviders and not to the families enrolled

-Pay premiums with SCHIP but not with Medicaid-Pay premiums with SCHIP but not with Medicaid

http://www.in.gov/fssa/maternal/hoosier_healthwise/benefits.htmInterview with David Roos (Vice President St. Joseph County Health Interview with David Roos (Vice President St. Joseph County Health Department droos@ckfindiana.org)Department droos@ckfindiana.org)

l

In case of an In case of an emergency…emergency…

Participants in the Hoosier Healthwise Participants in the Hoosier Healthwise system are told to contact their PMP system are told to contact their PMP firstfirst

If the doctor is not in but can speak If the doctor is not in but can speak with the patient, the doctor will with the patient, the doctor will further direct themfurther direct them

In the event of an immediate emergency In the event of an immediate emergency they must go to the hospital and contact they must go to the hospital and contact their PMP from the hospitaltheir PMP from the hospital

(the use of the PMP is to hopefully prevent emergencies by (the use of the PMP is to hopefully prevent emergencies by using preventative care)using preventative care)

http://www.in.gov/fssa/maternal/hoosier_healthwise/benefits.html

Memorial HospitalMemorial Hospital

Activity (1/1/2005–1/1/2006)Activity (1/1/2005–1/1/2006) Admissions:Admissions:

18,15818,158 Inpatient surgeries:Inpatient surgeries:

4,9124,912 Outpatient visits:Outpatient visits:

157,043157,043 Outpatient surgeries:Outpatient surgeries:

8,7208,720 Emergency room visits:Emergency room visits:

48,52748,527 Births:Births:

3,2513,251 Number of beds:Number of beds:

325325 http://www.usnews.com/usnews/health/hospitals/directory/http://www.usnews.com/usnews/health/hospitals/directory/

numbers_6421290.htmnumbers_6421290.htm

Top 100 Hospital In U.S. Top 100 Hospital In U.S. in 2005in 2005

MethodsMethods Scoring hospitals on a set of weighted performance Scoring hospitals on a set of weighted performance measures centered on clinical excellence, operating measures centered on clinical excellence, operating efficiency and financial health, and responsiveness to efficiency and financial health, and responsiveness to the community: the community:

Risk-adjusted mortality index Risk-adjusted mortality index Risk-adjusted complications index Risk-adjusted complications index Risk-adjusted patient safety index Risk-adjusted patient safety index Core Measures Score Core Measures Score Severity-adjusted average length of stay Severity-adjusted average length of stay Expense per adjusted discharge, case mix- and wage-Expense per adjusted discharge, case mix- and wage-adjusted adjusted

Profitability (operating profit margin) Profitability (operating profit margin) Cash to total debt ratio Cash to total debt ratio Growth in patient volumeGrowth in patient volume

100 Top Hospitals: National Benchmarks for Success —100 Top Hospitals: National Benchmarks for Success — 20052005 http://www.100tophospitals.com/default.aspxhttp://www.100tophospitals.com/default.aspx

Allocation of Dollars and Persons Allocation of Dollars and Persons Served under Adopted Charity Served under Adopted Charity

PolicyPolicy

Most nonprofit hospitals adopt a Most nonprofit hospitals adopt a charity benefit policy to serve charity benefit policy to serve the medically indigent. On an the medically indigent. On an annual basis, the hospital will annual basis, the hospital will confirm the eligibility and set confirm the eligibility and set

aside dollars to ensure low-income aside dollars to ensure low-income persons can be offered needed persons can be offered needed

inpatient and outpatient hospital inpatient and outpatient hospital services.services.

Allocation of Dollars and Persons Allocation of Dollars and Persons Served under Adopted Charity Served under Adopted Charity

PolicyPolicy

20012001 20022002 20032003

Persons Persons served in served in the last 12 the last 12 monthsmonths

2,3212,321 2,1812,181 2,7992,799

Charity Charity Care Care Allocation Allocation

$1,406,9$1,406,97777

$1,477,1$1,477,12222

$1,939,2$1,939,26666

http://www.in.gov/isdh/regsvcs/acc/fiscal03/005053.pdf

Unreimbursed Costs of Charity Unreimbursed Costs of Charity Care, GovernmentCare, Government

Funded Programs, and Community Funded Programs, and Community BenefitsBenefits

Based on uniform definitions of Based on uniform definitions of costs, each nonprofit hospital costs, each nonprofit hospital

must identify the costs of must identify the costs of serving its community that are serving its community that are not reimbursed by government not reimbursed by government and other third party payers.and other third party payers.

Specialized Programs Specialized Programs UnreimbursedUnreimbursed

CostsCosts

•http://www.in.gov/isdh/regsvcs/acc/fiscal03/005053.pdf

Total unreimbursed costs of providing care Total unreimbursed costs of providing care to patients unable to pay, to patients to patients unable to pay, to patients

covered under government funded programs, covered under government funded programs, and for medical education, training and for medical education, training

($2,388,068) ($2,388,068)

Community Health Community Health EducationEducation

00

Community Programs and Community Programs and ServicesServices

($1,743,845) ($1,743,845)

Other Unreimbursed Other Unreimbursed CostsCosts

($1,196,700) ($1,196,700)

Total Costs of Total Costs of Providing Community Providing Community

BenefitsBenefits

($5,328,613) ($5,328,613)

Uncompensated CareUncompensated Care20032003 20042004 20052005

Net Net Patient Patient service service revenue revenue

$313,328$313,328 $335,189$335,189 $364,300$364,300

ProvisionProvisions for bad s for bad debtdebt

16,43616,436 18,34118,341 23,71623,716

Percent Percent of totalof total

5.24%5.24% 5.47%5.47% 6.51%6.51%

http://www.qualityoflife.org/aboutus/publications.cfm

Options for Uninsured- Options for Uninsured- UnderinsuredUnderinsured

Payment plans if possible.Payment plans if possible. Collect as much as possible if Collect as much as possible if continued procedures are needed. continued procedures are needed.

Discounts on procedures.Discounts on procedures. Collect as much as possible all Collect as much as possible all things considered. things considered.

Refer to various help agencies.Refer to various help agencies. Religious groups, clinics, etc. Religious groups, clinics, etc.

St. Joseph’s Regional St. Joseph’s Regional Medical CenterMedical Center

Established in 1882 by the Sisters Established in 1882 by the Sisters of Holy Crossof Holy Cross

Center’s Mission: To serve Center’s Mission: To serve together in Trinity Health in the together in Trinity Health in the spirit of the Gospel to heal body, spirit of the Gospel to heal body, mind and spirit to improve the mind and spirit to improve the health of our communities, and to health of our communities, and to steward the resources entrusted to steward the resources entrusted to us.us.

Outreach ProgramsOutreach Programs

Michelle Peters: Director of Michelle Peters: Director of Outreach ServicesOutreach Services

Outreach Programs offer primary and Outreach Programs offer primary and educational services to community educational services to community members in St. Joseph and Marshall members in St. Joseph and Marshall Counties. Counties.

Established to serve the un-insured, Established to serve the un-insured, under-insured and Medicaid under-insured and Medicaid populations in both counties. populations in both counties.

St. Joseph’s CountySt. Joseph’s County

Outreach Outreach Clinics/ServicesClinics/Services

Sister Maura Brannick Health Sister Maura Brannick Health Center – South BendCenter – South Bend

Healthy Family Center – Healthy Family Center – MishawakaMishawaka

Family Medicine Center – South Family Medicine Center – South BendBend

St. Joseph’s Urgent Care CenterSt. Joseph’s Urgent Care Center Mobile Medical UnitMobile Medical Unit

Mobile Medical UnitMobile Medical Unit

Established in December 2005Established in December 2005 40 Foot Long “Clinic on Wheels”40 Foot Long “Clinic on Wheels” ““We welcome any opportunity to help We welcome any opportunity to help those without healthcare simply those without healthcare simply because they have no way of coming to because they have no way of coming to us. I am proud to say that with the us. I am proud to say that with the Mobile Medical Unit, we are coming to Mobile Medical Unit, we are coming to them.” Nancy Hellyer, St. Joseph’s them.” Nancy Hellyer, St. Joseph’s Regional Medical Center Chief Regional Medical Center Chief Executive Officer. Executive Officer.

Mobile Medical UnitMobile Medical Unit

Mobile Medical UnitMobile Medical Unit

Staffed by a Family Nurse Staffed by a Family Nurse Practitioner, mammographer, and Practitioner, mammographer, and intake coordinator. intake coordinator.

Services Provided: Mammograms, Services Provided: Mammograms, physicals, women’s health, physicals, women’s health, health screenings, minor health screenings, minor illness, health maintenanceillness, health maintenance

Mobile Medical UnitMobile Medical Unit

Areas the MMU Serves:Areas the MMU Serves: West Side of South Bend (2 Days)West Side of South Bend (2 Days) Mishawaka (1 Day)Mishawaka (1 Day) Plymouth (2 Days)Plymouth (2 Days) Amish Country (Every 3Amish Country (Every 3rdrd Friday) Friday)

Schedule on the website shows where Schedule on the website shows where the MMU will be every day of the the MMU will be every day of the month:month:

http://sjmed.com/PDF/http://sjmed.com/PDF/MMU_2007_April_Schedule.pdfMMU_2007_April_Schedule.pdf

Problems with Outreach Problems with Outreach ServicesServices

Struggle to spread awareness of Struggle to spread awareness of these programs. these programs.

Trying to get more recognition Trying to get more recognition out there so that the community out there so that the community knows that St. Joe is doing all knows that St. Joe is doing all of this. of this.

Patients are missing their Patients are missing their preventative care because they preventative care because they are unaware of these programsare unaware of these programs

Working TogetherWorking Together

St. Joseph’s and Memorial have St. Joseph’s and Memorial have begun collaborating their begun collaborating their efforts through advertisements efforts through advertisements and fundingand funding

Local Businesses and Media are Local Businesses and Media are working to spread the word as working to spread the word as well well

What happens to a person who is unable to purchase What happens to a person who is unable to purchase medical insurance and is ineligible for Medicare or medical insurance and is ineligible for Medicare or

Medicaid?Medicaid?

The Sister Maura Brannick Health CenterChapin Street, South Bend

•Sponsored by St. Joseph Regional Medical Center

•60 Volunteer Doctors from the South Bend/Mishawaka Area

•Multilingual Staff including Social Workers and Financial Counselors

•Onsite Dental Clinic

•$5 Co-pay covering all services and medication

To become a patient:

•Application involving financial screening

•Necessary criteria:

-Ineligible for Medicaid or Medicare-Unable to obtain health insurance -Must be 150% below the government established poverty line.-Can not be a patient at another clinic

•All patients are assigned a primary care doctor.

Services at the Health Center

Preventive healthcare. •Treatment for acute injuries or illness. •Chronic disease management. •Screenings. •Free immunizations for those who qualify. •Head Start and school physicals. •Prenatal and OB care. •Drug Assistance Program w/pharmacist available. •Nutritional and diabetic counseling. •Dental clinic on site for general preventive and restorative dental care.

Any services that are necessary but not available because of a lack of equipment or any other reason at the Health Center are available at St. Joseph’s. Those such as eye specialists and ear nose and throat specialists are offered for free by the doctors of the St. Joseph Medical Center.

What happens in the case of an emergency?What happens in the case of an emergency?

•Patients are directed to St. Joseph’s Hospital for emergency care.

•Hospital bill is forwarded to the Health Center. The case is reviewed and in most instances the bills are covered.

•If a patient must be admitted:-Financial Advisor helps the patient apply for HCI, a government program that will cover the cost of the stay.-If not accepted by HCI, St. Joseph’s Regional Medical Center

absorbs the cost of the stay.

Information provided in an interview with Lilia Periquet, Social Work Coordinator (4/3/07)

http://sjmed.com/svc_outreach_HC_SB.htm

~University health insurance (Megalife) is ~University health insurance (Megalife) is only mandatory for graduate and only mandatory for graduate and international students (undergraduates do international students (undergraduates do not need to provide proof of insurance, not need to provide proof of insurance, they only need to call in August to remove they only need to call in August to remove Megalife from their billing account).Megalife from their billing account).

~Students are not charged to been seen by ~Students are not charged to been seen by professionals at the health center, but professionals at the health center, but supplies, medicines, procedures, labs, and supplies, medicines, procedures, labs, and x-rays x-rays

~All charges except for lab and radiology ~All charges except for lab and radiology are billed directly to Student Accounts, are billed directly to Student Accounts, they do not file claimsthey do not file claims

~An itemized statement will be given to ~An itemized statement will be given to the student or sent through campus mail the student or sent through campus mail for them to file with their insurance if for them to file with their insurance if they are not a part of Megalife.they are not a part of Megalife.

““All Notre Dame students are All Notre Dame students are invited to use our medical invited to use our medical services regardless of having services regardless of having private, school sponsored private, school sponsored insurance, or no insurance insurance, or no insurance coverage.” Ann Elizabeth Kleva, coverage.” Ann Elizabeth Kleva, RN, MSA, Director, University RN, MSA, Director, University Health Care ServicesHealth Care Services

The services listed below are the financial The services listed below are the financial responsibilities of a patient:responsibilities of a patient:

•• Laboratory tests Laboratory tests •• X-rays X-rays •• Injections, including allergy shots Injections, including allergy shots •• Medications Medications •• Medical supplies Medical supplies •• Medical procedures Medical procedures •• Consultations with physicians outside Consultations with physicians outside

University Health Center University Health Center •• Hospitalization and / or treatment at a Hospitalization and / or treatment at a

community hospital or emergency room community hospital or emergency room

ND Health Services does not take care of payments for you

ND Health Services only ND Health Services only takes Megalife Insurancetakes Megalife Insurance

““The only insurance that we take is The only insurance that we take is the Notre Dame MegaLife Insurance, the Notre Dame MegaLife Insurance, If you have private insurance, we If you have private insurance, we will provide you with a detailed will provide you with a detailed receipt for filing with your receipt for filing with your insurance company for reimbursement insurance company for reimbursement each time you receive a each time you receive a prescription. We can also provide a prescription. We can also provide a detailed statement upon request.”detailed statement upon request.”

Options for PaymentOptions for Payment

Deferred paymentDeferred payment Payment in installmentsPayment in installments Rector funds (on a case by case Rector funds (on a case by case basis)basis)

Who is Uninsured?Who is Uninsured?

Not always what you expectNot always what you expectSmall Business ownersSmall Business ownersTransitional workersTransitional workers

Divorced individualsDivorced individuals Single working malesSingle working males Notre Dame studentsNotre Dame students

College GraduatesCollege Graduates

This is not just a problem contained by a This is not just a problem contained by a certain socioeconomic stratum, it certain socioeconomic stratum, it encompasses people from all walks of life. encompasses people from all walks of life.