January 25, 2008
i t e m s o f i n t e r e s t f r o m t h e m e d i a
USA Today – January 24, 2008
Employers put health coverage in workers' hands
By Julie Appleby
Nick Trikolas plans to drop health Critics say the change would end The idea comes as the percentage of
insurance for his employees and the long-standing, implicit social employers providing insurance
give them money to buy their own pact to provide coverage to sick and shrinks and the number of uninsured
coverage. He says doing so will put healthy workers alike in favor of a Americans grows. Last year, 60% of
him in the vanguard of a movement more Wild West, go-it-alone employers offered group coverage,
by employers searching for answers approach that could benefit young down from 69% in 2000. The
to rising health costs. and healthy workers but leave those number of uninsured rose to 46.6
older and sicker unable to get million, up from 44.8 million in
"This may be the future of health medical insurance. 2005.
insurance," says Trikolas, CEO of
Ilios Partners in Chicago, which That's because ending group Large companies use group
plans to switch its 100 employees coverage removes a key protection coverage as an important
from group to individual coverage in group insurance plans. Insurers recruitment and retention tool, but
this year. cannot reject members of group smaller firms struggle more with
plans for health reasons, and costs and are less likely to offer
As health insurance costs continue everyone in the group pays the same group coverage.
to rise, some employers are premium.
adopting a controversial new Proponents of individual coverage,
approach: ending group coverage In most states, insurers can reject including Paul Zane Pilzer, whose
and giving employees $50 to $200 individual applicants for health Zane Benefits firm offers services
or so a month to help them buy their reasons and can charge widely that help employers make the
own. varying premiums based on the switch, say most workers will be
applicant's age, health history and able to buy coverage on their own.
The shift is touted as a lower-cost other factors. Only in a handful of
way for employers to offer workers states, such as New York, The healthiest, Pilzer says, will get
some kind of health coverage, while Massachusetts and New Jersey, coverage for less than they pay now.
making smaller and more must insurers sell coverage to Monthly premiums can be less than
predictable financial contributions everyone, regardless of their health. $100 for some younger, healthier
toward that coverage. Like other people but several times that for
companies considering the switch, "What scares me is it's tempting for others.
Ilios will pay a portion of an employer who may have one or
employees' medical costs into tax- two sick employees to say, 'You're "The healthy employees don't have
free accounts that workers can tap. not my problem, try to get coverage to pay for sick employees," says
It also will provide a link to an from the state,' " says John Pilzer, a software entrepreneur and
independent website where workers Hickman, an Atlanta attorney who author. He says employers can save
can compare price quotes from a advises businesses on their benefit money because they contribute a set
variety of insurers. plans. "It could leave a lot of people amount per employee — often far
without coverage." He says the new less than they pay for group
If broadly adopted, the new model model could work if Congress coverage.
would represent a fundamental shift passes national rules requiring
in health coverage in the USA. Most insurers to take everyone, regardless Sara Rosenbaum, a law professor at
people with health insurance are in of his or her health. George Washington University
group plans offered by their School of Public Health, says
employers. offering money toward individual
policies "may be somewhat helpful access plans that would make "Those scenarios present widely
for workers in businesses that have insurance available to people with varying health care needs.
never been able to offer insurance serious medical conditions. Something like this gives us and our
coverage," but it is a "radical step employees a little more flexibility."
backward" for those who decide to The group said insurers should
cancel group policies. provide coverage to those who What happens if some can't get
aren't sick enough to qualify for the coverage?
She says proponents may mislead state plans. And, it said, insurers
employers into thinking individual should not cancel policies solely "Currently, we don't have any issues
and group coverage are the same, because applicants provided like that at all," Davis says. "We'll
when there are often striking incomplete medical information, so have to address that if it occurs. As
differences. long as any omissions were we bring new people on, we'll get a
unintentional. better sense of how it will work. We
"Many employees may find may jump into it and say it's the best
themselves shut out of the Because individual policies are tied thing we've ever seen, but we will
individual market," Rosenbaum to each applicant's medical history, evaluate that as we go."
says, "and even if they can get in, insurers can limit or exclude certain
the coverage is dramatically less conditions. For example, an insurer Canopy's Kashyap says most people
than what they can get in group may offer a person with hay fever a can get insurance. Those who
products." policy that excludes coverage of any cannot, he says, should be looked
upper respiratory condition. upon like bad drivers, who have to
Reimbursement accounts "Something as simple as hay fever pay more for auto insurance. He
may mean you are not covered if expects health insurers, possibly
Though no one tracks the number of you get pneumonia," Rosenbaum with the help of government or
employers who send workers out on says. employers, ultimately will develop
their own, it is only a fraction of the coverage for higher-risk people.
total number who offer health Bosses offer assurances
insurance. Pilzer says he has more "There are some people in the
than 100 clients; his company sets Like some other employers minority who will be adversely
up and manages tax-free medical contacted, Trikolas says he doesn't impacted, but the system in general
reimbursement accounts for the expect his employees, who are is designed for the majority,"
clients' employees. He sold his first mainly in their 20s and 30s, will Kashyap says.
company to Steve Case's Revolution have a problem qualifying for
Health, which offers the service individual insurance. If any do, he Bret Berneche, chief executive
through Sam's Club. says the company will help them officer of Cardinal Homes in
find coverage. Wylliesburg, Va., used Zane
"This is a multibillion (dollar) benefits to help get health insurance
opportunity," says Vik Kashyap, "I can guarantee you that no for himself and his 112 employees.
founder of Canopy Financial. Last company would leave those people
month, Canopy began a similar high and dry," Trikolas says. In August, Berneche told his
reimbursement service and steers employees that their group health
workers to insurers who sell David Davis, executive vice insurance would end that month.
individual health policies. president of Sweet and Sassy
Franchising, which franchises salon Between premium increases and
The insurance industry has and spa services aimed at girls ages mounting state and federal rules,
acknowledged the difficulties some 5 to 12, says his company plans to offering insurance was costing the
people face in getting coverage. In introduce the Canopy program this company too much — $846,000 a
2007, officials in California and year and end its group coverage. year.
Connecticut fined several insurers Davis, whose company is based in
for canceling individual policies Southlake, Texas, says the main "It was certainly a blow," Berneche
after patients racked up large goal is to give workers more says. "The choice was having the
medical bills. options. health plan we had or going out of
A proposal released last month by "We have employees who have
America's Health Insurance Plans, families with young kids, some After he canceled the group plan, he
the industry's lobbying arm, called have older kids and some heard about Pilzer's program and
on states to create guaranteed- employees are single," Davis says. signed on. Cardinal puts $100 to
$200 a month into each employee's kicks in each year. The cost of must cover and how applicants can
health reimbursement account. prescriptions adds $200 to his be scrutinized.
monthly costs. He says his total
Even if Berneche carries out his costs are at least $1,000 a month The Department of Labor and the
plan to nearly double the size of his more than under his group policy. Treasury Department are
company, he still expects to save at Still, he says, "I am happier today considering whether federal rules
least $360,000 this year with the with this program … than I was that apply to group insurance also
new program. Zane Benefits before." apply in programs such as Zane's, in
handles the accounts and reimburses which an employer makes a
employees out of their individual Berneche says he can talk more contribution but doesn't offer a
accounts for medical expenses. openly with company employees group plan, a statement from the
about health issues. He does not feel Department of Labor says.
Many employees were able to buy as constrained by federal and state
individual policies for less than the rules and has more control over For instance, says Mila Kofman, a
monthly amount put in by Cardinal, health costs. health policy professor at
Berneche says. The money also can Georgetown University, "what
be used for eyeglasses, dental care "I had to worry about that every happens if an employee can't buy an
and other medical expenses. year," Berneche says. "We're no individual policy" but others in the
longer in the health care business." company can? "Then you have a
"I don't know if everyone bought potential violation of the non-
insurance. But there are various Legal issues discrimination provisions" in
ways to get some kind of health federal law.
coverage, through state programs Legal questions remain about
and self-pay programs and whether to classify this hybrid Daryl Richard, a spokesman for
catastrophic insurance programs," coverage as group or individual UnitedHealth, says, "A number of
he says. "Everyone here has a health policies. Consumer protections are groups, including brokers, insurers
reimbursement arrangement that not as strong in individual plans and government agencies, are
they can spend the way that best because states allow them more seeking to fully understand the
suits their families' needs." leeway than group plans. nuances of how individual and
employer-sponsored coverage may
Though some pay less for premiums Berneche had to certify on his best work together in compliance
than they did under the company- individual insurance application that with both state and federal
subsidized group plan, others, his company was not reimbursing regulations."
including Berneche, pay more. him. Yet the contributions his
company provides are at least a The main goal, he says, "is finding
He and his wife, Dorothy, both in partial reimbursement. ways to make health coverage
their 40s, pay about $900 a month available to as many Americans as
in premiums, and each has annual In Virginia and many other states, possible."
deductibles of $5,000, meaning policies sold as individual plans
that's what they pay before coverage have different rules on what they
HealthLeaders Media – January 23, 2008
Survey compares rural and urban/suburban physicians
By Ben Cole
The nation's current doctor shortage perceptions of practicing medicine "Most of the physicians were pretty
is most acute in rural America, and in rural America versus practicing pleased with how rural medical
an aging U.S. population combined in areas with populations of 50,000 practices worked for them," says
with an increased interest in or more. Tim Skinner, executive director of
"quality of life" issues will likely the National Rural Recruitment and
make the situation worse before it The survey found that there may be Retention Network in La Crosse,
gets better, according to fewer differences, at least clinically, WI. "There are a lot of plusses to
representatives from between practicing in rural areas the practice of rural medicine--and
LocumTenens.com. The physician and urban ones than one might actually many of the rural practices
recruitment firm recently surveyed think. have the same equipment, the same
doctors to better understand their technology as suburban and urban
practices do. Much of it is quite up- MD, a surgeon who practices in Perhaps the most telling finding
to-date." Ogdensburg, NY. "Rural settings from the LocumTenens.com survey
can be more attractive to physicians was why physicians who had not
Of those surveyed who have who are interested in control of practiced in a rural setting had never
practiced in rural areas, for lifestyle: no traffic, little pollution, done so. The three top answers were
example, 31 percent said they think first-name basis for many never found the right opportunity
profitability among rural practices conversations, really getting to there (26 percent), never been
was about the same when compared know the people in a community. offered a position there (23
with their urban counterparts, and For the physician who likes the percent), and never considered it
23 percent even said rural practices anonymity of a big city, rural life (19 percent). Only 4 percent
were more profitable. Only 18 would probably not be desirable; answered they never practiced in a
percent said practicing in a rural however, for someone who enjoys rural setting because they did not
setting was more frustrating than solitude and space, rural life can be want to work there.
working in an urban facility, and 45 attractive."
percent said urban and rural settings "As a former physician recruiter, I
were "about the same" in regard to Because of this, Skinner says rural thought it was stunning to see that
frustration. facilities need to look at a potential only 4 percent of responding
physician's background and physicians with no rural practice
There are, however, stark interests when trying to recruit. "A experience said they didn't want to
differences between the two-- physician who is going to go to a practice medicine in rural America,"
especially when it comes to small, rural community in says LocumTenens.com Senior
connecting with patients. Of those Wisconsin is probably going to be Vice President Pamela McKemie.
surveyed who had practiced in rural very interested in hunting and "What we'd like rural hospital
areas, 52 percent said they think fishing, as opposed to the physician executives to 'get' from our survey
doctors have a closer relationships who is going to go to a desert area results is that physicians from all
with patients in a rural practice, in Arizona and New Mexico who types of environments are open to
compared with 3 percent that said might be more interested in cultural practicing rural medicine, but
they think doctors have closer artifacts, archeology, anthropology, you've got to approach them about
relationships with patients in an and desert life," Skinner says. "You your opportunity before they can
urban or suburban practice. have to look at those preferences." consider it."
"What's different is you have a more Smaller facilities should also take This is another example of why
personal connection," says Jim steps to show potential physicians rural facilities need to be a little
Stone, MD, who practices in that they will not be overwhelmed more cognizant of making sure the
Atlantic, IA. "Medicine has become by being the only, or one of few, invitation to practice isn't restricted
a volume-based profession, and in doctors in a community. to a small group of physicians who
an urban setting you have much less McLoughlin suggests community are born in rural areas, Skinner says.
time to spend with patients." and rural hospitals seek partnerships
with larger city or teaching hospitals "We really need to emphasize the
The survey also gauged the by becoming part of an extended connection between the community
physicians' thoughts on lifestyle telemedicine network. That way, development piece and the medical
comparisons between urban and physicians practicing in the rural staff development piece," Skinner
rural settings. Predictably, the location don't feel isolated from says. "In a small town they have to
findings were all over the map--31 colleagues, McLoughlin says. put that together because lifestyle
percent said they liked rural settings issues have a great deal to do with
more, 19 percent said they preferred "When a 'tough case' comes into the people either appreciating a smaller
urban settings, and 15 percent said hospital, the rural practitioner would community or not."
life was about the same. have access for input from a larger
department of physicians or Skinner says it is crucial that
Doctors say where one prefers to possibly even from those practicing facilities not only promote
practice is simply a matter of the at an academic center," McLoughlin satisfaction among staff working
type of person they are and the says. "Avoiding the isolation of with patients and practices in rural
lifestyle they are accustomed to. "I 'now I'm stuck with this patient that facility, but also work with the
think it really has a lot to do with I can't figure out' should be a major community as a whole to help draw
the physician's personality and also goal of any rural hospital trying to potential physicians. He suggests
the desires of the physician's recruit physicians." healthcare providers tout agencies
family," says James C. McLoughlin, and resources such as social and
human services that can potentially work with the community to attract recreational and cultural activities.'
support physician practices. physicians. If the community piece is missing,
Stipulating how close the nearest they might pass on a rural practice
college is for potentially furthering "The smaller the town, the more even if they offer the physician and
the physician's education, important the community the physician's family everything
developing a strong community- development piece is," Skinner that they need."
based Web site, and promoting says. "What they can do is they can
available leisure activities in the really step up and say, 'This is what Ben Cole is associate editor with
area are all ways providers can our schools offer, here are our HealthLeaders Online News.
Boston Globe – January 20, 2008
State health plan saves towns money
By John Laidler
Three area communities are helping Bisignani said Saugus has been increases have been in the "double
to blaze a trail for other cities and averaging 15 to 20 percent increases digits and high double digits" in
towns seeking to ease soaring in its healthcare costs the last recent years.
employee health insurance costs. several years. With its much larger
pool of subscribers - 285,000 He said preliminary estimates
Groveland, Saugus, and Winthrop compared with Saugus's 2,500 - the indicate the town will spend
are among five municipalities that insurance commission has been able $250,000 less in healthcare next
have taken advantage of a state law to limit its cost increases to 6 to 10 fiscal year than the current one, and
adopted last July that allows public percent, he said. $750,000 less than what it would
groups to join the state's employee have paid had it remained with its
healthcare system as a way to save Bisignani projects savings this fiscal current insurer.
money. year at about $300,000. Employees
will save on average $6 a week in Joel Barrera, senior project director
The five communities - the others premiums for a family plan, for the Metropolitan Area Planning
are Holbrook and Millis - along depending on what plan they Council, said the fact that only a
with four regional school districts, a choose. handful have enrolled in the system
charter school, and two regional to date is not surprising since the
planning councils, all met a first- "What it does is stabilize the current law did not pass until July 25, and
year deadline last October to enroll fiscal year's costs . . . and it communities had until Oct. 1 - later
in the Group Insurance minimizes the increases in future extended to Oct. 29 - to join.
Commission, the agency that fiscal years," said Bisignani, who
administers the state's health estimated the town will save Under the law, a municipality can
insurance plan. One other $600,000 in fiscal 2009. enroll only if the option is approved
community, Springfield, was able to by at least a 70 percent weighted
join the insurance commission in While the state plan requires some vote of a committee representing its
2006 because it was under a state higher copayments, Bisignani said employee unions following a
financial control board. most employees will save money by coalition bargaining process, where
sharing in the overall cost savings. the municipality's chief executive
With the exception of Saugus, the In Saugus, the town pays 90 percent negotiates with the multiunion
enrollments will become effective of health insurance costs. committee.
July 1. Because of its severe fiscal
crunch, state lawmakers allowed In Winthrop, Town Council "I think the real test is next Oct. 1,"
Saugus to join Jan. 1. president Thomas E. Reilly said, Barrera said, referring to the
"The financial impact of this is deadline for communities seeking to
Andrew Bisignani, Saugus town enormous for the town." join the group in fiscal 2010.
manager, said joining the insurance
group is expected to bring modest "As with most communities, we Barrera said a number of other
long-term financial relief to the have a huge problem with communities, including some in this
town, which has a $5 million budget healthcare. Ours, given the size and region, have discussed joining.
shortfall this fiscal year, about $2 claims history we have, was a
million of it caused by a deficit in particularly bad one," Reilly said, He anticipates 30 municipalities and
its self-insurance program. noting that annual healthcare other entities will attempt the union
negotiations needed to join the the town and the union were able to communities, Groveland's employee
system, and that about 10 will end reach agreement, but Bisignani said contracts do not include any
up enlisting by the deadline. it took considerable negotiation. guarantees of copay levels or the
selection of any particular
"The good thing is that this is a new "We started negotiating probably in providers.
option that communities have," he April and we finished in
said. While not the only vehicle for September," he said. "It was not He said that limited the issues on
cutting costs, he said it is a "solid easy. We had some very hard the table.
one and the right one for some bargaining and we had to give back
communities." some benefits to the unions." Labrecque said the town is pleased
by the financial relief it stands to
Dolores L. Mitchell, executive Reilly credits early and active gain from taking advantage of the
director of the Group Insurance discussions among town officials new law. Had Groveland belonged
Commission, said joining might not and union leaders for Winthrop's this year, he estimates it would have
be in the best interest of those ability to achieve an agreement. saved about $105,000 of its
communities that are already $400,000 in health insurance costs.
aggressively moving to reduce "The key to it was there was a great He said the actual savings next
health costs. "But there are some deal of cooperation and mutual fiscal year could be more significant
that would really save money, and I respect between the town manager, since the town's premium, which
think they ought to give it serious the superintendent of schools, and had been rising 12 to 15 percent a
thought. We will help in any way to the unions," he said. "As a result, year under its current insurer, could
make the transition work for them," they were able to put something have climbed as high as 18 percent
she said. together within the timeline." more.
For some communities, achieving Groveland finance director Greg "I think any law that gives us
the needed support from unions is Labrecque said the negotiations in options is a good law," Labrecque
proving a difficult or his town went relatively smoothly said.
insurmountable hurdle. In Saugus, because unlike in some larger
For the Record – January 21, 2008
By Elizabeth S. Roop
In today’s healthcare environment, estimates increases patient trust and The Push for Transparency
more patients are requesting cost satisfaction. Through its Patient Friendly Billing
estimates before selecting a Project, the HFMA has been a vocal
hospital. By automating that “There is always angst if someone advocate of greater transparency
process, facilities could gain an asks how much something costs and and overall reform of the healthcare
upper hand on the competition. you can’t provide an estimate. pricing structure through the
People in the corporate world don’t establishment of a pricing system
Heeding the call for greater understand why it’s a problem [for that does the following:
transparency in response to the rise hospitals],” says Richard L.
in high-deductible and consumer- Gundling, CMA, vice president of • is simple to administer and
driven health plans, a growing the Healthcare Financial communicate;
number of hospitals are Management Association (HFMA).
implementing or refining systems “To have a system in place to give • establishes a framework that is
and processes to support the up-front pricing goes a long way rational and defensible in relation to
increased patient demand for price toward communicating with the objective benchmarks;
estimates. patient and establishing a greater
trust in the community and with • creates accountability by
Given the number of unknowns that decision makers. If you can’t give at empowering consumers to make
can impact the final price for least a range, people think you’re price comparisons;
services provided, it can be tricky to hiding something or you’re not
achieve a suitable level of accuracy, running your operations as • allows for full coverage of
but those hospitals making the effort efficiently as you can.” financial requirements related to
have discovered that providing
providing care and other community much now. But a lot of people want by one when a patient calls. But that
benefits; and a certain idea of … their out-of- is not a streamlined process or an
pocket costs.” efficient way to handle estimates,
• provides stability and especially as transparency and
predictability in the administrative Effective Systems Required defensible pricing emerges and
process. The trick, particularly for hospitals, becomes more of a priority to
is to provide an estimate that hospitals and consumers.”
In “Reconstructing Hospital Pricing accounts for as many variables as
Systems: A Call to Action for possible and presents them in a Craneware’s answer is the Patient
Hospital Financial Leaders,” the meaningful, defensible, and Charge Estimator, a software tool
HFMA notes that a driving force comparable way. There is no that provides estimates for inpatient
behind the call for price “industry standard” for compiling and outpatient procedures based on
transparency is the rise of price information, and the process a hospital’s historical claims data,
consumerism. Higher deductibles for doing so varies from facility to chargemaster files, and negotiated
and copayments, as well as the facility. However, price information third-party contracts. The
growing popularity of consumer- should ultimately be able to information can also be filtered by
driven plans such as health savings withstand scrutiny and be easily procedural descriptions, CPT and
accounts (HSAs), are forcing compared across providers. HCPCS codes, ICD-9-CM
consumers to take on more of the procedure and diagnostic codes,
financial burden. “Getting the functions up and going diagnosis-related groups, etc.
and having a centralized pricing
This has prompted many hospitals area is all part of it. The With each estimate, a customized
to make their prices public, a marketplace is moving that way letter is created that can be sent
strategy that includes posting price anyway,” says Gundling. “But directly to the requester
and quality information on the Web. hospitals have traditionally operated electronically or by fax or mail.
Others are cooperating with state in a wholesale environment where Estimates are also saved within
hospital association initiatives to most of their customers were the Patient Charge Estimator’s
consolidate pricing information into government and large insurance database, allowing the hospital to
a single location. Even Medicare is companies, so the systems are set up analyze market trends and behaviors
publishing payment information on for that. But now, with consumers, and compare estimates with final
the most common procedures. it’s more of a retail environment. charges.
It’s a whole new paradigm.”
Legislation is also ratcheting up the A Better Way
pressure for increased transparency. Tim Weakley, product marketing University Hospital in Augusta, Ga.,
Currently, more than 30 states manager at Craneware, Inc., agrees deployed the Patient Charge
require hospitals to report pricing that the key to keeping up with the Estimator after it noticed a
information, and six have voluntary demand for transparency in an significant upswing in calls from
reporting systems in place. The evolving healthcare market is consumers facing the prospect of
American Hospital Association having the right systems in place to significant out-of-pocket costs. In
supports legislation that would efficiently develop accurate, the past, estimates were based on
require insurers to provide more defensible price estimates. The historical data compiled annually in
information on out-of-pocket problem is that many hospitals don’t a spreadsheet. When a patient called
expenses and require the Agency for realize that their existing processes with a procedure code or
Healthcare Research and Quality to are not adequate for handling the description, someone would search
conduct a study on what consumers high demand for estimates and the document for the data needed to
want to know about pricing. accountability that the growth in provide an estimate. It was a time-
consumerism may generate. consuming process that could not
The ultimate goal is to arm patients account for extraneous charges.
with enough information about cost “If you talk to [hospitals] now, most
and quality so they can open a of them do not have a process in “It’s easy to find a procedure code,
dialogue with their providers to place to do this,” Weakley says. but sometimes there are supplies,
determine the best care options. “They may think they do, whether pharmaceuticals, and other
they’re referencing handwritten procedures that go along with the
“It starts the conversation,” says notes or spreadsheets of common main procedure. If we were quoting
Gundling. “I don’t know that a lot procedures, or printing out reports based only on a procedure code, a
of people will necessarily price from the business office and lot of times those other items were
shop; I don’t see that happening manually going through them one left off,” says Brian Patterson, RN,
chargemaster coordinator in go back into the claims database can’t because patients respond
University’s revenue management and see what procedures have been differently. That’s the biggest
department. done that are like those to challenge in estimating.”
defensively set a price going
With the automated system in place, forward to make sure we are In “Reconstructing Hospital Pricing
estimates are now generated in recovering our cost. It ultimately Systems,” the HFMA agrees that
minutes and are more accurate and gets back to overall productivity the need to adjust treatment to
complete than those created with the because we are not reinventing an address unique patient needs or the
manual system. University’s current estimate that we’ve already done. If degree of clinical difficulty is a
estimating process “empowers the it’s in our system, anyone in the complicating factor when quoting
patient to prepare financially for a network can use that estimate estimates. For example, while it
procedure,” says Patterson. “It again.” may be easy to provide an estimate
speeds up our workflow because the for a mammogram, the same cannot
estimate can be done fairly quickly. Communication and Clarity be said for a more complex
It is also a satisfier because if we Despite the improvements both procedure such as a mastectomy.
have provided an estimate and the these facilities have seen as a result Providing price range estimates is
patient responds as all other patients of automating the process, there are one way to deal with these kinds of
did to the treatment or procedure still too many variables that affect discrepancies, although the best
with no additional treatment needed, the final cost of care to consider any course of action is for a hospital to
the estimate is fairly accurate and estimate binding. A significant issue “establish a frank and ongoing
shows that we are credible in what is the fragmented nature of the dialogue with its community about
we do.” healthcare payment system. For pricing systems and the steps the
example, while the hospital can provider is taking to make the
The story at Mercy Medical Center provide an estimate for its own situation better,” the report says.
in Cedar Rapids, Iowa, is similar. In charges, separate charges may also
the past, when a prospective patient be levied for care and services The HFMA also recommends that
would call for an estimate, the provided by nonaffiliated clinicians. communication initiatives
counselor would contact the Differences between estimated and surrounding pricing should focus on
appropriate department to obtain the actual charges can also crop up the following:
requested information or go to when the quote provided does not
medical records to research the include additional charges beyond • cost differences in relation to
information necessary to provide a the procedure itself. nearby facilities;
price range. According to Mercy
Medical reimbursement specialist “If you’re just quoting out the • charity care policies and discounts
Kara Arnold-Arons, the biggest procedure and not the room charges for the uninsured and underinsured;
problems with that largely manual and other procedures, it may not be
system were time, accuracy, and an accurate representation of the • how healthcare financing works;
standardization. With demand for full, true charges,” says Arnold-
estimates on the rise, the facility Arons. • the “hidden tax” or cost shift that
knew it needed a better, more results from Medicare/Medicaid and
efficient process for generating and Variances also occur when the self-pay shortfalls and its effects on
tracking estimates. patient’s care requires more than the hospital prices; and
norm for the procedure in question,
Mercy Medical also implemented which is possibly the most • the different ways prices are
the Patient Charge Estimator, which significant issue at University reported and what can and cannot
allows the hospital’s financial Hospital. be learned from them.
counselors to rapidly respond to
estimate requests and provide more “While we can give a ballpark That dialogue is something every
accurate pricing information. It has figure, patients respond differently hospital needs to have with patients
also become an important analytical to treatment. These estimates are if they want them to have any
and pricing tool for Arnold-Arons. being given without medical confidence in the estimates they are
knowledge or information other providing, says Arnold-Arons.
“I can go back and see what patient than the procedure in question,”
counselors are quoting out vs. what says Patterson. “Sometimes, the “We need to get our patients
is actually getting billed,” she says. patients feel like we should be able educated and understanding where
“I run into situations where new to honor an estimate like a [these charges] come from and how
procedures are occurring, and I can mechanic honors an oil change. We this price is defensible, how it is fair
and reasonable,” she says. “It’s generated and to educate their me?’ They will start having that
going to be a learning game for patients on the factors that affect the conversation about cost and quality
most organizations right now.” cost of care provided as well as how with their doctors, and price
to balance cost with quality. estimates are the best way we can
Eventually, hospitals will have little communicate that. It’s like any
choice but to implement systems to “That’s what consumerism is,” says other business that needs to put its
increase the speed and accuracy Gundling. “Patients will stop and customers’ interests first.”
with which estimates can be ask, ‘Are there other options for
Washington Post – January 22, 2008
Speaking Their Own Language
By Sue Anne Pressley Montes
Lilian Diaz, an emergency room 2002, according to Martine Charles, requests are for Spanish interpreters,
technician, used to feel Inova's director of cultural the first course was in Spanish, but
apprehensive when a doctor or competence. The District's largest Pesquera hopes to hold sessions in
nurse at her Takoma Park hospital hospital, Washington Hospital Mandarin, Korean, Vietnamese,
would ask her to interpret for a Center, relies largely on eight French and Russian, languages that
Spanish-speaking patient. She knew people specifically hired as Spanish are also in demand locally.
she was chosen because of her interpreters, with Chinese, French Employees who complete the
Spanish surname, but what if she and Vietnamese interpreters also course receive extra pay for their
told someone the wrong thing? Her available, said Brian Miller, the services.
Spanish was fine for everyday hospital's manager of international
matters, but was it really good services. At Suburban Hospital in Elfred Deynes-Morales, a
enough, she wondered, to explain a Bethesda, about 50 employees, with respiratory technician who has
life-threatening illness to a fearful varying degrees of Spanish fluency, worked at Washington Adventist for
patient? recently attended Spanish classes 20 years, said he jumped at the
provided by Montgomery College, chance to attend the class. He used
Now Diaz and a dozen of her co- where they learned health-care- to be asked to assist with
workers have new confidence in related terms, senior vice president interpreting once or twice a week,
their skills. They are the first Dennis Parnell said. he said. As the number of non-
graduates of a program at Adventist English-speaking patients has
Health Care Systems that trains The Adventist program, offered increased, requests have risen to 10
already-bilingual staff in the through the system's year-old to 12 a day.
technical terms and cultural nuances Center on Health Disparities, was
of interpreting in a hospital setting. born of necessity. There never seem "One of the reasons I took the class
It is one way area health-care to be enough trained interpreters on is I didn't think I knew it all," he
providers are trying to meet the site, and the alternatives -- using said. "Before, it was an impromptu
demand for qualified interpreters to telephone interpreting services or type of scenario, where I walked in,
help inform and reassure a growing enlisting a patient's relatives -- are not knowing what was going on
community of non-English- sometimes problematic. with the patient, and moved right
speaking patients. along. Now by introducing myself
"When family members, for and talking to the doctor, it gives
"Coming here, I was surprised how example, interpret for patients, me an idea what the doctor is
much my Spanish was needed," said many things could be omitted," said looking for, and I can build a little
the Guatemalan-born Diaz, 25, who Marcos Pesquera, the center's bit of trust between me and the
has worked at Washington executive director. "If the son is patient."
Adventist Hospital for less than a interpreting for the mother, the son
year. She is called on, she said, might be embarrassed by certain A native of Puerto Rico, Deynes-
"every day, multiple times a day." things. " Morales said his training came in
handy recently when two members
Communicating with patients who Pesquera started out by training six of a Salvadoran family drove up to
speak little or no English is an employees to be teachers, and by the hospital from North Carolina,
urgent priority at area hospitals. In October 2007, the employees had searching for a lost brother. The two
Virginia, the Inova Health System settled in for the three-day program. spoke little English. After talking
has trained 400 employees since Since 80 percent of Adventist's with them in Spanish, Deynes-
Morales determined that the man to be "cultural brokers," Pesquera Spanish-speaking home. "Instead of
they sought was not an Adventist said, understanding that many of the rambling on . . . I learned to let the
patient. Then he began calling other patients are frightened and may doctors talk to the patients -- I'm the
area hospitals. Finally, he contacted have had minimal contact with vessel."
police and helped the family fill out doctors or hospitals in the past.
a missing-person report. They learn how to handle terms like Lilian Diaz said she has come to
"gallstones" and "blood thinners" think of her role as "the voice."
He does not know whether the two that have no exact Spanish
ever found their brother -- "We are translations, and how to blend into Now she feels more qualified to
taught not to get too caught up the background to allow the patient help out in an exchange between
emotionally," he said -- but he said to feel as if he or she is conversing doctor and patient. "I took a test. I
he was glad he could relieve some directly with the doctor. can do this," she said.
of the stress they were feeling by
helping them work out a plan of "It could be as basic as 'I need you And at the end of the workday, she
action. to take your medicine,' to 'You're said, "I can say, 'Okay, I did my job,
having bypass surgery and this is I helped someone out' and walk
Participants in the class, who are what that means,' " said Vashti away with a smile."
tested for proficiency in both Mann, 43, a registered nurse in
Spanish and English, also are taught intensive care, who was raised in a
USA Today – January 21, 2008
Rising health care costs put focus on illegal immigrants
By Richard Wolf
BENSON, N.C. — Juan Perez had As the debate over the residency •On a national level, an effort to add
stomach pains for a month before status of the nation's estimated 12 legal immigrant children to the State
deciding to visit a health clinic here million illegal immigrants boils, Children's Health Insurance
that is open Thursday nights so another battle is simmering over Program was blocked in the Senate
migrant farmworkers don't miss a what — if any — benefits they last year. Instead, lawmakers added
day working in the fields. deserve while they're here. Some of language to ensure that illegal
the most heated arguments on the immigrants were excluded.
As an illegal, uninsured immigrant, issue focus on health care. So far,
Perez has had problems in the past immigrants are losing: "The phrase 'illegal immigrant' is
— not only with his health, but with just radioactive at the moment,"
navigating the U.S. health care •In Texas, where the state says Leighton Ku, a health analyst
maze. In Michigan, there was no comptroller estimates illegal at the liberal Center on Budget and
interpreter at his local health clinic, immigrants cost hospitals $1.3 Policy Priorities. "Efforts to provide
the bills had to be paid in billion in 2006, the University of additional benefits for the
installments, and co-workers Texas Medical Branch in Galveston undocumented would be essentially
warned that a visit to a doctor could is considering denying cancer care perceived as adding fuel to the fire."
lead to deportation. In North to such immigrants.
Carolina, he's found a health care Illegal immigrants can get
home at Tiffany Revels' weekly •State legislatures across the emergency care through Medicaid,
clinic — providing he can hitch a country are seeking to limit the the federal-state program for the
ride there. costs to taxpayers of illegal poor and people with disabilities.
immigration, including health care But they can't get non-emergency
"The biggest concern is getting sick, benefits. In May, Oklahoma care unless they pay. They are
because you don't have anyone lawmakers restricted illegal ineligible for most other public
here," Perez says after Revels, a immigrants from receiving most benefits.
family nurse practitioner at the public benefits; other states, such as
federally funded clinic, prescribes Nebraska, are seeking to follow suit. Data on health care costs for illegal
two antibiotics and Pepto-Bismol A bill introduced in Indiana this immigrants are sketchy because
tablets for his bacterial gastritis. month would make hospitals report hospitals and community health
"You are here by yourself." how much they spend on illegal centers don't ask about patients'
immigrants. legal status. In California, a 2004
study by the Federation for
American Immigration Reform put amount of work that they have to prenatal care, as well as injuries and
the state's annual cost at $1.4 do." chronic disease complications.
billion. Similar studies in Colorado
and Minnesota in 2005 came up A potent political issue At the state and local level, illegal
with much smaller estimates: $31 immigrants already cost more in
million and $17 million, Opponents of illegal immigration public services such as education
respectively. see health care as a benefit that and health care than they pay in
illegal immigrants don't deserve — taxes, the Congressional Budget
One thing is clear: Undocumented and that taxpayers can't afford. Office reported recently. Illegal
immigrants are driving up the immigrants make up less than 5% of
number of people without health In a special election to fill the seat the cost in most states, but closer to
insurance. The Pew Hispanic Center of the late Rep. Paul Gillmor, R- 10% in some California counties. In
estimates that 59% of the nation's Ohio, last month, the National 2000, counties along the Mexican
illegal immigrants are uninsured, Republican Congressional border lost more than $800 million
compared with 25% of legal Committee attacked Democrat in health care services for which
immigrants and 14% of U.S. Robin Weirauch for backing they were not paid; about 25% of
citizens. Illegal immigrants universal health insurance because that went to care for illegal
represent about 15% of the nation's it could extend taxpayer-funded immigrants, according to a report by
47 million uninsured people — and health care to illegal immigrants. the United States/Mexico Border
about 30% of the increase since She lost the race. Counties Coalition.
Steven Camarota of the Some states, including New York,
"If you want to do something that conservative Center for Immigration Illinois and Washington, as well as
will have a meaningful impact on Studies says offering non- several California counties, cover
the problem of the uninsured, then emergency Medicaid to illegal illegal immigrant children with state
you must talk about undocumented immigrants would be more tax dollars. "Kids are the more
immigrants," says James Smith, a expensive than leaving them sympathetic group, and they're less
senior economist at the RAND uninsured and in need of occasional costly," says Sonal Ambegaokar of
Corp. hospital care. In those cases, the National Immigration Law
hospitals lose money, and taxpayers Center, an advocacy group for low-
Because most illegal immigrants are pick up the tab. income immigrants.
relatively young and healthy, they
generally don't need as much health "Either you enforce the law and Since 2003, California's San Mateo
care treatment as U.S. citizens, don't have so many illegals, or you County has used local tax dollars as
studies show. But while they shut up about the cost," he says. well as money from hospitals and
account for less than 2% of national non-profit groups to provide health
medical spending, their growing While state governments, Congress, insurance to all low-income
presence is a problem in places such the Bush administration and children, regardless of immigration
as eastern North Carolina, one of presidential candidates wrestle with status. "These children are in our
the nation's poorest areas. how to provide health coverage to schools. They're part of our
uninsured Americans, illegal community," says Beverly Thames,
Statewide, illegal immigrants immigrants rely on a patchwork of spokeswoman for the county health
accounted for one in four new federally funded community health department. "It's just important that
residents from 1990 to 2004, centers, which charge little for basic they have access to health care."
according to a University of North services and don't seek proof of
Carolina study. The state ranks citizenship. For medicine, they San Francisco goes further, adding
ninth in the nation for illegal often rely on free prescription adults at local expense. Some cities,
immigrants with more than 300,000, samples or over-the-counter drugs. including New York, encourage
according to the Pew Hispanic illegal immigrants to use public
Center. From 2001 to 2004, spending for services such as health clinics
emergency Medicaid for illegal without risking deportation.
For hospitals, "the burden of the immigrants rose by 28% in North
uninsured immigrant is huge," says Carolina, said a March 2007 article Direct federal aid has been minimal,
Jeff Spade, vice president of the in the Journal of the American but in 2003, Congress appropriated
North Carolina Hospital Medical Association. Researchers $1 billion over four years for
Association. "It's exploded the cited increases in childbirth and hospitals and other health care
providers that serve illegal
immigrants. More than 15,000 pain of illness or injury, so they live with the Mexican Consulate to
providers have registered for with their afflictions rather than arrange transportation back to their
payments, according to the Centers seeking help until their health native countries. If that can't be
for Medicare and Medicaid problems become critical. That arranged, the patients remain in the
Services. makes things worse — for them, for hospital for weeks or months.
hospitals that eventually treat them,
The sweeping overhauls of the and for taxpayers who ultimately "It's a real Catch-22," says Sharon
nation's health care system proposed foot the bill. Coulter James, senior vice president
by Democrats Hillary Rodham at the University of North Carolina
Clinton, Barack Obama and John "They're scared to see the doctors," Hospitals. "We would never put that
Edwards would not provide says Genaro Diaz,a legal resident patient out on the street in an unsafe
coverage for illegal immigrants. who, at 59, is a father figure to environment. But there are patients
"Because the issue is so politically many of the mostly male who need those beds."
hot, people are staying away from farmworkers here. "They think
it," says Cecilia Munoz, senior vice they'll send them back to Mexico." In an effort to help local health
president at the National Council of officials better understand the
La Raza, the nation's largest Now, at least some are coming to immigrants who are inundating their
Hispanic advocacy group. Only community health centers, part of a area, the University of North
Dennis Kucinich of Ohio, a national matrix of more than 4,000 Carolina's Center for International
Democratic long shot, proposes federally funded health centers that Understanding sponsors week-long
covering them. have sprung up throughout the immersion programs in Mexico.
country during the past 40 years. In Janet Hadar, director of clinical care
That's likely to mean little change in 2006, those centers served 6 million management for UNC Hospitals,
undocumented immigrants' health uninsured patients, a 50% increase recently returned from a trip that
care status, already the worst in the since 2001. exposed her to residents' unsanitary
nation. Even among children, 53% living conditions. "It made me much
are uninsured, according to Jeffrey At Goshen Medical Center, nursing more sympathetic to this
Passel of the Pew Hispanic Center. assistant Jessica Roberts recalls a population," she says.
That compares with 9% of U.S. woman who arrived more than eight
citizens' children. months pregnant with her eighth Revels went on the same trip. Now,
child — for her first prenatal visit. she's back treating ailments large
In North Carolina's rural Duplin "A lot of Hispanic patients are and small: skin rashes and
County, more than one in four scared of coming to the doctor's hypertension, infections and
people are uninsured. The area's job office because of who they're going nosebleeds. Most patients pay $6
growth is in low-wage agribusiness to meet," she says, referring to their per visit and $6 per prescription.
— "plucking chickens and gutting fear of deportation.
hogs," says Greg Bounds, chief Slowly, she's building a steady
executive officer of Goshen At Duplin General Hospital, the clientele. Ignacio Hernandez
Medical Center, the area's largest challenge is staying afloat. Because complained recently of recurrent
group of community health centers. so many patients are seniors on eye pain after being struck by a
Businesses need the influx of illegal Medicare, low-income residents on sweet potato in the fields.
immigrants to take hard-to-fill jobs, Medicaid or uninsured people who Guadalupe Cortez came for his
but hospitals lose money when the can't pay their bills, it's difficult to monthly diabetes check and
workers need emergency care. turn a profit. "We're living off emerged with a bag of insulin
reserves," CEO Harvey Case says. samples. Without the clinic, "I don't
Until recently, most illegal know what I'd do," he says.
immigrants here had one health care The University of North Carolina's
strategy. "They just weren't getting four hospitals are seeing an increase On some nights in 2006, "we would
care before," Bounds says. "They in the number of undocumented only see eight patients," Revels says
were just suffering and dying." immigrants who need care for major between treating farmworkers'
illnesses or injuries. Because they ailments. More recently, "I have not
'Scared to see the doctors' only qualify for Medicaid on an had one slow night."
emergency basis, their funding often
For many illegal immigrants, the runs out before they're able to leave.
fear of deportation outweighs the Hospital officials sometimes work