Hospitals and health systems are making stark choices between offering models to assist their communities and reduce medical costs−or raking in profits, no matter how outrageous and shame-provoking their charges might be. Evidence of the extremes came this week in reports about alternative realities.
Let’s start with the positive view, recognizing exemplary efforts in the Charlotte, N.C.-area to both help patients and to sharply cut medical costs. Forward-looking health policy experts decided to dive into the highest Medicaid users of emergency services, discovering, for example, that just one patient, a homeless alcoholic man, visited the ER 223 times in 15 months and had undergone 150 redundant and needless X-rays or other scans. Many of the top 100 “frequent flyers,” poor and repeat ER patients, took an exceedingly costly route to fill prescriptions or to seek pregnancy or other routine tests; 86 of these individuals were known to have behavioral woes, including depression or bipolar disease. The experts found that these individuals visited multiple ERs on the same day, sometimes crossing a street or two to do so. They appeared on hot or cold days, suggesting their real need might not be medical but for shelter.
Community Care North Carolina — an umbrella group, with cooperation and support from hospitals, social workers, nurses, and social service agencies — searched out the heaviest using Medicaid-ER patients. They needed to comb the streets, jails, and even a strip club. They helped the patients find responsive primary care doctors, and other assistance, for example, in managing chronic illnesses and conditions. They connected them with social service agencies for assistance with existing housing, nutrition, jobs, and transportation programs. As the Charlotte Observer reports:
From 2013 to 2014, emergency room use by Medicaid patients dropped by 17 percent in Mecklenburg, Union and Anson counties. That meant 29,590 fewer visits in the three-county network. Because ER visits sometimes lead to unnecessary hospital stays, inpatient rates dropped as well – 5,873 fewer hospital stays.
The group that helped bring about these results with the Medicaid-covered poor also has run a pilot to help hospitals with uninsured frequent patients, 35 of them, many with little education, unable to speak English, and with mental health issues. Through this initiative, savings were achieved in one year of “$285,000 on care that would have been provided for free. … Emergency room visits dropped by a third.” The group has been recognized for its work with a $100,000 national award.
Shaming, naming without effect
Meantime, avarice and not public interest appears to fuel a set of Florida hospitals. They were part of a fetid fifty, singled out by health policy researchers who asserted that select hospitals across the country charged the uninsured 10 times the actual cost of patient care. A year after this “naming and shaming,” researchers in Florida checked to see if national ignominy altered the profiteering hospitals in the Sunshine State.
Instead, they raised their prices, and, as the Washington Post reported: “There was no evidence that the negative publicity resulted in any reduction in charges. Instead, [researchers] found that overall charges were significantly higher after the publicity than in previous quarters.”
Karoline Mortensen, one of the researchers of the study published in the peer-reviewed Journal of Health Care Finance, told the Post: “There’s nothing stopping them. They’re not being held accountable to anyone.”
The hospitals operate in noncompetitive markets, and face no pressure to disclose or to discuss their charges. Florida has no oversight on hospital charges. Millions of uninsured patients, the Post says, find themselves exceedingly vulnerable to exploitation when they require hospitalization, because they need medical care and no one, such as big insurers, stand with them to negotiate with or to battle hospitals over charges. the Sunshine State relies heavily on tourists and has many non-resident visitors who also may get hit with high bills because, if they do have insurance, they are likely to be seeking care outside their health care networks where lower charges have been negotiated by insurers. Florida also is one of the states that hasn’t expanded Medicaid under the Affordable Care Act, meaning that uninsured patients who must seek care in the pricey 20 hospitals are further out of luck in possibly getting government help for their wallet-busting medical care. Only one of the 20 costly institutions, the Post notes, is not-for-profit; the rest are part of corporate chains, and their costs are significantly higher−not just for the uninsured.
These pricey places also don’t deliver simply fabulous care-giving for their cost, as the paper says, they are “less likely than other hospitals in Florida to achieve three or more stars in the quality metrics system used by the Centers for Medicare & Medicaid Services.”