Uninsured patients require creative discharge plans
April 1, 2012 8 minutes read
Uninsured patients require creative discharge plans
Work with providers, agencies to find placement
With the increase in uninsured and underinsured patients, hospitals face the challenge of finding post-acute care for unfunded or underfunded patients, or keeping them in a bed when they no longer need the acute level of care.
Today's hospitals are treating a lot of patients whose car e is expensive and who don't have a lot of funding, particularly for post-acute care, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management, a Wellesley, MA-based case management consulting firm. "Case managers need to look at ways for patients to get the care they need after discharge, rather than keeping them in the hospital when they no longer need an acute level of care," she says.
Donna Zazworsky, RN, MS, CCM, FAAN, vice president of community health and continuum care for Carondelet Health Network in Tucson, AZ, points out that patients who don't have insurance often remain in the acute care hospital longer than necessary, because they have no funding for home health or durable medical equipment. Others have extended lengths of stay in an acute care facility because facilities that can provide a lower level of care won't take patients when they won't be reimbursed for their care. Keeping patients longer than necessary is an expensive proposition for the hospital, as well as exposing patients to potential infections and other risk factors associated with a hospital stay, Zazworsky adds.
Matt Boettcher, LSW, MSW, vice president for continuum of care for Scott and White Healthcare, with headquarters in Temple, TX, and consultant for The Center for Case Management adds that case managers are in a position to help move uninsured patients through the continuum of care, but it's a challenge they can't meet alone. "As case management professionals, we have the responsibility to develop a network of community resources and contacts, and to work with community agencies and other providers to help the uninsured find care after discharge," he says. (For resources for the uninsured and indigent, see box, below.)
Arrange with local pharmacies to provide assistance for people who need it and set up contracts with skilled nursing facilities, assisted living facilities, and equipment vendors to get post-acute services at a discounted rate.
Keep in mind that patients who are discharged to home with home health services have to have a physician to verify orders with the home care agency and that the home health nurse can call with questions or concerns. This may be a problem with the uninsured since many people without insurance don't have a primary care physician, and may not have seen a doctor for five or 10 years, Boettcher points out. "Case managers need to develop physician resources, whether it's a resident clinic or a clinic that takes indigent patients on a sliding scale, and get the patients connected so they'll have a primary care provider," he says.
Boettcher adds that in many cases, it makes sense for hospitals to pay for patients to go to a lower level of care when they no longer need acute care services, rather than keeping them in the hospital and not being able to fill the beds with paying patients. For instance, if an uninsured patient needs IV antibiotics for four weeks and your hospital has a daily rate of $2,000, it would cost $60,000 to keep him in the hospital. On the other hand, it would cost much less for the hospital to pay for a home care agency to administer IV antibiotics.
Paying for post-acute services for people who can't afford them can help with throughput, prevent readmissions, and help hospitals prove that they deserve to continue non-profit status, Boettcher says. Federal law stipulates that hospitals that pay no taxes and make profits have to provide free care as a community benefit in order to maintain their tax-exempt status. He advises that when hospitals are paying to take care of patients at the right level of care, it should be counted as a community benefit and not as bad debt.
"Sometimes it makes good financial sense to pay money not to lose money. It may be a hard pill for the chief financial officer to swallow, unless the case manager paints the scenario that shows the hospital is better off," he says. If the hospital is in the position of paying for a skilled nursing stay, offer the facility at the Medicaid rate. "It works better if you work with facilities that have the same culture and facility as your hospital," he suggests. For instance, non-profit hospitals do better contracting with other non-profit organizations.
Chris Nesheim, RN, MS, CMAC, system director, case management for Lee Memorial Health System with headquarters in Ft Myers, FL, has developed an arrangement with 17 skilled nursing facilities in the area to take indigent patients at a negotiated rate paid by the hospital system. "We negotiate a daily rate on a case-by-case basis. If patients just need bed rest and minimal care, we agree for the hospital to pay the Medicaid rate. If they need a lot of drugs, we find out the cost and take that into account when we negotiate the rate," she says. The hospital system pays the Medicare daily rate for patients who need major wound care or other intensive services.
It's more cost-effective to pay for post-acute care and free up beds, particularly in the winter months when "snow birds" and other vacationers flock to the warm climate, Nesheim says. "In summer, when capacity isn't a huge issue, we may keep them in the hospital until they can safely be discharged," she says.
Zander points out that as lengths-of-stay are getting shorter and case managers are pressured to move patients out and free up beds, it's often a challenge for overworked case managers to find appropriate discharge options for patients, particularly those without funding. She recommends that hospital case managers start early in the stay to identify their patients' potential healthcare and medication needs, and appropriate resources that are available within the community.
Zazworsky adds that case managers need to look beyond the immediate situation at what is going on in patient's life when he or she leaves the hospital. Find out what kind of support system the patient has at home, financial issues, transportation problems, or other roadblocks to compliance. Case managers should work with social workers in the hospital, and social service agencies in the community to make sure their patients have shelter, food, and other basics. Help your patients get on food stamp programs, energy savings programs, and other types of assistance. "If someone is not living in a safe and secure environment, if they don't have food or are worrying about whether their utilities are going to be cut off, they aren't going to take care of their health," she says.
Sources
For more information, contact:
- Matt Boettcher, LSW, MSW, Vice President for Continuum of Care, Scott and White Healthcare, Temple, TX. Email: [email protected].
- Chris Nesheim, RN, MS, CMAC, System Director, Case Management, Lee Memorial Health System, Ft. Myers, FL. Email: [email protected] .
- Karen Zander, RN, MS, CMAC, FAAN, Principal and Co-Owner, the Center for Case Management, Wellesley, MA. Email: [email protected].
- Donna Zazworsky, RN, MS, CCM, FAAN, Vice President of Community Health and Continuum Care, Carondelet Health Network, Tucson, AZ. Email: [email protected].
Unfunded patients are on the increase Some may be eligible for benefits More than 53 million Americans, around 20% of the total population, are uninsured for various reasons, points out Matt Boettcher, LSW, MSW, vice president for continuum of care for Scott and White Healthcare, with headquarters in Temple, TX, and consultant for the Center for Case Management, a patient care management consulting firm based in Wellesley, MA. As health insurance costs have escalated, some employers have reduced coverage for employees, raised deductibles, or stopped providing health insurance altogether. Many people who lost their jobs can't afford the premiums to keep their insurance under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Some people who are uninsured have jobs but they don't make enough to pay for insurance, they work for a small business that is not required to provide insurance and they can't afford private insurance, or they have a pre-existing condition that makes it impossible to find coverage. Renee Perez, community health outreach coordinator/emergency department navigator at St. Mary's Hospital, part of the Tucson, AZ, Carondelet Health Network, adds that a significant number of uninsured patients seeking care in her emergency department previously qualified for healthcare assistance but lost their eligibility due to cuts in state and federal funding. Boettcher says that there typically are three categories of uninsured people — those who might become eligible for benefits, those who have used up their benefits and those who will never have benefits. Undocumented immigrants make up the bulk of the third category, he says. Ankeny Minoux, president of the Foundation for Health Coverage Education, a non-profit organization dedicated to helping the uninsured access health coverage, with headquarters in San Jose, CA, points out that many patients who don't have insurance don't realize that they are eligible for other funding to pay for their healthcare. In fact, when her organization conducted a survey of 28,163 uninsured patients who presented to the emergency department in a large hospital system in California, it found that 80.54% of patients were eligible for public health coverage programs but didn't know it. "There are options today for people who are uninsured and who need healthcare but many people are not aware that they can get coverage, and those who qualify have a lot of hurdles to overcome in order to fill out an application to enroll in a funding program," Minoux says. The Foundation for Health Coverage Education has compiled details and eligibility requirements for hundreds of programs that give financial assistance to the uninsured and underinsured. Patients can log into the organization's website, www.CoverageForAll.org, answer a five-question eligibility quiz, and get a personalized list of health coverage options, including program details and benefits, approximate monthly cost, a list of documents needed for each program, and applications. "This is a great starting point for case managers looking for discharge options and follow-up care for patients, she says. In addition to the website, the organization operates a 24-hour U.S. Uninsured Help Line, (800-234-1317) with translators available for more than 240 languages. The organization has partnered with the American Cancer Society, the American Heart Association, the American Lung Association, and the American Diabetes Association to help them identify assistance programs. Donna Zazworsky, RN, MS, CCM, FAAN, vice president of community health and continuum care for Carondelet Health Network in Tucson, AZ, points out that hospitals face the problem of uninsured patients, many with chronic illnesses, are flooding their emergency departments because they can't afford treatment at a primary care provider, or they have no money to fill their prescriptions. Helping patients connect with a primary care provider should be a priority for hospital-based case managers whether they are in the emergency department or the acute care unit, Zazworsky says. When uninsured patients who come to the emergency department at St. Mary's Hospital are referred to Perez, she logs onto the State of Arizona's electronic application for assistance to screen patients for eligibility for healthcare coverage, cash assistance, nutrition assistance, and other community resources. "Many patients aren't familiar with programs that could assist them and they don't know how to find out if they are eligible," she says. If patients are eligible, she submits the application, and then gives them the list of documents, such as birth certificates and proof of income, they need to prove eligibility. When patients come back to the emergency department and bring Perez their paperwork, she adds that to the application to expedite program eligibility. |
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