US Hospitals Try Free Basic Care for Uninsured

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Hospitals Try Free Basic Care for Uninsured By ERIK ECKHOLM

AUSTIN, Tex. — Unable to afford health insurance, Dee Dee Dodd had

for years been mixing occasional doctor visits with clumsy efforts to

self-manage her insulin-dependent diabetes, getting sicker all the

while.

In one 18-month period, Ms. Dodd, 38, was rushed almost monthly to

the emergency room, spent weeks in the intensive care unit and

accumulated more than $191,000 in unpaid bills.

That is when nurses at the Seton Family of Hospitals tagged her as

a " frequent flier, " a repeat visitor whose ailments — and expenses —

might be curbed with more regular care. The hospital began offering

her free primary care through its charity program.

With the number of uninsured people in the United States reaching a

record 46.6 million last year, up by 7 million from 2000, Seton is

one of a small number of hospital systems around the country to have

done the math and acted on it. Officials decided that for many

patients with chronic diseases, it would be cheaper to provide free

preventive care than to absorb the high cost of repeated emergencies.

With patients like Ms. Dodd, " they can have better care and we can

reduce the costs for the hospital, " said Dr. , medical

director of three community health centers run by Seton, a Roman

Catholic hospital network that uses its profits and donations to

provide nearly free care to 5,000 of the working poor. Over the last

18 months, Ms. Dodd's health has improved, and her medical bills have

been cut nearly in half.

Reaching out to uninsured patients, especially those with chronic

conditions like diabetes, hypertension, congestive heart failure or

asthma, is a recent tactic of " a handful of visionary hospital

systems around the country, " said , president of the

Commonwealth Fund, a foundation in New York that concentrates on

health care. These institutions are searching for ways to fend off

disease and large debts by bringing uninsured visitors into

continuing basic care.

The public hospital systems in New York and Denver, for example, have

both worked to steer uninsured patients to community clinics,

charging modest fees, if any. New York's public system, the Health

and Hospitals Corporation, has assigned some 240,000 uninsured

patients to personal primary care doctors. A computerized system

tracks those with chronic conditions, and when necessary, social

workers contact patients to make sure they get checkups and follow

medical advice.

" For most preventive efforts there is an upfront expense, " said Alan

D. Aviles, president of the corporation. " But over the long term it

saves money. "

Denver's public system, Denver Health, has 41,000 uninsured patients

enrolled in its clinics. Officials there calculate that for every

dollar they spend on prenatal care for uninsured women, they save

more than $7 in newborn and child care.

The " safety net " plan of the Seton system in Central Texas accepts

people making 150 percent to 250 percent of the federal poverty limit

and has resources to support 5,000 patients. (People below the

poverty line, which is $13,200 a year for a family of two in the

contiguous states, can obtain care through the public clinic system.)

Officials scrutinize the records of plan members to see who is still

overusing the emergency room or being repeatedly hospitalized — these

high-cost patients total some 40 each month — then assign them

caseworkers to help improve care and bring down costs.

A special effort to educate 631 asthma patients saved the plan

$475,000 in one year, Seton officials said.

In a more unusual step, Seton officials also look for frequent

emergency room users who do not qualify for the hospital's charity

plan because they live in a different county, like Ms. Dodd, or have

incomes just above the threshold. In a dozen cases so far, all

involving diabetics, a committee has judged that it makes financial

sense to bring these people into the charity plan anyway and provide

intensive support.

Other answers to the insurance crisis are being tried around the

country, including the creation of subsidized, bare-bones policies

for small businesses. Vermont, Maine and especially Massachusetts are

using combinations of state and federal money and employer mandates

to extend insurance.

Still, only a fraction of the uninsured, in Central Texas and in most

other states, are benefiting.

" All these local efforts are commendable, but they are like sticking

fingers in the dikes, " Ms. of the Commonwealth Fund said,

noting that the larger trend was hospitals' seeking to avoid the

uninsured.

Nowhere is the problem more acute than in Texas, where nearly a

quarter of the population is uninsured, the nation's highest rate.

Small businesses here are unlikely to offer benefits, and the state

government's unusually stringent restrictions on Medicaid for adults

leave many of the working poor at risk.

Even without counting the large immigrant population, Texas has the

country's highest share of uninsured, at 21 percent, according to the

Center for Public Policy Priorities in Austin.

" All the hospitals here provide some uncompensated care, and they are

eating it and passing the costs along to the payers, " said

A. Young Brown, president of the County Healthcare District,

which was set up last year to oversee care of the indigent through

public clinics, drawing on property taxes to pay.

" So insurance rates go up, and then more businesses drop insurance, "

Ms. Young Brown continued, describing a trend unfolding

nationwide. " It's hard to see where it will end. We hear a cry for

national and state leadership. "

The private People's Community Clinic, supported in part by the St.

's Hospital system, gives primary care to 11,000 people in

Austin who are uninsured or on Medicaid and related programs.

" I think we are a good Band-Aid for those able to come to our

clinic, " Regina Rogoff, director of the clinic, said. " But it's not a

solution to have such a ragtag, makeshift system. "

Austin hospitals and charity clinics have also joined in a pioneering

data-sharing system to track visits by uninsured patients and fight

unnecessary use of the emergency room. But rural counties in Texas

offer little aid, and rural residents with serious maladies end up

traveling to urban emergency rooms.

The current patchwork also pits different levels of government

against each other.

Natavidad ez, 51, who used to work as a bookbinder for $7 an

hour and never had insurance, has found herself in a bureaucratic

nightmare.

In March 2005, Ms. ez, a Seton patient, was found to have liver

cancer. She was put on Medicaid, applied for federal disability and

was put in line for a liver transplant, without which, doctors said,

she had six months to two years to live. Through the summer of 2005,

she made the hour-and-a-half drive from her home to San for

preparatory tests.

That August, she was awarded disability payments of $561 a month. But

because her income surpassed the $535 limit for Medicaid in her

circumstances, she said, she was told by the state that her coverage

had ended, and the hospital said it could not proceed with a

transplant.

" I asked Social Security if they couldn't just reduce my payments by

$30 a month, " she said, " but they said it doesn't work that way. "

In another twist, by federal rules, she will qualify for Medicare two

years after the initial finding of disability. She awaits the start

of Medicare coverage next March, when she can rejoin the transplant

line.

In Texas, as throughout the country, the coverage of poor children

through Medicaid and related programs expanded greatly over the last

decade. But a majority of states do not provide Medicaid to parents

making even poverty-line incomes, and Texas is one of the least

generous: here, a working parent of two does not qualify for coverage

if he or she makes more than $3,696 in a year, leaving people like

Ms. Dodd to fend for themselves.

Ms. Dodd, who worked as a dental assistant, is married to a truck

driver, has four children and lives on a country road in Hays County,

south of Austin. Ten years ago, after her weight fell to 82 pounds,

she learned that she was a " brittle diabetic, " subject to rapid and

dangerous changes in blood sugar. She saw a doctor only sporadically

because visits cost $120 — money she did not have.

" I had to stop working, so then I couldn't afford to go to the

doctor, and then I had to go to the emergency room, " Ms. Dodd said.

She was having repeated episodes of ketoacidosis, a chemical

imbalance that sometimes put her into life-threatening comas. Years

of poor care had weakened her and led to side effects like esophogeal

ulcers that could probably have been prevented, her doctors said.

Ms. Dodd still has problems, but the use of a $3,200 insulin pump

paid for by Seton, which automatically adjusts her insulin levels,

along with access to an endocrinologist and home counseling have

reduced their severity. Her care in the last 18 months has cost Seton

$104,697, far below the $191,277 for the previous period. More

important, the later figures include less hospital time and more

medicines and expert advice.

" The money we save, " Dr. , of Seton, said, " money that is not

hemorrhaging through the I.C.U., is money we can do so much more with

to help her upfront. "

http://www.nytimes.com/2006/10/25/health/25insure.html