Unreimbursed Care Research Articles

From what works to what matters: Whole person cancer care and the integrative oncology leadership collaborative (IOLC).

e13567 Background: In 2021-2022, a two-year integrative oncology leadership collaborative ( IOLC ) was established with a goal to routinize whole person care. Thirteen cancer organizations met virtually 1-2x/month, including community, federal and academic centers. The IOLC defined whole person cancer care, adapted & tested open-source patient intake/PROs, education, and workflow resources from primary care, anchored in “what matters” for patients in oncology, and implemented practice change in their settings. Methods: Based on concepts and tools used in whole person primary care , and, with iterative discussion, the IOLC defined minimal required elements for whole person cancer care. Patient advocates, oncology social workers, physicians & nurses came together to draw from efforts that alleviate suffering in palliative, integrative, supportive, and other forms of (mostly) unreimbursed care. Six cancer survivor-advocate members vetted patient-facing resources. Subject matter experts reviewed topics important for clinical initiatives (e.g. group visit models , patient education resources ), shared best practices and solidified commitments to provide whole person care. To assess outcomes, a post-participation survey was fielded. Results: Minimal required elements (MREs) of whole person care were defined as: 1) inclusion of patient & caregiver voice in programming/care plans, 2) explicitly anchoring to “what matters” to the patient in shared decision making and goals of care (using PROs), and 3) supporting safe choices in complementary & integrative modalities. Challenges faced across organizations were: 1) leadership involvement, 2) patient understanding/engagement, 3) resource availability (time/financial), and 4) team alignment. Adaptation of primary care tools to oncology was successful; 15 “pocket guides” gained 2049 page views in 20 mos (top 3: cannabis 18%, nutrition 13%, patient advocacy 10%) and the American Cancer Society adopted the IOLC resources for distribution in 2024. Multi-institutional success occurred via publications and projects such as retooled nurse navigation, survivorship & wellness programs . Survey response rate was 54% (7 of 13 clinical sites). 89% increased whole person health services following IOLC participation (44% moderately or significantly). 100% reported use of the resources in patient care (55% often, 45% periodically). Conclusions: A definition of whole person cancer care, derived from broad consensus, identified MREs that allowed startup success across practice settings. An inclusive community of professionals & patients furthered whole person care with national impact, partnerships and culture change based on what matters to patients.

Use of Care Guides to Reduce Emergency Department Visits by High-Frequency Utilizers

BackgroundHigh-frequency utilizers are defined as patients who present 10 or more times to the emergency department in a rolling 12-month period. High-frequency utilizers contribute to emergency department overcrowding and misuse of resources, and reduce the efficiency of health care systems. Care guides have proven to be an effective tool in reducing high-frequency utilizers. ObjectiveThe objective of this quality improvement project was to determine if implementing a care guide for high-frequency utilizers to address the core needs of the patient and facilitate resources through case management consultation decreases the number of visits and the cost of unreimbursed care to the emergency department from high-frequency utilizers. MethodsWe implemented care guides for high-frequency utilizers in September 2014. Prior to initiating the care guides, we educated the physicians, nurses, case managers, and social workers in the emergency department. ResultsFollowing the implementation of the care guides, there was a steady decline in the number of high-frequency utilizers (338 in 2013–68 in 2021), the number of total emergency department visits by high-frequency utilizers (6025 in 2013–1033 in 2021), and unreimbursed care ($2,068,063 in 2013–$589,298 in 2021). ConclusionThe use of care guides was a successful strategy in reducing emergency department visits and the cost of unreimbursed care by high-frequency utilizers by providing them with the education and resources they require to receive health care services in appropriate settings.

The Cost Shifting Economics of United States Emergency Department Professional Services (2016–2019)

We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments. We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance. In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion. Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

Health system resource use among populations with complex social and behavioral needs in an urban, safety-net health system

BackgroundCosts incurred by health systems when caring for populations with social or behavioral complexity are poorly understood. We compared the frequency and costs of unreimbursed care among individuals with complexity factors (homelessness, a history of county jail incarceration, and/or substance use disorder or mental illness [SUD/MI]). MethodsWe conducted a cross-sectional analysis using electronic health record data for adults aged 18 and older between January 1, 2016 and December 31, 2017 from a Midwestern safety-net health system. Zero-inflated negative binomial regression models were used to assess risk-adjusted associations between complexity factors and care coordination encounters, missed appointments, and excess inpatient days. ResultsOur sample included 154,719 unique patients; 6.8% were identified as homeless, 7.8% had a history of county jail incarceration, and 20.6% had SUD/MI. Individuals with complexity factors were more likely to be African-American, Native American, or covered by Medicaid. In adjusted models, homelessness and SUD/MI were significantly associated with care coordination encounters (RR 1.8 [95% CI,1.7–2.0]; RR 1.9 [95% CI,1.8–2.0]), missed appointments (RR 1.5 [95% CI,1.4–1.6]; RR 1.7 [95% CI,1.7–1.8]), and excess inpatient days (RR 1.5 [95% CI,1.3–1.8]; RR 2.8 [95% CI,2.5–3.1]). County jail incarceration was associated with a significant increase in missed appointments. In 2017, SUD/MI accounted for 81.8% ($7,773,000/$9,502,000) of excess costs among those with social or behavioral complexity. ConclusionsSocial and behavioral complexity are independently associated with high levels of unreimbursed health system resource use. ImplicationsFuture payment models should account for the health system resources required to care for populations with complex social and behavioral needs. Level of evidenceIV.

The New Wallet Biopsy and Involuntary Patient Transfers Abroad: How Physicians Can Help Protect Patients.

The Emergency Medical Treatment and Active Labor Act in 1986 was intended to bring an end to incidents of "patient dumping." However, due to the conflation of various federal legislative provisions, hospitals faced with the prospect of long-term unreimbursed care of an immigrant patient, whether legally present in the United States or not, are in some cases having such patients transported to another country. These transfers are often being effectuated without patient consent. After an overview of the flaws in the legal system that have effectively encouraged such patient transfers, this essay uses a clinical case to demonstrate how physicians can collaborate with an interdisciplinary team and with family members to ensure that the best interests of immigrant patients are met. Finally, the essay calls on physicians to advocate for the development of hospital policies and practices that will protect patients from international patient dumping.

High Deductibles and Living Paycheck-to-Paycheck: A Loan-Based Model for Primary Care Coverage

To date, healthcare funding models have been limited to insurance, savings programs, and unreimbursed care, with insurance being the dominant model. However, many modern insurance panels include deductibles which are fundamentally incompatible with the reality that many Americans live paycheck-to-paycheck. By reexamining old assumptions of how healthcare should be funded, in the context of a modern society with ubiquitous information technology, a new model could alleviate a common source of frustration for voters while preserving recent policy advancements. This paper outlines a proposal which could bridge the coverage gap created by high deductible levels, which are common in both ACA exchange plans and many employer provided plans today, using a loan-based approach. Such an approach would seem to greatly reduce the rather substantial transaction costs in healthcare by simplifying most transactions and provide a more patient-centered approach for common transactions up to a deductible limit. A specific proposal of how to implement such a proposal, using existing systems, is presented and payment scenarios are also presented. On the provider-side, debit card processing systems, which are widely used to process health savings account (HSA) payments, could be combined with something like the federal student loan program for loan repayment. The federal student loan program provides substantial funding with highly flexible repayment terms in a manner which is currently slightly profitable to taxpayers. Combining these two existing systems could provide much needed relief to patients in a way which is more patient-centered, reduces cost, expands coverage, and at minimal cost to taxpayers. Additionally, we show how the current health savings account framework could facilitate this if IRS regulations we modified to: 1) allow accounts to carry negative balances and 2) make interest expense related to medical care an allowable expense.

Effects of Expanded California Health Coverage on Hospitals: Implications for ACA Medicaid Expansions.

To assess the effects on hospitals of early California actions to expand insurance coverage for low-income uninsured adults after passage of the Affordable Care Act. Data from the California Office of Statewide Health Planning and Development and the California Department of Health were merged with U.S. census data for 294 short-term general hospitals during the period 2009-2012. A difference-in-difference analysis was conducted with hospitals in counties that did not implement insurance expansions used as a comparison group. Variables examined included payer mix, costs of unreimbursed care, and hospital operating margin. Sensitivity analyses were conducted as well as a triple difference analysis. Effects were estimated for hospitals overall and by ownership type. California insurance expansions primarily benefited for-profit hospitals, with these facilities experiencing significant decreases in self-pay patients, increases in county-covered patients, and reductions in charity care. Most models yielded no significant change in payer mix and conflicting changes in unreimbursed care for nonprofit hospitals. California hospitals that treated the most uninsured prior to insurance expansions did not as a group experience substantial benefit in terms of reduced uninsured burden or better financial performance after program expansions occurred.

Emergency department profits are likely to continue as the Affordable Care Act expands coverage.

To better understand the financial viability of hospital emergency departments (EDs), we created national estimates of the cost to hospitals of providing ED care and the associated hospital revenue using hospital financial reports and patient claims data from 2009. We then estimated the effect the Affordable Care Act (ACA) will have on the future profitability of providing ED care. We estimated that hospital revenue from ED care exceeded costs for that care by $6.1 billion in 2009, representing a profit margin of 7.8 percent (net revenue expressed as a percentage of total revenue). However, this is primarily because hospitals make enough profit on the privately insured ($17 billion) to cover underpayment from all other payer groups, such as Medicare, Medicaid, and unreimbursed care. Assuming current payer reimbursement rates, ACA reforms could result in an additional 4.4-percentage-point increase in profit margins for hospital-based EDs compared to what could be the case without the reforms.

Cancer-Reducing Lifestyle Factors Probed

den from parents while allowing the CMS to document the child’s citizenship status would be to allow newborns whose births were covered by emergency Medicaid to receive presumptive coverage until the CMS receives a bill from the hospital documenting the birth, Michaels suggested. He emphasized that these children, who are US citizens, had no say in where they were born nor in US policies regarding immigration or enforcement, and that they should not be held responsible for the decisions made by their parents or officials. “It’s the innocent baby who ends up potentially suffering harm in a case where a parent is deterred by the atmosphere of fear,” he said. Others added that many physicians, hospitals, clinics, and other health care sources are likely to provide care for these patients regardless of their Medicaid status and also should not be left holding the bag for unreimbursed care. “I don’t think physicians want to be in a situation where they are enforcing the [immigration] law,” Kellerman said. “It’s not fair to put either the physicians or children in the middle of US immigration policy.”

Charity for the dying: who receives unreimbursed hospice care?

Many deaths occur among persons without insurance coverage for hospice care. We examined the patient and agency characteristics associated with receiving unreimbursed hospice care in a national survey. We examined the receipt of unreimbursed care using the 1998 National Home and Hospice Care Survey (NHHCS) discharge dataset. Overall, only 3% of hospice patients received unreimbursed care. Because 98% of older adults are eligible for Medicare, we stratified multivariate analysis on age greater or less than 65 years. Among persons less than 65 years of age, younger, nonwhite persons were more likely to receive unreimbursed care, as were persons with cancer. Agencies providing unreimbursed care to persons over the age of 65 years were more likely to be not-for-profit and freestanding. Recipients of unreimbursed hospice care are demographically similar to the uninsured, and whether uninsured persons receive unreimbursed hospice care depends on clinical and agency organizational factors related to the motivation to provide unreimbursed care.

Why Nurses Stay

EACH AND EVERY day, nurses do extraordinary things that affect lives of others-nursing is true make a difference profession. Janet Quinn's perspective on nurses as everyday heroes is one that hospitals and health systems should embrace. While I do not agree with her overall approach to caring and healing healthcare system by forming holistic Nightingale units, I do concur that care for caregiver is essential and is an area on which healthcare administrators should focus. Although it is true that hospital work is demanding and stressful and nurses are leaving nursing in general (particularly hospital nursing), many nurses are staying. It is beneficial to focus on why those RNs are staying as well as what drives some away. Research suggests that nursing satisfaction increases when nurses are empowered to do what matters in their work and their important role is recognized, along with having stable and positive work relationships. No magic bullet exists, nor is it necessary to create one under guise of pilot units such as Nightingale units to develop a hospital culture that retains nurses. A number of other nursing care delivery approaches have been tested, such as Planetree patient care units in y8os and patient-focused care in 1990s. None have been able to demonstrate improved outcomes in arena of patient care delivery or costs that are sustainable or can be replicated on a large scale. Such is case with Nightingale units. Quinn states that the nursing shortage is symptom of a diseased healthcare system environment that indicates something is toxic, dangerous, and potentially lethal. I propose that if such a disease exists, cure lies in healing profession of nursing. Quinn suggests providing habitats for healing, that is, providing an environment that attracts and nurtures nurses. This is a noteworthy goal. Furthermore, she contends that bottom-line, business-oriented focus of healthcare is overemphasized to detriment of caring and healing. I have a different perspective and would argue that a business-oriented approach and a reasonable bottom line are part of effective stewardship that enables care and healing mission to occur. Declining reimbursement from both public and private sectors and significant increases in unreimbursed care, coupled with escalating wages, pharmaceutical costs, and other operating costs, require a business-oriented approach to ensure care for those we serve. It is also necessary if we are to afford competitive wages and benefits that our healthcare workers deserve. Patient acuity in inpatient setting requires intensive nursing care, albeit through medical model of care. This is a reality of American hospital-- inpatients require acute care. Although some modalities described in Nightingale units have merit, they should be evidence based and affect clinical outcomes. …

Cost of Treating Uninsured Jeopardizing Trauma Centers

Cost of Treating Uninsured Jeopardizing Trauma Centers

A COMPARISON OF DENTAL CARE EXPENDITURES AND OFFICE-BASED MEDICAL CARE EXPENDITURES, 1987

This article compares national estimates of utilization of and expenditures for dental care and office-based medical care. The comparison includes respondents in several socioeconomic and demographic categories. The focus of the analyses is on dental care and office-based medical care utilization during 1987. Specifically, the authors provide national estimates for numbers of dental and office-based medical visits made, expenditures for and sources of payment for each of several socioeconomic and demographic categories using household survey data from the 1987 National Medical Expenditure Survey, or NMES. Data show that out-of-pocket expenditures are greater for dental care than for office-based medical care; that few Medicaid dollars are spent on dental care; that insurance is an important component of dental and office-based medical care; and that dentists provide greater amounts of unreimbursed care than do their office-based physician counterparts. NMES data show that dental care expenditures are considerable, almost as large as expenditures for office-based medical care, and are a significant component of all nonhospital health care expenditures for noninstitutionalized Americans. U.S. dentists provide a significant amount of care. By understanding these analyses, practitioners will be better positioned to provide care and to better meet the dental needs of all Americans.

Denver Health: initiatives for survival.

Denver Health is an integrated public health care delivery system in a highly competitive market. It includes the 911 emergency response system, a 349-bed acute care hospital, a locked forensic unit, ten federally qualified community health centers, ten school-based clinics, the public health department, a 100-bed nonmedical detoxification unit with a nonambulance transport service, and the regional poison control center. The system has several advantages for survival in the current marketplace, including this vertically integrated structure with neighborhood-based, community-oriented primary care, which has been in place for thirty years; a lack of debt; a good physical plant; highquality physicians; and a strong university affiliation. However, like all public systems, Denver Health faces some serious challenges to long-term survival. As a department of city/county government, it previously lacked operational flexibility, having the burdens of city purchasing and civil service and legal constraints. In addition, the Denver metropolitan marketplace has become increasingly competitive over the past two years. Finally, like other public systems, it has an extraordinary burden of unreimbursed care.

Outcome of Cardiovascular Collapse in Pediatric Blunt Trauma

Study objectives: To determine the survival and functional outcome of pediatric blunt trauma victims demonstrating cardiovascular collapse, including pulseless cardiopulmonary arrest or severe hypotension, on initial presentation in an emergency department. Design: Seven-year consecutive case-control series. Setting: Level I trauma center and university teaching hospital. Participants: Two thousand one hundred twenty consecutive pediatric victims of blunt trauma less than 16 years old admitted to a Level I trauma center from August 1984 through December 1991 had a mortality of 5.2%. Thirty-eight patients (1.8%) demonstrated pulseless cardiac arrest or severe hypotension (systolic blood pressure of 50 mm Hg or less) on initial presentation in the ED. Interventions: All patients received basic and advanced life support consistent with guidelines published by the American Heart Association, American Academy of Pediatrics, and American College of Surgeons. Measurements and main results: Survival, functional outcome, and donor status were reviewed. Outcome of ED resuscitation (death or reanimation), post-ED destination (morgue, operating room, or pediatric ICU) length of hospitalization, functional outcome after hospital discharge, time to death (time from admission to ED to declaration of death), cause of death, total hospital costs, total hospital charges, and organ donation were reviewed. There were no functional survivors among 38 pediatric victims of blunt trauma who presented to the ED in pulseless cardiac arrest or with severe hypotension. Eleven of the 12 patients who were transferred to the pediatric ICU died; the single survivor demonstrated profound neurologic impairment six years after hospitalization. Six of these 12 patients were eligible potential donors and resulted in four multiorgan donors during the seven-year study. The mean hospital unreimbursed care for the 38 study patients was $3,514 per patient. Conclusion: No child who presented with pulseless cardiac arrest or severe hypotension following blunt trauma achieved functional survival. Reimbursed care for pediatric victims of blunt trauma demonstrating cardiovascular collapse is disproportionately poor compared with that for pediatric patients who maintain hemodynamic integrity in the ED. Half of all patients who were stabilized sufficiently for transfer to the pediatric ICU were eligible potential organ donors. Therefore aggressive resuscitation of these patients may be justified if organ donation is seriously contemplated and aggressively pursued. [Hazinski MF, Chahine AA, Holcomb GW III, Morris JA Jr: Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med June 1994;23:1229-1235.]

EMERGENCY DEPARTMENT THORACOTOMY IN CHILDREN

Although emergency department (ED) thoracotomy is performed only in selected adult trauma victims, it continues to be widely used in children. To evaluate if use of this liberal policy is justified in children, the charts of 23 pediatric trauma victims who underwent ED thoracotomy at our institution in the past 5 years were reviewed. Mechanism of injury was blunt trauma in 65% and penetrating injury in 35%. Optimal field care was provided, with the majority (74%) of these patients having had intubation and vascular access achieved in the field and transported within 10 minutes to the trauma center. Thoracotomy and open cardiac massage were performed within 5 minutes of arrival in the ED. Despite this aggressive management, only one child (4.4%) survived to discharge, although transient restoration of spontaneous circulation (RSC) was achieved in four (17.4%) children. There were no survivors in the blunt trauma group. All patients with penetrating trauma who had no vital signs in the field died. The cost of ED thoracotomy was $2,740 +/- $214; however, the total hospitalization charges per patient averaged $14,848 +/- $1,724. Forty-six percent of total charges were reimbursed, and financial loss to the hospital per patient was $6,448 +/- $1,441. This study demonstrates that children who arrive at the ED following blunt or penetrating trauma with no cardiac rhythm are unsalvageable and should not undergo ED thoracotomy. The burden of unreimbursed care for this procedure is not trivial. Indications for ED thoracotomy in pediatric trauma victims should therefore be the same as those currently used for adult trauma victims.

Policy, Politics, Health, and Medicine: A Marxist View

Policy, Politics, Health, and Medicine: A Marxist View

Controversial issues in home health care: a roundtable discussion

Controversial issues in home health care (HHC) were discussed by a panel of four individuals involved in or knowledgeable about HHC. The panel addressed the following issues: reluctance of health professionals to participate in home care, challenges in providing HHC services, assigning responsibility for HHC services, reimbursement considerations in joint-venture arrangements, assuming fiscal responsibility for unreimbursed care, selecting HHC providers, defining patient rights, selecting drug products for home-care patients, competing with community pharmacists, circumvention of pharmacist input in preparation of solutions for home infusion, and the future of HHC. Hospital pharmacists who plan to become involved or are already involved in providing HHC services should become familiar with these controversial issues.