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PubMed1984

Provider participation in competitive bidding for indigent patients.

In this analysis of provider decisions in bidding for indigent medical care contracts, a general conceptual framework is developed where each provider bid is associated with a series of decisions and uncertain events that define a set of possible outcomes. The uncertainty surrounding probability and outcome estimates and the variation in provider objective functions lead to bidding behaviors that can vary widely across providers. The general framework is then applied to a discussion of the bidding strategies employed in the Arizona experiment by four different types of bidders. The article concludes with a discussion of state actions that can reduce provider uncertainty in the bidding process.

Arizona↗
PubMed1979

The status of aid to the medically needy.

Medical indigence, as incorporated in Medicaid legislation, is official recognition that medical expenses are frequently large and often unpredictable, and that the consequences of not using needed services because of their cost can be serious. Under the law, states may make eligible for medical vendor payments people whose incomes, while sufficient for the normal expenses of living, are not large enough to cover the costs of medical care. States which choose to do so may enroll people for Medicaid benefits whose incomes are as much as 133 1/3 percent of the eligibility level for cash grants to families of comparable size under the state's program of Aid to Families with Dependent Children (AFDC). Of fifty jurisdictions with Medicaid programs, twenty-one have decided not to include the medically indigent. Of the remaining twenty-nine, ten have set eligibility at levels less than the figure at which an AFDC family would begin to receive cash income maintenance grants, and twenty-two have set them below the maximum permitted by federal law. Similar figures are presented for the aged showing that twenty states have set eligibility levels below that for the Supplemental Security Income program. Thus, the concept of medical indigence has been eroded by eligibility decisions in more than half of the states, although it remains important, especially for the elderly with large expenses for long-term care.

Eligibility Determination↗
PubMed1989

Promotion of patient appointment compliance in indigent pediatric medical care by use of a microcomputer.

A computerized system for appointment scheduling, medical record keeping, medical billing, patient tracking, and epidemiologic data generation was developed and applied in an indigent pediatric otologic clinic. Functions used to augment appointment compliance are 1) notifying the referring physicians, agencies, and health department coordinators of failed appointments and sending medical information on the attended appointments, 2) listing patients who failed appointments, 3) production of mailings for failed appointments, 4) automatic rescheduling of failed appointments, and 5) automatic calculation of patient attendance ratios. The attendance ratio can be used to help identify patients for referral to social service workers and to implement rewards designed to promote medical compliance. The automatic rescheduling of failed appointments resulted in 21% of new patients and 30% of return patients above controls returning for a medical visit. The recalled had much lower economic status than our average clinic patient, ie, the system was effective in reaching the target population.

Ambulatory Care Information Systems↗
PubMed1996

Academic medical centers and the care of underserved populations.

As the number of Americans at risk of being underserved continues to rise, a better understanding of safety-net providers of health care is needed to help ensure continuing care for the underserved. In this article, the authors have begun the process of defining the role of academic medical centers (AMCs) as a group in the care of those persons most at risk of being underserved--the medically indigent and members of minority and poor populations--by quantifying the amount of inpatient care that AMCs provide to these individuals. The study went beyond previous work by using nationally representative sources of data (from 1989 to 1994) and by examining more than one underserved population rather than only the medically indigent. The study focused on AMCs and other hospitals in urban areas and excluded hospitals in rural areas. The detailed findings confirm previous observations that urban AMCs of all types provide a large and disproportionate share of care for the medically indigent and the underserved members of minority and poor populations and that members of these populations constituted the majority of patients cared for in many AMCs in recent years. The findings show that the proportion of patients from underserved groups admitted to all urban hospitals is rising and that this growth is faster among AMCs than other hospitals. The authors comment that AMCs, because of their prominent and historical role in caring for the underserved, have the opportunity to lead efforts to continue such service through innovative approaches to health care and the prevention of illness. Whether AMCs can seize this opportunity when confronted by price competition and government policies that reduce AMCs' capacity to care for the underserved remains to be seen.

Academic Medical Centers↗
PubMed2000

Utilization of health care services among adults attending a health fair in South Los Angeles County.

A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 +/- 2.2) than those who did (8.0 +/-2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care.

Adolescent↗
PubMed1991

State-Aid Cancer Clinics: treatment and follow-up services for indigent patients.

State-Aid Cancer Clinics in South Carolina provide outpatient services for medically indigent patients who have a diagnosed cancer or a suspicious Pap smear and who are referred by a physician. The program pays only for outpatient services provided in one of the nine cancer clinic hospitals. Professional services, transportation and inpatient services are not covered. Although program funds are limited, the State-Aid Cancer Clinics served 3,767 patients in FV 1989; 1,104 of these were new patients and 2,663 were for continuing care. The program's operation is dependent upon the interest and support of the medical profession, particularly those physicians who give of their time and talent without pay to treat the medically indigent patients served in the clinics. This truly is a unique partnership in which the public and private sectors share a common goal of reducing unnecessary mortality and morbidity associated with cancer in South Carolina.

Ambulatory Care↗
PubMed1988

Putting vision into practice to meet the needs of the poor.

In 1986 the Sisters of Charity of the Incarnate Word, a multi-institutional system based in Houston, established specific mission objectives for all its healthcare facilities to meet the challenge of caring for the medically indigent in their communities. In response, St. Michael's Hospital, Texarkana, AR, established the Medical Indigent Committee to develop project proposals. To gain approval, proposals had to meet criteria established by the Sisters of Charity corporate office. These were consistency with mission, evidence of need, operational feasibility, and financial feasibility. The committee's first task was to collect information on the health status of the poor in its service area. Based on their findings, the committee decided to target the elderly and the very young for programs. After some brainstorming sessions, the committee developed three proposals: 1. Home Care Skills. 2. Pulmonary Rehabilitation Program. 3. Sick Child Clinic. By the end of 1986 the first two proposals were approved and funded; the Sick Child Clinic was not, because of operational concerns. The hospital offered the first Home Care Skills course in June 1987 and repeated it later that year. The 16-hour program proved so successful that the hospital is now considering having the class videotaped. The Pulmonary Rehabilitation Program began in May 1987. Although the hospital has not yet determined whether it has achieved its goal of reducing readmissions for poor patients with chronic obstructive pulmonary disease, program attendance exceeds that of other classes by more than 50 percent.

Arkansas↗
PubMed1991

Loss of Medicaid and access to health services.

In this article, the authors assessed the effects of the loss of Medicaid eligibility on access to health services by the medically indigent population in two California counties. An historically derived baseline of health services received by each county's medically indigent adults under Medicaid was compared with the volume of services provided by the county to the same population after they lost Medicaid eligibility. The baseline figures were used as an "expected" volume of services which can be compared with the actual, or "observed," volume of services. The analysis found fewer hospital discharges than expected in Los Angeles and much fewer outpatient visits than expected in Orange County, suggesting that these groups experienced substantial reductions in access related to loss of Medicaid eligibility.

Ambulatory Care↗
PubMedDate not supplied

Changing patterns of obstetric practice in Washington State: the impact of tort reform.

Rapidly rising malpractice premiums have profoundly altered patterns of obstetrical practice. In the summer of 1986, the state of Washington enacted major tort reform legislation intended to stabilize the costs of liability insurance. Following passage of the legislation, we surveyed obstetricians, family physicians, and midwives in the state to assess the likely impact of tort reform on future practice patterns. Largely because of malpractice concerns, 40% of family physicians, 15% of obstetricians, and 27% of midwives had discontinued obstetrical practice. Although obstetrical participation has decreased most dramatically for family physicians, the mean number of deliveries per physician has increased to the extent that the proportion of deliveries attended by family physicians has remained stable at about 30%. However, as fewer family physicians practice obstetrics, the availability of care has diminished in rural areas. The passage of tort reform legislation has induced one-third of those respondents currently practicing obstetrics to at least temporarily continue to practice obstetrics. Despite tort reform, however, the majority of respondents either do not provide or ration care to the medically indigent. The major deleterious social impact of the professional liability problem is reduced access to care in rural areas and a severe curtailment of care to the medically indigent. Tort reform alone will not solve these problems.

Family Practice↗
PubMed1988

DRG calculation and utilization patterns: a review of method and policy.

This paper examines methodological and policy issues of interest to medical geographers who use diagnosis-related groups (DRGs) in their research. Methodological issues are studied in terms of the calculation of DRGs and variation in the utilization of surgical and medical DRGs. It is argued that a shift to a single DRG price system should first address the (i) regional disparities that currently exist and the need for large-scale indices of medical wages and labor costs; (ii) severity of illness measurements other than the present nominal ones; and (iii) wide variation among medical versus surgical procedures. The Department of Commerce's Economic Analysis Area is recommended to remedy the problem of geographic scale. Policy issues of interest to medical geographers center around the shift to greater hospital specialization which is likely to continue across the country. Inner-city, rural and teaching hospitals may continue to be inadequately reimbursed by DRGs, treat more medically indigent, or both. Medical geographers should be aware of the policy and methodological issues involved not only in DRGs, but in proposed prospective payment systems for ambulatory and long-term care.

Aged↗
PubMed1989

The search for solutions to the indigent care crisis.

Providing care to the medically indigent is draining the financial resources of many hospitals. While a unified plan has yet to emerge from Congress, several proposals are being considered. These range from expanding Medicaid to requiring that employers provide a minimum level of healthcare benefits to employees. Meanwhile, states have begun to cope with the problem on their own. Special taxes, lotteries, supplements, and universal insurance plans are among the solutions being tested. Despite these efforts, the question of who will pay for those who cannot remains largely unanswered.

Economics, Hospital↗
PubMed1993

Changing characteristics of schizophrenic patients admitted to state hospitals.

OBJECTIVE: Characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 were studied to examine changes in the demographic profile of the patient population and in principal sources of payment for hospitalization over the study period. METHODS: Information on patients' demographic characteristics and principal payment sources was obtained from a nationally representative data base compiled about every five years by the National Institute of Mental Health. RESULTS: Among schizophrenic patients admitted between 1970 and 1986, the proportion of African-American males increased. By 1986 patients were less likely to pay for care through private insurance or their own resources. They were more likely to receive Medicare and to lack medical insurance. Medicare use increased largely among white patients, and medical indigency largely among African-American patients. CONCLUSIONS: Changes in the characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 may be related to changes in nosology, in the prevalence of schizophrenia, and in the types of patients likely to be admitted to state hospitals. The increase in the number of medically indigent patients accentuates the need for more adequate finding of state hospitals.

Adult↗
PubMed1999

Shifting the costs of indigent care back to county governments.

Despite a decade of steadily rising prosperity, Texans are losing health care benefits at an alarming rate. As many as 41 million people in this country, or 15% of the population, lack health care coverage of any kind. Most of these people are under age 65 and are gainfully employed, but their employers don't provide coverage and/or don't pay them enough to afford it themselves. Most have minimum wage jobs and are ineligible for Medicaid. These individuals plant the gardens, work in fine restaurants, clean expensive houses, and generally benefit the communities in which they reside. Texas law suggests that county governments and property owners should pick up the tab for the medically indigent. However, as the uninsured numbers grow, county governments are finding ways to extricate their taxpayers and the institutions they support from the obligatory role as payer of "last resort" for these people. While reimbursement from government programs, managed care, and commercial insurers is putting tremendous financial pressure on health care providers, the county systems simply are not assuming their financial, legal, or ethical responsibilities for those outside the protective cover of these programs. In my experience, health care for the medically indigent has become "charity care" at the profit and nonprofit hospitals in the state. The strain is palpable in the emergency rooms, where by law the medical crises of the poor must be treated. This de facto safety net is fraying, and our political leaders need to make the painful decision to raise sufficient tax revenues to remove the weight.

Eligibility Determination↗
PubMed1988

Patient compliance with aggressive multimodal therapy in locally advanced breast cancer.

This study of compliance was performed to determine whether a medically indigent population with breast carcinoma that has been neglected is an appropriate group for inclusion in an aggressive combined treatment program. After incisional biopsy, 28 locally advanced breast cancer (LABC) patients received two cycles of cytoxan, Adriamycin, 5-Fluorouracil, and tamoxifen (CAFT) followed by a simple mastectomy and level I axillary dissection. After surgery, patients received four additional cycles of CAFT alternating with three cycles of 15 Gy to the chest wall and regional lymphatics. Compliance was defined as overall compliance, the percentage of patients completing the protocol as described; and appointment compliance, the ratio between treatments or appointments attended versus those scheduled. Overall compliance was 75% (21 of 28 patients). The total number of appointments scheduled was 1054 (mean, 37 +/- 2), and the total attended was 965 (mean, 34 +/- 3), giving an appointment compliance rate of 91.7%. Compliance did not vary significantly with age, marital status, nationality, the presence of complications, or delay to diagnosis. Compliance did decrease significantly with time. There was 100% overall compliance at 2 months, 82% at 6 months, and 75% at 1 year. We conclude that although our patients had neglected their disease and were medically indigent, they were highly motivated patients once in therapy. This suggests that complex treatment regimens are feasible as well as effective for the treatment of LABC.

Adult↗
PubMed1988

Patient dumping in the hospital emergency department: renewed interest in an old problem.

Alarm about the adverse effects of transferring emergency patients for economic reasons has resulted in federal legislation aimed at curbing the practice. We review the history of common law hospital liability for denial of emergency care and analyze the federal legislation designed to restrict the transfer of medically indigent patients with emergency problems. We conclude that the currently proposed solutions to patient dumping will have limited effectiveness without more specific incentives for the provision of health care to the medically indigent.

Emergency Service, Hospital↗
PubMed1991

Access to health care. One neurologist's perspective.

Millions of residents of the United States have difficulty obtaining health care. Barriers impeding access to care include poverty, physical unavailability of health care services, absence of health insurance, and physicians unwilling to care for uninsured patients. Many patients do not successfully use health services because of educational, cultural, and language barriers. A major access barrier is lack of health insurance. Over 30 million people in the United States have none, the so-called medically indigent. Among them are over 3 million people with neurologic disorders. They have additional barriers to overcome because often they cannot work, cannot drive, have difficulty using public transportation, and have major cognitive and communication impairments. Medical and governmental bodies are debating solutions to the health care access crisis. Physicians should actively participate in this national debate. Neurologists should address the special needs of patients with neurological disorders.

Health Services Accessibility↗
PubMed2001

Physicians pulling back from charity care.

Physicians have long provided care to the medically indigent for free or at reduced rates. However, recent findings from the Center for Studying Health System Change (HSC) indicate that the proportion of physicians providing charity care dropped from 76 percent to 72 percent between 1997 and 1999. In the short term, most medically indigent people are still getting care. But policy makers should take note that reduced physician participation in charity care will hurt the poor if-as projected-growth in physician supply slows and the number of uninsured rises along with escalating health care costs. This Issue Brief discusses the extent of the decline in physician provision of charity care, the reasons for the decline and implications for the future of the safety net.

Forecasting↗