Slow growth in charity care. Rise in uncompensated-care spending slowest since '86.
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Charities↗
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State trends in hospital uncompensated care.
In recent years hospital uncompensated care has been declining in the seven states studied here: California, Florida, Washington, Connecticut, Maryland, New Jersey, and New York. We document these declines and compare trends in uncompensated care in safety-net and other hospitals between the early 1980s and the early to mid-1990s. We discuss state responses to deal with the declines in hospital uncompensated care and their likely impact on the observed trends.
California↗
Altruism or moral hazard: the impact of hospital uncompensated care pools.
Empirical evidence from New Jersey supports theories of hospitals altruism. From 1987 to 1992, New Jersey reimbursed hospitals for uncompensated care through the Uncompensated Care Trust Fund. The Trust Fund reduced the shadow price of charity care, inducing hospitals to increase their provision of uncompensated care. Hospitals increased inpatient uncompensated care by an average of 14.8% and statewide uncompensated care increased by $360 million during 1987-1990. Empirical evidence suggests that the state effectively addressed the moral hazard problem created by the Trust Fund by auditing uncompensated care and regulating hospital collection procedures.
Altruism↗
How do uncompensated care pools affect the level and type of care? Results from New York State.
Uncompensated care pools have been used by several states in their attempt to aid hospitals and increase the volume of care provided to patients without health insurance. We examined the uncompensated care pool used in New York State between 1983 and 1987. Our primary interest was to estimate the impact of the pools on the level and type of care provided to uninsured patients. Our results indicate that hospitals responded to the pools by increasing the volume of care provided to uninsured patients. Without the pools, over 30,000 fewer adjusted hospital admissions would have been provided to the uninsured in a typical year. Many of these newly purchased admissions were for "nondiscretionary" medical care, suggesting that beneficial care to the indigent was rationed prior to the introduction of the uncompensated care pools.
Charities↗
The supply of uncompensated care in Pennsylvania hospitals: motives and financial consequences.
The need for uncompensated care has increased during a period in which hospitals are confronted with public and private-sector fiscal pressures. Using a panel design (1995--1998) on Pennsylvania private, not-for-profit general hospitals, we found the provision of uncompensated care is positively associated with financial surpluses, the provision of uncompensated care by neighboring hospitals, bed capacity, proportion of outpatient visits that are emergency, and the unemployment rate (a proxy for need for uncompensated care). Other analysis found that the provision of uncompensated care was not associated with operating surplus, except in hospitals that provide very large amounts of uncompensated care. Provision of services to Medicaid patients and HMO penetration had a negative impact on profitability.
Economics, Hospital↗
Hospital provision of uncompensated care and public program enrollment.
Hospital provision of uncompensated care is partly a function of insurance coverage of state populations. As states expand insurance coverage options and reduce the number of uninsured, hospital provision of uncompensated care should also decrease. Controlling for hospital characteristics and market factors, the authors estimate that increases in MinnesotaCare (a state-subsidized health insurance program for the working poor) enrollment resulted in a 5-year cumulative savings of $58.6 million in hospital uncompensated care costs. Efforts to evaluate access expansions should take into account the costs of the program and the savings associated with reductions in hospital uncompensated care.
Adolescent↗
Factors associated with the provision of uncompensated care in Pennsylvania hospitals.
Data from 190 Pennsylvania hospitals in 1995 were used in regression analysis of the determinants of uncompensated care and profitability. Uncompensated care as a percentage of operating expenses was negatively related with hospital size and positively associated with obstetrical services emphasis, emergency visit mix, area unemployment rate, and sole community hospital status. Hospital profitability was not associated with uncompensated care; it was negatively associated with HMO penetration, Medicare and Medicaid share of admissions and religious ownership; and it was positively associated with medium size. Pennsylvania hospitals may have been shielded from the financial burdens of uncompensated care by the availability of funds from other sources that may not be available in the future. Consequently, unless new sources of funding are developed or insurance coverage expanded, financial pressures from providing uncompensated care may cause hospitals to face the dilemma of abandoning uninsured patients or risking financial insolvency.
Health Services Research↗
Do uncompensated care pools change the distribution of hospital care to the uninsured?
In 1983, New York State established an uncompensated care pool using the New York Prospective Hospital Reimbursement Methodology (NYPHRM). Two policy objectives of the NYPHRM were (1) to encourage more equitable distribution of uncompensated care across hospitals and (2) to increase access to hospital care for the uninsured. This article demonstrates that the New York uncompensated care pool was only moderately successful in achieving these goals. The principal findings are that the NYPHRM did result in routine care being redistributed away from hospitals that traditionally provided care to the uninsured, while provision of highly technological care was not significantly redistributed. This article suggests that if the primary policy goal is to increase access to care for the uninsured by changing the distribution of hospitals willing to provide care, the uncompensated care pool approach is moderately effective.
Diagnosis-Related Groups↗
The burden of uncompensated care grows.
It is not surprising that costs for uncompensated care are rising dramatically for most hospitals. What generally has not been understood is that uncompensated care costs are rising faster than overall hospital costs, and government subsidies are failing to keep pace. In addition, the unpaid care problem no longer is being shouldered by one specific group. The facilities seeing the greatest increases in expenditures are those not traditionally associated with uncompensated care--small, non-teaching, non-disproportionate care, and suburban hospitals. Finally, a hospital's commitment to care for the uninsured cannot be predicted by any common classification. This information emerged from an analysis conducted by the Prospective Payment Assessment Commission in an effort to develop a basis for devising options to address the uncompensated care problem.
Economics, Hospital↗
Doing away with uncompensated care of the uninsured.
As more people lose their health insurance, an increasing volume of uncompensated care is absorbing billions of dollars of limited resources of the nation's hospitals, health systems, and other provider organizations. As yet, no provider organization has developed a comprehensive management approach to address this growing problem. Currently, the money spent on uncompensated care is viewed as a drain on institutional bottom lines rather than as a fund dedicated to improving the health of uninsured patients and prospective patients. If an accountable executive were made responsible for managing this problem by paying for all of this care on a case-by-case basis as third parties do, uncompensated care could be eliminated. Payment for each case would come from the institutional resources no longer required for uncompensated care. There is reason to hypothesize that with effective management, a significant amount of the resources currently absorbed by uncompensated care could be shifted from excessive inpatient care to more productive, innovative community initiatives. This paper outlines a six-point management program designed to increase the income and decrease the expense currently associated with uncompensated care, while improving quality, patient satisfaction, and outcomes. The program can be carried out by an individual provider organization, or as a collaborative program involving two or more organizations. Recommended are demonstration projects to test the feasibility and net cost or cost savings of such an approach, preferably starting in one-hospital towns.
Community Health Services↗
Access to emergency medical care: emergency physicians and uncompensated care. American College of Emergency Physicians.
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Cost Control↗
Sorting the financial issues in special patient care: the problem of uncompensated care.
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Dental Care for Persons with Disabilities↗
Uncompensated care provided by emergency physicians in Florida emergency departments.
Uncompensated emergency department (ED) visits can negatively affect patients, clinicians, and hospitals, particularly as overcrowding occurs. Florida provides a unique market to analyze uncompensated ED care due to the high percent of for-profit hospitals, which typically provide significantly less uncompensated care, coupled with the older population that is more likely to be insured through Medicare. A survey of 188 Florida hospital emergency physician groups was conducted to estimate the level of uncompensated care provided by each ED physician group in 1998. The response rate was 44 percent (eighty-three ED physician groups). All ED physician groups provided substantial uncompensated care regardless of hospital ownership type. Uncompensated care averaged 46.8 percent and ranged from 25.8 to 79.4 percent. A model was developed to predict the amount of uncompensated care using ED volume and payer mix. A rise in the percent of self-pay patients causes a disproportionate increase in uncompensated care, such that EDs with high levels of self-pay visits have markedly higher uncompensated care rates. The results suggest the need for a uniform reporting method of ED physician uncompensated care cost.
Data Collection↗
Medicaid expansions for pregnant women and infants: easing hospitals' uncompensated care burdens?
Hospitals' bad debt and charity care increased by nearly 30% between 1987 and 1990. However, beginning in 1987, federal legislation expanded Medicaid eligibility to pregnant women and infants with family incomes up to 133% of the federal poverty level, and gave states the option to extend coverage up to 185% of poverty. These expansions likely reduced the need for free hospital care. Controlling for other factors associated with provision of uncompensated care, this analysis shows the Medicaid expansions reduced uncompensated care by roughly 5.4%. For hospitals with a significant commitment to maternity and infant care, the burdens of uncompensated care were 28.5% lower than they would have been without the expansions.
Economics, Hospital↗
Public insurance substituting for private insurance: new evidence regarding public hospitals, uncompensated care funds, and Medicaid.
This paper examines the impact of public health insurance programs, whether structured as subsidies to health care providers (public hospitals and uncompensated care reimbursement funds) or as direct insurance (Medicaid), on the purchase of private health insurance. The presence of a public hospital is associated with a lower likelihood of private insurance for those with incomes between 100-200% and 200-400% of the poverty level. Uncompensated care reimbursement funds were associated with less purchase of private health insurance and a higher likelihood of being uninsured across all income groups. More generous Medicaid programs showed both safety-net and crowd out effects.
Hospitals, Public↗
Uncompensated care and hospital conversions in Florida.
Hospital conversions to for-profit ownership have prompted concern about continuing access to care for the poor or uninsured. This DataWatch presents an analysis of the rate of uncompensated care provided by Florida hospitals before and after converting to for-profit ownership. Uncompensated care declined greatly in the converting public hospitals, which had a significant commitment to uncompensated care before conversion. Among converting nonprofit hospitals, uncompensated care levels were low before conversion and did not change following conversion. The study suggests that policymakers should assess the risk entailed in a conversion by considering the hospital's historic mission and its current role in the community.
Florida↗
Uncompensated care. Balancing on a thin fiscal line.
Uncompensated care affects every hospital in Texas--and threatens the very survival of some. As the volume of uninsured services grows, and the question of who will pay for those who cannot remains largely unanswered, hospital administrators are left to perform fiscal balancing acts. Health Texas visited with three hospitals that typify the serious problems uncompensated care poses for the health care industry.
Acquired Immunodeficiency Syndrome↗
Restrictive reimbursement policies and uncompensated care in California hospitals, 1981-1986.
To examine the effect of restrictive state, federal, and private hospital reimbursement policies in California, we examined trends in uncompensated care and other deductions from hospital revenues from 1981 to 1986. During a period when the number of uninsured in California increased substantially, uncompensated care grew, but not as rapidly as other deductions from revenue, especially Medi-Cal and private-sector contractual allowances. A trend toward redistribution of uncompensated care from public to private hospitals reversed. Voluntary teaching hospitals, whose Medi-Cal and private-sector contractual allowances grew rapidly, recently reported a decline in uncompensated care. As reimbursement pressures increase, private hospitals may resist pressures to provide uncompensated care, increasing the burden on public institutions and perhaps limiting the access of indigents to quality care.
California↗