American College of Physicians: Internal Medicine — Doctors for Adults ®

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As the uninsured population grows, the health care safety net unravels

From the September 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Over the years, Newark, N.J., urologist Joshua L. Weisbrod, MD, DO, has treated his fair share of uninsured patients. And while he finds charity care a fulfilling part of his practice, he is increasingly frustrated by what he says is a serious roadblock to indigent care.

The problem? Fewer and fewer physicians are willing to volunteer their time to care for the uninsured. Some blame shrinking reimbursements and some say they just don't have the time, but the end result is the same: Needy patients are going without care.

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Dr. Weisbrod, a member of a foundation that recruits physician volunteers, is not alone in facing this problem. Across the country, both public and private programs claim that they are struggling under the burden of too many patients and too little money. The nation's safety net for the uninsured, it seems, is being severely strained.

Part of the problem is one of simple mathematics. With more than 43 million uninsured—and better than 1 million more joining their ranks every year—indigent programs are trying to do more with shrinking resources.

The growing numbers of uninsured are only part of the picture, however. More and more doctors, hospitals and programs are sending a clear message that they have no more free service to spare. Like the physicians in Dr. Weisbrod's area, many providers are feeling pressured by managed care, federal budget cuts and overall belt-tightening. As a result, they are being forced to limit their indigent efforts—or withdraw altogether.

Groups like the College are stepping up their efforts to convince politicians and businesses to expand health care access. (See "College to spend nearly $1 million to make access a campaign issue") But even if such efforts pay off, they require time that many programs—and patients—may not have.

Here is a look at how four programs in the nation's charity care network are struggling to deal with these forces, and some of the setbacks they face.

Stopgap care in El Paso

While lack of health care is a national problem, the highest concentrations of uninsured are clustered in the Southwest, in the states that run along the Mexican border from California to Texas. Nowhere is the problem greater than in El Paso, Texas, where nearly 40% of the city's residents have no health insurance.

At the center of this health care crisis is the Centro San Vicente, a nonprofit organization that runs three primary care clinics. The main Centro clinic is open 12 hours a day during the week—to accommodate the working poor—while one satellite clinic serves the city's homeless and another just outside El Paso treats migrant workers. The majority of clinic patients are uninsured.

Like physicians in indigent clinics across the country, staff physicians at Centro San Vicente find themselves forced to base treatment decisions on financial considerations. When possible, they dole out free drugs provided by drug company assistance programs; when that fails, they frequently prescribe older, cheaper drugs.

Many patients make the short trip to Mexico and purchase discount medications that have been discontinued in the United States, complicating treatment. And patients frequently circumvent modern medicine altogether, using traditional herbal remedies that can mask symptoms and sometimes lead to more acute conditions.

As a result, by the time they turn to Centro's clinics, many patients are seriously ill. Jose G. Calderon, DO, one of the center's six staff physicians, said that the physicians see a high incidence of diabetes, hypertension and hypolipemia—and that they must temper their expectations for patient compliance.

Conditions that would get insured patients hospitalized are routinely managed on an outpatient basis. Dr. Calderon recalled how one patient, swollen throughout his legs and waist from complications of heart failure and emphysema, refused to go to the hospital. "He just didn't want to have that burden of debt," Dr. Calderon said.

Even as the clinics' patients try to put off care for as long as possible, demand for services is sharply on the rise. The number of patients seen at the center's main clinic jumped from roughly 8,000 in 1992 to almost 29,000 in 1998.

In part, the increase is due to local factors. A substantial population of undocumented immigrants lives in El Paso, attracted by jobs that pay more than in Mexico. But because many of the jobs pay minimum wage and offer no benefits, the immigrants find themselves without health care coverage.

Even jobs that pay more than minimum wage often come with no benefits. Like much of the rest of the country, El Paso is booming with new business start-ups. While small businesses have created most of the country's new jobs this decade, they offer benefits only half as often as larger, established companies.

Ironically, in a time of unparalleled economic growth, organizations like the Centro clinics are finding themselves short of funds. The Centro clinics already rely upon federal grants, state and city funding, subsidies from a Catholic religious order and sliding-scale patient fees, but they need more money to meet patient demand.

Administrators are pursuing more grants and federal funding, and they hope to get some financial relief when Texas switches to managed Medicaid later this year. But given the local job market and the growing numbers of uninsured, "resources are getting thinner and thinner," said medical director Jesus Alonzo, MD. "Most definitely, it is a strain on all systems."

Physician goodwill in New Jersey

More than a thousand miles away, Michael T. Hymanson, DO, a gastroenterologist in Woodbridge, N.J., also provides indigent care, but in a very different environment. Instead of working in a clinic, Dr. Hymanson sees uninsured patients in his own office for free.

He is one of 175 private practice physicians who volunteer charity services through the Jewish Renaissance Foundation. The nonprofit Foundation, which is based in Perth Amboy, asks each of its physician volunteers to treat three to five pro bono patients every year, sending patients directly to physicians' offices.

The low number of referrals keeps his practice from being swamped with charity cases, Dr. Hymanson explained. Seeing patients in his office ensures more timely care; he treats urgent Foundation referrals the same day they're made, and fits in other Foundation patients within a week.

Dr. Hymanson likes the Foundation's model because he thinks that patients get better care in private practice than they'd find in a clinic or emergency room setting. "There's more time to address individual problems and to outline a complete program," he said. Some of the 1,600 patients treated by the Foundation since its inception in 1995 have even undergone surgery as part of the program. The Foundation's efforts are part of an estimated $10 billion of uncompensated care provided by American physicians each year. The problem with the model, however, is that it relies on physicians to open their practices to the uninsured through their own goodwill. And in today's managed care environment, physicians are giving away fewer of their services.

The non-profit Center for Studying Health System Change in Washington has found that physicians in small medical groups—particularly part-owners, like Dr. Hymanson—donate more charity services than do employed physicians or those working in larger practices. Center studies have also shown that the more a practice earns from managed care, the less charity care it provides. The corporatization of medicine, it seems, is bad news for patients who don't have health insurance.

At the same time, physicians are struggling with shrinking Medicare and insurance reimbursements, which used to subsidize their charity efforts. The result is that more and more physicians feel they've "maxed out" their ability to donate free care.

It is that burnout that urologist Dr. Weisbrod has encountered as he tries to expand the volunteer physician network to nearby Newark. Many Newark physicians, he's found, have hospital affiliations but have closed their city offices, making the kind of private practice safety net that works around Perth Amboy unfeasible. And many Newark physicians are reluctant to take on more charity care.

"As soon as you start talking pro bono," Dr. Weisbrod said, "you hear, 'Well, 30% or 40% of the patients I see at the hospital are pro bono. I'm already doing enough.' "

Tennessee's shrinking universal coverage

Rather than rely on private efforts, a number of states have tried to solve the access problem with public solutions. In 1994, Tennessee launched its controversial TennCare program, one of only two state attempts at universal coverage. (The other is in Oregon.)

TennCare was based on a simple premise: Take state and federal Medicaid funds and convert that money to managed care payments. By doing so, the state could stretch its health care dollars and cover not only the Medicaid population, but the working poor—individuals who are working but still unable to afford health care—and "uninsurables," individuals with pre-existing conditions like AIDS who are often ineligible for private insurance.

Today, several hundred "uninsurables" receive care at Nashville's Comprehensive Care Clinic, the state's only dedicated facility for HIV/AIDS. The clinic offers patients a wide range of services including case management, clinical trial screening and ophthalmology, as well as help finding housing and support groups. According to medical director Stephen P. Raffanti, FACP, such comprehensive care ensures much better compliance and outcomes. Because of TennCare coverage, that care is available to patients as soon as they're diagnosed.

While physicians in the state have been unhappy with the fees paid by Tenncare, the program has helped extend care to needy populations. "The beauty of the TennCare program," Dr. Raffanti said, "is that it has allowed us to offer really comprehensive, extensive health care coverage to an historically medically indigent population."

Thanks to TennCare, HIV patients in Tennessee don't have to wait until they're disabled or impoverished to get comprehensive care under Medicaid. And unlike typical Medicaid programs that pay for only a few therapies, TennCare covers a full HIV formulary. That enables the clinic to devote its Ryan White Act funds—used in other states to pay for those drugs—to more experimental medications, or other services like dental care. It also frees up funds to treat HIV patients who don't yet meet state residency requirements.

Despite the success of centers like the Comprehensive Care Clinic, however, Tennessee has already begun to roll back its original plan of universal access. Only one year after TennCare began, the state stopped enrolling the working poor. Now TennCare's "uninsurable" enrollment is under fire: Program officials want to suspend enrolling patients with pre-existing conditions, including those with HIV.

Some of the problems are financial. To stretch their funds, state officials are considering limiting benefits and raising premiums, actions that could force more people out of the system.

But another part of the problem, state officials say, is that insurance companies are gaming the system. They charge that insurers are dumping high-risk patients into the TennCare program to avoid having to pay for expensive care.

Whatever the cause, Dr. Raffanti finds the prospect of yanking the TennCare safety net out from under future HIV patients devastating. "Our newly diagnosed and not-Medicaid-eligible uninsured patients will have to rely on Ryan White funds for meds, labs and medical care," he said. "This will exhaust that funding quickly and then I don't know what options will be available. It certainly will be more difficult to provide high quality care."

Cancer care in San Diego

Another cornerstone of indigent care, the nation's hospital system, is also in trouble. While hospitals give an estimated $20 billion of uncompensated care each year, they are now struggling with substantial Medicare cuts. Making matters worse is another trend: the closing of public hospitals. In many cities, private hospitals must now shoulder charity care, without the benefit of local funds often available to public hospitals.

That crunch is being felt in San Diego, which has no county hospital. While hospitals everywhere have been slammed with federal cutbacks, the dozen-plus private hospitals in San Diego face additional pressure from a 70% managed care penetration rate. Faced with many of the same immigrant health care problems present in other border towns, like El Paso, San Diego hospital administrators say that they're close to just breaking even.

The squeeze on San Diego's private hospitals is now being played out in one program for uninsured women. In 1994, California launched its Breast Cancer Early Detection Program (BCEDP) to provide free breast cancer screenings to uninsured women. Almost immediately, however, the program revealed a desperate dilemma: There was no state fund to treat uninsured women who were diagnosed. A year later, a dozen uninsured women with breast cancer in the San Diego area alone remained untreated.

"It was just appalling," said Jon M. Greif, DO, who learned that some women had known their diagnoses for months, with no means to get care. A breast cancer surgeon at Kaiser Permanente in San Diego, Dr. Greif assembled a team of Permanente physicians and treated the 12 patients at a cost to Kaiser of $170,000.

By 1996, funds had been found to treat BCEDP patients, and $12 million paid to the state by Blue Cross/Blue Shield when it adopted for-profit status has since been used to reimburse hospitals and physicians for treating 1,000 uninsured women statewide. Additional funds are expected to pay for treatment through next year, while the California legislature considers bills to establish a permanent state treatment fund.

In San Diego, a handful of hospitals have joined Kaiser to treat the roughly 40 local uninsured women each year who are diagnosed through the detection program. (Dr. Greif at Kaiser continues to operate on a dozen every year.) But while reimbursement is available, some San Diego hospitals are refusing to treat patients from the program. Administrators claim that reimbursement falls too short of actual treatment costs.

"I have had a couple of hospitals that have just denied me, literally the day that surgery was scheduled," said Joanne Thomas, San Diego's BCEDP patient coordinator. "They think they've done enough charity work for the year." As some private hospitals in San Diego refuse to treat indigent women with breast cancer, the load for those hospitals that do extend care just gets heavier.

While the safety net for breast cancer care for the uninsured in San Diego is being strained, it is still holding. The bigger problem, however, is that the program is the only state-sponsored vehicle for uninsured Californians who have cancer. Other patients with different cancers but no insurance are largely left on their own.

"We ask them what they can honestly afford a month, and it may be over 30 years," said Sara Rosenthal, MD, a radiation oncologist in San Diego who treats uninsured patients. "We tell them that's fine—but a lot of our patients don't live 30 years."

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