The health care conundrum: Providing access to the uninsured while balancing costs

Wisconsin Medical Journal, Vol. 104, No. 8, 2005

By Christy Mokrohisky, MBA and Donald C. Logan, MD

Who deserves access to health care? If we agree everyone deserves medical care, who bears the responsibility of paying for care for the uninsured and underinsured?

In this article, we will address the financial impact that the uninsured have on the health care delivery system and outline the efforts of Dean Health System to offer quality care to the uninsured through innovative programs and community partnerships.

Delivery health care is a balancing act of providing access to quality care and managing costs. Today, the debate primarily relates to cost concerns. Health care professionals feel boxed in by lower reimbursement rates. Employers, facing rising health care costs for their employees, are making tough decisions about their ability to offer their employees affordable health insurance. Yet it may be the patient, paying more out-of-pocket expenses than ever before, who feels the sharpest sting of rising health care costs.

And the costs show no signs of slowing, especially given the growing number of uninsured and underinsured in America. Access to affordable health care is an issue that hits home to our nation's 45 million uninsured (see sidebar). The number is staggering to most of us in the health care industry.

Even more daunting than the number of uninsured is the way in which they access health care. The uninsured often use emergency departments as their primary care homes. They need more sophisticated and expensive care because they postpone diagnosis, delay needed tests, and often don't have enough money to fill their prescription medications, according to the Center for Studying Health System Change.

As a nation, we need to identify the consequences of caring for a population that does not have access to preventative health care. As physicians and administrators, our challenge is not simply providing access to care for the uninsured, it is providing more efficient and cost-effective care.

Who Bears Financial Responsibility?

Health care professionals are being asked to bear a substantial financial responsibility for patients who do not have the ability to pay their medical bills. Uninsured patients and those on government programs with low reimbursement rates for services, such as Medicaid, cost health care systems more than they can recover.

Cost shifting occurs when one group of patients pays less than the true cost of their medical care. In order to recover the costs of patients who can't pay, provider systems increase prices for those who can. The result of cost shifting: everyone with health insurance ends up paying more for care.

In the case of the uninsured, the cost of care is transferred to patients with health insurance. Insurance companies manage inflated prices by imparting a great financial load to their members in the form of higher premiums, deductibles, and co-pays. Consequently, higher costs for both the seriously ill and low-income workers create a financial burden they are often unable to absorb, forcing many to enter into the pool of uninsured Americans.

The private and public sectors endlessly debate who is more equipped to manage patient care and curb cost shifting. Discussions of universal coverage and consumer-driven plans are at the heart of those debates. Are additional government programs needed to care for the uninsured or is Medicaid adding to the problem of cost shifting? What is the role of the health care professional community in addressing issues of the uninsured?

Innovative Solutions

Physicians and administrators at Dean Health System engaged in discussions on these topics 12 years ago and established what is known today as Dean's Community Advocacy & Partnerships Department.

This department manages uninsured and other vulnerable patients by teaming up with community organizations and delivering programs tailored to the individual needs of our patients. The programs have won local and national awards for innovative solutions to advance health care delivery and improve community well-being.

Here is an overview of some of Dean's programs:

  • Community Care is a health benefits counseling program that helps uninsured and underinsured patients obtain assistance through programs such as Badger Care, Emergency Medical Assistance, and Social Security Insurance. Patients who don't qualify for public assistance may receive free or reduced-cost care through Community Care's write-off program. Writing off bills for qualifying patients fits with our organization's mission to improve the health of our community. It also makes good business sense. In addition to transferring bad debt expenses to charity care write-offs, Community Care brings in revenue by billing out more charges to public assistance programs than we write off as charity care.
  • Prenatal Care Coordination uses outreach and early intervention to significantly increase the likelihood that vulnerable pregnant patients will deliver healthy babies. A registered nurse coordinator contacts each patient referred to the program to determine individual needs such as transportation, child care, and smoking cessation programs. It's a win/win situation: Patients receive ongoing prenatal care, and physicians report a healthy decrease in the number of "no-shows."
  • The Neighborhood Asthma Clinic is a collaboration between Dean Health System, Dean Health Plan, St. Marys Hospital Medical Center, and the Dean Foundation. The clinic helps break down the barriers underserved residents face by providing screening, diagnosis, education, and treatment of asthma at no cost to the patient. In 2004, 82% of patients at the Asthma Clinic felt their asthma had improved or stayed the same; 60% of patients had not gone to an emergency department for asthma treatment since their last visit to the Asthma Clinic. Partnerships like this provide efficient and cost-effective care.
  • Dean Neighborhood OB/GYN Clinic is a community-based clinic assisting mostly uninsured and underinsured patients. The clinic has implemented Shared Medical Appointments (SMAs) as an alternative to traditional office visits. SMAs allow women to see their physician with other patients with similar medical conditions. Patients have a private exam, spend time in a group with their physician, and benefit from the questions and comments of other patients in a group discussion.
  • Neighborhood Child Health Clinic is a collaboration of private and public health care professionals who partner to bring free physician exams and other screenings including immunizations, hearing, vision, dental, and lead testing six times a year to area children in low-income neighborhoods. Of the children served in 2004, 64% were uninsured.

Health care professionals will continue to feel the impact of the uninsured on our individual patients and our businesses. Although concerns of access, cost, and quality related to the uninsured are too big for any health care system to tackle on its own, there is a role for health care professionals in managing patients in our communities who lack health insurance.

One Third of Americans are Estimated to Be Uninsured or Underinsured

  • 45 million Americans are uninsured according to the 2004 US Census report. In Wisconsin, about 6% of state residents are uninsured.
  • Eight of 10 uninsured individuals come from families where there are working adults. Nearly 50% of all uninsured workers are either self-employed or work for firms with fewer than 25 employees. These numbers shatter one of the most common public misperceptions: that the uninsured are unemployed or choose not to work.
  • Those at the highest risk of being uninsured include the poor, young adults, those living in southern and western states, minorities, and noncitizens. Nearly two-thirds of the uninsured come from low-income families (less than $30,000 for a family of three).
  • 80 million Americans are estimated to be underinsured, owning policies that don't cover comprehensive health care needs.

Unless otherwise noted, data is from the Kaiser Family Foundation.