Holly Barnett and Dr. Erin Maughan, College of Nursing
Utah currently offers several government-funded insurance programs to help insure its residents who would otherwise go without. Despite the implementation of these programs, 18.9% of adults and 10% of children live in Utah without medical insurance (MSNBC Interactive, Utah Department of Health). This group of uninsured adults and children are at greater risk for delayed care, resulting in an increased likelihood for advanced illness and, therefore, decreased health (Ayanian et al, 2000). For this reason, it is important to identify those Utah residents not covered under a medical insurance policy and connect them with the proper programs. The hospital is an appropriate location to find Utah’s uninsured residents because between 21-40% of emergency room (ER) patients do not have medical insurance (Cunningham, 2006). One reason for such high rates of uninsured patients is due to the Emergency Medical Treatment and Active Labor Act of 1986 which mandates uninsured patients cannot be turned away from the ER without treatment.
I wanted to know the methods which were implemented by the hospitals to help uninsured patients find insurance and the effectiveness of those methods. Two hospitals in Salt Lake City, Utah were chosen for this research because of their similar size and patient census. My plan was to evaluate their different methods and outcomes individually and then compare the two hospitals. One of the hospitals, however, did not have a written protocol for how patients without insurance were given insurance counseling for the time period I was studying. This hospital was excluded from the study, but has reorganized its patient access system since then and may be a good candidate for this research in the future. Only one hospital was used for this study.
At the selected hospital, a financial counselor is notified of each uninsured patient’s admittance and approaches the patient to offer financial counseling. Insurance applications and other paperwork is often completed while the patient is still in the hospital. For this study, data was extracted from financial counseling records of fifty patients who entered the hospital without insurance coverage. Of these fifty records, the following trends were discovered. The highest number of uninsured patients were admitted to the hospital through the emergency department (36%), followed by physician referrals (34%) and labor and delivery or newborn admittance (26%). Only 4% of the uninsured patients evaluated were admitted as a transfer from another facility. 74% of these uninsured patients were approached by a financial counselor while still in the hospital while 26% of these patients left the hospital without having spoken with a financial counselor. It took over 24 hours for the financial counselors to receive notification of the patient’s admittance for 30% of these uninsured patients. This amount of time would pose problems for those patients with short hospital stays. Of the patients who were contacted by a financial counselor while in the hospital, 21.6% were contacted 48 hours or more after admittance. Of those contacted before 2 days, it took an average of 25.2 hours for a financial counselor to meet with the patient.
Financial counselors routinely evaluated patients for Medicaid. Forty-five (90%) of the uninsured patients were evaluated for and/or applied for Medicaid. Only five patients were evaluated for additional insurance programs different from Medicaid. Four patients have no record of being evaluated for any insurance programs. Of those patients who applied for insurance (43), 60.5% were accepted. Acceptance for insurance was highest among the young. Patients under 18-years-old (10) were accepted 90% of the time while patients 18-years-old or older (33) were only accepted 51.5% of the time. There was also a higher acceptance rate among patients of Latin/Hispanic descent (77.8%) compared to white/caucasion descent (50%).
Acceptance rates varied depending on the reason for hospitalization. The two patients admitted especially for physical rehabilitation were accepted for insurance while the two patients admitted for psychological reasons were not accepted for insurance coverage. Patients admitted for labor and delivery and newborn care were accepted for insurance at a high rate of 87.5%, patients with general medical or surgical needs were accepted at a rate of 47.06%, and patients with trauma or burns were accepted at a rate of only 33.3%. Since the majority of the patients who applied for insurance were applying for Medicaid, these rates help describe what type of patient Medicaid will insure, keeping in mind Medicaid’s tendency to cover chronic disability, families with children, and pregnancy. Another notable trend in insurance acceptance rates deals with how the patient was admitted. The patient who was admitted through the Labor and Delivery or Newborn units had a much a higher chance of being accepted for insurance (83.3%) than the patient who was admitted through the emergency department (33.3%).
Part of my research is to evaluate the financial burden associated with unisurance for patients and hospitals. On average, each patient who entered the hospital without insurance (excluding one patient whose insurance application is still pending) had $3,098.25 out-of-pocket expenses. The out-of pocket expense rose to $8,930.25 per patient when including only patients not accepted for insurance coverage (17). The average charity discount given to all 49 patients was greater than the average amount of patient expenses, equaling $5,016.07 per patient. When unpaid bills were included, hospital expenses rose to $7,924.31 per patient. This means that the hospital can expect to lose almost $8,000 for each uninsured patient admitted, even with the financial counseling system in-place. Of patients who entered the hospital without insurance, 32.7% (16) had a portion of their bill that was never paid and was classified as “bad debt”.
Though Medicaid is a great resource and helped cover several hospital bills in this study, many uninsured patients still do not qualify for its coverage and remain uninsured. While in the hospital, patients should be evaluated for additional insurance programs and given counseling on what other insurance options they have.
References
- Ayanian, J.Z., Weissman, J.S., Schneider, E.C., Ginsburg, J.A., & Zaslavsky, A.M. (2000). Unmet health needs of uninsured adults in the United States. Journal of the American Medical Association.
284(16), 2061-2069. - Cunningham, P.J. (2006). What accounts for differences in the use of hospital emergency departments across U.S. communities? Heath Affairs –Web Exclusive. Retrieved October 27, 2006, from http://content.healthaffairs. org/cgi/reprint/hlthaff.25.w324v1?ijkey=ufo2ov5OC4Q4s&keytype=ref&siteid=healthaff
- MSNBC Interactive. (2005). Emergency room visits reach record high. Retrieved October 27, 2006 from http://www.msnbc.msn.com/id/7995137/
- Utah Department of Health (n.d.). 1 in 10 Utah children are uninsured. Retrieved October 27, 2006, from http://health.utah.gov/chip/Adobe%20PDF%20Files/1%20in%2010%20Utah%20Children%20Are%20Uninsured%208-05.pdf