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How Far Will the Safety Net Stretch? Providers to the Uninsured

How Far Will the Safety Net Stretch? Providers to the Uninsured. Research Team Carol Murry, Health Policy D. William Wood, Sociology Heather Young Leslie, Anthropology J.D. Baker and Jin Young Choi, Graduate Assistants. Third Technical Workshop – May 23, 2003

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How Far Will the Safety Net Stretch? Providers to the Uninsured

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  1. How Far Will the Safety Net Stretch? Providers to the Uninsured Research Team Carol Murry, Health Policy D. William Wood, Sociology Heather Young Leslie, Anthropology J.D. Baker and Jin Young Choi, Graduate Assistants Third Technical Workshop – May 23, 2003 This research is funded in part through a U.S. Health Resources and Services Administration State Planning Grant to the Hawaii State Department of Health, Prime Contract No. 1 PO9 OA 00046-01. Sub-contract to Research Corporation of the University of Hawaii, Project No. 659075. Research conducted by University of Hawaii, Social Science Research Institute in collaboration with the Hawaii State Department of Health,Hawaii Institute for Public Affairs/Hawaii Uninsured Project and the Hawaii Health Information Corporation.

  2. Purpose of Provider Interviews • Introduce voices and recommendations of providers to the policy-making process • Inform quantitative analyses and policy-makers of possible meanings and implications of findings • Impact on individuals, families, safety net facilities and providers. • Who pays and what are the costs?

  3. Methodology: • Multiple Methods • Long, semi-structured interviews • Recorded field interviews on 5 islands • Summarization and computerization of all interviews • Transcription of selected interviews • Qualitative analysis using ATLAS/ti software to ease coding and model building based on grounded theory

  4. Community health centers HHSC Hospitals Private Hospitals Dental Vans Care-a-Vans Private Provider Offices Pharmacy Social Service Agencies Student Health Service HIV Service Agency Mental Health Clinic Native Hawaiian Health System Youth Outreach Program Beach & Park Outreach Multiple Voices:Safety Net Facilities

  5. Medical Doctors Doctor of Osteopathy Nurse Practitioners Certified Nurse Assistant Outreach Workers Dentist Dental Assistant Billing Managers District Health Officers Executive Directors Benefits Case Managers Hospital Administrators Pharmacist Social Workers Public Health Nurses Psychiatric Nurse Spec. Native Hawaiian Healers Multiple Voices: Providers

  6. Provider Interviews by Island

  7. Provider interviews by type facility

  8. Results What we’ve found so far…

  9. Impact on Safety Net Facilities • Losing money - patient can’t qualify for QUEST and can’t pay • Medicaid and Medicare reimbursements too low • Must raise funds to cover uncompensated care • Cannot turn away (EMTALA) • Must serve in lieu of missing services

  10. Impact on Providers • Angry, crying, can’t sleep • Ability to diagnose is limited • Wasted time discussing cost and finding alternate RX • Provide pro bono care • View job as “calling” • Must modify treatment

  11. Impact on patients • Depressed, frustrated, angry • Can’t afford drugs • Harassed for payment • Few choices for care • Poor outcomes

  12. Safety Net Policies and Programs • Don’t turn anyone away • Sliding scale • Free care, especially dental • Free drugs • Rural health grant for uninsured • Charity care

  13. What do providers need from system? • Affordable coverage • Cover drugs, lab, x-ray,pre-existing conditions • Ease QUEST bureaucracy, solve problems • More community health centers, free clinics • Let patients pay small amounts over time • Health promotion, disease prevention

  14. Native Hawaiian • Loss cultural identity is risk factor • Poor health indicators • Niihau patients may lack docs, English • Native Hawaiian health system • Access to land and water impacts health • Spirituality important to indigenous healing

  15. Caring for uninsured diabetics • Patients avoid clinic because of debt • Avoidable complications, e.g. amputation lead to more expensive care • Patients don’t take needed drugs - can’t pay

  16. Uninsured and Disabled • Even providers don’t understand spend-down • Call system abysmal • Advise patients not to apply for disability unless no choice • Provider believes patient died due to problems with system

  17. The Dilemma of who pays: Creative Solutions • Intense assistance for QUEST enrollment • Help patient plan how to pay bill • Aggressive collection • Encourage divestment of assets • Reverse mortgages • Proactive about guardianship and advance directives

  18. The Ultimate Costs of Uninsurance • Families suffer. Children’s lives are impacted. • Two doctors believe their patients died as a result of being uninsured. • Safety net providers are set up as providers of last resort. Who pays? We all do – the uninsured, providers, and all the rest.

  19. Providers Recommend to Work Groups • Revise eligibility criteria and simplify QUEST • Create low-cost coverage options • Examine charges • State should contract for lab, x-ray, drugs • Universal coverage • Cover preventive care, long term care • Address retention, underinsurance, CFA

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