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Hospitals to reduce costs for uninsured patients

Published December 24, 2003

If you're uninsured and need emergency hospital care in the Tampa Bay area, you have a better chance of getting a discount today than you would have had six months ago.

And in another six months, you may get an even better deal.

Hospitals, stung by media criticism of longstanding billing policies and a pending congressional investigation into their collection practices, are exploring ways to give price cuts to the 43.6-million Americans who have no insurance.

In October, HCA Inc., the nation's largest hospital chain, initiated a sliding scale of discounts for patients with incomes of up to nearly $36,000 for an individual and $73,600 for a family of four. HCA has nine hospitals in the bay area.

And BayCare Health System, with another nine hospitals locally, has raised its charity benchmark, making more uninsured patients eligible for free care. The income cutoff for individuals has gone up to $22,450 from $17,960.

It has long been considered an unfortunate irony in the health care industry that people with the least ability to pay - those without insurance coverage - are the only ones expected to pay full charges for hospital procedures.

Medicare, the federal government's health insurance for seniors, reimburses for medical procedures at a predetermined rate, based on the hospital's location and the patient's diagnosis and level of care. Medicare's payment is often considerably lower than the full charges.

Private insurers and HMOs peg their reimbursements to Medicare, sometimes paying even less than the government program. But an uninsured person, with no insurer or government agency negotiating discounts, has routinely been hit with the full charge, an amount that often seems wildly inflated and out-of-reach for all but the wealthiest. That has produced bills of $5,000 for kidney stone treatment and $80,000 for a heart-valve operation.

Hospitals have blamed the inequity on Medicare, pointing to a Medicare rule that says all patients must be charged the same amount for identical services, even though not everyone actually pays that rate. Medicare wants to make sure that if discounts are given to the uninsured, the cost is not borne by the Medicare trust fund.

The hospital industry has been embarrassed in recent months by a series of articles in the Wall Street Journal highlighting hospitals' zealous pursuit of the uninsured for unpaid bills. None of the published cases involved hospitals in the Tampa Bay area, which said they seldom if ever pursue legal action against uninsured patients.

"I can't think of any time we've ever sued on these types of patients," said Steve Short, senior vice president of finance at Tampa General Hospital. "The collection agency will try to do whatever they can, but most of the time, they come up with nothing."

Last week the American Hospital Association, which represents nearly 5,000 hospitals, asked Medicare to remove "a string of barriers that discourage hospitals from reducing charges or forgiving debt . . . without potentially running afoul of the law." The trade group, which said its members provided $22.3-billion in uncompensated care last year, also issued guidelines for billing and collecting from the uninsured in an effort to dampen criticism.

"In the absence of health care for all, there's no one to negotiate for this large group of people," said Amy Lee, an AHA spokeswoman of the nation's uninsured. "That's what we want to fix."

With Medicare and HMOs paying less than the cost of care, Lee said, about one-third of the nation's hospitals are operating in the red, while another third are "barely hanging on."

Executives with hospitals in the Tampa Bay area said they work to see if uninsured patients qualify for coverage through the state Medicaid program or county indigent aid. Hillsborough County's program is the most generous; Pinellas has limited benefits; Pasco has no county benefits.

Government programs typically cover about about one-third of the hospital's charges, said Frank Murphy, president and chief executive of BayCare, which has a staff of 25 who try to find assistance for the uninsured. "We do what we can to obtain public funding," he said. "Then we write off the remainder of the account."

If patients' income or assets make them ineligible for public assistance, Florida guidelines allow the hospital to classify their charges as uncompensated charity care if the individual's income is less than $17,960, which is 200 percent of the federal poverty limit. (The 2003 poverty guidelines are $8,980 for an individual and $18,400 for a family of four.) The state, which reviews hospitals' annual cost reports along with Medicare, also allows hospitals to write off as charity bills that exceed 25 percent of a family's income.

BayCare's Murphy said his board decided a year ago that too many of its uninsured patients exceeded the state's financial guidelines. It expanded the hospital system's charity limit to 250 percent of the federal poverty guidelines. That means an individual's income would have to exceed $22,450 before he or she would be charged for care.

"We don't find too many patients who don't qualify for help in some manner," said Murphy, who estimated that about 9 percent of BayCare's annual admissions of 112,000 are uninsured. "That's why the board decided to raise the guideline, to keep that number as small as possible. None of us want to get in fights with patients."

BayCare's board is considering discounts for those uninsured whose income is above the charity benchmark. Tampa General Hospital, which says less than 1 percent of its patients fit the definition of uninsured working poor, is also considering a sliding scale of discounts.

At University Community Hospitals in Tampa, Helen Ellis Hospital in Tarpon Springs and Sun Coast Hospital in Largo, uninsured patients who don't qualify as charity care are eligible for a 30 percent discount if the account is paid within 21 days. Payment plans are also offered.

At Bayfront Medical Center in St. Petersburg, discounts are determined on a case-by-case basis.

HCA instituted discounts of up to 65 percent for the uninsured whose income is up to 400 percent of the federal poverty guidelines. A company spokesman said the policy change had been under discussion for a year before it was submitted to Medicare for approval.

"We felt the issue of the uninsured was important enough that we wanted to create a companywide policy with real and significant discounts," said Ed Fishbough, a spokesman at HCA in Nashville.

HCA estimated that if its discount plan had been in effect last year, its pretax income and earnings per share would have been reduced by about $25-million and 3 cents a share. In 2002, HCA earned $833-million or $1.59 a share on revenues of $19.7-billion.

- Times researcher Caryn Baird contributed to this report. Kris Hundley can be reached at or 727 892-2996.

[Last modified December 24, 2003, 01:16:08]

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