Testimony before the
COMMITTEE ON HUMAN SERVICES
of the Council of the District of Columbia
The Status of the Closure of the DC Health and
Hospitals Public Benefit Corporation and Transition of Services Formerly
Provided at DC General Hospital To Greater Southeast Community Hospital
Presented by Robert A. Malson, President
District of Columbia Hospital Association
June 22, 2001
I. INTRODUCTION
Chairperson Allen and members of the Committee on Human Services, I
am Robert Malson, President of the District of Columbia Hospital
Association (DCHA). As you know, DCHA represents all full service and
most specialty hospitals in the District of Columbia, plus our
affiliates, Malcolm Grow Medical Center at Andrews Air Force Base and
the National Naval Medical Center in Bethesda, Md. The comments I make
today represent the most recent views expressed by the hospitals' chief
executive officers – the DCHA Board of Directors – speaking
collectively on behalf of the hospital industry in Washington, DC, and
should not in any way be interpreted as representing any single
individual hospital.
I appreciate this opportunity to express the Association’s views
about the status of the closure of the Public Benefit Corporation and
the transition of services formerly provided at DC General Hospital. As
you know, I testified before this committee last September about how the
proposed changes might impact the residents and hospitals of the
District of Columbia and how some of the pitfalls might be avoided. The
DCHA Board of Directors, consisting of all the hospital CEOs, met
yesterday and agreed that they appreciate the comments the Mayor has
made on several occasions that private hospitals will not be expected to
bear additional uncompensated care burdens under the new system. They
are particularly pleased with the Mayor’s commitment to make
"mid-course corrections" as the transition proceeds to make
the new system work.
We have also been working closely with the Department of Health’s
transition and Alliance officials on several efforts as we all work to
ensure that no patient falls through the cracks. I want to emphasize
that the hospitals are committed to continuing their tradition of
providing quality patient care. However, we still believe there are some
issues that must be addressed during this transition for the best
interest of the patients that need health care services.
II. OUTREACH AND PUBLIC INFORMATION
Last September, I reported that our major concern was the inability
of the private acute care hospitals to absorb all of the patients who
were served by the PBC because of such issues as transportation, clogged
operating rooms and intensive care units, and over-used emergency rooms.
Specifically I said, "Whether such a facility is operated by the
PBC or some other entity is not the issue; it is a question of service
to patients near to where they live and where they need care."
Now we are seeing overcrowded emergency rooms, with ambulance
diversions and re-routing becoming routine. According to the May 2001
Reroute Report Summary issued by the DC Fire and EMS Department, the
District’s hospitals were on diversion or reroute for more than 1200
hours last month. The reasons given for over 1100 hours of that time
were for staffing or that the emergency department was full.
This appears to be a national phenomenon, not solely attributable to
the closing of DCGH. But, I can comfortably say that the public’s
confusion over the status of the DCGH emergency room and where to seek
care, has led to significant increases in visits of patients with
ambulatory sensitive conditions at all the emergency rooms, particularly
Providence, Howard and the Washington Hospital Center. These hospitals
have experienced double digit percentage increases in uninsured patients
in the emergency room, in outpatient clinics and in inpatient
admissions.
In addition to significant increases in most emergency departments,
we have also begun to see a significant increase in inpatient admissions
city-wide. In April, inpatient admissions were up 10 percent citywide
– over and above the DCGH situation. This makes the absorption of PBC
patients – whether insured or uninsured – an increasingly difficult
proposition.
We are well aware that one of the Mayor’s objectives in this
privatization initiative is that the DC Healthcare Alliance will
increase primary care access sites, which DCHA wholeheartedly supports.
But all good intentions will not change patient behavior overnight and
patients will still go to emergency rooms when they are ill, even if it
would be more appropriate to go to a clinic or private physician for
immediate treatment. We applaud the Alliance’s initial outreach effort
to notify thousands of former DCGH patients to educate them on where
they should seek care. However, more needs to done to educate potential
Alliance enrollees who qualify below the 200 percent of the federal
poverty level.
III. ELIGIBILITY AND ENROLLMENT
Confusion has existed since the contract was signed with respect to
enrollment and eligibility. At one point, only patients seen at the PBC
within the past two years were going to be eligible. Now, we understand
that eligibility has been broadened to include all those who need care
with incomes below 200 percent of the federal poverty level. This is an
important distinction and one that will enfranchise many more of the
city’s uninsured. DCHA and its members enthusiastically support this
change.
However, we are still concerned that the plan to enroll beneficiaries
is inadequate because it limits enrollment sites to eight – the six
clinics (former PBC), DCGH and Greater Southeast Community Hospital.
This limited enrollment plan completely disregards the utilization
patterns of many of the city’s uninsured: they enter the system
through the hospital emergency departments. Experience has shown that a
significant percentage of uninsured patients wait until they are very
ill before seeking treatment and then, present themselves in an
emergency room. Hospitals have worked closely with the Income
Maintenance Administration (IMA) in recent years to develop an effective
system of assisting potential Medicaid enrollees with the application
process. In the past year, IMA has provided a Roving Supervisor who can
certify Medicaid enrollees on-site.
The DCHA Board of Directors feels strongly that there must be similar
procedures instituted in hospitals that allow: (1) hospitals to assist
eligible Alliance patients with enrollment; and (2) direct those
enrollees to the most accessible primary care or other appropriate site
for follow-up care. We have relayed this concern to Karen Dale, Chief
Operating Officer for the Alliance at DC Chartered Health at this week’s
DCHA Government Relations/Financial Policy Committee Meeting. We hope we
can work with her to develop these enrollment procedures as soon as
possible.
IV. CARE PROVIDED BY NON ALLIANCE PROVIDERS
The timetable for the District’s transition to privatization of
public health services to the uninsured and undersinsured was
accelerated to meet the June 25th date when all inpatients are expected
to be transferred from DCGH. As mentioned earlier, all private hospitals
emergency departments and inpatient units are flooded with current and
former DCGH patients who do not have enough information at this point as
to where they should seek health care. We know that Greater Southeast
Community Hospital and its Alliance partners are doing their best to
upgrade and expand the facilities to accommodate the new patient load,
but those efforts will not be ready for a few more months.
Therefore, in the interest of assuring that quality health care
services are available and accessible to the former DCGH patients, as
well as those patients who would have sought care at DCGH, it is
important to monitor emergency room and other services provided by
non-Alliance hospitals.
The non-Alliance hospitals are committed to do whatever is necessary
to make sure that no patient falls through the cracks during this
abbreviated transition period and beyond. This means that emergency
patients will be cared for appropriately, and NOT transferred to an
Alliance provider unless requested by the patient. This practice has
been followed for decades with respect to DC General Hospital and
uninsured patients who came to private hospital emergency rooms. Private
hospitals only transferred patients back to DCGH when the patient
requested it or when the private hospital did not have the appropriate
clinical services. Alliance patients should not be transferred
indiscriminately, but private hospitals do need financial support to
expand their coverage to these newly eligible patients.
The DCHA Board yesterday strongly agreed that an interim short-term
appropriation should be made to support non-Alliance hospitals now
covering those gaps in services that are currently unavailable through
the Alliance providers. DCHA suggests that a reimbursement mechanism,
separate from the Alliance contract, begin for Emergency Room/Trauma
Services because data for those services can be easily collected,
quantified and analyzed. In addition, this is the area of service we
anticipate will require the most access to alternative providers during
the transition.
DCHA offers its assistance to convene a small working group of
hospital financial officers on potential strategies for short and long
term reimbursement issues. The goal of such a group would be twofold:
(1) to make sure that Alliance patients have access to necessary
emergency care; and (2) to make sure that private hospitals continue to
be able to serve their communities.
Let me assure you that the private hospitals are committed to
maintaining the levels of uncompensated care they have been providing
for years. To this end, DCHA is collaborating with Health Safety Net
Administration officials on standards to determine the hospitals’
Maintenance of Effort (MOE) levels and an appropriate definition of
"charity care." There is a meeting scheduled for next week to
discuss these issues and we will be glad to keep the Council apprised of
the progress of those discussions.
V. CONCLUSION
DCHA and its member hospitals are doing everything possible to see
that the Alliance succeeds. But I will reiterate what I said last
September, "If this plan is incomplete or is bungled in its
execution, the negative impact will be felt first by the most vulnerable
of our citizens and second, by all of us, including those who have
health insurance."
While the Mayor has stated his commitment to provide health care
services to the poor, there is still great uncertainty about how the
city and the private hospitals will share the responsibility for this
city’s most vulnerable residents. The DCHA Board of Directors is
committed to their missions to serve our communities, but we cannot do
this alone, and we certainly cannot do this if we are not involved in
the critical processes I outlined earlier. Our expertise must be part of
the dialogue and the solution.
Once again, thank you, Mrs. Allen, for holding this hearing and for
this opportunity to present the Association’s comments and concerns. I
will be pleased to answer any questions the Committee may have.
GLOSSARY OF FINANCIAL TERMS
BAD-DEBT: The amounts from patient accounts which are "written
off" because they are unpaid despite attempts to collect payment from
either the patient and/or the insurance company.
CHARGES: The dollar amount billed for a service by a health care
provider, similar to the "retail" price.
CHARITY CARE: The amount from patient accounts which are "written
off" because a patient cannot pay for services rendered by the health
care provider. These are services for which the provider never expected
payment.
COSTS: The actual dollar amount incurred in providing a health service.
DISCHARGE: The formal release of a patient from a hospital after an
acute episode of illness.
INPATIENT SERVICES: Health care treatment rendered to a patient while
residing in the hospital.
MANAGED CARE: An entity that "manages" or controls what it
spends on health care by closely monitoring how health care providers
render services to patients.
OPERATING MARGIN: The percent difference between operating expenses and
operating revenue.
OUTPATIENT SERVICES: Health care treatment rendered to a patient
without being admitted to stay overnight in the hospital.
PAYOR MIX: The percentage of patients from each category of payors. The
major payor classes included in the payor mix are: Medicare, Medicaid,
Blue Cross, commercial insurance, managed care contracts, and self-pay
patients.
UNSPONSORED CARE: The actual cost of services rendered to patients for
which the health care provider does not expect to receive payment.
Unsponsored care is a combination of bad-debt and charity care. |
