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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

San Mateo County Grand Jury • 2004-2005

Issue | Background | Findings | Conclusions | Recommendations | Responses | Attachments San Mateo County Indigent

Published: June 20, 2005 32 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings 17 findings

Issue a request for proposal (RFP), within 90 days, to review public health care services provided by the county with particular emphasis on indigent care. Qualified proposals should demonstrate a high level of experience and active involvement with indigent care in California. The RFP should include but not be limited to a study of: (cid:131) Advantages and disadvantages of the payer model as compared to San Mateo County’s provider health care system and should include the fiscal, medical, and social effects of each. (cid:131) The effectiveness of the provider model currently employed. (cid:131) The sale or lease to a third party, (e.g. Stanford Medical Center, University of California San Francisco Medical Center), of the San Mateo Medical Center and clinics with the agreement it remain a provider of medical care to the indigent. Response: Disagree. It is premature to issue a request for proposal (RFP) until the County has the information needed to make decisions related to employing a payer vs. provider model. The County acknowledges that it needs to determine the best approach to providing and funding indigent healthcare to meet its obligation under Section 17000 of the California Welfare and Institutions Code. It has recently developed separate financial assistance policies for the medically indigent, charity care, and self-pay, and has begun a pilot process to conduct full screening and verification of uninsured persons applying for health care coverage. The data gathered during the pilot (October 2005 through March 2006) will be used to better define the medically indigent population and the County’s financial responsibility under Section 17000. It will also provide more information about the charity care population being served at SMMC. This type of information is needed by County staff or outside consultants to analyze the advantages and disadvantages of a payer vs. provider model. It should be noted that a similar proposal to examine a payer model was considered in 1993 when the construction funding for SMMC was being discussed. At that time, there was little interest on the part of the private community hospitals to assume responsibility for SMMC’s population, particularly the psychiatric and long-term care components, which comprise over half of SMMC’s current bed capacity. There is also limited capacity in the private sector for absorbing the large volume of SMMC outpatient clinic visits. The current SMMC leadership has more recently attempted to create affiliations with Sutter, Kaiser, CHW, UCSF, Stanford and Palo Alto Medical Foundation, with limited success. II. Revenue Enhancement and Cost Reduction San Mateo Medical Center The Board of Supervisors should authorize the County Manager to direct the Director of the San Mateo Medical Center to: General Operations

Require enrollees of the WELL program to pay the annual fee within three months of enrollment or commit to a more suitable payment plan. Response: Agree. Currently patients are asked for payment prior to or on the same day of the visit. Patients should expect to pay off the full amount of the annual fee in a timely manner. SMMC will explore shortening the timeframe in which a patient must pay the annual fee and what the penalty should be for non-compliance. This will be accomplished by the end of the fiscal year.

Triage WELL and other uninsured patients requesting emergency room services. Those determined not to be in need of immediate care should be directed to clinics for follow-up care. Although triage may slightly increase the medical liability and add initially to the administrative burden of emergency personnel, it would dissuade patients from using emergency services for non-emergency needs. Response: Agree in principle but find it difficult to implement due to recently enacted federal legislation called the Emergency Medical Treatment and Labor Act (EMTALA). This act requires all patients to be medically stabilized in the emergency room by a physician prior to discharge. In addition, all patients seeking emergency room care must be seen and treated by a physician regardless of ability to pay or type of insurance coverage. It is doubtful that this type of change would ultimately lower the Medical Center’s costs since the patient, if referred later to a clinic, would be treated twice by a physician. However, Emergency Room management and Ambulatory Care management are currently looking at ways to reduce the number of patients being seen in the emergency room for non-urgent care. This includes educating patients on the alternatives for receiving non-urgent care outside of the emergency room.

Instruct screeners to verbally verify patient eligibility with each hospital visit and annually confirm and document patient continued eligibility. Response: Agree. SMMC does annually confirm and document continued WELL eligibility and verify patient eligibility with each hospital visit. In the outpatient clinics, registrars verbally verify demographic and insurance information with each visit.

Develop a formal indigent care policy that specifies the qualifications required to receive medical care. This policy should be posted and published, where appropriate and any individual seeking medical services should be required to formally acknowledge the qualifications established. Response: Agree. The Health Department, Human Services Agency, the County Manager’s Office and SMMC have recently developed four financial assistance policies, including a formal indigent care policy. They will be posted and published in conjunction with the expanded WELL eligibility pilot program. Patients will be required to acknowledge the qualifications established to be eligible to receive financial assistance.

Transfer all accounts over 90 days past due and not eligible for the WELL program to the Revenue Services Collection Unit. Response: Agree. Currently any self-pay account greater than 30 days is assigned to the Revenue Services Collection Unit. As part of the new WELL Eligibility pilot program, this timeframe will be extended to any account greater than 90 days delinquent because SMMC will be forming an in-house self-pay team to collect on accounts that did not qualify for WELL or other coverage, including additional self-pay accounts that receive the new Health Care Discount option (charity care discount).

Suspend the 50% cash discount option that is available to uninsured patients with resources. Initiate a study that establishes the profitability of offering this option. Response: Agree that a study should be established to review the profitability of offering this option, but do not concur on suspending the cash discount option for uninsured patients with resources. The compelling reasons for offering discounts to self-pay patients are threefold, 1) self-pay patients represent the only payer group that has no option but to pay full charges, while all other payers receive some sort of discount. It is difficult to justify not offering a discount without the appearance of exploitation and it has become a community standard among hospitals to offer a discount, 2) this discount still allows the Medical Center to recover its costs, and 3) offering a discount allows the Medical Center to resolve its outstanding bills sooner, which lowers days in accounts receivable and reduces bad debt write-offs. A study will be performed by the end of the fiscal year.

Require non-critical patients to provide identification prior to receiving initial treatment and inform them that a subsequent visit will require a documentation and verification process. Response: Agree with the implementation of the new WELL Eligibility pilot program. All patients that present without insurance coverage will be screened for financial assistance through a formal documentation and verification process. Screening Operations

Investigate the cost, advisability, and timeliness of outsourcing the entire screening process as it relates to indigent care across all programs. Response: Agree. Community Health Advocates from the SMMC and the Health Department, as well as community-based organizations, will be performing the screening function during the pilot process to conduct full screening and verification of uninsured applicants. The Human Services Agency will also be reviewing a portion of applications that are determined eligible for the WELL and Discounted Health Care (charity care) programs. Outsourcing of the screening process will be explored after the pilot has been completed and results evaluated at the end of the current fiscal year.

F10

Upgrade the enrollment process to identify those individuals who do not qualify for medical care programs because of residency, income, or asset criteria by making verification of qualifying criteria mandatory in all cases and creating a prescribed script for screeners to determine that all relevant issues are covered. Response: Agree. The County has initiated a pilot process to conduct full screening and verification of uninsured persons applying for health care coverage. Data collection will take place from October 2005 through March 2006 using a web-based screening tool called One-e-App. It is estimated that this effort will cost $950,000. This includes modifications to One-e-App, extra help staffing and increases to community-based provider contracts, equipment and supplies.

F11

Create or integrate a countywide, inter-departmental database to facilitate monitoring of program participants. Response: Agree. As part of its information technology strategic plan, SMMC, along with the County’s Information Services Department and other applicable departments has begun work on an unduplicated client database that will track health and social services provided to individuals by County departments including SMMC, the Health Department and Human Services Agency. The unduplicated client database will use a common client database across these three departments so that program data about common clients can facilitate better services for clients and for analytical and statistical reporting purposes. This is referred to as the “Applicable Client Record Store (ACRS) and this technology approach lays important groundwork for other County operations. ACRS allows County departments who share clients to identify client records in the same way. This process will allow better Countywide reporting to measure the effectiveness of services provided by the County and to determine unmet needs. Cost estimates are not available at this time, but there will be costs incurred by the County for these efforts.

F12

Combine all screening processes under one department to enhance operational control and consistent application of qualifying criteria. Response: Agree. Alternatives to performing the screening process will be explored after the screening and verification pilot process has been completed and evaluated at the end of the fiscal year. There will be consistent application of qualifying criteria during the pilot, given the features offered by the One-e-App screening tool, including eligibility calculation logics for all programs and the validation of all required data fields and verification documents.

F13

Redesign the WELL Program’s self-declarative form to impress upon applicants the seriousness of the process and that providing false or inaccurate information may have legal ramifications. Response: Agree. The WELL self-declaration process has been eliminated as part of the screening and verification pilot that is estimated to cost $950,000. The financial assistance policies, application forms, and brochures have been modified in order to emphasize the consequences of providing false or inaccurate information, including denial or dis-enrollment, and criminal charges for perjury. Private Pay Patients The San Mateo Board of Supervisors should require that San Mateo Medical Center:

F14

Build a for-fee parking structure and offer valet parking providing convenient facility access for those unable or unwilling to negotiate parking lot distances. Response: A study is currently underway to evaluate additional parking. We anticipate recommendations by the end of October. However, it is doubtful that the majority of patients and visitors to SMMC would be able to pay for parking.

F15

Initiate a publicity campaign describing hospital capabilities and desirability as a provider of health care services. Response: Agree. We agree that SMMC is more than a "County hospital" and that its new hospital, in addition to its clinics and its many key programs, offer County residents quality services that anyone should be proud to use. Unfortunately, because many people have not seen or heard from the Medical Center, public perception may not match this reality. As the Grand Jury report states, to date we have signed agreements that enable us to accommodate private-pay patients yet the hard work of attracting them remains. We will be working on this effort through targeted outreach and publicity campaigns that focus on service lines where we have capacity. It is important to note than most of the clinics are filled to capacity and some have waits as long as three months for non-urgent visits so we can therefore only market certain services unless we open additional capacity. As much of the Grand Jury report focuses on cost, it is also important to note that publicity campaigns will require an investment in order to generate goodwill and eventual growth in volume. For example, we are developing an outreach campaign for the Ron Robinson Senior Care Center, in order to tell the community about its services and most important, about the benefits that this Center offers to seniors and caregivers. We will be preparing a similar campaign for the new Keller Women and Children's Center, scheduled to open in 2006.

F16

Affiliate with other medical groups capable of referring doctors and patients. Response: Numerous conversations with private physicians and medical groups were unsuccessful in generating significant additional private patients. Most physicians are affiliated with a hospital and are not interested in the additional drive time to SMMC. We are considering opening a private primary care office near SMMC to increase capacity and access for private pay patients and increase ancillary and hospital volume. Indigent Care and Charity Care Cost Sharing

F17

The Board of Supervisors should research and explore methods to encourage the other non-profit hospitals to substantially increase their charity care. Response: Agree. Charity care is defined as free or discounted health and health-related services provided to persons who are uninsured and cannot afford to pay or who are not eligible for public programs. SMMC provides 95% of indigent in the county and a majority of the Medi-Cal or underinsured care. The County General Fund will contribute over $54 million in FY 2005-06 toward these costs. It is anticipated that these costs will rise given continued increases in costs related to providing healthcare. While most private hospitals have maintained their non-profit status by contributing to the community for the community’s benefit and or by providing care to the underinsured, they have not significantly contributed to costs directly related to indigent care. There have been efforts to highlight the need for other hospitals to contribute to costs incurred by SMMC for indigent patients. One of the recommendations from the Southern San Mateo County Task Force on New Hospital Construction in its June 2004 report was for the County to “create a vehicle that includes all hospitals in order to dialogue as a group and see how the charity care issue can be resolved.” The Hospital Consortium of San Mateo County, which includes SMMC, Mills-Peninsula Health Services, Sequoia Hospital and Seton Medical Center/Seton Coastside, has recently attempted to quantify each organization’s contribution to indigent/charity care and benefits provided to the community. The County is developing separate policies for medically indigent care, for which the County is financially responsible under its Section 17000 mandate, and charity care, in an attempt to further quantify costs incurred for charity care patients. The charity care policy was developed based on income and asset standards used by other community hospitals. The policies will be implemented during the eligibility screening and verification pilot that will start in late October. The results of the pilot will be used to further define the County’s obligation under Section 17000, which will not include charity care. Estimated costs for charity care will then be developed so that the Board can make decisions on how these costs should be funded by the County and other hospitals in the community. The County has also reviewed San Francisco’s charity care ordinance that requires annual publication and dissemination of charity care statistics for all hospitals in the City, and will explore recommending a similar ordinance after completion of the pilot at the end of the fiscal year.

Recommendations 17

R1

Issue a request for proposal (RFP), , to review public health care services provided by the county with particular emphasis on indigent care. Qualified 1 proposals should demonstrate a high level of experience and active involvement with indigent care in California. The RFP should include but not be limited to a study of • Advantages and disadvantages of the payer model as compared to San Mateo County’s provider health care system and should include the fiscal, medical, and social effects of each. • The effectiveness of the provider model currently employed. • The sale or lease to a third party, (e.g. Stanford University Medical Center, University of California San Francisco Medical Center), of the San Mateo Medical Center and clinics with the agreement it remain a provider of medical care to the indigent. II. Revenue Enhancement and Cost Reduction San Mateo Medical Center The Board of Supervisors should authorize the County Manager to direct the Director of the San Mateo Medical Center to: General Operations:
R2

Require enrollees of the WELL program to pay the annual fee within three months of enrollment or commit to a more suitable payment plan.
R3

Triage WELL and other uninsured patients requesting emergency room services. Those determined not to be in need of immediate care should be directed to clinics for follow-up care. Although triage may slightly increase the possibility of medical liability and add initially to the administrative burden of emergency room personnel, it would dissuade patients from using emergency room services for non-emergency needs.
R4

Instruct screeners to verbally verify patient eligibility with each hospital visit and annually confirm and document patient continued eligibility.
R5

Develop a formal indigent care policy that specifies the qualifications required to receive medical care. This policy should be posted and published, where appropriate, and any individual seeking medical services should be required to formally acknowledge the qualifications established.
R6

Transfer all accounts over 90 days past due and not eligible for the WELL program to the Revenue Services Collection Unit.
R7

Suspend the 50% cash discount option that is available to uninsured patients with resources. Initiate a study that establishes the profitability of offering this option. 2
R8

Require non-critical patients to provide identification prior to receiving initial treatment and inform them that a subsequent visit will require a documentation and verification process. Screening Operations:
R9

Investigate the cost, advisability, and timeliness of outsourcing the entire screening process as it relates to indigent care across all programs.
R10

Upgrade the enrollment process to identify those individuals who do not qualify for medical care programs because of residency, income, or asset criteria by making verification of qualifying criteria mandatory in all cases and creating a prescribed script for screeners to determine that all relevant issues are covered.
R11

Create or integrate a county wide, inter-departmental database to facilitate monitoring of program participants.
R12

Combine all the screening processes under one department to enhance operational control and consistent application of qualifying criteria.
R13

Redesign the WELL Program’s self-declarative form to impress upon applicants the seriousness of the process and that providing false or inaccurate information may have legal ramifications. Private Pay Patients The San Mateo Board of Supervisors should require that San Mateo Medical Center:
R14

Build a for-fee parking structure and offer valet parking providing convenient facility access for those unable or unwilling to negotiate parking lot distances.
R15

Initiate a publicity campaign describing hospital capabilities and desirability as a provider of health care services.
R16

Affiliate with other medical groups capable of referring doctors and patients. Indigent Care and Charity Care Cost Sharing
R17

The Board of Supervisors should research and explore methods to encourage the other non-profit hospitals to substantially increase their charity care. San Mateo County Indigent Health Care Issue What can San Mateo County do to reduce the annual appropriation for indigent health care?

Conclusions 4

CL1 Page 7

The Grand Jury researched Orange, San Diego, and Santa Barbara counties regarding their indigent care programs as they approximated conditions in San Mateo County. Each has a different approach to indigent care but all use the managed care concept as the key factor to controlling costs. San Francisco City and County has outsourced a portion of its indigent care program. 7 The rising cost of supporting SMMC is not sustainable. Currently, expenditures exceed revenues by over $150,000 a day. Indigent care is a complex issue beginning with patient screening and continuing through providing quality health care at a reasonable cost. SMC support of indigent health care for FY 2003/2004 was 150% of the expenditure for FY 2000/2001. The counties reviewed, to varying degrees, have decided that outsourcing of medical services is an economically preferred alternative to the provider model. There is insufficient information available today to establish whether SMC should also consider outsourcing its medical services. See Appendix A, Converting of a Public Hospital to a Private Hospital for a discussion of the various effects of closing a public hospital.
CL2 Page 12

SMMC provides a full range of health care services to all residents of the county and was specifically built to offer indigent care not elsewhere provided. SMMC represents the health care safety net for the community with over 90% of its patients supported by state, federal, or SMC public health programs. Patients lacking either resources or insurance and not served by any other hospital in the county, require SMC to provide a general fund appropriation to SMMC totaling $59.5 million dollars for the FY 2003/2004. The hospital has taken steps to ameliorate this subsidy by contracting with a cadre of physicians and attracting their patients, developing recognized specialty programs, and contracting or negotiating with established health insurers. Additional steps must be taken to improve account collections as well as strengthening patient screening to insure that all potential sources of patient funding have been evaluated. The current screening process is operational and well managed, but there are many areas that require procedural reinforcement and improved computer system integration. The County Controller has stated that a sample eligibility test revealed that 20% of WELL patients were improperly enrolled and a savings was possible by verifying patient provided eligibility information. 12
CL3 Page 15

SMMC has a significant access and parking problem that must be resolved to attract new revenue producing patients. Privately insured patients represent the biggest potential for revenue growth. Results to date indicate limited success in attracting this group. Continuing efforts must be made to attract community doctors and their patients assuring them that SMMC is more than a “County Hospital”. Adding medical specialties, 15 publicizing the awarding of honors for excellence, and proclaiming the receipt of prestigious grants demonstrate the transformation that has occurred. SMMC lacks affiliation with medical groups such as Mills-Peninsula Medical Group, Camino Medical Group, or Palo Alto Medical Foundation that serve as a source of doctor and patient referrals.
CL4 Page 18

Although non-profit hospitals benefit from their tax advantages, they are not doing their share in providing charity care. San Mateo County seems indecisive and unable to come up with a viable solution to sharing the burden of charity care. “Critics argue that the county doesn’t have the authority to force a hospital, beyond current state and federal law, to care for a patient who can’t pay,” (Ref. 5). As in Santa Cruz County, SMC must use leverage, such as approving new construction of a hospital, to force an Access to Medical Care Agreement with a non-profit hospital. If so, they must word any agreement clearly to focus on charity care and avoid the loophole of “community care.”

No Responses Found 2

Government entities assigned to respond to this report. No response documents have been linked in our database.

County of San Mateo Agency

San Mateo County Board of Supervisors Elected County Office