Communities must tackle care for the uninsured

Growing problem affects 44 million Americans

Providing medical care for the uninsured should be a community initiative and not just the responsibility of hospitals that provide indigent care, asserts Donna Zazworsky, MS, RN, CCM, FAAN, director of community and outreach for St. Elizabeth of Hungary Clinic in Tucson, AZ.

"The community must problem solve together," says Zazworsky, who also is managing partner for Case Manager Solutions, LLC.

The number of people without health insurance is growing rapidly and included about 44 million Americans last year, according to the U.S. Census Bureau. When they get sick, the uninsured tend to show up in hospital emergency departments (EDs) because they don’t have a primary care physician or because they know the hospital can’t turn them away.

ED physicians report about 30% of their patients are without health insurance. In a survey of 2,000 ED physicians conducted by the American College of Emergency Physicians, 72% say the number of uninsured treated in the last year has increased, and 70% say it’s like to increase this year.

The vast majority of people without insurance are not homeless. The population includes college students and educated people who get into situations where they can’t afford health insurance, Zazworsky says. "The biggest problem is the near-poor, people who are making more than minimum wage or have two jobs but are making too much to be eligible for Medicaid. They aren’t making enough to cover the cost of insurance. That number is growing," she adds.

Workers can’t afford insurance premiums

Part of the problem is the rising cost of health insurance premiums, which cause employers to shift more of the cost of benefits to employees.

"It either makes the cost of insurance unaffordable, or the deductibles and copays increase to a point where employees opt out of the plan because they can’t afford it," Zazworsky says.

She tells of employees who have refused raises because they would make their families ineligible for Medicaid and they have a better health program with Medicaid and can’t afford the plan that the company offers.

The working poor often frequent Zazworsky’s immunization clinics at local schools because even though they have insurance, they can’t afford the copay.

In Tucson, there are several strategies of care for the uninsured. One program is through the coordinated effort of the Pima Community Access Program (PCAP), a network of physician specialists and hospitals that have agreed to accept a large discount on their fees. This program was originally funded by the Health Resources and Services Administration Healthy Community Access Program Grants, which enabled communities to establish infrastructures to support the care of the uninsured. Their target is families at 100% to 250% of the national family poverty level that do not qualify for Medicaid or other government funding sources. Every hospital takes its turn in treating uninsured patients, Zazworsky says.

The patients in the program are assigned to a medical home, a community health center, or a clinic. They are educated about the health care system and how to seek treatment at the clinic instead of using the hospital ED.

Providers charge 30% of Medicare charges for specialty visits and agree not to charge more than $400 per day or $2,000 per hospital visit. The idea is to spread the burden.

Many of the patients in that program can afford the reduced rates, Zazworsky explains.

Even with the discounts, in some instances when expensive procedures are prescribed, people are faced with the problem of deciding if they’re going to pay rent or pay for an MRI, she adds. "A lot of times, the program makes them eligible for Medicaid benefits if they run up a high bill. We have seen patients that are $3 over the Medicaid allowable income," she says.

The patients must pay $20 every six months for the service, but many wait until something happens to them to think about it. "This group of people tends to not think ahead and buy prevention. They wait until something happens and go to the emergency room," she says.

St. Elizabeth of Hungary Clinic is a faith-based clinic that has provided care to the uninsured for more than 43 years, relying on donations and grants. It offers primary care, specialty clinics, obstetrics, dental, nurse case management, and community outreach. Zazworsky works with more than 170 volunteer physicians, dentists, nurse practitioners, and nurses.

The clinic’s staff and community case managers conduct an assessment that looks at medical history, financial, sociodemographics, family systems, cultural beliefs, health beliefs, and values. They identify potential health care needs, benefits, barriers, and appropriate resources.

The case managers connect patients with a medical home, establish referral processes with community resources, and coordinate pharmaceutical patient advocacy programs. They negotiate specialists and hospital discounted fees and track variances.

On the hospital side, case managers should do their homework up front and find out what community resources are available for someone who is uninsured, Zazworsky suggests. "Their No. 1 goal should be to get the person into a medical home, a primary care setting where they can be sent for regular follow-up," she says.

If your organization has a lot of uninsured people coming through the ED, find out who are the frequent fliers and take steps to reduce their number, Zazworsky adds.

She suggests working with the social services department and the hospital marketing department to find out what kinds of special funds can be accessed.

Some hospitals have special funds that can help pay for medication and services for people who need care but have no insurance. "The key is not to drop the ball after the person leaves the hospital. Make sure they are handed off into another system for follow-up care. Otherwise, they’ll be right back in your emergency room," Zazworsky says.

Consider establishing a relationship with a community health center. In Tucson, Zazworsky’s organization joined with a hospital and got a joint grant to fund a Saturday clinic to follow up on the uninsured patients who showed up in the hospital’s ED. The physicians at the ED refer the patients to the clinic for follow-up visits.

(For more information on the problems and solutions to the growing number of uninsured, go to the following web sites: