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Feature: Caring for All Texans
Serving the Uninsured
Every year, physicians and residents from the University of Texas Southwestern Medical Center at Dallas deliver more than 18,800 babies. They treat more than 87,000 hospital patients. They oversee 2 million out-patient visits.
Every year, by providing these services, UT Southwestern loses $282 million in uncompensated care.
"In Dallas, I would say, we're on the verge of a crisis," said Kern Wildenthal, president of UT Southwestern. "It's a dilemma for our staff. Do you continue to try to meet the need, find alternate sources to cover the costs - or do you somehow reduce the amount of care that otherwise you would be providing?"
With Texas' 25-28 percent rate of uninsured hovering well above the national average of 15 percent, all six of UT System's health-related institutions face similar struggles. Higher costs and the growth of numbers of uninsured patients lead to increasingly difficult decisions about which patients the institutions can treat, the services and prescription drugs they can offer, and how efficiently they can deliver treatment.
Across the UT System in FY 2004, hospitals, dental clinics and physicians provided more than $1.3 billion in health care to the uninsured. Indigents and elderly patients may be eligible for Medicaid and Medicare, respectively, but these are usually only partial reimbursements that can take months to process.
"The problem is, the state is not providing direct appropriations to cover costs," said Wildenthal. "Payments come through Medicare and Medicaid - and those payments don't keep up with the numbers we have."
In 1998, for example, the University of Texas Medical Branch in Galveston found itself grappling with an $80 million budget shortfall. With growing numbers of uninsured patients, reimbursement delays and declining state support, UTMB feared its losses from uncompensated medical care jeopardized its survival.
To decrease its losses - but still continue its mission to treat the poor, UTMB established Demand and Access Management Program, or DAMP. DAMP, which is described as a rationing of medical services, provides strict guidelines about which patients can be treated and which services can be offered. Emergency patients with life-threatening conditions are stabilized and children are never denied care. But others who lack insurance must pay a fee before seeing a doctor; if patients can prove they are indigent, the fee is reduced.
"I try to treat it as a business decision," said Joan Richardson, medical director for inpatient services at UTMB. "But, for me, that's pretty impossible. I happen to be of the opinion that if somebody's sick, they need to be taken care of. It's tough on people like me with careers that spanned 30 years in medicine. Things weren't always this tough."
After seven years, DAMP has helped UTMB steady its precarious financial situation. UTMB's percentage of uninsured patients, which numbered 26 percent in 1998, fell to 17 percent in 2003. More recently, though, the percentage of uninsured has risen to 19.5 percent, said David M. Connaughton, UTMB'S associate chief financial officer.
Unlike UTMB, UT Southwestern contracts with a Dallas County hospital, Parkland Health & Hospital System, where most of its indigent patients come for treatment. This partnership limits UT Southwestern's options in diminishing its patient load.
"We have a contract to render services at Parkland," Southwestern's president Wildenthal said. "We're not in charge of intake the way Galveston is. It's not our decision to turn away one patient and see another."
With demand for services exceeding the number of caregivers, Wildenthal said, "We end up requiring intolerable, lengthy waits for those who aren't emergencies. If surgery needs to be done within a matter of days or weeks - sometimes, it's delayed for months. In the emergency room, with anything less than a life-threatening problem, you'll have to join the queue and wait."
UT health institutions also try to provide more efficient medical services through cost-cutting, technological advances and sheer ingenuity, as well as by finding new sources of funding.
At Parkland Hospital 's emergency room, Claudie Jimenez pointed to computer monitors that are part of information system improvements that have reduced "door-to-doc" time from six to two hours. "It's a tracking system," said Jimenez, assistant medical director of the emergency department. "You can pull this up on any computer, see vitals, and get to sick patients sooner. Doctors have a much better grasp of who's waiting for help and how sick they are."
Joan Richardson says that, after working at UTMB for years, she now finds the stories of many uninsured are hauntingly similar.
"You're talking about a person from just about any place in Texas who's fallen on hard times," she said. "They have no health insurance, no access to care - and a terrible health problem."
Recently, Richardson was able to arrange medical care for such a patient, a middle-aged woman with complications from surgery. "This was a surgical complication that was important for our medical students to have the opportunity to participate in repairing," she said. "So we were able to get her in and take care of her through our teaching waiver."
Good news for UTMB and its indigent patients also came when the hospital discovered drug manufacturers offer assistance programs for patients who can't afford their drugs.
But this is a small flutter of hopeful news in a growing problem that is overwhelming the poor and hospitals across the country.
"We've had to figure out new and creative ways to help patients, to make a dollar go further," Richardson said. "So that's not all bad.
"But costs are spiraling out of control and too many people lack access to basic medical services. I think we all know our health-care system in this country is in crisis - and something has to be done."
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