"Our 1400 Problem" by Bill Walczak

This article is more than 12 years old.

Codman Square Health Center has taken a number of financial hits this year. We started off the fiscal year in October with about $200,000 in cuts from a safety net program that was eliminated from the budget. We took another hit with the Governor’s 9C cuts in October. Just prior to writing this blog, I opened yet another envelope from the Department of Public Health containing a contract amendment reducing a grant for at risk women and adolescents from $90,000 to $76,500 for this fiscal year. Among other expenses, the grant supports a registered nurse who performs case management duties for pregnant women and girls. We have already received other reduction letters, and, combined with the expected lowering of reimbursement through cuts in Medicaid managed care, we are looking at about $250,000 - $300,000 in cuts from October’s 9C budget reductions. This is forcing managers at Codman Square to scramble to find new ways to increase revenue or reduce cost amounting to a combined total of $500,000 just to break even on a cash basis (meaning we would show an operating loss of nearly a million dollars, but it would be mainly from not funding depreciation).

This brings us to our 1400 problem.

1400 is the number of patients (out of just over 20,000 seen annually) who don’t have insurance. Health reform has created an insurance system for most of our patients, and most of our patients who don’t qualify for insurance qualify for the Health Safety Net system, the system that replaced the so-called “free care pool.” Despite our best efforts to enroll previously uninsured patients into the new system, we seem to have hit a wall of sorts at about 1400 uninsured patients. Our analysis shows that if we were able to get these 1400 patients into an insurance system or into the Health Safety Net, we could find about $250,000 of that half million we need.

It isn’t easy. The first thing you need to know is that the number doesn’t represent a static group. In other words, some of the number are people who just don’t want to qualify or don’t qualify for the new system, but many others are a revolving door of people who are in insurance then out.

Also, Codman Square grows by about 300 new patients per month, and many of them are uninsured. On Friday, while I was talking to some of our insurance counselors (our fastest growing department), a “typical” new patient arrived in insurance services. Recently laid off from her job, she can’t afford to keep her insurance from her recent job through COBRA (which requires you to pay 100% of the cost of insurance). She is currently on medication and it has run out. One of our insurance counselors had her apply for Mass Health (the way in which eligibility for any of the products for the uninsured is determined). She was asked to bring in information (which could include paystubs, SSI, unemployment check, child support, size of family verification, etc.), and if she does it soon, we will get paid for the services we provided. If not, she will become another source of bad debt. In the meantime, of course we saw the patient.

Codman’s insurance counselors are pleased with the new system of verifying insurance. In addition to being able to apply for insurance through the “Virtual Gateway,” a program called NEHEN allows them to check some private insurances, which ensures that a bill will be sent to the proper insurance, a very big deal when you have a limited amount of time to submit a bill.

The biggest problem, according to the counselors, is a lack of follow up on the part of patients. One counselor said that half of the names on her uninsured list are patients who either don’t respond to eligibility letters sent them by Mass Health, or had insurance but have fallen off. Typically this happens when the state sends an eligibility or renewal letter in the mail, but the mail doesn’t get to the patient either because the patient has moved (many of our patients have different addresses every time they come in) and didn’t tell the state, or the envelope didn’t get to the right address (another problem in low income areas). In many cases, the patient will get the envelope but not open it. This could be because the patient thinks it’s just another bill (nearly all our patients are seriously in debt according to a survey done by the Access Project) or because there’s a language barrier and they don’t understand what they’re getting. Our counselors tell the patients to look for an envelope with purple lettering on it (Mass Health’s envelopes typically have purple lettering) and to bring the letter into the health center so they can be assisted with it. However, if they don’t open the envelope and provide information to the state, their application is terminated or they are removed from insurance.

Patients are also removed from coverage if they are required to pay premiums and fail to do so, and some (especially Caribbean immigrants) stay with relatives in the Caribbean during the winter and allow the insurance to expire.

Codman providers see the patients and Codman insurance counselors try to get the patient to provide the necessary information to allow them to get insured. Unfortunately, many do not and the Health Center’s response is to bill the patients who by and large don’t pay. One counselor told me of an uninsured diabetic patient who owes the Health Center more than $2000 but refuses to bring in information that would allow her to be insured. We continue to see the patient, of course, and continue to ask the patient for her information, and continue to plead for her to get it in, but the patient knows we will see her anyway. So we are a paper tiger – we have to depend on the good will of the patient to follow up and get insurance. “We do a lot of begging,” says one counselor.

Codman Square has just authorized the hiring of an additional counselor to chase after the 1400. We really can’t afford to do it, but we can’t afford not to either. We should bring in three dollars for every one we spend, and that looks good at times like this. We’re just thankful that the remaining 18,600 patients we have are more cooperative.

Bill Walczak
CEO, Codman Square Health Center

This program aired on December 2, 2008. The audio for this program is not available.