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Increasing Access to Health Care: Examination of Hospital Community Benefits and Free Care Programs

Posted on: Wednesday, 10 August 2005, 03:01 CDT

The present study explored hospital community benefits and free care programs at seven hospitals in Nassau and Suffolk counties in Long Island, New York. There were two components to this project: (1) assessment of information regarding the availability of free care and (2) an analysis of the community benefits information filed with state regulatory offices. Results show that not one of the seven hospitals consistently informed surveyors that free care was available to low-income, uninsured people. Surveyors had difficulty obtaining written free care policies. The article concludes with suggestions for government agencies, hospital administrators, social workers, and other advocates on how to get involved in efforts to increase access to health care for the uninsured population.

KEY WORDS: community benefits; charity care; free care; health care access; medically uninsured population

For low-income, uninsured individuals who cannot afford to pay for their medical care, free care, also known as charity care, may be the only means to receive medical treatment. The problem is that the existence of this safety net is virtually unknown.

Free care is medical care provided by a hospital without the expectation of payment. Sometimes it includes discounted services for patients who are able to pay some of the cost of their care (Community Catalyst, 2002). In exchange for this service, nonprofit hospitals are classified as charities and receive millions of dollars in tax benefits.This concept, with its roots in colonial charity and public responsibility concerns, was reflected in the first U.S. hospitals and embedded in those established by religious orders in the 18th and 19th centuries (Sultz & Young, 2001). An important piece of legislation that relates to the provision of free care is the 1946 Hospital Survey and Construction Act (P.L. 79- 725), also known as the Hill-Burton Act, and its amendments, including the 1975 Public Health Service Act, initiation of a substantial compliance review process in the 1980s, and Charitable Facility Compliance Alternative (CFCA),which was added in the mid- 1990s (Health Resources and Services Administration [HRSA], 2003). Under Hill-Burton some hospitals and other health facilities were provided money for construction and modernization. The facilities that received these funds agreed to provide a reasonable volume of services to people unable to pay and to make their services available to all people residing in the facility's area (HRSA, 2003). Granting hospitals 501(c)(3) nonprofit status is another mechanism designed to encourage the provision of charity care. Of the 4,915 U.S. community hospitals, 3,003, or 61 percent, are classified as 501 (c) (3) nonprofit, tax-exempt organizations (American Hospital Association, 2002). These organizations enjoy significant financial advantages from their tax-exempt status. For example, Ott (2001) explained that

tax-exempt organizations do not pay corporate income taxes and in most states also are exempt from a variety of state and local taxes, including, for example, property, sales, franchise, and use taxes. Many tax-exempt organizations also are eligible for lower U.S. Postal Service rates. Individuals and corporations who donate money and other items of value to 501(c)(3) non-profit organizations are entitled to deduct the value of their gifts from their federal income taxes and, in most states, also from state income taxes, (p. 143)

The idea of granting tax-exempt status originated in 1917, three years after inception of the federal personal income tax by the 16th Amendment.The notion was based on nonpublic agencies providing services that the government would have been required to furnish (Internal Revenue Service [IRS], 2000). In exchange for this favorable tax status, however, all nonprofit organizations, including hospitals, are required to provide "community benefits," namely unreimbursed goods and services that address local community- identified health needs and concerns.Thus, in addition to any moral suasion of social responsibility to provide health care for those unable to pay, tax rulings and federal and state health department regulations engender the obligation of hospitals to provide charity services (Health Care For All, 2002; Noble, Hyams, & Kane, 1998).

INSURANCE STATUS

In 1999, 42.1 million non-elderly people were without health insurance in the United States (Hoffman & Pohl, 2000). Certainly, this casts a blight on the American ethos of fairness and justice. Although more white, non-Hispanic people are uninsured in terms of total numbers because they make up a greater percentage of the population, as a group they are less likely to be uninsured. Among Hispanic Americans, 35 percent are uninsured; among non-Hispanic African Americans, 22.8 are without insurance. Nearly one-third (32.8 percent) of Native Americans and Alaska Natives lack health insurance. Among Asian/Pacific Islander Americans, the probability of being without health insurance is 22 percent. For white non- Hispanic adults this likelihood is 12.7 percent compared with 17.5 percent in the general population (Institute of Medicine [IOM], 2002a). Racial and ethnic minority groups' lack of access to health services and barriers to the health system infrastructure and information result in consistent disparities in race and ethnic health statistics (Cunningham & Kemper, 1998; Eng et al., 1998; HRSA, 2001; HRSA, 2002; Sultz & Young, 2001). According to Seiffert and Sokol (1999), uninsured people are

less likely to have a regular doctor and more likely to receive care from emergency department or hospital outpatient clinics; receive fewer preventive health services; delay care, do not fill prescriptions, and come into the hospital more severely ill; are hospitalized more frequently for conditions that could have been treated on an ambulatory basis; have shorter hospital stays and often use fewer discretionary, high-cost procedures, (p. iii)

Similarly, the primary findings in a report issued by the IOM (2002b) were that working-age Americans without health insurance are sicker and die sooner; receive poorer care for acute situations when they are in the hospital; and receive too little care too late.

For proponents of the current U.S. health care system, the proverbial "safety net," a patchwork of public facilities and charity care, affords sufficient access to needed health services (Pauly & HofF, 2002). Critics argue, however, that quality is suspect and information about availability and eligibility fail to trickle down systematically to uninsured and vulnerable populations (Altman, Reinhardt, & Shields, 1998; DC Watch, 2000).The linchpin to this safety net is charity care. However, studies suggest that the provision of and information about available charity care varies across communities regardless of state laws requiring hospitals to provide free services to those in need (Cunningham & Kemper, 1998; Feder, Levitt, O'Brien,& Rowland, 2001; KeUy, 1998; 1999;Weiss & Campo, 2001).The variations in availability and access to health care across communities seem less a function of the uninsured population than of community and institutional variables (IOM, 2001). Thus, it is extremely difficult to chart community and institutional characteristics that affect access to health care for uninsured people, as communities differ in the organization and provision of care for medically indigent people.This situation challenges advocates for poor and uninsured people because most hospitals are required to provide charity care given their nonprofit status. Nevertheless, considerable debates swirl around related issues such as payment structures (Berliner &Delgado, 1991,1993; Zicklin, 1993) and hospitals'levels of charity care (Frank & Salkever, 1991 ; Margolis, 1990; Nicholson, 2000).There are also disagreements over whether hospitals provide charity care and community benefits commensurate with the financial advantages they receive as nonprofit, tax-exempt organizations (Altman & Shactman, 1997; Hasan, 1996; Seay, 1992). In addition, questions arise concerning whether sufficient information about the availability of charity care is communicated adequately to the public (Robert Wood Johnson Foundation, 1999). In 2001 the U.S. Department of Health and Human Services (HHS), Office of Minority Health (OMH) issued a report titled the National Standards on Culturally and Linguistically Appropriate Services in Health Care to support a more consistent and comprehensive approach to cultural and linguistic competence in health care. These 14 standards are significant because questions are often raised about whether charity care services are publicized in a culturally and linguistically competent manner that is appropriate for the area served by the hospital (HHS, OMH, 2001).

BACKGROUND

New York State, one of the nation's most regulated health services states, claims about 3 million medically uninsured residents (Liska,Brennan, & Bruen, 1998). Long Island, America's first suburb, often portrayed and glamorized as home to the rich and famous, paradoxically is estimated to have 437,000 medically un\insured residents (Long Island Association, 2000; Long Island Health Access Monitoring Project, 2002). Hospital charity care in New York State is regulated under NY CLS Pub Health 2807. Under the legislation, nonprofit hospital mission statements must identify the communities and populations they serve and describe their commitment to meeting the health care needs of their communities. Each year hospitals must submit material to the New York commissioner of health, including their mission statement and implementation report on their performance in meeting the health care needs of their communities, providing charity care services, and improving access to health services for the underserved population. In addition, every three years, the hospital board of directors must review and modify the mission statement, seek community views regarding issues such as hospital performance and service priorities, and demonstrate the hospital's commitment, including financial, to charity care and to improve access for the underserved population. Finally, the board must prepare a statement showing the hospital's resources and the proportion devoted to charity and reduced-price services or efforts to increase access.

The purpose of this study was to explore whether Long Island hospitals comply with charity care regulations and to examine whether the hospitals adequately communicate the availability of this care to medically uninsured people in their community. There were two components to this project: (1) assessment of information regarding the availability of free care and (2) an analysis of the community benefits information filed with state regulatory offices.

METHOD

Sample

Seven local hospitals from Long Island, New York, were selected for this study because they represent diverse health systems and locations. Five hospitals were from Nassau County and two were from Suffolk County. At the time of the study, none of the hospitals were part of the Hill-Burton program.

Procedure

In spring 2000,24 people were trained to carry out the free care monitoring interviews. Three methods were used at each of the seven hospitals to gather information: (1) uninsured telephone survey, (2) community agency telephone survey, and (3) faithbased organization visits.

Uninsured Telephone Survey. Surveyors were instructed to call a particular hospital and were provided with a general telephone number for that facility. They were also told to make at least three telephone calls and to place these calls at various times of the day and on various days of the week. The purpose of the telephone calls was to determine whether information provided by the hospital was consistent, and what information would be available outside of normal business hours. In addition, some surveyors placed the telephone calls in Spanish or Haitian, to determine whether the hospitals were able to handle these requests for information.

Surveyors were provided with a suggested script that they could personalize so that they felt comfortable requesting information.They were to find out how to get care at the hospital for someone who had no insurance.

Community Agency Telephone Survey. Surveyors, all of whom worked for social services agencies, were instructed to call a particular hospital and were provided with a general phone number for that facility.The surveyors were instructed to make at least two telephone calls: one to the social work department and one to billing. All calls placed in this segment of the study were in English. Surveyors received a suggested script that they could adapt as needed and were to place the calls requesting information in their professional capacity-that is, to gather information for their own agency clients who might need free care.

Faith-Based Organization Visits. Surveyors associated with faith- based organizations were asked to make an in-person visit to their assigned hospital and determine what information was available. The surveyors were to look for signs or postings about payment and other information available to patients and visitors.They were also to talk to staff.

Surveyors were provided with a suggested script that reflected their volunteer status with a religious institution. In this capacity, the surveyors were gathering information about the hospital's charity care policy.

Community Benefits. For this second component of the study, researchers reviewed the seven hospitals' mission statements, community service plans, and financial reports related to the cost of charity care. Hospitals are required to submit all of this information to comply with provisions of the Health Care Reform Act that relate to community benefits.

RESULTS

Free Care Survey

Key findings of the free care survey revealed the following:

* At none of the seven hospitals did staff consistently inform surveyors that free care was available.

* Some surveyors at four hospitals were told that free care to low-income, uninsured individuals was available; other surveyors were told that free care was unavailable. At the other three hospitals, staff consistently informed surveyors that no free care was available.

* Only one hospital provided a written free care policy upon request.

* Surveyors for the uninsured telephone surveys had a much harder time obtaining responses to their questions than did surveyors from community agencies or faith-based organizations. Non-English- speaking surveyors were almost never able to obtain information on free care from any of the hospitals.

Uninsured Phone Surveys

The surveyors attemped 47 surveys and completed 43 (91 percent). Of the 21 surveys attempted in a language other than English, two (10 percent) were completed. During 11 surveys (26 percent), the person being interviewed refused to answer questions. Of the 15 surveyors who carried out the uninsured telephone surveys, five (33 percent) reported that someone was rude to them, and 10 (67 percent) reported that they would not be comfortable going to this hospital for care. For the 43 completed surveys, 27 staff members at the hospital said that the hospital did not have free care available. In only one case was any surveyor told that there was a free care policy at the hospital.

Community Agency Phone Surveys

To complete the surveys for all seven hospitals, surveyors placed 24 phone calls, and for 13 of these calls, the surveyor was transferred. Surveyors spoke to 38 people. Of the 38 people, three (8 percent) said that they would refer the patient elsewhere for health services, three (8 percent) said they did not know if there was a free care policy, five (13 percent) said that there was no free care available, but that a reduced fee or payment plan was possible, and two (5 percent) said that free care was available. Other calls resulted in ambiguous answers (that is, "bring in identifying information and pay stubs,""the patient should apply for Medicaid,"and"I asked my supervisor and she told you to call someone who might know for sure." Surveyors asked people at all seven hospitals to send written material about their free care policy. At only four hospitals did someone agree to do so; three actually sent materials, and in only one of these cases was it clearly indicated in the materials that free care was available at the hospital.

Faith-Based Organization Visits

To complete these surveys, a volunteer visited each of the seven hospitals. Thirteen people were interviewed during these visits. Of those 13 people, five (38 percent) said that a reduced fee was available, and one (8 percent) said that decisions were made on a case-by-case basis. At only two hospitals was written information provided about policies related to fees and payment, and only one said that free care was available.

Community Benefits Review

The key findings of this component of the study were:

* Materials were often difficult to obtain.

* The reports were often incomplete. As presently prepared by the hospitals, the reports were quite different and often hard to follow.

* Little or no detail was provided about the priorities identified by the community and the hospitals' implementation of a community benefits program that reflected these priorities.

* There was a lack of clarity about the state's expectations with regard to the requirement to demonstrate financial and operational commitment to charity care services and improving access to health services for the underserved population.

For all seven hospitals, a mission statement was available. Only six (86 percent) mission statements met the requirement to identify populations and communities served and articulated a commitment to meet the health care needs of the community.

Only five of the seven hospitals (71 percent) had filed an implementation report with the state. For these five hospitals, appropriate information was included in the implementation report about how the hospital would meet the health care needs of the community and underserved residents. However, an inspection of the information provided showed that it did not meet the intent of this requirement. For example, one hospital reported such activities as educating high school seniors about careers in health care, educating physicians in another country, and participating in a local parade as "meeting the health care needs of the communities." Another hospital provided no information that described the community demographically and, thus, was incapable of documenting that it was meeting community needs. Another facility listed such activities as participation in a community festival and supervision of college students as being components of charity care. Another hospital provided no information about how the needs of the communities were assessed, making it impossible to conclude whether implementation plans are appropriate to meet needs or to assess progress in meeting changing community needs.

Information available to the public about implementa\tion plans and financial resources devoted to free care or reduced-charge services was almost nonexistent. Only four of the seven hospitals indicated that the information had been filed with the state, and in none of these cases was the information complete. The weakest component of these reports related specifically to the requirement to summarize the financial resources devoted to free care or reduced- charge services by the hospital. Only three of the seven hospitals provided this information in enough detail for the researcher to determine the amount of funds dedicated to these purposes.

Only two of the seven hospitals complied with the requirement to review and modify their mission statements. And, although six of the seven hospitals provided evidence that they sought the views of the community on their activities, in all cases it was without detail, showed an inadequate process, or provided no information about what was done with the information obtained.

Of the four hospitals that provided the state with a statement that shows the portion of the hospital's resources devoted to free or reduced-charge services, only one provided enough detail to determine the portion allocated to these activities. Only one hospital met the requirement to show the portion of the hospital's resources devoted to efforts to increase access to care.

DISCUSSION AND RECOMMENDATIONS

The results of this hospital community benefits and free care programs study show that steps are needed to improve access to medical care for individuals who are vulnerable and medically indigent. Free care is an important safety net that allows low- income, uninsured people to receive medical care.

For many working people who do not get health benefits from their employer, free care or reducedfee medical benefits may be the only way obtain essential health care services (Community Catalyst, 2002). People who are unable to pay for medical care and are unaware, or worse, uninformed, that free care exists, may not seek care.

The findings of this study reveal the seven Long Island hospitals failed to advise patients consistently of the existence of free care. Not one of the seven hospitals consistently informed surveyors that free care was available to low-income, uninsured people. Staff at four of the hospitals informed some surveyors that free care was available and told other surveyors that free care was not available. Staff from the remaining three hospitals consistently told surveyors that no free care was available to uninsured and low-income individuals. Surveyors had difficulty obtaining written free care policies (only one hospital filled this request). Several surveyors were told to go elsewhere for free care. Spanish or Haitian- speaking surveyors were almost never able to obtain information, despite the comprehensive development of national standards on how to provide culturally and linguistically appropriate services in health care (HHS, OMH, 2001). Not publicizing or providing culturally competent health care services can put the entire community at risk. Take the example of tuberculosis. The disease does not select its casualties on the basis of who has access to health care or who has the lower income. There are also secondary economic consequences of denying health care to poor people. Often, people with acute or serious illnesses cannot sustain fulltime work- if they can work at all. This affects the larger community. Consider the absence of this taxable income on the economy as an example. It is crucial that medically uninsured individuals and faith-based and community-based advocates know that free care is available.This can be accomplished in several ways.

Hospital administrators can adopt uniform charity care policies and prominently display these policies in areas where patients are likely to view them. Hospital administrators can also incorporate into their new-employee orientations or ongoing staff training a curriculum that provides staff with accurate and consistent information about free care for patients. In addition, hospitals should facilitate awareness of and access to free care for non- English-speaking individuals by using culturally competent methods such as supplying effective translator services and posting signs in languages that are common to the community where the hospital is located. A free care community outreach program may also inform individuals that free care programs exist.

The findings of this study are relevant to advocates for the medically uninsured population, policymakers, and community members. With 42.1 million Americans lacking health insurance (Huffman & Pohl, 2000), increasing access to health care should be viewed as an issue to be addressed now. It is important that advocacy efforts include direct work with hospitals to develop free care policies that are responsive to community needs. Advocates and other community members can also monitor hospital compliance, participate on hospital advisory boards, and assess the health care needs of the community. At the direct service level, social work advocates and related professionals can help the medically uninsured population by learning about and staying current on health care policies that can help meet the needs of their individual clients.This may require social services agencies to develop education programs for their staff. For example, an organization may sponsor a seminar on health care reform.

The findings from the community benefits review portion of this study suggest that despite state requirements, materials were difficult to obtain.The materials were difficult to review and understand and lacked adequate financial information. In addition, state requirements were often unclear, making it difficult to determine whether hospitals were meeting the intent of the law. Consequently, it is important that uniform standards are established in New York and other states that allow discretionary decision making for individual hospitals. Clarity of requirements can facilitate a process whereby hospitals understand specific policies and the spirit of legislative intent cannot be ignored. It can also strengthen the role of state agencies, because the importance of these requirements will be underscored. These standards should include how hospitals develop or modify their standards for charity care and how they communicate and monitor this care. State agencies also must establish uniform requirements to reduce the proportion of hospital revenues devoted to services such as free care and the inconsistencies in how hospitals publicize and report this crucial safety net.

We must not forget that voluntary hospitals are nonprofit institutions with a public service mission and are required to maintain charitable care policies. The IRS expects nonprofit hospitals to provide free or reduced-fee care and publicize the availability of charity care as a requirement for maintaining their nonprofit status. In addition, under New York State's Health Care Reform Act, nonprofit hospitals are required to provide community benefits and to involve their community in determining what programs their members need. Although nonprofit hospitals have an obligation to provide free care and other community benefits, this study revealed a disturbing fact. The hospitals in the present study consistently failed to inform people without insurance that free care exists. Consequently, it is important that hospitals'public monies are dependent on state-established eligibility standards for charity care and a uniform application. States can also develop minimal requirements for hospitals' provision of free care, actively monitor compliance by developing a consistent reporting format, and apply a financial penalty if hospitals fail to provide the required information.

Social workers and related professionals need to be better educated about charity care issues and their broader public policy implications. This includes developing an understanding of federal and state health regulations, 1RS codes, and rulings affecting tax- exempt organizations. Practitioners need to articulate and act on the ethical obligations of nonprofit organizations, particularly these institutions' mission concerning poor and medically indigent people. Social workers must also be involved in the political arenas that affect health services legislation.

Historically, the social work profession has addressed social forces that affect an individual's social environment. More than 100 years since its inception, the profession continues to maintain the belief that society should share some responsibility for its members and encourages social workers to seek social change. This is characterized in the NASW Code of Ethics (NASW, 2000), which emphasizes social workers' responsibilities to both clients and society to enhance social and emotional functioning. In this context, there are many roles for the social work profession. U.S. social welfare policy is constantly changing. For example, Hopps and Collins (1995) explained that passage of the Social Security Act of 1935 was recognition that social and societal ills 'were not simply caused by individual problems, but were created by structural problems in the economy and deficits in human capital investment. Today, most people believe the United States is experiencing a health care crisis. Health care costs are rising, and many Americans are finding health care services inaccessible. The need for social worker involvement in this policy process is increasing as societal attitudes begin to embrace the notion of universal health care. Social workers can continue to gather data and educate the public on health coverage issues. Several grassroots movements underway would welcome more social workers to share their knowledge and skills to increase access to health care for all. (A list of health-related advocacy organizations can be found at th\e end of this article.)

Future research should include an investigation of hospital charity care in other regions of the country to provide a better understanding of factors related to accessible health services for poor and uninsured people. Health services researchers are also encouraged to further examine health disparities between insured and uninsured people. Because poor and medically uninsured people may depend on hospital services for their medical care, additional studies of hospital charity care policies, community health needs, and how these policies are communicated and facilitated is encouraged. Research such as this can provide a better understanding of factors related to health care access.

ORGANIZATIONS PROVIDING HEALTH CARE-RELATED ADVOCACY INFORMATION IN THE UNITED STATES

* Alliance for Health Reform: http://www. allhealth.org/

* Community Voices: http://www.communityvoices. org/

* Families USA: http://www.familiesusa.org/

* Robert Wood Johnson Foundation: http://www. rwjf.org/

* The Center for Budget and Policy Priorities: http://www. cbpp.org/pubs/health.htm

* The Commonwealth Fund: http://www.cmwf. org/

* The Kaiser Family Foundation: http://www. kaisernetwork.org/

* The Urban Institute: http://www.urban.org/ content/ IssuesInFocus/HealthPolicyOnline/ HPOnline.htm

* Universal Health Care Action Network (UHCAN): http:// www.uhcan.org/

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Elissa D. Giffords, DSHf is assistant professor, Soda/ Work Department, Long Island University-C. W. Post Campus, 720 Northern Boulevard, Brookville, NY 11548; e-mail: GiffordsE@aol.com or Elissa.Giffords@liu.edu. Linda Wenze, PhD, is associate professor, Health Care and Public Administration Department, Long Island OniversityC. W. Post Campus, Brookville, NY. David M. Weiss, PhD, is associate professor, Hofstra University, Hempstead, NY. Donna Kass, MPA, and Rosemarie Guercia, MD, are co-directors, Long Island Access Monitoring Project. The authors acknowledge Long Island Coalition for a National Health Plan's Long Island Health Care Access Monitoring Project, which was funded by the Access Project, a national health care initiative supported by the Robert Wood Johnson Foundation and the Annie E. casey Foundation. The authors also acknowledge staff at Community Catalyst for their assistance. Please address correspondence to Dr. Elissa D. Giffords.

Original manuscript received September 25, 2002

Final revision received July 16, 2003

Accepted November 23, 2003

Copyright National Association of Social Workers, Incorporated Aug 2005

Source: Health & Social Work

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