Dial­y­sis dilemma

Fund­ing cut in Mi­ami could af­fect im­mi­grants

Modern Healthcare - - The Week In Healthcare - Jes­sica Zig­mond

Be­neath Jack­son Health Sys­tem’s re­cent de­ci­sion to stop pay­ments for out­pa­tient dial­y­sis treat­ments lies a deeper prob­lem: the des­per­ate need for dial­y­sis by il­le­gal im­mi­grants who can­not af­ford the treat­ment—and who do not qual­ify for Medi­care.

Mi­ami-based Jack­son, which does not have a li­cense to pro­vide dial­y­sis treat­ments, an­nounced ear­lier this month that it would no longer pro­vide fund­ing for pa­tients to re­ceive re­nal-care ser­vices at out­pa­tient clin­ics in Dade County, a move that will help the sys­tem save about $4.2 mil­lion a year, ac­cord­ing to Pres­i­dent and CEO Eneida Roldan. Con­se­quently, Bap­tist Health South Florida, Mercy Hospi­tal and the Uni­ver­sity of Mi­ami Hospi­tal have de­vised a unique—al­though tem­po­rary—so­lu­tion to the prob­lem: for the month of Jan­uary, the three hos­pi­tals will each kick in $50,000 to fund the dial­y­sis treat­ments un­til a more per­ma­nent so­lu­tion is es­tab­lished.

“Jack­son is too im­por­tant to the lifeblood of our sys­tem right now and our safety net hospi­tal,” said Brian Kee­ley, pres­i­dent and CEO of Bap­tist Health South Florida, also in Mi­ami. “If they can’t re­solve this is­sue, it’s a so­ci­etal is­sue, not a Jack­son or Bap­tist is­sue.”

It’s an is­sue in other states as well. Last fall, Grady Memo­rial Hospi­tal in At­lanta closed a dial­y­sis cen­ter for end-stage re­nal dis­ease af­ter a judge de­ter­mined that pa­tients who sued to keep the unit open were not en­ti­tled to the care. Sub­se­quently, il­le­gal im­mi­grants who were told about the clos­ing would have to re­turn to their home coun­tries of Hon­duras and Mex­ico, or re­lo­cate to states that pro­vided the care re­gard­less of im­mi­gra­tion sta­tus. Af­ter the clinic closed, Grady of­fered to pay for three months of dial­y­sis treat­ments at a clinic op­er­ated by Fre­se­nius Med­i­cal Ser­vices, ac­cord­ing to Denise Simp­son, a spokes­woman for Grady. Grady then ex­tended the dead­line un­til Jan. 3 and again un­til Feb. 3. A Grady of­fi­cial was un­avail­able to com­ment on the is­sue of il­le­gal im­mi­grants.

In Mi­ami, Jack­son had con­tracts with ven­dors who pro­vided dial­y­sis for about 175 pa­tients. In De­cem­ber 2009, a few of those con­tracts were up for ne­go­ti­a­tion, and some were ter­mi­nated, which af­fected about 85 pa­tients. Jack­son asked pa­tients to sup­ply doc­u­men­ta­tion to de­ter­mine if those pa­tients were el­i­gi­ble for fed­eral re­im­burse­ment, and was able to help con­vert 44 pa­tients to Medi­care. The sys­tem, which is gov­erned by the Pub­lic Health Trust, is try­ing to con­vert 29 more pa­tients to Medi­care, but there are 12 re­main­ing pa­tients who are il­le­gal im­mi­grants and will not qual­ify.

“The other 90 are be­ing treated in a con­tract that will ex­pire in Septem­ber,” Roldan said. “We’re try­ing to see how many of those can get con­verted to Medi­care prior to ex­pi­ra­tion of the con­tract,” she added. “We know that in this par­tic­u­lar group, there will be a higher per­cent­age of un­doc­u­ment­ed­care pa­tients.”

Bap­tist Health South Florida—one of the three hos­pi­tals work­ing to cre­ate a tem­po­rary so­lu­tion—has spent more than $1 mil­lion in the last year to cover the cost of un­funded pa­tients who re­quire dial­y­sis, both on an in­pa­tient and out­pa­tient ba­sis, ac­cord­ing to Kee­ley. “If we don’t do some­thing, they’re go­ing to end up in emer­gency de­part­ments,” Kee­ley said.

That’s a con­cern for emer­gency physi­cians who want to treat all pa­tients, but who rec­og­nize that dial­y­sis pa­tients in emer­gency de­part­ments could be tak­ing beds away from other pa­tients who are “acutely ill,” said An­gela Gard­ner, as­sis­tant pro­fes­sor of the depart­ment of surgery/emer­gency medicine at the Uni­ver­sity of Texas South­west­ern Med­i­cal Cen­ter at Dal­las. “We want peo­ple to feel it’s safe to come to the emer­gency depart­ment,” Gard­ner said.

Ad­min­is­ter­ing dial­y­sis to pa­tients in the emer­gency depart­ment “is not ideal,” Jack­son’s Roldan ac­knowl­edged, but, given that the sys­tem faced a pro­jected loss of $168 mil­lion for 2010 when Roldan be­gan in June 2009, end­ing th­ese pay­ments was one way to close that gap. Now the hospi­tal has 12 pa­tients to con­sider vs. 175. “As CEO, my No. 1 pri­or­ity is our pa­tients,” Roldan said, “but I also have a re­spon­si­bil­ity and stew­ard­ship to tax­pay­ers in this county.”

Still, the ques­tion of how to treat un­doc­u­mented pa­tients in the U.S. re­mains, and it’s a ma­jor prob­lem in the bor­der state of Florida, ac­cord­ing to Linda Quick, pres­i­dent of the South Florida Hospi­tal As­so­ci­a­tion. “Of the over 4 mil­lion peo­ple in Florida that are unin­sured, 1 mil­lion of them are un­doc­u­mented im­mi­grants,” Quick said.

There is no Emer­gency Med­i­cal Treat­ment and Ac­tive La­bor Act “equiv­a­lent for non­hos­pi­tal ser­vices,” Quick said. “The is­sue is there is no long-term-care fa­cil­ity that is re­quired to take peo­ple ir­re­spec­tive of their abil­ity to pay,” she added.

That’s why Quick’s group has sub­mit­ted a pro­posal to all of the re­gion’s hos­pi­tals to de­vise a long-range so­lu­tion to the prob­lem. Still pend­ing ap­proval, the plan would in­volve a con­tract be­tween the fa­cil­i­ties and one or more for-profit dial­y­sis cen­ters to pro­vide ser­vices to th­ese pa­tients at a ne­go­ti­ated rate.

“I think the prob­lems that South Florida have should be a wake-up call to the rest of the na­tion,” Quick said. “Both of them are in­di­ca­tors why we should sup­port health­care re­form and why we should ac­cept the fact that this is a melt­ing pot of a coun­try and we are al­ways go­ing to have peo­ple who haven’t lived here long enough to qual­ify for pub­lic pro­grams,” she added. “We’re like the wick of the large can­dle—it’s go­ing to get to them even­tu­ally.” <<

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