In 2009, the recession was in full swing, unemployment rates were high, and health care facilities were providing more than $39 billion a year in uncompensated care for the uninsured. Instead of riding out the recession with uncertainty and accruing more debt, Sharp HealthCare (San Diego, California) joined forces with the nonprofit Foundation for Health Coverage Education (FHCE) (San Mateo, California) to meet the problem head on. Sharp leveraged a Web-based eligibility software program and took on a strong patient advocacy role to provide uninsured patients with much-needed eligibility assistance. At the end of its 2012 fiscal year, Sharp had increased its direct self-pay revenue by $7.76 million, bouncing back from a $3.4 million loss in self-pay patient collections and account volume in 2009. Health care facilities in the United States that continue to battle for each collection dollar may consider adopting the architecture of this new patient advocacy approach. Why? The problem of uncompensated care in the emergency department is unlikely to disappear in 2014 when the Affordable Care Act requires all Americans to purchase health insurance. Consider this loophole: In California, the IRS tax penalty for consumers who fail to purchase health insurance will amount to just $95. “If you are an individual and you are expected to purchase premiums that are larger than $95 a year, I expect those individuals will continue to come to our emergency departments unfunded,” says Gerilynn Sevenikar, VP of Hospital Revenue Cycle, Sharp HealthCare. “How ready is your organization?” Sevenikar and Ankeny Minoux, former president of FHCE and current COO, PointCare (San Mateo, California), described their partnership to help uninsured patients get the assistance they were eligible for during the presentation, “How Health Systems Can Improve Their Bottom Line & Relationships with Uninsured Patients,” on March 4, 2013, at the annual Health Information and Management Systems Society (HIMSS) conference in New Orleans, Louisiana. The nonprofit FHCE was launched eight years ago in California, and its efforts have since touched more than 500 million people across the country by shedding light on options for patients who don’t know they have coverage. In 2012, FHCE’s for-profit sister company, PointCarePA, was launched to commercialize the hospital emergency department and clinic eligibility software developed for the Sharp HealthCare initiative. The Truly Uninsured While there are believed to be 48.6 million uninsured in the United States, the true number is closer to 12.5 million, Minoux explains. The remainder of the 48.6 million include a sizable number of people who are eligible for Medicare but not signed up (16.6 million), 10 million immigrants awaiting legal status, 6.5 million temporarily uninsured, and 4.3 million young adults. That’s according to an analysis of US Census Bureau data by Blue Cross Blue Shield of America. Many of the presumed uninsured, in fact, are simply uninformed. During the two-year pilot program, Sharp HealthCare discovered that a surprising 80% of uninsured patients who presented to the emergency department were eligible for some form of coverage, Minoux shares. Because of the complexity of signing up for a public program or lack of program awareness, many uninsured seek treatment in the emergency department, where care must be administered regardless of the ability to pay. Other uninsured patients try and fail to secure public assistance. One of the most common reasons for public funding denials is patients’ failure to provide information or to cooperate, Sevenikar says. “They just get lost in the quagmire,” she adds. Implementing Web Strategies The central component of the initiative was to leverage the FHCE’s free, online interactive program [link to http://coverageforall.org], which allows anyone—including individual uninsured emergency department patients—to identify public and private low-cost coverage options for which they may qualify. The five-step process is simple and fast at 90 seconds, Minoux says. In response to the patient’s answers, the software is set in motion, scanning the entire US health coverage system to provide information on program eligibility, application criteria, and benefits available nationwide. The database is based on an algorithm that is continually updated, but on average, every state has 20 to 30 public programs available, Minoux says. Sharp took the process a step further and embedded the quiz screen in its self-pay registration. To comply with state regulations, a custom matrix was developed for each unfunded patient who was treated in one of four Sharp emergency departments in San Diego County. “By storing the accumulated data, we can intelligently speak to our patients,” Sevenikar says. As mentioned, more than 80% of the patients who took the survey were not enrolled in free or low-cost government programs for which they were eligible. Each patient who took the quiz received a personalized checklist of all items needed to apply to each program. Getting Answers The Sharp HealthCare initiative was more than software, however. Before embarking on the journey to enlighten the uninsured, a Sharp executive team defined the problem it was facing by learning exactly how uninsured patients felt about the present system. The top issues were: • They wanted to pay • They wanted to pay less • They wanted longer to pay • They didn’t know what their options were Equipped with this market intelligence, Sharp built an all-encompassing program that began at intake and made it easier for its health care staff to have first-touch success with uninsured patients, leading to positive changes throughout its system. ` “Our goal was to be patient-sensitive and fiscally responsible, but with some caveats,” Sevenikar explains. Education about the program options was key for both patients and employees. It was important to ensure that patients understood their responsibility in the process. “Most self-pay patients want to contribute toward their bill, but because of the laborious nature of qualifying for assistance on both the patient’s and the hospital’s end, they often had to give up and leave the hospital unfunded. PointCare helped to solve that problem,” Sevenikar says.PointCarePA is a version of FHCE’s Web-based eligibility software that enables health systems, hospitals, and doctor's offices to educate uninsured patients at point-of-care or during community outreach. “We can customize it down to a charitable program level (as done for Sharp),” Minoux adds. Additional Program Elements The overall program developed to improve Sharp’s relationship with the uninsured encompassed many other elements, Sevenikar explains. Other important elements of the improvement strategy include: Patient-friendly, one-stop bill pay. Sharp hospital systems consolidated multiple statements into one statement per patient with a summary of charges by department to identify clearly the balance due. Expanding payment options to include a loan program. Sharp contracted with a low-cost loan company, which provided an easy qualification and application process and extended payment arrangements for up to five years. In the last 2.5 years to date, Sharp has secured $5 million through its funding program. Unifying the self-pay continuum, from point-of-service through billing toward a total cash goal. Sharp made the decision to continue monitoring point-of-service total patient collections, but decided it was more important to collect the right amount and to continue an appropriate dialogue with patients. The teams in the front end and back end of the billing process shared expectations, goals, rewards, and recognition. Improving its advocacy role with patients to secure funding. Sharp revised the role of traditional financial counselor to one of a financial navigator who was trained and informed to get into a detailed dialogue with patients while they were at the hospital. The financial navigator presents patients with clear solutions for managing their retroactive and future medical expenses, while guiding them toward choosing coverage that will benefit them and the health system. Initiating more patient-friendly intake methods. “It’s actually changing the mindset of my team that collects from self-pay patients,” Sevenikar says. “We work with them, hear their story, and do what’s right as opposed to pushing patients into situations that make them feel uncomfortable.” 2014 Open Exchange Expectations Sevenikar believes that the Sharp initiative will play as important a role in 2014 when the state health exchange opens as it does currently. “I see this process as a precursor to the health benefit exchange in California,” she explains. Open enrollment for the plans participating in the exchange is scheduled for October 2013, leading to an effective insurance start date of January 2014. “Do you think the unfunded population is going to the exchange in October?” she asks. “Do you know the profile of your unfunded and what to expect? I expect those individuals will continue to come to our emergency department unfunded,” Sevenikar explains. Expect cost shifts to happen in the public sector, Sevenikar advises, adding that hospital staffs will need to know how to work with the uninsured. “Health systems are going to be asked to do more at point-of-care,” she concludes.Deborah Hauss is a contributing writer for Health CXO.