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Weekly UpdatesEXECUTIVE SUMMARY
A shift in commercially insured patients to publicly insured or uninsured status has caused an increase in emergency department (ED) visits for routine and nonemergent care. Meanwhile, hospitals struggle to compensate for decreasing reimbursements across all payer groups and increasing underwritten costs of care for the uninsured. Children represent a particularly vulnerable population and a substantial proportion of uninsured patients.
In this study we assessed the efficacy and financial benefit of an insurance-referral program that is integrated into the routine pediatric ED admitting protocol of an academic hospital for the period 2004 to 2007. In this model, the ED of Stanford Hospital and Clinics acted as a referral agency to the San Mateo County Children's Health Initiative, a county coalition that carries out screening and enrollment assistance for public insurance. Referral from the ED was available 24 hours a day, and partnership with the county coalition negated the use of a hospital insurance-enrollment worker. Over the four-year study period, the referral program attained a successful linkage rate of 54.5 percent, which represents nearly 800 newly insured children. The vast majority (88.6 percent) of these pediatric patients were linked to Medicaid, which can reimburse retroactively for services rendered. For the academic hospital, this linkage rate resulted in $105,829.25 in insurance reimbursements and $658,559.97 deflected from bad-debt conversion.
This pilot program is a sustainable, medically responsible model for linking uninsured children who need medical services with healthcare insurance. In addition, the program has the potential to yield financial return for the hospital. Similar models may be implemented in EDs across the United States. Healthcare managers who are seeking to alleviate the financial impact of care for the uninsured may find this model to be useful.
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The U.S. Census Bureau (2006) estimates that 11.7 percent, or 8.7 million, children in the United States do not have health insurance and subsequently lack access to regular medical care. Established in 1997, the State Children's Health Insurance Program (SCHIP) is considered an overall success in increasing health insurance coverage for children, decreasing unmet healthcare needs, and promoting the use of preventive care. However, an estimated 70 percent of uninsured children eligible for either Medicaid or SCHIP are not enrolled (Center on Budget and Policy Priorities 2007). Uninsured children are more likely to be treated in emergency departments (EDs) for routine care (Newacheck et al. 1998).
The objective of this study was to evaluate the efficacy of an insurance-referral program embedded into the routine ED-registration protocol of an academic hospital. Available 24 hours a day and requiring no hospital staff to perform insurance enrollment, the program is a partnership between the ED-registration unit at Stanford Hospital and Clinics and the San Mateo County Children's Health Initiative (CHI). CHI is a county coalition that enrolls uninsured pediatric patients and their families in Medi-Cal (California's Medicaid program); Healthy Families (California's SCHIP); or Healthy Kids, an insurance program for children in San Mateo County whose family income is at or under 400 percent of the federal poverty level. The Healthy Kids program, initiated by a broad coalition of public and private funders in an effort to ensure universal health coverage for San Mateo County children, also covers undocumented children without private health insurance, and children who are ineligible for state or federally funded insurance programs. (1) Specifically, in this study we aimed to measure (1) the number and proportion of children enrolled in a health insurance program after an ED visit and (2) the reduction in underwritten costs for uninsured pediatric patients.
METHODS
Study Design and Population
This study is a retrospective assessment of an ED-based insurance referral program implemented in March 2004 at Stanford Hospital and Clinics (SHC), a tertiary care center in the San Francisco Bay Area. The program was designed to link uninsured pediatric patients and their families with federal-, state-, or county-funded insurance programs. We evaluated data for the period July 2004 to December 2007.
Our study setting was the ED at SHC. In 2007, SHC had 44,834 ED visits, of which 28.6 percent were patients under age 18. Our target population was all uninsured pediatric ED patients (18 years or younger) who were residents of San Mateo County.
All analyses featured in this article were completed as part of routine programmatic evaluation by SHC's billing and admitting departments. In compliance with HIPAA guidelines, these departments retained all personal identifiers. Institutional Review Board approval was waived by SHC's Human Subjects Research Committee.
ED Registration Protocol
As part of the routine registration process in the ED, the parents or guardians of pediatric patients were asked if they had health insurance following the medical screening of their children. If parents indicated that they did not have insurance, ED registrars gave them information about CHI and asked if they would like to complete a referral form. The ED registrars then faxed the referral form to CHI.
A community health advocate from CHI contacted the parents to set up an appointment or a home visit to discuss insurance options and to assist with the enrollment application. Completed applications were forwarded to the San Mateo County Human Services Agency (HSA--the county's Department of Social Services), where a staff member determined final eligibility and enrollment in one of the available health insurance programs (Medi-Cal, Healthy Families, or Healthy Kids). If CHI received a referral for a non-county resident, the referral was forwarded to the respective county's HSA. Monthly reports from CHI allowed ED registrars to verify insurance linkage and to update referred patients' accounts. The time frame from referral to linkage ranged from three weeks to three months.
ED pediatric patients verified as being enrolled in Medi-Cal, Healthy Families, or Healthy Kids were recorded as successful links.
Data Analysis
Frequency tabulations were used to measure the success rate of enrollment. A [chi square] test was used to compare demo graphics between linked and unlinked patients. Stata 10 was used for all analyses.
RESULTS
Program Enrollment and Financial Impact
Over the study period (2004-2007), the ED had an average annual pediatric census of 11,464 patients. Payer mix after linkage was composed of 6.6 percent uninsured, 43.2 percent commercial insurance, 48.9 percent government (public) insurance, and 1.3 percent other insurance. These proportions, however, were not static. From 2005 to 2007, there was a 2.9 percent decrease in uninsured children and a 6.9 percent increase in government or publicly insured children (see Table 1).
Between 2004 and 2007, the ED saw 3,050 uninsured pediatric patients. Of this number, 1,782 (58.4 percent) came from San Mateo County and were eligible for referral to CHI. During this time, 1,467 referrals were made to CHI from the ED; 1,168 referrals were for San Mateo County residents, giving a program capture rate of 65.5 percent. Of all referrals, 799 (54.5 percent) were successfully linked with insurance (see Table 1 and Table 2). At the time of data collection, 708 (88.6 percent) out of 799 linked accounts were successfully transferred to Medi-Cal; 59 (7.4 per-cent) accounts were transferred to state health insurance; and 32 (4.0 percent) were transferred to commercial or other insurance, including Healthy Kids. The remaining 668 (45.5 percent) accounts were entered as "bad debt"--that is, accounts receivable that remained uncollected and were written off as an expense on the hospital's income statement.
Seventy percent of out-of-county referrals were for residents of Santa Clara County (the county adjacent to San Mateo County). The distribution of insurance referrals and linkage stratified by county is listed in Table 2. The most common reason stated for nonlinkage to insurance was that CHI could not get in touch with parents as a result of unreturned phone calls and incorrect or disconnected phone numbers.
Bad-debt accounts as a proportion of total pediatric patients admitted to the ED per year fell substantially from 13.4 percent in 2003 to 8.8 percent in 2007. In terms of the absolute number of pediatric bad-debt accounts, CHI linkages accounted for a 14.3 percent reduction in the number of accounts during the program period (see Figure 1). The value of reimbursements from linked accounts over the four-year period was $105,829.25 (see Table 1). In addition, $658,559.97 in net charges on CHI accounts were not converted to bad debt because of partial reimbursement.
Demographics
Among all CHI referrals in the ED pediatric population, the median age was two years (see Table 3). Ethnically, 66.5 percent identified as Hispanic and 33.5 percent were non-Hispanic. Parental language of referred patients was 64.3 percent English and 35.2 percent Spanish. Demographic differences between linked and unlinked patients from San Mateo County are shown in Table 3. Linked patients tended to be younger, of Hispanic ethnicity, and Spanish speaking (p < 0.001 for all variables). Conversely, unlinked patients tended to be older, of non-Hispanic ethnicity, and English speaking (p < 0.001 for all variables).
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DISCUSSION
Our program evaluation demonstrates that the ED can be an effective site for insurance enrollment and linkage. The program is not only medically responsible but also financially beneficial for the hospital. The financial gains are substantial in defraying the cost of uncompensated pediatric care. This is particularly relevant given that the number of uninsured and underinsured patients has increased dramatically since 2001 and is projected to continue throughout the current economic recession (Hurley, Katz, and Felland 2008).
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