By Anthony Spangler, Fort Worth Star-Telegram, Texas, Fort Worth Star-Telegram, Texas
Dec. 18–The Tarrant County Medical Society says the JPS Health Network is shifting its mission from charity care to becoming the “hospital of choice” for insured patients, creating a two-tiered system that could leave many of the county’s poorest patients without care.
In a recent letter to JPS Chief Executive David Cecero, the society said the taxpayer-supported hospital has refused to accept some transfer patients from local hospitals and discourages treatment of the poor and uninsured by using a complicated application process.
“The safety net facility must behave like a safety net,” Dr. Gary Floyd, president of the medical society, wrote in the letter to Cecero. The letter is posted on the society’s Web site and is printed in the November issue of the society’s Tarrant County Physician magazine.
The letter was also signed by Dr. James L. Norman, who is chairman of a medical society task force on indigent care. Many of the concerns were raised by JPS physicians, Floyd said.
“No one expects JPS to take care of all of our charity care,” Floyd said in a recent interview. “The other nonprofit hospitals share that responsibility. But for our public hospital to deflect even a portion of their share is wrong.”
JPS is trying to attract more patients with insurance or the ability to pay to offset the rising cost of charity care, officials said. The network is increasing its patient admissions, emergency care and clinic appointments, and has posted more than $80 million in surpluses in the past two years.
JPS has used the cash to expand clinics and school-based programs, buy an Arlington hospital, and begin expansion of its Fort Worth hospital.
“Let me assure you that our mission and vision has not shifted, nor will it,” Cecero wrote in a response published last week in the society’s December magazine. “We understand our mission and we are proud of our role in the Tarrant County community.”
Harold Samuels, chairman of the JPS board, said a majority of the hospital board has supported Cecero’s efforts to increase the number of paying patients or those with insurance.
“We are never going to have enough money to serve all the people who need medical care,” Samuels said. “So if we can generate some dollars from paying patients, then we can provide more care to the indigent.”
Samuels said he wants to know about problems so they can be fixed.
“I understand those concerns were brought by our physicians and, perhaps, they felt like our administration wasn’t responding quickly enough to those concerns,” he said. “I would prefer that we learn about these things and address them before they are made public. But I don’t have a problem with the way we learned about these problems.”
Tarrant County commissioners, who appoint JPS board members and approve the network’s tax rate and budget, voiced support for the hospital district’s financial well-being and the services it provides to the community.
But at least one commissioner urged JPS to improve its working relationship with physicians. “A hospital can’t always be run like a business,” Commissioner Glen Whitley said. “Cecero still has to get better acquainted with a public hospital role and build a better relationship with physicians and other hospital chief executives.”
Seeking treatment
JPS patients qualify for the network’s free or subsidized health care, known as the Connection program, if they are legal residents of Tarrant County, do not have health insurance, are not already covered under a government program such as Medicaid, and have an income below 200 percent of the federal poverty level. Poverty criteria are affected by the number of family members.
JPS officials said they could not immediately provide the Star-Telegram with the number of Connection patients treated in the past year, but they released figures showing that 35,175 Connection patients were served during the 2004-05 fiscal year. About 27 percent of JPS patients are in the Connection program.
About 432,000 people in the Fort Worth-Arlington metropolitan statistical area lack health insurance, according to a report by the Texas comptroller’s office in April. The agency also reported that about 567,000 in the area fall below 200 percent of the federal poverty level.
Numbers were not available on how many people in Tarrant County qualify as both poor and uninsured.
“JPS Health system was established as our county’s public hospital and is charged with caring for patients without resources,” Floyd wrote in the letter from the doctors group. “But the number of patients enrolled in JPS Connection should be more representative of the eligible population. The system should be somewhat biased in favor of these patients.”
In the past year, the number of JPS’s poorest patients — those on Medicaid and in the Connection program — have declined 10.5 percent, while the number of patients with insurance rose 1.2 percent.
Medical society officials say JPS would reach more people if the application process were simpler.
JPS officials say the process can be daunting, but it is necessary because one application is used for Connection, as well for as state and federal programs. They say the process protects taxpayers by ensuring applicants are truly in need.
Patient Lucile Harmon was not overwhelmed by the necessary paperwork but said questions about how she spends her money were intrusive.
“It was easy,” said Harmon, 53, of Fort Worth. “But they want to know how you spend every dollar on food or this or that. “It seemed like they wanted me to prove that I really needed help. It was already difficult on my pride to go to the county hospital.”
Many indigent patients do not seek care until they have an emergency, pushing up the cost, JPS officials said. About 85 percent of patients admitted to the network’s John Peter Smith Hospital are first seen in the emergency room, officials said.
“If we could get more people enrolled in the system and get them treated at clinics, we wouldn’t have as many people seeing a doctor for the first time in the ER,” said Robert Earley, JPS senior vice president.
Some emergency patients are asked for cash deposits if they have not yet applied for the Connection program. The inability to pay does not delay emergency treatment, officials said.
“Unless it’s urgent, they will have to make an appointment,” said Gale Pileggi, JPS chief financial officer. “Patients should never be told they have to be screened before they receive services.”
The medical society letter also criticizes the network’s response to other hospitals that handle Connection patients, saying JPS has refused to accept transfer of some patients who have received initial treatment elsewhere.
The network is also slow in providing medical records of those patients who have been denied transfer, according to the letter.
JPS records show that the network accepts about 94 percent of transfer requests from area health facilities, with about half of the denials based on a lack of bed space.
“We have tried to find more rooms, but the demand just keeps growing,” said Ron Stutes, JPS chief operating officer. “Most of the time, we are at 105 [percent] to 108 percent capacity.”
When JPS does deny the transfer of a Connection patient, it can take up to two weeks for the treating hospital to obtain a copy of the patient’s medical records. JPS averages about 15 days to share patient medical records, in line with state standards, officials said.
“The problem has been that when JPS won’t take the patient back, they need to get the patient records to the other hospitals quicker,” Floyd said. “It would save money if you didn’t have to duplicate tests that might have already been performed at JPS.”
The network is in the process of developing a medical records hot line for other health care providers to request JPS patient records, JPS Chief Medical Officer Jay Haynes said. It is unclear when that system will be available.
Covering costs
The Connection program is not the only charity care provided by JPS. Most self-pay patients, who make up nearly 15 percent of the network’s caseload, are eventually written off as charity care as well, officials said.
“We collect only 1 [percent] to 2 percent of the charges from the uninsured, self-paying patients,” Pileggi said. “That is virtually no compensation, which we count toward charity care.”
The cost of uncompensated care provided at JPS during the 2004-05 fiscal year, which ended Sept. 30, was estimated at $271 million. The hospital district received $211 million from property taxes during that time.
The network’s financial data show that other public money offsets much of that shortfall. JPS received $72 million in federal funds for the 2004-05 year. That money — known as dispro funding — is given to hospitals that provide a disproportionate amount of care to low-income patients.
JPS, like other nonprofit health care providers, is exempt from paying property taxes and can receive charitable grants.
“I think it is disingenuous of JPS to portray charity care as a money-losing prospect since they receive property tax money and get dispro funds,” said Floyd.
JPS officials say paying patients help offset charity costs, because insurance companies reimburse for charges at a higher rate than governmental programs such as Medicare and Medicaid.
“With more insured patients, there is a reimbursement above cost for your services, with the extra cash intended for capital investment,” Pileggi said.
Thomas Marks, interim chief financial officer for the nonprofit University of Michigan Hospital in Ann Arbor, said insured patients are critical for the survival of public hospitals.
“Although most are not-for-profit, that doesn’t mean they don’t need to make money,” he said. “A hospital is a very capital-intensive business. It takes a large amount of money to afford new technology.”
Operating a hospital at peak capacity is key to keeping costs down, he said. “It is more efficient to keep your beds full,” Marks said. “And since the majority of U.S. citizens have health care through private insurance, it only makes sense to have a good mix.”
Airing concerns
Top executives at JPS admit the concerns raised by the medical society have merit, but they say better communication within the medical community could have prevented the issues from being overstated.
JPS has asked the medical society to create a position on its board for a JPS executive. “We don’t think publicizing their concerns was the best way to work these issues out,” Earley said.
Others praised the physicians for speaking up.
“The doctors who sent that letter to Cecero are very conservative and well-respected within the medical community,” said Dr. Wayne Williams, former head of community medicine at JPS.
“For them to air things publicly speaks volumes,” he said. “When doctors think their patients are being treated poorly, they speak up as patient advocates.”
Anthony Spangler, (817) 390-7420 [email protected]
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