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Written
Statement
of
Anthony R. Tersigni, Ed.D., FACHE
PRESIDENT AND CHIEF EXECUTIVE OFFICER
of Ascension Health
Before The
Subcommittee on Oversight and Investigations
Of The
U.S. House Committee on Energy & Commerce
June 24, 2004
Mr. Chairman and
Members of the Subcommittee:
Thank
you for the opportunity to appear before you.Ascension Health commends the Subcommittee on Oversight and
Investigations for its interest in uninsured patients.
I am Anthony R. Tersigni, Ed.D.,
FACHE, President and Chief Executive Officerof Ascension Health, one of the nation's largest nonprofit Catholic
health systems.Ascension Health was formed in 1999 when sponsors of two
Catholic hospital systems that shared a centuries-old commitment to care for the
poor - the Sisters of St. Joseph of Nazareth and four provinces of the
Daughters of Charity - agreed to unite their health systems and continue their
ministries as one.
Today,
Ascension Health carries on our sponsors' strong commitment to care for the
poor and the uninsured.It
continues to be central to our mission - and the work of the Catholic sponsors
that remain active in the leadership and operation of Ascension Health.It is reflected in the principles and strategies that guide
our operations [See attachment 1].In
2003 alone, Ascension Health provided more than half a billion dollars in charity care and community benefits. In other
words, for every dollar we made from our operations, we spent nearly four
dollars on charity care and community benefits.
Because of our tradition of caring
for the most vulnerable among us, our hospitals and clinics - or, as we call
them, our health ministries - play a unique and extremely important role in
our society, serving as a healthcare safety net for millions of uninsured
Americans.For the thousands of
religious and lay persons who work in our hospitals, this is a calling.It is humbling to lead an organization whose origin, as well as its
Mission moving forward, is due to women who have dedicated not just their
careers, but their lives, to providing care to people who are poor.
Today,
I want to address three points:
§ What we do right
§ How in the past we fell short in some areas and what we're doing
to address these issues
§ Our response to the Subcommittee's request for information
Later
on in my statement I will also lay out in greater detail our Call to Action initiative.It
is perhaps the best expression of our Mission, Vision and Values.Our Call to Action has as its goals the achievement of 100 percent
access to healthcare for every person who lives in the communities we serve -
certainly an ambitious goal, but one that speaks to our compassion for the poor
and vulnerable.
What
We Do Right
Every
one of our health ministires has had charity care policies in place for years,
if not decades.We publish and post
our charity policies throughout our health ministries.Our financial counselors are dedicated professionals who
share our values and who strive to do the right thing.They answer patient questions over the phone about our
charges.They seek out patients who
may be in need before they go home and make attempts to contact patients later
on to discuss how their financial obligations could be eased.They help patients qualify for financial assistance so they can get the
healthcare they need.
In
addition, the men and women who work in our health ministries every day save the
lives or relieve the suffering of hundreds of people who do not have health
insurance.The Subcommittee need
not take our word for it. Our patients are our toughest judges, and it is in
their words that our success is revealed [See attachment 2].
For
example, we received a letter from a woman who was a patient at SETON Southwest
Healthcare Center in Austin, Texas:
I
am writing. today to tell you how thankful I am that your organization was
able to assist me on 100% of the hospital bill I accumulated while a patient at
Seton SW..
Earlier
this year, my world fell apart.I
lost my job and my health insurance.Shortly
there after, my fiancé left me for someone else.I lost my home and . pretty much the life that I had
planned on.It was at that point, I
thought I had lost everything and then I lost my health.Once that was gone, I grasped on to all that I had left which was my
family, friends and faith..Being
that sick, was one of the most humbling experiences of my life.I was unable to work and very worried about how I would pay my hospital
bill.Stress doesn't help my
medical condition at all.Please
know that it was a wonderful surprise to hear that my bill was taken to a zero
balance.
It
is said that everything happens for a reason.I would like you to know that I had a wonderful experience while in
Seton.The nursing staff was
excellent and they inspired me.I
have decided that I want to be a nurse. I am feeling better now and plan to enroll in nursing school next year.I hope that I can offer the same compassion and inspiration to someone
else in their time of pain and illness..
From
another letter we received from a patient:
I
recently had an operation to remove my gall-bladder. The operation went
well, and I am now in recovery. I don't know how to thank you.
Words cannot express my gratitude. The cost of the operation had been a
big burden to me. I had just started a new life in America and was
financially unstable; in addition, I had no medical insurance.
Thankfully,
you heard of my situation . and funded my operation. Because of you, I
was able to have the operation safely. I believe that all of this is due
to your organization, which truly personifies the love and spirit of Christ.
I thank you . with all my heart. I do not know how I will ever be
able to repay you for all your help. Right now, all I can do is pray, and
I will pray for you and your hospital continuously and diligently. I will also
do my best to follow your example and help others with the love of Christ.
Again, I thank you for the love you have shown me. I will always be
praying for your hospital and your mission.
Mr.
Chairman, for every letter like those two, there are hundreds, maybe thousands,
of positive stories just like it that
are not told. I have additional
representative letters from patients from across the nation. I request that
these letters be made a part of the record [Attachment 2].Each one is a very personal story, and each one thanks the health
ministry that provided care - in some cases, life-saving emergency care. Each
person expresses heartfelt gratitude to Ascension Health for reducing or
eliminating his or her hospital bill or eliminating it entirely.
How
We Fell Short in Some Areas and What We're Doing to Address These Issues
That
Ascension Health gets many things right is not to say we get everything right.Formed
just four and a half years ago, Ascension Health is a young system that is still
in the process of integrating the many management and information systems used
by our health ministries.As a part
of that effort, which began in early 2003, we reviewed the billing and
collection policies that existed throughout our system and determined that we,
as a system, needed more clarity and consistency in this important area.The Subcommittee's work also
prompted us to examine our policies more carefully, which led to our identifying
a number of opportunities for improvement.
We
learned, for example, that our policies were not always explicit and each health
ministry did things a little differently.Consequently,
we could not speak to an Ascension Health system-wide billing and collection
policy.Nor did we have a process
that could measure the effectiveness of our health ministries' charity care
programs in reaching those in need.Our
billing and collection practices were not receiving the level of attention or
oversight by our senior management team that, in retrospect, they should have
received.And we had no system-wide policy that addressed the level of
charges for uninsured patients.
As
a result, we believe too many patients, even if only one, had come to our
emergency rooms and, in spite of the charity care and financial assistance
programs our health ministries have had in place for years, they had returned
home fearful and anxious about the bills they could not pay.Unfortunately, there are times when patients do not respond to our
communications and their needs are not fully met.
Regrettably,
it has on occasion become necessary for hospitals, even those such as ours that
are dedicated to the poor, to refer cases to collection agencies. And the truth
is, we have not wanted to be in the business of bill collecting. We have learned
through this investigation that there have been instances, and I believe they
are rare, when collection agencies have been more aggressive in their practices
than our values would support. That there may only be a few instances does not
excuse us.
We
concluded from this review that the experience the poor and uninsured have when
they come to us for care is too important to allow completely local variation.Although Ascension Health is newly formed and somewhat decentralized, we
determined that we needed a level of consistency throughout Ascension Health
regarding the care and billing of the uninsured. As a system, we needed
assurances that our charity and financial assistance programs were meeting
certain minimum standards and reflecting our values.
In
December 2003, a single, system-wide policy was approved by our Board of
Trustees, subject to approval by the Centers for Medicare and Medicaid Services
(CMS).It is important to point out
that this policy is a "floor" - it is the least that we require of our
health ministries, many of which have been and will continue to be more generous
in their care for the poor and uninsured than this new floor requires.
Ascension Health Policy
Regarding Care for the Poor and Uninsured
The Ascension Health policy is
premised on several core values and principles, including our commitment to, and
reverence for, human dignity and the common good; our special concern for, and
solidarity with, poor and vulnerable persons; and our dedication to distributive
justice and stewardship.
The
Ascension Health policy establishes minimum guidelines relating to the level of
charges, if any, that would apply to an uninsured patient, depending upon his or
her particular circumstances: those who are poor based on poverty guidelines;
those who face special circumstances; and those who are determined or presumed
(by not applying for financial assistance) to have the means to pay [See
attachment 3].The policy is as
follows:
Charity
Care.For the poorest
patients, Ascension Health covers 100 percent of their hospital bills.To qualify, a patient must have household income at or below the federal
poverty level (FPL).Those with household incomes between 101 and 200 percent of
FPL will have their charges reduced on a sliding-scale basis.The poverty limits will be adjusted at each health ministry based on area
wages.
Financial
Assistance. Income is not
the only determinant of need.So
our Financial Assistance program considers a broader picture of a patient's
financial resources and circumstances.Each
health ministry must have a written policy that considers income as well as the
patient's assets, size of the medical bill and other financial obligations
(e.g., for housing, transportation and childcare). For example, a married adult male with annual income of $14,500 a year is
making 120 percent of FPL and, therefore, would be entitled to a sliding scale
adjustment of his hospital bill, leaving him responsible for, say, 20 percent of
it.However, if the bill is
$30,000, he would still owe $6,000.If
he had no assets or had other obligations, he could have problems paying his
medical bill.
Finally, because of the complexity and subjectivity of its guidelines,
our health ministries are required to have review boards that consider patient
appeals of adverse determinations.
Uninsured
Patients with Means to Pay.Not
all uninsured patients are poor and even those who are don't always apply for
financial assistance (out of reluctance to fully disclose finances, fear or
embarrassment, or other reasons).In
the interests of fairness and clarity, these patients are charged a rate
comparable to the discounted rate each local health ministry has negotiated with
its "best paying" insurers.This
portion of the policy is subject to approval of CMS.(The commercial payers whose rates are used as the benchmark
must account for at least 3 percent of that particular health ministry's
patient volume.)
Mr. Chairman, I would like to
reiterate that this policy represents the floor.It represents the least any of our health ministries will do. We are a system that
believes in distributed leadership. Local health providers know more about local
needs than those at the home office, so if an Ascension Health ministry wants to
go above and beyond the policy I just explained to the Subcommittee, it may. In
fact, many of our health ministries currently are going above and beyond what is
required in our new policy.
The Ascension Health policy on
discounts for the uninsured also addresses billing and collection practices. The
policy requires that employees and agents of each health ministry treat patients
and their families with dignity, respect and compassion. Patients must be
provided prompt access to charge information and be advised of applicable
policies, including charity care and financial assistance, in easily understood
terms and in the language common to the community. Policies must also be posted
in hospital reception and registration areas.
Patients qualifying for financial
assistance are to be provided with both extended payment options that are
appropriate for their financial status and access to financial counseling.
Outstanding balances on accounts are to be pursued fairly and consistently.
With respect to collection practices,
the system-wide policy adopts several key principles:
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Ascension Health
will not take action to cause bench warrants to be issued.
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Liens on personal
residences will not be sought against individuals who qualify for charity or
financial assistance.
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Ascension Health
will not authorize a collection effort that will result in a bankruptcy.
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Interest may only
be charged to patients not qualifying for charity or financial assistance,
and only if they are not complying with payment arrangements.
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Collection
agencies must follow Ascension Health's system-wide policy for billing and
collection.
Ascension
Health's Response Highlights Our Charity Care & Values
In
October of 2003, Ascension Health complied with a request from this Subcommittee
for detailed information regarding four key areas: billing and collection
policies and practices for the uninsured; collections from uninsured patients;
operating incomes overall and from uninsured patients; and mark-ups for
services.Ascension Health worked diligently with 44 health ministries
to assemble the requested information at a cost of over $400,000 [See
attachments 4 and 5].A brief
outline of our submission follows:
ˇ Each of these health ministries has a billing and collection policy for
the uninsured.Furthermore, all of
our health ministries reported offering charity care to the poor, and all
reported providing assistance to patients for enrolling in public
health-insurance programs.
ˇ The aggregate data collected from the 44 Ascension Health ministries
shows that uninsured collections as a percent of uninsured charges ranged from
only 5 to 10.0 percent for the various periods reported [See attachment 4, p.
14-17].In fact, our health
ministries lost $222 million on uncompensated services to the uninsured in 2003.
ˇ Services provided to the uninsured had a negative impact on margins at
every health ministry during the periods reported.Let me reiterate that point, because the claim has been made by some that
hospitals "make money" from these services: every Ascension Health hospital
lost money on the services provided to the uninsured.
Mr. Chairman, I direct
the Subcommittee's particular attention to the attached chart, entitled
"Charges, Costs and Collections on a Per Equivalent Patient Day Basis"
[Attachment 6].As you can see, the
collections from the uninsured represent the smallest portion of collected
services.As I mentioned, some have
suggested that hospitals are somehow "making money" by providing these
services. However, we provide them because it is our mission to serve those most
in need, and we are unsure, as experienced healthcare administrators, exactly
how anyone could recoup 100 percent or more of the aggregate costs of services
for uninsured patients.
Moving
Forward: "Healthcare That Leaves No One Behind"
Although the purpose of this
statement is to address issues raised by the Subcommittee relating to billing
and collection practices, we believe a full understanding of our fundamental
operating principles and some system-wide achievements in serving the uninsured
will help inform the work of the Subcommittee. I will now describe several
important and representative activities.
Our
Mission, Vision and Values are reflected every day in our ministry to care for
the poor and uninsured. Their best expression is found in our Call to Action, a strategic initiative that dedicates Ascension
Health to achieving "Healthcare That Works; Healthcare That Is Safe; and
Healthcare That Leaves No One Behind."
Our
Call to Action's last component has
as its goal 100 percent access to healthcare for everyone in the communities we
serve. In furtherance of 100 percent access, Ascension Health is providing
leadership at the national level to sustain and strengthen the safety net for
the poor and uninsured throughout the United States. Ascension Health worked
closely with Congress to help craft the Healthy Communities Access Program that
provides infrastructure dollars to local communities to strengthen the local
safety net.Ascension Health was
then the only organization in the country that made a commitment to match
first-year federal funds for expanding access.
Ultimately,
Ascension Health contributed over $7 million, which was used to catalyze local
leadership in eight communities to achieve 100 percent access. Dollars were
invested to design and implement information systems to link all safety-net
providers, hire case managers, screen uninsured individuals for insurance
eligibility, design disease management programs for the uninsured, and
facilitate a number of other critical activities to bring health services to
uninsured persons. With four years of experience and results, we are now
designing model programs that other communities can replicate in their efforts
to achieve 100 percent access to healthcare.
For
example, in Tawas City, Michigan this year, Ascension Health ministry leadership
brought together all of the local safety-net providers in a public-private
partnership that now provides healthcare to the uninsured. This safety net
coalition has received close to $1 million of federal funding.
In
Austin, Texas, our SETON Healthcare Network recently joined with the Travis
County Medical Society in an effort to have every private primary care physician
in the city voluntarily take ten uninsured patients into his or her practice,
and every private specialist take 20 uninsured patients. Although still in its
early stages, this combined, community-wide program has already provided
"medical homes" to 250 individuals without insurance and has set its sights
on doing the same for all of Austin's uninsured.
In
Detroit, Michigan, a coalition of the city's three major health systems
(Ascension Health's St. John Health, Henry Ford Health System and the Detroit
Medical Center) are working in partnership with the Detroit Health Department
and three local federally qualified health centers to enroll uninsured patients
into a "virtual HMO" that case manages their care across multiple providers.
The program also collaborates with several other safety net healthcare providers
in the city.
In
New Orleans, Louisiana, the Ascension Health primary clinic for the poor has
joined forces with the public hospital and all other safety-net providers to
expand access to healthcare.In
some parishes, the number of uninsured exceeds 80 percent of the population. In
Nashville, Tennessee, the health department is working with our Saint Thomas
Health Services to provide free pharmaceuticals to the uninsured.
Our
five-year goal for the "Healthcare That Leaves No One Behind" initiative is
to achieve 100 percent access to healthcare in the communities we serve.Each of our hospital chief executive officers is charged with the
responsibility to work towards 100 percent access within his or her own
community and is held accountable for these efforts by me and our board.
In
addition to our hospitals, Ascension Health owns and operates dozens of clinics
for the uninsured throughout the country. Ascension Health is currently leading
an effort by the nation's major Catholic health systems to work with the
federal government on ways to expand these services to the uninsured.
In
furtherance of our Call to Action,
Ascension Health was the only health system in the country last year to have 100
percent participation in "Cover the Uninsured Week," which was sponsored by
numerous national organizations to raise awareness of the plight of the
uninsured. At every Ascension Health hospital, activities were held during the
week, enrolling thousands of eligible poor persons into insurance assistance
programs offered by states and the federal government.Today, these thousands carry an insurance card when they seek healthcare
services, thanks to the collective work of Ascension Health ministries.
Finally,
our ministry to the poor extends beyond healthcare. The commitment our hospitals
have made to pay a "living wage" is just one example.We believe that the people who work in our health ministries
should have a decent standard of living and be able to live within our
communities.
Conclusion
Mr. Chairman, Ascension Health and
our original sponsors take our tradition and commitment to care for the poor and
uninsured very seriously.For us it
is both a social and solemn obligation.I
have described for the Subcommittee how the men and women who staff our
hospitals and clinics work tirelessly to care for individuals who are poor and
uninsured. I have also
presented the numerous efforts across the country in which Ascension Health
employees, working closely with public and private partners, are striving to
increase access to healthcare for everyone in their communities.
It
is true that, throughout the nation, Ascension Health is responding to the needs
of the poor and vulnerable.Our new
billing policy will prevent some of the problems the uninsured have faced in the
past.But the work of ten Ascension
Health systems or 100 or 1,000 would still fall short and leave many of the
health needs of the poor unmet.We
as a nation can do better.
We therefore urge Congress to adopt
policies and provide adequate funding to achieve universal healthcare access for
all Americans.The change that is
necessary to address the needs of the nation's 44 million uninsured will take
a much greater collective effort than any one hospital system can undertake.
Thank
you, Mr. Chairman. I look forward to answering any questions the Subcommittee
may have.
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