1. How Far Will the Safety Net Stretch? Providers to the Uninsured Third Technical Workshop – May 23, 2003 This research is funded in part through a U.S. Health Resources and Services Administration State Planning Grant to the Hawaii State Department of Health, Prime Contract No. 1 PO9 OA 00046-01. Sub-contract to Research Corporation of the University of Hawaii, Project No. 659075. Research conducted by University of Hawaii, Social Science Research Institute in collaboration with the Hawaii State Department of Health,Hawaii Institute for Public Affairs/Hawaii Uninsured Project and the Hawaii Health Information Corporation. Research Team Carol Murry, Health Policy D. William Wood, Sociology Heather Young Leslie, Anthropology J.D. Baker and Jin Young Choi, Graduate Assistants

2. Purpose of Provider Interviews Introduce voices and recommendations of providers to the policy-making process Inform quantitative analyses and policy-makers of possible meanings and implications of findings – Impact on individuals, families, safety net facilities and providers. – Who pays and what are the costs?

3. Methodology: Multiple Methods – Long, semi-structured interviews – Recorded field interviews on 5 islands – Summarization and computerization of all interviews – Transcription of selected interviews – Qualitative analysis using ATLAS/ti software to ease coding and model building based on grounded theory

4. Multiple Voices:Safety Net Facilities Community health centers HHSC Hospitals Private Hospitals Dental Vans Care-a-Vans Private Provider Offices Pharmacy Social Service Agencies Student Health Service HIV Service Agency Mental Health Clinic Native Hawaiian Health System Youth Outreach Program Beach & Park Outreach

5. Multiple Voices: Providers Medical Doctors Doctor of Osteopathy Nurse Practitioners Certified Nurse Assistant Outreach Workers Dentist Dental Assistant Billing Managers District Health Officers Executive Directors Benefits Case Managers Hospital Administrators Pharmacist Social Workers Public Health Nurses Psychiatric Nurse Spec. Native Hawaiian Healers

7. Provider Interviews by Island

8. Provider interviews by type facility

9. Results What we’ve found so far…

10. Impact on Safety Net Facilities Losing money - patient can’t qualify for QUEST and can’t pay Medicaid and Medicare reimbursements too low Must raise funds to cover uncompensated care Cannot turn away (EMTALA) Must serve in lieu of missing services

11. Impact on Providers Angry, crying, can’t sleep Ability to diagnose is limited Wasted time discussing cost and finding alternate RX Provide pro bono care View job as “calling” Must modify treatment

12. Impact on patients Depressed, frustrated, angry Can’t afford drugs Harassed for payment Few choices for care Poor outcomes

13. Safety Net Policies and Programs Don’t turn anyone away Sliding scale Free care, especially dental Free drugs Rural health grant for uninsured Charity care

14. What do providers need from system? Affordable coverage Cover drugs, lab, x-ray,pre-existing conditions Ease QUEST bureaucracy, solve problems More community health centers, free clinics Let patients pay small amounts over time Health promotion, disease prevention

15. Native Hawaiian Loss cultural identity is risk factor Poor health indicators Niihau patients may lack docs, English Native Hawaiian health system Access to land and water impacts health Spirituality important to indigenous healing

16. Caring for uninsured diabetics Patients avoid clinic because of debt Avoidable complications, e.g. amputation lead to more expensive care Patients don’t take needed drugs - can’t pay

17. Uninsured and Disabled Even providers don’t understand spend-down Call system abysmal Advise patients not to apply for disability unless no choice Provider believes patient died due to problems with system

18. The Dilemma of who pays: Creative Solutions Intense assistance for QUEST enrollment Help patient plan how to pay bill Aggressive collection Encourage divestment of assets Reverse mortgages Proactive about guardianship and advance directives

19. The Ultimate Costs of Uninsurance Families suffer. Children’s lives are impacted. Two doctors believe their patients died as a result of being uninsured. Safety net providers are set up as providers of last resort. Who pays? We all do – the uninsured, providers, and all the rest.

20. Providers Recommend to Work Groups Revise eligibility criteria and simplify QUEST Create low-cost coverage options Examine charges State should contract for lab, x-ray, drugs Universal coverage Cover preventive care, long term care Address retention, underinsurance, CFA