Bureaucratic problems led to less than optimal care, internal UNM hospital memo shows

One Native American woman had hoped to renew her health care coverage at the University of New Mexico Hospital last year. But when she showed up for a scheduled appointment she got a fresh batch of headaches.

Showing up at one office for an appointment, the woman was “then redirected by that office to go to yet another office, and finally after 30 minutes of going around in circles was back to the first office who told her she missed her appointment and needed to reschedule,” the authors of a report wrote, ending on a down note: “Six weeks later she is in need of medical care but is delaying it because she has not been able to renew her UNM Care coverage.”

The woman’s health care, it turns out, was through a special program available to financially eligible Bernalillo County residents called UNM Care. But the bureaucratic maze that confronted her proved too daunting, according to a two-page internal memo produced in June 2009 by the Office of Community Affairs at the UNM Health Sciences Center, which includes the hospital.

The woman’s experience personified what two staff people at the Office of Community Affairs found at New Mexico’s busiest hospital, a facility that treats more than 150,000 individuals a year and is the state’s only Level 1 trauma center.

Staff and providers at UNM Hospital “do not know about or promote financial assistance programs when serving patients,” the authors noted.

The June 17, 2009 memo also offered other examples of problems, opening a small window into the sometime Byzantine world of health care, especially on the insurance – or payment – side. The report doesn’t explain where exactly the breakdowns occurred in the system.

Billy Sparks, a spokesman for the University of New Mexico Health Sciences Center, told the Independent on Thursday that the two-page internal memo had provoked a dialogue between the community and the hospital and that the hospital had changed its financial assistance system. He didn’t say when that change occurred or what those changes were.

The memo’s authors identified problems beyond financial assistance, including improper denial of services.

In one instance, “a 9-yr old cancer patient, covered by Children’s Medical Services (CMS), presented for a PET-scan that was ordered by his doctor as a preventative measure for his aggressive cancer,” the report noted.

The child “was denied services because the ‘insurance company denied procedure’” even though the family was qualified for the self-pay discount program and could have “been charged a co-pay so their son could receive the procedure,” the authors noted. “Instead, frontline staff only considered primary payer source and denied services without looking at other payment options.”

That story served to illustrate what the authors saw as “no formal, objective appeals process when eligibility is denied in the self-pay discount program,” which primarily impacts immigrants, the memo reads.

Dizzying array of funding sources and payment plans

UNM Hospital, the state’s busiest medical facility, caters to Albuquerque and Bernalillo County populations but its sphere of care stretches well beyond the county’s borders. In 2007, a quarter of the more than 160,000 individuals who were treated at UNMH or at one of its clinics were from beyond Bernalillo County, according to a separate 2009 report on UNMH’s patients and how they are paid. Over the same period, the system racked up 632,000 medical visits.

The brisk business meant that the hospital’s staff confronted a dizzying array of insurance plans covering patients. Altogether, there were 85 funding sources and 177 payment plans for individuals treated in the hospital system, the report showed.

More than half of those treated in the UNMH system that year were on some type of government health insurance – Medicaid, Medicare or Indian Health Services to name just a few.

Roughly a quarter of patients, meanwhile, relied on commercial or private health care plans. And just under 16,000 of UNMH’s patients, or 15.6 percent, in 2007 were labeled “self-pay,” meaning they didn’t have insurance, the 2009 report noted.

“We do have all these possibilities but we don’t deny care to anyone,” Sparks said.

As a public hospital, UNMH also tries to treat everyone who walks in the door, he said.  And that can result in financial problems. The hospital experienced “uncompensated care” — meaning it didn’t recover money for medical services – valued at $180 million from July 1, 2008 to June 30, 2009, up from $152 million two years before, Sparks said.

Other problems identified

The hospital might attempt to treat everyone who walks in the door, but the memo paints an impressionistic portrait of an institution beset by challenges.

Among other findings in the memo were:

Communications between patients and the business office is not routine or easy to establish. The approach to common customer service-type interaction, from asking simple clarifying questions about a bill to negotiating a payment plan, is not available. But this is common and expected in most other service industries such as utility companies and banks, for example.

When a payment arrangement is made, it is very difficult to adjust the payment if economic circumstances change for the patient. An attitude of “no excuses” is encountered.

The three-tiered billing system: business office, extended business office, and collections agency, is a burdensome, complicated and confusing process for patients to navigate. Communication between the three billing tiers is limited and it takes a long time to receive resolution on an account.

Billing & collections practices are rigidly implemented regardless of whether a patient has been determined to be low-income and uninsured, and in spite of demonstrated coverage through state Medicaid or Medicare for most of their billed services.

To illustrate the last point, the authors wrote of a family of a 6-month-old baby boy treated at UNMH.

The family “began receiving collection notices and daily phone calls several months after the baby had been in the hospital,” the authors wrote.

The authors continue:

The baby’s stay had already been covered by Emergency Medical Services for Aliens (EMSA), and the family was surprised by the notices and calls. Although the baby’s mother tried to explain this to the collection agency worker, she was told that they would not stop collection attempts until they have proof of payment from UNM Hospital. A year later, this family continues to be harassed by the collection agency on this account.