Parkland growing tired of picking up neighbors' tab
Patients from Collin, elsewhere say they have no place else to turn
10:41 PM CDT on Wednesday, June 23, 2004
By SHERRY JACOBSON / The Dallas Morning News
Gordon Broward had meager medical options when the pain in his lower back became too much to bear.
The unemployed telecom manager had no medical insurance. He had no money to pay for a doctor visit. And there was no public hospital in Collin County that would readily accept him as a patient.
So the 47-year-old Plano resident drove 20 miles south to the only public facility he knew, Parkland Memorial Hospital in Dallas.
His painful act of desperation, and that of thousands of other out-of-county residents, has turned into a major political issue in Dallas County. Officials are questioning why so many people are crossing county lines to get to Parkland and then leaving without paying their bills.
Parkland growing tired of picking up neighbors' tab
County looks to spread cost of wayward patients
Last year, Dallas County taxpayers were forced to cover almost $33 million in unpaid medical expenses at Parkland by nonresidents. Two-thirds of the non-Dallas County visits were from neighboring Collin, Denton and Tarrant counties. "It isn't fair," said Dallas County Judge Margaret Keliher, who leads the Commissioners Court. "Our taxpayers are getting stuck paying for people who come to Parkland from other counties and don't pay their bills." Mr. Broward admitted that he was one of them. After eight hours in the emergency room, tests showed he had a deteriorating disc in his back that someday might require surgery. He was grateful for the diagnosis but couldn't pay the $1,086 bill.
"I feel really bad about it," he explained of the unpaid bill from November. "I started a new job recently, and I have major debts from being unemployed. There's no way I can pay it." Parkland officials have heard it time and again from uninsured, out-of-county patients. They have no public hospital at home, so Parkland has to bail them out. "The real problem isn't poor rural counties," said Dr. Ron Anderson, Parkland's president and chief executive officer. "It's wealthy counties that don't have the will to take care of their own people."
Collin County factor
Collin County is Texas' wealthiest county, according to the 2000 census. Its residents had a median household income of $70,292 in 1999 compared with $43,119 for Dallas County households. A recent report on Parkland's out-of-county expenses indicates that Collin County residents make more visits to Dallas County's public hospital than residents of any other county. Last year, people from Collin County accounted for 18,657 outpatient visits at Parkland as well as 1,776 hospital admissions, which totaled a third of the Dallas hospital's out-of-county care. Although most of those Collin County patients had public or private insurance coverage, their unpaid bills totaled $7.3 million.
However, Parkland officials blame most of the loss on low insurance reimbursement. Counties can't be billed when Medicaid and even commercial carriers do not pay hospitals the full cost of care. In the big picture, out-of-county patients are a relatively small piece of Parkland's $812 million annual budget. But the issue is as much about fairness as it is about money. Parkland officials said they would be happy if Collin County, for one, would fork over a greater share of the cost of caring for its uninsured residents. Their care at the Dallas hospital alone totaled $2.7 million in 2003. "We do everything we can legally do to collect this money from out-of-county patients," said John Gates, Parkland's chief financial officer. "It seems to me that other counties should recognize our problem and help us pay these bills. It's the decent thing to do."
Collin did pay Parkland $84,890 last year for taking care of a small group of patients who qualified as indigent by that county's criteria. But Collin's indigent coverage only goes to the poorest residents – those whose incomes don't exceed 25 percent of the federal poverty level or $4,712 a year for a family of four. Collin County Commissioner Phyllis Cole defended her county's decision to support only the poorest uninsured residents. "We're not supposed to be a health care provider of all uninsured people," she insisted. "We're a provider of last resort." In Texas, counties that don't have hospital districts or public hospitals are responsible for providing health care for only their indigent residents. But state law allows counties to define the indigent income level they are willing to cover – as low as 21 percent of the federal poverty level. Most counties pick the lowest end of the scale, meaning that the vast majority of the state's 5.4 million uninsured residents don't qualify for indigent coverage.
Texas has the nation's highest level of uninsured residents, 24.7 percent, mainly due to high unemployment, a heavy migrant population, a service-based economy and relatively weak health programs, experts said. The state's Medicaid program, for example, covers adults only if they have children younger than 19 and earn no more than 25 percent of the federal poverty level. "It falls on the big public hospitals in the state, including Parkland, to pick up a disproportionate share of their care," said Dr. Anderson of the uninsured. Ms. Cole said Collin County decided to target only its poorest residents for indigent care in the belief that many people simply choose not to buy health insurance. "In some way or fashion, they made that decision," she said. "It's up to you what you chose to do" about getting health insurance. An estimated 78,000 Collin County residents are uninsured, according to a 2002 study by the Dallas/Fort Worth Hospital Council. Aside from those who go to Parkland, it's not clear where they get medical care.
Collin County officials blame Parkland for allowing such easy access to its services. "Parkland has been taking our residents in their clinics for years, and they don't question their income levels and where they come from," Ms. Cole said. "Parkland likes to blame their problems on Collin County. That's just an easy way out. " There is no denying that Dallas County's public health system serves up a tempting buffet of medical options including 10 community clinics, 150 specialty clinics, a 985-bed hospital and a highly regarded emergency room. Dr. Anderson said federal law prohibits Parkland from turning away people who need immediate treatment, regardless of where they live. In recent years, Parkland staffers have tried to send patients back to Collin County and elsewhere – but only after their medical conditions have been stabilized, he said. Parkland's top administrators reject the idea that the hospital and its staff are to blame for responding to the needs of sick and injured people. "Why do we continue to blame doctors for taking care of sick people?" Dr. Anderson asked. "There has to be a better way to fix this problem than to blame us for doing what we're supposed to do."
Sale of hospital
Parkland became a medical magnet for Collin County residents after Collin County officials sold the county's public hospital in 1983. That was the year voters rejected a $16 million bond election to renovate Collin Memorial Hospital, the public hospital in McKinney, the county seat. Collin County officials felt they had no option but to sell it, said County Commissioner Jerry Hoagland, who approved of the sale. "It was quite old and too expensive to maintain," he said of the then 25-year-old hospital. "We sold it for lack of public support and got about $13 million, which was a lot of money in 1983." Since then, a trust fund has paid for indigent health care in Collin County, using money from the hospital's sale, accrued interest and a portion of the state's tobacco settlement. The fund is valued at $24 million.
Little available in Collin
Uninsured patients who venture into Collin County's public health system find a handful of community clinics in Plano and McKinney. The facilities usually are open once or twice a week and are staffed by volunteer doctors and nurses, who often must turn away patients because the operations are so small. "Our elected officials don't realize how bad it is," said Dr. Jim Wilson, a McKinney family practitioner, who volunteers Thursday nights at the Collin County Adult Clinic in Plano. "We'll have to turn away 20 to 24 people tonight because we just don't have the capability to serve them." On a recent Thursday, the makeshift clinic, which is in office space belonging to St. Mark's Catholic Church, had four volunteer doctors juggling 64 patients, most of them Hispanic adults seeking medication for chronic conditions such as diabetes, hypertension and heart disease.
The doctors examined their patients behind coat racks draped with white sheets and wrote about 100 prescriptions before the three-hour session ended. Several patients in the clinic's overcrowded waiting room said their previous doctors had been willing to give them free medication until they could no longer afford an office visit. "Our family doctor was giving us free drug samples until April, when my wife got a letter that said it would end," said Tony Kuehn, a Plano resident who has been uninsured since he lost his job last year. After a six-hour wait at the clinic, he left with two of the drugs he sought and a prescription for a third. The growing demand for free prescription drugs in Collin County has become a burden on the Plano clinic, said Jerry Weis, its spokesman. "We don't want these patients to keep coming back to us every month for refills, but there's nowhere else for them to go in this county."
In its first year of operation, the free clinic subsisted mainly on donated drug samples, a $50,000 grant from county commissioners and a smattering of $10 donations from patients. With its patient load now exceeding 1,000 people, the clinic needs a permanent site and better cooperation with other health care providers in the county, Mr. Weis said. "The hospitals are not willing to take uninsured patients," he said. "In fact, they stabilize people in their emergency rooms and send them to us. I guess they have no other recourse." Private hospitals in Collin County are seeing more and more uninsured patients in their emergency rooms, complained several officials. "People are using our ER as a family practice doctor," said Sandra Fulce, director of business development and community relations at North Central Medical Center in McKinney. She estimated that her hospital spent $27 million last year caring for uninsured patients.
"The private, for-profit hospitals pay a tremendous amount of taxes in this county," she said. "But we can't continue to absorb the burden of indigent care." Collin County will spend about $2 million reimbursing some of the health providers, including North Central Medical Center, for treating the county's indigent residents. Another $500,000 will be spent on direct indigent care at the county health department. By comparison, Dallas County property owners will pay $322 million in taxes for Parkland, about 10 percent of which covers the unpaid bills of out-of-county patients. The public hospital, which gets more than 60 percent of its funding from Medicare, Medicaid and other sources, treated about 350,000 patients last year. Officials predict that the growing political pressures in Dallas County eventually could convince some Parkland patients to go back to their home counties. Collin County, for one, is expecting its indigent patient load to grow to about 700 people this year from about 400 in 2003.
"Three months ago, Parkland said they were going to be turning away our patients, but we never saw a blip in our [indigent] numbers," said Collin County Administrator Bill Bilyeu. "Did those people just stop needing health care? I don't know."