Originally posted by mac the knight
...just inside the lobby of the hospital is a door marked "Financial Counsellor"....no seriously, if I had my digital camera to hand....

Working Off Hospital Bills: A Newsmaker Interview With Rick Batt

Cathy Tokarski

March 24, 2004 — Editor's Note: With 43 million people, or 15% of the U.S. population, lacking health insurance, most hospitals are struggling to cope with mounting bad debt.

Franklin Memorial Hospital, a 70-bed nonprofit facility in rural Farmington, Maine, has developed an innovative program that allows patients to work off their debts by performing a service of value to the hospital, whether it is reading to pediatric patients, tending to gardens, or helping transport patients.

Called Contract for Care, the program has reduced the hospital's bad debt load, although its charity care costs have gone up proportionately. More important, however, the program has provided a mechanism for patients to fulfill their financial obligation while expanding the range of services the hospital can offer. Nearly all of the patients who enroll in the program complete the service they agree to perform.

To learn more about the Contract for Care program, Medscape's Cathy Tokarski spoke with Rick Batt, chief executive of Franklin Community Health Network, the system that operates the hospital.

Medscape: What prompted Franklin Memorial Hospital to develop the Contract for Care program?

Mr. Batt: About seven years ago, a gentleman arrived in my office and said he needed to speak to me. He was an author and a former college professor, but by then, he was in his mid-70s and living in a cabin out in the woods with a younger wife and children in their young teens. One of the children needed to be admitted for medical care, but he couldn't afford to pay for it. He had Social Security and Medicare, but his royalties had run out by that point and he had no insurance for his wife and children.

He told me he was embarrassed to go through our hospital's charity care program. He broke down in tears in my office, and I was thinking, this is unbelievable. In any event, he did agree to charity care, and our conversation turned to his prize-winning books and other writing projects he was involved in.

In the course of the conversation I asked him if maybe he would want to help us with writing our brochures; not as a quid pro quo, but maybe as a volunteer. He thought it was a terrific idea, and left my office feeling terrific. He walked in embarrassed and sort of trembling and fearful and walked out feeling as though he could help us.

A couple of years after that, our hospital teamed up with other health and social service agencies. Each of us got teamed up with one or two families without health insurance and not covered by Medicare or Medicaid to find out what their health needs were. I personally thought — as many doctors and people in the health profession do — that our major health problem [for these families] was a lack of health insurance. But when we met these families, health insurance is not even on their list. It's not on their radar screen when they're worried about the house payment, the rent payment, buying food, whatever.

We also found out through this that no one knew what we were doing, that no one knew about the [charity care and other] programs we had available even though we ran ads in the newspapers about them. Well, lots of people without money don't buy newspapers. Out of that experience our board asked how do we make it a noble experience for someone to get charity care, and I remembered the story of the author, and told it to the group. They said, why don't we do this institutionally? So the idea was born.

Medscape: Explain how this program works. What activities do former patients perform to pay off their debt?

Mr. Batt: We don't have thousands of people participating. It's probably between 30 and 40 per year. A person who wants to apply meets with our volunteer director, and they can do whatever we mutually agree they can do. There's wide latitude about what they could do, but it has to be associated with our organization — they can't plant flowers at the town hall.

Two people have made us phenomenally beautiful quilts that are hanging on the walls in the hospital. We have one person who works outside, and we have gardens in summer that are spectacular. We have had people reading to children on pediatric units, and other people working in more traditional volunteer roles, like [escorting] patients, distributing mail, and so on. We don't substitute anyone for a paid staff member.

Medscape: How do you assign a monetary value to these services?

Mr. Batt: After we see what the person would be interested in doing and that it has some practical value to the organization, we assign a value of either $30 or $35 per hour. The value we assign is far more than what you would pay, but the trouble was that if we valued the service at $8 per hour, it would take forever to work things off.

The services also have a value — most hospitals wouldn't have the flowers that we have or people reading to children in pediatric units. If we didn't have [this program], we wouldn't have it either, but it does add a dimension to the service we provide. The service can be performed by a family member, a friend, coworker, or neighbor, but about two thirds of the time it is the patient[s] themselves [who perform the service] when they are healthy.

Medscape: What is the average dollar amount that a patient who participates in this program contributes through the voluntary work?

Mr. Batt: There are huge variations — from as high as $10,000 to as low $500. But this isn't for bills for an office visit. I would estimate the average is between $2,000 and $3,000 — the cost of a couple of days in the hospital.

Medscape: What do you think accounts for the high participation rate?

Mr. Batt: Because most people don't want charity. Let me be precise — most people who are not on Medicare or Medicaid don't want charity. We have a very generous charity care policy here so that if you are at 100% of federal poverty ($18,600 for a family of four), we write it off. [The patient does not] pay anything for the care that we provide. Between 100% and 200% of the federal poverty line, we have a sliding fee scale, where we write off some.

The Contract for Care program does not substitute for charity care. What it substitutes for is the private-pay balance that is owed to us. We will pursue someone at 150% of the federal poverty line, because they owe something. People can, through this Contract for Care program, pay what they would otherwise owe.

We originally got blasted by social advocates, saying that we were forcing people to work. That's not what we were trying to do. People who participate in this program know that they have an obligation, and that we will come after them. Some could duck it, but most people really don't want to walk away from their obligations.

Medscape: What results have you seen?

Mr. Batt: This program has been an absolutely phenomenal boon to us in terms of public relations. You could come to west central Maine and ask anyone in the gas station about Franklin Memorial Hospital and one of the things they would mention is the Contract for Care program. People either have participated, or they know of someone who has, or they just think it's a really cool idea. There's something old-fashioned about it, like the days when they couldn't pay a doctor, but they'd bring him a basket of apples or a chicken.

An unexpected result is that our bad debt went down, but our charity care went up proportionately. The point is people don't stop paying. The overall combination of bad debt and charity care did not go up. We have roughly $2 million in charity care deductions from our revenue; $500,000 was from bad debt. The total is $2.5 million [combined charity care and bad debt] deductions off of a $50 million budget.

Medscape: Should the federal government encourage local solutions like this to address the lack of health insurance in this country, or is this a band-aid approach that can only work in specific situations?

Mr. Batt: I think the federal government should do a lot more to try to get people toward universal coverage. Absent their doing so, I don't know that it is helpful for the federal government to advise local solutions.

Our point is that communities should stop waiting for the federal government to come down with the big, golden solution from the sky — they'll have to do it by themselves. The federal government should step up to the plate, but as local communities, let's not hold our breath, let's get going.

Originally posted by xabiachica
We were never planning to make our stay in US permanent, permanent (just long term, permanent) so didn't bother.
When our younger dd got an ear infection it came to nearly 200 dollars.
We actually worked out that good health insurance would have cost us less than dh was paying in National Insurance contributions in UK!