The Georgia Scroll
January 1998
Ga Better Healthcare
Program -
For Better Or Worse?
By Jim Brown, Director of Business Office
Sumter Regional Hospital – Americus, GA
Calendar Year 1995 brought the Georgia Better Healthcare Program (GBHC) to a majority of the Providers throughout our State. From the beginning I had some concerns about how this program would effect our institution, therefore, I made it my challenge to determine how to overcome many of the shortcomings. From talking with many of you I have determined that these same concerns are shared by a significant number of us.
I am writing this article as a means of sharing these concerns and soliciting input from other members of the Georgia Chapter about how they have overcome these problems or minimized their negative impact on their facility.
Let me outline to you the problems we encountered:
1. PROBLEM: Upon beginning the program we talked with the GBHC Representatives and were told that we should be able to follow our normal Triage policies which would mean that the SRH Nursing Staff would evaluate GBHC patients and determine if their situation required "Emergency" attention or if those whose condition was "routine in nature" could be referred to their PCP.
We learned through our ER Physicians that by following this procedure we were AT RISK for COBRA violations. Under the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA), HCFA has been citing hospitals for failure to provide "appropriate medical screenings". Upon advice from our attorneys we learned that an, "appropriate medical screening includes the ability of the Clinician to order ancillary services, ie: Lab tests, Radiology exams, etc. By Hospital By- Laws these tests can only be ordered by Physicians, not Nursing personnel.
I see this as a clear fallacy of the GBHC Program — once you have to get a Physician involved in the screening, they are going to want to order tests to protect themselves from medical malpractice. Once this is done, then the institution has incurred costs that are not always covered by the GBHC program.
2. PROBLEM: Recruitment of Emergency Physicians in rural areas many times requires that they receive a set fee and have no liability or financial incentive to reduce the amount of tests that are ordered for an ER patient. Based on their desire to provide quality care for their patients and to reduce their own liability for malpractice, these Physicians order tests to rule out any suspected conditions.
Since GBHC pays the hospitals only $10.00 for each ER encounter that is determined by Georgia’s Medicaid Program by Final Diagnosis to be of a "non-emergency nature", hospitals tend to lose money on a high percentage of the patients seen.
3. PROBLEM: The GBHC Program has no incentive for either the patient or the Primary Care Physician to minimize the times that they use the Emergency Rooms at the hospitals.
For years many of the patients had no regular Physician. The only way that they knew to receive medical treatment was to go to the Emergency Room of the hospital for every ailment that they had. It is hard to change this pattern. The PCP receives a monthly stipend of $3 for every GBHC patient that they are responsible for.
4. PROBLEM: We have encountered a problem with having adequate access to the Primary Care Physicians for After Hours calls.
PCP’s are not incented to be available to the Hospital for After Hours patients. Even when reported to the GBHC Program no changes in behavior have occurred.
5. PROBLEM: The GBHC Program promised the PCP’s that they would receive a regular report of the patient’s visits.
The PCP’s that I have talked with have not received these reports.
Are these problems that we have encountered unique to our institution or are they symptomatic of the entire GBHC Program?
I am told that since the initiation of the GBHC program the State of Georgia has saved over $42 million. This has been done at the expense of the Providers. We all know that when one Payer — Medicare, Medicaid or Commercial — fails to cover the cost of treating their patients, that this deficit must be made up by the remaining Payers or by supplements from the taxpayers. The concept of Managed Care may be a good one — when implemented in such a way as to share the liability among all participants — however, I am concerned that the GBHC program lacks this sharing. With the GBHC Program the revenues received have been reduced without an offsetting reduction in costs.
If this situation continues — costs continue but revenues are reduced — there will be a reduction in the medical infrastructure in the rural community. Based on our experience SRH is receiving only twenty cents (20 cents) on every dollar spent on treating a Medicaid patient seen through the ER. We all know that no one can survive very long with that type of reimbursement.
Please consider the following questions related to the GA Better Healthcare Program:
1. Why does the PCP received a monthly stipend for each patient per month, while the hospital receives no such monthly reimbursement?
2. Why is the patient not financially penalized for seeking unnecessary treatment in the ER?
3. How do we get the GBHC Program to be more proactive in addressing the concerns of the hospitals and Physicians?
4. How do we get the GBHC Program to broaden their definition of an Emergency Room Visit to be more in line with other Managed Care or Insurance Plans?
Have you found the Magic Solution for overcoming these obstacles with the GA Better Healthcare Program? If you have the answer will you share it with your fellow GA HFMA members? I’d love to hear from you.
Jim Brown has been Director of Business Office at Sumter Regional Hospital for the past 5 years and a member of HFMA for the past 10 years. He is a Fellow, CMPA, CMCP.