It may take four to six weeks for a patient without an established PCP to get a new patient appointment. “This is a huge impediment, as the patient won’t have anyone to ensure that he or she continues along the proper care path,” Dr. Sears says.
Figure 2. Characteristics of the Nonelderly Uninsured, 2014NOTES: The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,055 in 2014. Data may not total 100% due to rounding. SOURCE: Kaiser Family Foundation analysis of the 2015 ASEC Supplement to the CPS.
“Studies estimate that more than half of medication errors that patients experience occur during transitions and after discharge,” Dr. Sears says.2 “Intervention with a healthcare provider who can review proper use after discharge can dramatically reduce errors and [improve] patient outcomes.”
Rates of patients without a PCP vary by region for Sound Physicians. In the northwest region, about 25% of admitted patients lack a PCP; in the gulf region, the figure can be as high as 60%.
“In Texas, there is a large number of patients and not as many PCPs,” he adds. “There is also a larger percentage of patients without health insurance. Sometimes patients have coverage but have never established care with a PCP.”
As a result of not having a PCP to transition to, some patients return to the hospital soon after discharge, Dr. Feldpush notes.
Tips for Treating Uninsured Patients
Some facilities have found successful ways to help hospitalized patients without health insurance. Dr. Sears says that hospitalists can investigate which clinics accept uninsured patients or which local physician groups are willing to see them after discharge, in exchange for hospitalists taking care of them in the hospital. They also can investigate the community-based insurance programs that are available.
Coker
Teresa Coker, MSN, ARNP, FNP-BC, a Sound Physicians program manager at Mercy Medical Center in Cedar Rapids, Iowa, says that when patients lack insurance at her hospital, an organization will review the patient’s case, determine insurance eligibility, and assist the patient in completing the appropriate paperwork. When patients are not eligible, they are instructed to inquire about the hospital’s charity care program if they receive a bill they are unable to pay.
In addition, the community has a free health clinic that serves those without insurance. “Patients are given the address and hours prior to discharge, because it is walk-in only,” Coker says. “All patients are recommended to follow up within one week, or sooner if medications are needed.”
Dr. Englander
Dr. Englander advocates that physicians take into account medication costs, transportation, and other social considerations when planning care after hospitalization. The team at OHSU developed a low-cost formulary (based in part on widely available $4 plans from national pharmacy chains), and OHSU provides medications for uninsured patients in the program for up to 30 days following discharge.
For patients who can’t afford the $4 drug plan, case managers offer coupons for $4 prescriptions, says Malik Merchant, MD, area medical officer for the Schumachergroup in Harker Heights, Texas. He says that as many as 30% of the patients in his area are undocumented or unassigned. For more expensive medications, a social worker offers pharmaceutical company coupons when they are available. The institution also has a small budget to pay for drugs.
Dr. Merchant
Dr. Merchant has found the biggest challenge to be the transition of care from inpatient to outpatient.
“Case managers and social workers prepare a financial worksheet that provides the possibility of overall cost savings for the institution, if patients are willing to participate in some upfront cost,” he says. “When our parent institution came on board, we developed contracts with local pharmacies, [a] skilled nursing facility, and PCPs to take these patients until they recovered from an acute illness. Our institution paid for these services at a reduced rate but saved money by reducing the length of their hospital stay.”