Arkansas Uninsured Facts Reported

The Employee Benefit Research Institute (EBRI), Washington, D.C., released a report in July on the characteristics of the uninsured populations in each of the 50 states. According to the EBRI data, which is based on the March 1997 Current Population Survey of the U.S. Census Bureau, 24.9% of Arkansas' non-elderly population is uninsured, giving the state the third highest uninsured rate in the country. Only Arizona and Texas had higher rates. Arkansas' non-elderly population also had the third lowest rate of private health insurance coverage, ranking just ahead of New Mexico and Arizona. Among the other facts about the state's uninsured population included in the report were the following:

• Children living in Arkansas - infants through age 17 - had a lower rate of employment-based health coverage (48.7%) than the national rate (58.9%). And 20.8% of all Arkansas children are uninsured, compared with a 14.8% national rate.
• Sixty-two percent of all Arkansas workers have employment-based health insurance. Nationally, 72.3% of workers have health insurance furnished through their employer.
• While 64.1% of Arkansas workers in firms with 1,000 or more employees had coverage in their own name, only 19.4% of workers in firms with fewer than 10 employees had coverage.
• Government employees (6.8%) and workers in the wholesale trade (13.8%) have the lowest uninsured rates in Arkansas, while construction workers (47.3%) and those who are self employed (40.7%) have the highest rate.

Arkansans' Charges Among Lowest

Patients who are admitted to hospitals in Arkansas for medical and surgical services related to illness and injury continue to pay less than patients of hospitals located in the region or across the country. According to information in the 1998 edition of Hospital Statistics, published by the American Hospital Association, the bill for an average stay in an Arkansas hospital was $9,151 in 1996, the most recent year for which data is available. That's 18% less than patients in the west south central region of the U.S. (AR, LA, OK, TX) were billed ($11,163) and 21% less than the average inpatient bill sent out by hospitals nationwide ($11,658). The average billed charges in Arkansas' hospitals were also less than all but one of its bordering states. Average bills in those states were: Texas ($11,945), Oklahoma ($9,542), Missouri ($11,828), Tennessee ($10,362), Mississippi ($8,684), and Louisiana ($10,680).

Although the average amount billed for a full patient stay in an Arkansas hospital was $9,151, the average amount actually paid by patients or payer organizations was $5,032, about 55% of the total. Due to payment policies of government programs like Medicare and Medicaid, non-covered charges insurance companies don't pay, managed care discounts, charity care provided by the state's hospitals, and bad debts for services provided patients who have no insurance and can't afford to pay for either all or part of the services they receive, 45% of the bills for hospital care in the state are never paid. Among the bordering states, the rate of uncollectible bills range from 43% in Mississippi to 48% in Texas. Within the region an average 47% of the bills are written off. Nationwide, hospitals write-off an average 45% of their billed charges.

Calendar

• October 4-7, Little Rock
      AHA 68th Annual Meeting and Trade Show
• October 15-16, Searcy
      Arkansas Healthcare Human Resources Association
• October 21, Little Rock
      Applying Inpatient Coding Skills Under PPS
• October 23, Springdale
      Arkansas Association for Hospital Engineering
• October 30, Little Rock
      Documenting Hospital Meetings
• November 10-11, Memphis
      The Facility of the Future
• November 11, Little Rock
      Arkansas Council of Nurse Managers
• November 13, Hot Springs
      Arkansas Society for Healthcare Consumer Advocacy

'Dumping' Settlements Jump

According to the Health and Human Services (HHS), 17 hospitals in 11 states settled "patient dumping" charges, paying a total of more than $530,000. The settlements, which were entered from February to April of this year, ranged from as little as $5,000 to as much as $150,000, with none of the 17 hospitals admitting to any wrongdoing or liability.

Federal law prohibits patient dumping, the practice of denying basic medical screening to patients because they lack the ability to pay. The 1986 law, known as the Emergency Medical Treatment and Active Labor Act (EMTALA), also prohibits the transfer of medically unstable patients based on economic reasons. The maximum civil monetary penalty for patient dumping is $50,000 per violation.

The unusually high number of settlements is a sign that HHS is getting more aggressive in its enforcement efforts involving dumping. In this year's first quarter, 23 hospitals inked patient-dumping settlements with HHS. Six hospitals in four states settled dumping charges with HHS in January alone, paying a total of $129,000. The number of settlements reached this year has already exceeded the total number signed in 1996. That year, HHS settled with at least 15 hospitals accused of patient dumping.

AHA EMTALA Seminar Notes

During a recent seminar on the Emergency Medical Treatment and Active Labor Act (EMTALA) sponsored by the Arkansas Hospital Association (AHA), several speakers provided detailed explanations of the law and actions necessary for hospitals to fully comply with its requirements. Harold Simpson, a leading healthcare attorney in the state; Val Buck and Wanda Theus of the Arkansas Department of Health; AHA legal counsel Diane Mackey; and attorney Lynda Johnson each reviewed various aspects of the act. Among their remarks, the group of speakers touched on the following items:

• From 1990 through May 1998, the Arkansas Department of Health has been notified of 85 possible COBRA violations, 25% of which have been substantiated.
• The most common EMTALA problem among hospitals is inappropriate screening of patients and insufficient documentation of those services.
• There are three basic requirements for EMTALA: screening, stabilization, and limits on transfer.
• The six keys to EMTALA readiness are: know the requirements, have detailed policies and forms in place, educate medical/hospital staff, emphasize EMTALA compliance constantly, monitor constantly for EMTALA compliance, and respond promptly to suspected problems.
• Quality assurance is extremely important to successful EMTALA compliance.
• Hospitals may be fined for not reporting another hospital suspected of an EMTALA violation.

Since many different types of hospital personnel need to hear the information covered during the program, the AHA is developing a streamlined version of the workshop to be offered across the state during the next six months. Arkansas hospitals will receive information about the workshops as soon as it is available.

Arkansas PAC Donor Law Overturned

The three-judge panel of the U.S. 8th Circuit Court of Appeals in St. Louis ruled recently that Arkansas' donor limits on campaign contributions are "unconstitutionally low." The ruling effectively struck down the state's Initiated Act 1 of 1996 which was passed by two-thirds of those voting on the issue in the 1996 general election. Initiated Act 1 limited contributions to $300 per election for state constitutional offices and $100 per election for other state and local races.

U.S. Judge Morris Arnold of Little Rock, who wrote the opinion, said limits were an infringement on the public's First Amendment right to support a candidate of one's own choice. The judges also ruled that a provision in the law allowing small-donor Political Action Committees (PACs) to contribute more per election than other such committees violated the equal protection clause of the 14th Amendment. Scott Trotter, an attorney for Citizens for a Clean Government, said his client would probably seek an appeal of this ruling as well.

Based on the 8th Circuit Court's opinion, contributions to the Arkansas Hospital Association PAC (AHAPAC) are no longer limited to $200. Contributions to the AHAPAC and the American Hospital Association PAC may now be given directly to the AHAPAC. The AHAPAC can then make the appropriate distribution to the American Hospital Association's federal PAC.

Arkansas Hospitals Complete Escheat Win

Arkansas hospitals won a major victory in April when Pulaski County Chancery Judge W. H. Dillahunty ruled in favor of Baptist Health on a lawsuit involving the Arkansas Uniform Disposition of Unclaimed Property Act of 1989, the state's escheat law. In his ruling, Judge Dillahunty said provisions of the Act do not apply to a hospital. Dillahunty ruled that the court "finds the 'holding' of another's unclaimed property, as envisioned within the boundaries of this statute, is simply not within the ordinary course of a hospital's business." Further, he wrote, "A hospital is not to be included within the scope of this statute by virtue of a miscellaneous 'catch-all' provision."

The ruling also relieves hospitals from the requirement to report to the State Auditor about unclaimed property they hold. Since the requirements of the Act do not apply to hospitals, there is no requirement to report, according to the order filed by Chancellor Dillahunty.

The ruling was the second favorable decision handed down on the case, which was originally filed in 1995. In August 1996, Chancellor Anabelle Clinton Imber issued several findings favorable to hospitals, but other issues were left unresolved. After Judge Imber was elected to the Arkansas Supreme Court, Chancellor Dillahunty continued hearing the arguments.

Baptist Health originally filed suit against the State Auditor's office over issues related to the Act. The Arkansas Hospital Association later joined the action as an intervenor on behalf of all Arkansas hospitals, which would be subject to the Act if the Auditor prevailed. The ruling should save hospitals throughout Arkansas millions of dollars that could have been identified as unclaimed property and recovered by the State Auditor. The Auditor has 30 days to appeal the decision.

Arkansas Hospitals Among Top Employers

The Arkansas Hospital Association often touts the fact that hospitals in the state collectively employ almost 45,000 Arkansans in a wide range of positions filled by administrative and professional employees, highly specialized biomedical and technical personnel, and skilled and unskilled workers. In many counties, local hospitals are the single largest employer. According to Arkansas Business, three Arkansas hospitals and health systems are ranked among the state's 25 largest employers.

The publication showed Baptist Health to be the state's fifth largest employer with 6,000 employees. St. Vincent Infirmary Medical Center (4,000 employees) was ranked 12th, and Arkansas Children's Hospital (2,706 employees) occupied the spot as Arkansas' 22nd largest employer. The four companies ranking in front of Baptist Health to make up the top five employers are Arkansas State Government (45,648), Wal-Mart Stores, Inc. (34,014), the U.S. Government (21,200), and Tyson Foods (19,127).

Hospital Policy Fights Resistant Bacteria

An Arkansas hospital has taken the offensive in combating antibiotic resistance, creating a hospital-wide program to stop the spread of vancomycin-resistant enterococcus (VRE), which is resistant to the antibiotics used to treat staph and strep infections.

St. Mary's Hospital in Rogers targeted VRE because vancomycin is used often as the last line of defense on patients who have developed resistance to most other antibiotics, says Charlene Ingwell, R.N., a nurse educator who developed a staff guide on VRE infection control. Nationwide, the number of VRE cases has been steadily climbing from 0.3% of hospital enterococcal infections in 1989 to 7.9% in 1993, according to the Centers for Disease Control and Prevention (CDC). In intensive care units, the VRE rate rose from 0.4% to 13.6%. The rate of VRE infection at St. Mary's has gone down slightly from eight (for the annual period ending October 1996) to four so far in 1998.

Using CDC guidelines, St. Mary's recommends that vancomycin be given only to patients with life-threatening illnesses and serious infections, Ingwell says. "You want to use vancomycin on someone who is resistant or allergic to other antibiotics to which the organism is sensitive," not "just because it's a 'good' antibiotic."

Vancomycin also should not be used as a routine surgical prophylaxis or as a routine prophylaxis for low-birthweight infants, Ingwell says. Instead, use should be based on specified procedures (such as cardiac surgeries involving implantation of prosthetics) or medical history.

The education program emphasizes early detection through careful medical histories, including reviewing past vancomycin use, monitoring lab tests and culture results; and alertness to symptoms such as fever, chills, and drainage from wounds. Tracking vancomycin use is another way to help patients at risk for VRE, she adds. For instance, when a physician orders vancomycin for a patient, the pharmacy flags the order for the hospital's quality resource management team, which reviews the chart using CDC guidelines.

The most effective way to control VRE infections among patients is to stop its spread in the first place, Ingwell notes. VRE patients are isolated from other patients while hospitalized at St. Mary's. VRE patients must have at least three negative cultures, taken one week apart, before being removed from isolation status.

Because VRE can live up to 30 days on surfaces, the environmental services department cleans VRE patients' rooms twice a day and, using a special checklist as a guide, spends several hours scouring their rooms after discharge.
For more information on the VRE teaching packet, which includes overheads, flow charts, evaluation forms, and control plans, contact Ingwell at (501) 636-0200, ext. 2325.

(reprinted from The Quality Letter, July 1998)