Poor Health

More than a quarter of the hospitals in the Pittsburgh area closed in the first decade of the 21s century, drastically reducing the amount of charitable care available to the poor.

The failure of the remaining hospitals to provide adequate care to low-income patients and the inability of free and government-funded clinics to fill the gap has left the region's health safety net badly frayed.

The closures of 11 of 39 hospitals here between 2000 and 2010 left the region's poor "worse off," said Wilford Payne, executive director of Primary Care Health Services in Pittsburgh, which runs 11 federally qualified health centers in Allegheny County.

"When you think about a St. Francis that took care of so many people with mental health needs, or a Mercy Providence that was one of the few hospitals that provided real charity care, and South Side, and Braddock, and Aliquippa and on and on," said Mr. Payne, who has headed Primary Care Health Services for 37 years. "Everyone one of them did some charity work and reached out to poor people and did their share."

"That doesn't happen now," he said.

Why?

"Everyone knows you go broke providing health care to broke people," said Braddock Mayor John Fetterman, whose community lost its hospital in 2010.

• Related: Two different stories when hospitals closed in Braddock and East Cleveland
• Related: Wilford Payne has seen a lot in 37 years of providing care to the poor
• Related: See a sortable list of area hospitals' uncompensated care

Broke people usually have no insurance or they are on Medicaid. Hospitals and doctors lose money serving such patients, since they get no reimbursement or reimbursement below levels they'd get from better insured patients.

That's why hospitals seek to avoid poor patients.

In Pittsburgh, St. Francis Central, St. Francis Medical Center and Mercy Providence — all Catholic institutions now closed — once were routinely among the largest providers of uncompensated care in the region. (Uncompensated care includes charitable care and bad debt.) St. Francis Medical Center, for example, provided three times the region's average percentage of uncompensated care in its last year of operation in 2002.

"The problem as always was money," said Sister Ann Carville, who was vice chair of St. Francis Health System when UPMC bought and then tore down St. Francis Medical Center in Lawrenceville. "We really lived by the principle that we wouldn't turn anyone away, and we didn't."

But now only one city hospital, UPMC Mercy, is in the top 10, although the region's largest concentration of poverty continues to be in city neighborhoods.

UPMC Mercy put 4.63 percent of its patient revenues into uncompensated care in 2013, according to state data. The city's five other hospitals provide less than half that percentage of their revenues to uncompensated care. UPMC Shadyside-Presbyterian, Allegheny General, West Penn, Children's Hospital of Pittsburgh of UPMC and Magee-Womens of UPMC all provide around 2 percent, putting them in the bottom half in uncompensated care in the region.

Will Cook, president of UPMC Mercy, said the long history of the Sisters of Mercy "built our reputation over time and people in need are naturally drawn here."

"UPMC has not funneled [poor] patients here," he said. "But I think we should. Because we do potentially provide better depth and breadth of services to this community."

He said government insurance programs that cover most poor children and many poor women mean Magee and Children's have lower charity care levels.

Liz Allen, chief financial officer for Allegheny Health Network, the parent company to Allegheny General and West Penn, attributed their low percentages to "the way it's calculated" but offered no details.

Of the 11 that closed, all but Mercy Jeannette provided higher than the regional averages of uncompensated care.

Most hospitals locally say they will provide free charity care to patients with incomes up to 200 percent of federal poverty level (about $23,000 for a single person) and discounted care, typically on a sliding scale, for patients with incomes of up to 400 percent.

Though no hospital in the region would say that they seek to avoid poor patients, there are obvious and not-so-obvious ways to discourage them from accessing health care.

Practices used by local hospitals include using narrower financial parameters; making patients reapply for free or discounted care frequently; not listing financial assistance programs or applications online; and reporting patients to credit bureaus. Though it is rare nationally, nine hospitals in the Pittsburgh area routinely report patients with delinquent bills to credit bureaus and eight do not put financial assistance information on their websites.

Free clinics and federally qualified health centers are now trying to fill the gap left by the loss of hospitals and doctors. There has been a steady increase in the clinics: There was one FQHC in Allegheny County, where the bulk of the region's poor and uninsured reside, when Mr. Payne came to town in 1977; now there are 22. From just one free clinic in 1994 — the Birmingham Free Clinic on the South Side — there are now five in the county, with at least three more in surrounding counties. But it's not enough to address the unmet needs, Mr. Payne said.

"I don't think we could ever pick up what the hospitals did," Mr. Payne said, "no matter how many of us there are."

Health officials here and nationally argue that hospitals are fading as the main sources of medical care, and that as outpatient services increase, it's less important for patients to have a nearby hospital.

Karen Wolk Feinstein, president and CEO of the Jewish Healthcare Foundation in Pittsburgh, said the hospital closures were inevitable because of the loss of population and that they were a part of the evolution of health care.

"We were over-bedded [as a region] and they had to close," she said. "We need to find new models of care, and to do that you just can't keep all the beds going."

But as hospitals that disproportionately served the poor were closing, the region saw hundreds of millions of dollars poured into health care in wealthier communities.

Residents of older, declining towns like Jeannette, Bellevue and Braddock that had lost medical facilities watched as UPMC Passavant in the North Hills underwent renovation and expansion, UPMC East in Monroeville became the region's first newly created hospital in 40 years, and outpatient centers and medical malls began to appear in affluent areas (such as St. Clair Hospital's operation in Peters or Allegheny Health Network's in Pine).

Local officials paid attention to the expansions at other hospitals while theirs were closing, said Paul Cusick, former Bellevue mayor and vice president of the Suburban General Advisory Board. "But we were limited in our ability to change it," he said.

Bellevue was happy when it finally convinced the old West Penn Allegheny Health System, which closed Suburban General, to open an urgent care center at the old hospital.

"I believe it was the best we could get at the time," Mr. Cusick said. "But I'd be a lot happier if the hospital was still here. It was a small hospital, but we miss the personal care that you got in a hospital."

But most health systems that found money to invest in wealthier communities didn't marshal resources to serve the patients in the poorer communities that had lost hospitals, such as Aliquippa, Brownsville or Jeanette.

Area hospitals were sending delinquent bills to debt collections long after most health systems around the country discontinued the practice. Until recently UPMC was one of only two of the 18 health systems on the coveted U.S. News & World Report's Best Hospitals list (which includes the likes of Mayo Clinic, Cleveland Clinic, Johns Hopkins and others) to do so.

But UPMC ended the practice on March 1 this year, said Annie Hilliard, associate director of the revenue cycle

patient concierge service for UPMC, in recognition that the practice "hurt people who were trying to do it the right way" and pay their bills.

Like most local hospitals, UPMC also used to have a lengthy financial assistance application for uninsured patients.

"When I started in financial assistance in 2006, [the application] was 16 pages long," said Ms. Hilliard, who said it "absolutely" was a barrier to care.

Ed Kelly, a retired physician who has been medical director of Catholic Charities Free Health Center since it opened in 2007, said he began complaining to UPMC about the form shortly after the health center began operations.

The form was so long that patients sometimes would simply give up and go without the financial assistance, Dr. Kelly said, which often meant going without health care.

Ms. Hilliard said she worked to streamline the form, "And every year since then we've tried to reduce it."

It is now two pages long, standard in the region.

Even a shorter form, though, doesn't make it possible for everyone to get charity or discounted care at UPMC or anywhere else.

UPMC McKeesport, for example, operates in the Monongahela Valley where as much as 65 percent of the population lives below the poverty line.

In 2007, one of its family physicians there, Bill Markle, started the 9th Street Free Clinic in a former McKeesport YWCA because he simply could not provide all the care to the poor who were showing up at his office.

"We'd know what to do for people [at his UPMC office] but we couldn't do it because they couldn't afford it," he said. "And when we opened [the free clinic] there was such an onslaught of people who had not had care in a long time."

In some parts of the region, the hospitals as well as their patients are struggling financially. That means that in areas where free and discounted care is urgently needed, the hospitals are sometimes doing even less than their more prosperous counterparts.

The hospital that provided the least amount of charity care in the region was Ohio Valley Hospital in McKees Rocks, which provided only about $130,000, or about 2

10 of a percent of total expenses, in charity care in 2012.

The struggling urban hospital lost about $4 million on operations last year, according to state data.

It reports patients to credit bureaus if they fall behind on paying their bills, and does not list its financial assistance policies or the application on its website.

In an email response to questions, Ohio Valley spokeswoman Jamie Evanac said that the hospital was in the process of revamping its website and would be adding its financial assistance policy and application to the site soon. Several other hospitals also said they planned similar changes to their websites.

Ohio Valley initially said it also did not have a set federal poverty level at which it provided discount care because it provided such financial assistance on a "case by case basis." But a week later it said it had just recently reviewed that policy and decided to set the limit for discount care at 300 percent of the federal poverty level.

"We are not trying to discourage any patients from using Ohio Valley Hospital," Ms. Evanac said in the email.

Monongahela Valley Hospital, by comparison, has less nearby competition for patients than Ohio Valley and provides more than double the percentage of charity care that Ohio Valley does for more than $500,000 in charity care.

It does not report its patients to credit bureaus if they don't pay on time and it allows patients to stay qualified for free or discount care for a year before it requires them to reapply, making it easier for the poor to obtain care.

Mon Valley's website also makes it easy to find its charity care policy and application form, two clicks away from its home page, under an "About MVH" tab.

"It's not there by accident," said Louis Panza, Mon Valley's president for the last decade. "It's where it belongs."

"We discussed that for the website and said, 'Put it where you can find it,'" he said.

Mon Valley also has ties to a federally qualified health center.

For example, a patient who comes into Mon Valley's emergency room and does not have insurance or a primary care doctor is referred to Mon Valley Community Health Services in Monessen for primary care.

"That's good for us, it's good for Mon Valley and it's good for the patient's health," said Luther Sheets, chief operating officer of Southwestern Pennsylvania Human Services, which runs the health center.

In addition, when the health center lost a primary care doctor recently, Mon Valley loaned it three part-time physicians until Mr. Sheets could hire a new one.

"When you have a community that has limited resources, you try to help, and you try not to duplicate resources that they provide," Mr. Panza said.

But because of the loss of so many hospitals, residents who once would have gotten charity care at a local hospital now have fewer options for the full range of healthcare they might need, from primary care, to speciality and diagnostic care.

Rich Engle, 43, a restaurant worker with no insurance from Bloomfield, took two buses to get across town to Birmingham Free Clinic on the South Side, bypassing three hospitals that were closer.

"Anything short of a catastrophic injury and I'm just going to tough it out" and not see a doctor he has to pay, he said one evening this spring while waiting to get a physical from volunteer doctors at the clinic. "When times are tough you go into survival mode, you know?"

Birmingham Clinic, which started as a program for the homeless in 1994, began to see steep increases in patients after the closures of St. Francis Central in Uptown in 2000, its sister hospital, St. Francis Medical Center in Lawrenceville in 2002, and Mercy Providence on the North Side in 2004.

The free clinic now sees more than 3,200 patients a year with a nearly all-volunteer staff and the numbers continue to rise.

Clinic director Mary Herbert said it is telling that two decades after opening, the facility regularly gets patients who come for the first time and say: "It has been years since I've seen a doctor, but this issue flared up and I don't have insurance."

The need for services as hospitals closed also became clear to Catholic Charities, which in 2003 began considering whether it should open a free clinic.

"I don't know that we were responding to a specific need of any one closure," said Dr. Kelly, "but the need we found in the community, who now had fewer places to go."

A finger on Myrtis Henderson's left hand is stuck in a bent position, a cyst on the tendon freezing any motion.

Ms. Henderson is a long-time patient of Jeannette South-Paul at the Matilda Theiss Family Health Center in the Hill District. Dr. South-Paul has helped her keep control of her diabetes, but the finger is another matter.

"The only thing that is going to help that is a surgical procedure," Dr. South-Paul told Ms. Henderson, an unemployed pre-school teacher, at a recent appointment. "And until you have insurance, I can't help you."

Ms. Henderson, 45, is one of many patients who fall into a yawning gap in the health safety net. They need specialty care but are unable to get it because they don't have insurance or have inadequate insurance. They either can't get a specialist to accept them as a patient or can't afford to pay upfront for the visit.

The specialist gap exists because few clinics for low-income patients have specialists on staff. The clinics often have no direct connection with the specialists, who are typically affiliated with hospitals or large practices. Even when they do have connections, they can't always arrange timely, affordable specialty care.

Many specialists aren't eager to take low-income people because they aren't likely to be reimbursed well for the care of such patients, who are either uninsured, on Medicaid, or underinsured. While the Affordable Care Act opens up coverage to patients who didn't have it before, some carry deductibles that are so high they still can't afford to see specialists.

Moreover, even if the clinic can schedule an appointment, the patient might not end up going because there are upfront charges that put the appointment out of reach.

So the patients, as well as the clinics and doctors who treat them and recognize the need for specialty care, struggle with the cycle of sporadic, incomplete care.

Even if a patient begins their medical journey at a hospital emergency room, patients often find that unless their health problem is imminently life threatening, they are given minimal service, and they have to try to access a specialist on their own.

• Related: Dr. Bill Markle runs a free clinic in McKeesport that provides care to the community's uninsured patients
• Related: A lack of transportation often means poor patients don't get the health care they need

Back at the Theiss clinic, Dr. South-Paul tries to work the patchwork system to get care for the patients. She is chair of the department of family medicine at the University of Pittsburgh School of Medicine as well as a physician at Theiss, which is affiliated with UPMC.

"There is one orthopedic surgical place I know that does free procedures once a month," she told Ms. Henderson. "But they only do hips. But I'll do my best and see if we can find someone."

"It just bothers me all the time," Ms. Henderson said about the ganglion cyst on her middle finger.

"I wish I could just make it go away. But I can't," Dr. South-Paul replied. "I could get a [cost] estimate." But it wouldn't be a free or inexpensive visit, she said.

"I'll wait to see if I can get in the [Medicaid] system first," Ms. Henderson answered.

But two months later, Ms. Henderson still had not had the surgery because she had not yet qualified for Medicaid and could not afford to pay for it out-of-pocket.

Cases like Ms. Henderson's are not an aberration. Medical directors, doctors, nurses and other patients say failure to get access to specialty or diagnostic care happens all to often for the uninsured and underinsured.

"They fall through the cracks," said Diane Nieder, the nursing director for Primary Care Health Services in Pittsburgh, Allegheny County's largest network of federally qualified health centers.

Without the speciality care they need, she said, "The patient lives with it, ends up in an emergency room, or they come back here and we try to Band-aid it the best we can and deal with it."

In one major paper in 2007 from researchers at Harvard Medical School, surveys from 439 federally qualified community health centers (CHCs) around the country found that the difficulty accessing specialty care was true not only for those without insurance — a long known problem — but also those on Medicaid.

"Our findings suggest that lack of access to specialty services is a more important problem for CHCs than previously thought," the authors wrote. "Referrals to off-site specialty services are frequently needed, yet medical directors reported major problems obtaining access to specialized medical and mental health services for uninsured patients and those covered by Medicaid. Particularly for the uninsured, these reported problems are pervasive and affect sizable numbers of patients."

There is no data about how many patients lack access to specialty care. But there are roughly 35 million uninsured Americans and millions more who are underinsured or on Medicaid. All of those people potentially could have difficulty getting specialty care should they need it.

There also is no national data that shows the cost to health systems when poor patients do not go to see a specialist when they need to. What is known is that inpatient care and emergency room treatment are more expensive than outpatient office visits with specialists, and yet for health care providers the current payment system acts as a disincentive to providing specialty care to the poor. A 2013 National Institutes of Health study found that the average cost of a visit to the emergency department in the United States was $2,168. Many specialists charge at least $350, and office visits that involve procedures can cost more.

Leroi Hicks, now vice chair of the department of medicine at Christiana Care Health System in Delaware and author of the Harvard study, said the main problem is systemic.

"Even now, with all the changes we're going through with health care, we still operate under a system where specialists are operating under a fee-for-service model and not a plan for the patient's overall health," he said. Because of that, "we shouldn't be surprised that doctors who don't get reimbursed for a service don't provide care to people without insurance."

That's also why hospitals are not likely to provide more such care, said Ken Bream, a University of Pennsylvania physician who has long worked with underserved populations in Philadelphia.

"If the University of Pennsylvania was to announce it was going to start taking uninsured patients in for specialty physicians, our competitors, Jefferson [Hospital] and Temple [Hospital] would start referring their patients here in droves," he said. "They can't open the door a crack because people would rush in."

But specialists and hospitals often say they are not aware of patients facing barriers to specialty care and that they readily accept such patients.

"That is not my reality," said Karen Shaffer-Platt, who oversees UPMC's Patient Financial Services Center, which helps patients apply for insurance coverage or charity or discounted care for the region's largest medical provider.

"There is no [financial] gate-keeping done for any request for an appointment" at UPMC, she said. "We are convinced we have a way to see every patient who wants to be seen."

That stance is not surprising to Cheri Rinehard, executive director of the Pennsylvania Association of Community Health Centers, who spent 17 years working for the Hospital and Healthcare Association of Pennsylvania.

"I was part of these conversations where [hospital officials] truly believe they were doing everything they could and that there were not these big holes in the safety net," she said. "They just don't understand what patients go through after they leave the hospital or the doctor's office."

But safety-net patients and medical staffers say the problem isn't well recognized because of what often happens after the initial referral.

Patients sometimes do schedule the specialist or diagnostic appointment. But once they're told they need $350 up front to see the doctor because they don't have insurance, they're underinsured, or, more recently, their new Affordable Care Act bronze plan insurance has a $3,000 deductible, they simply never go, or they cancel without an explanation.

And no one is counting that person as one who needed but did not get specialty care. The problem is difficult to quantify because patients don't notify anyone that they have not received specialty care that was recommended, though primary care doctors see it regularly.

"I've seen that happen with my patients," said Diane Emes, a family practice physician in California, Pa., and part-time with Mon Valley Community Health Services, a federally qualified health center in Monessen. "Try getting a referral [with an uninsured patient]. It just doesn't happen. Or if they do, they don't go" when they're told how much it will cost.

After she realizes a patient of hers won't go to a specialist because of the out-of-pocket costs, or the specialist won't see them because they don't have insurance, Dr. Emes said she stops trying to refer the patient.

Then, she said, "sometimes you try to do what you can with stuff you can't really handle as a family practice physician."

If the patient's situation is more critical, she said she starts making what she called the "Hey buddy!" calls herself, asking other doctors if they or someone else would see a patient who won't be covered by insurance.

Multiple specialists said they get such calls and take on uninsured patients.

"I've taken care of a lot of people for nothing over the years," said Ronald Pellegrini, a prominent local cardiothoracic surgeon who has worked at Mercy Hospital, UPMC Passavant and now Forbes Regional Hospital. "Someone will call and tell the secretary or the office manager," and the doctor sees the patient.

That may be how it's often done, said Wilford Payne, for 37 years the executive director of Primary Care Health Services. But not everyone has that kind of access to specialists. "And that's no way to run a health system."

Though no similar program exists in the Pittsburgh region, there are programs in Indianapolis, Cleveland, Baltimore, suburban Philadelphia and elsewhere around the country that bring together the health centers that serve the poor and the health systems that control the specialists and diagnostic services. They work to coordinate care so that any patient who needs specialty care can get it.

Groups of specialists also have tried to organize to provide such care, as a group in Pennsylvania's Lancaster County is doing.

Not all the efforts have succeeded or endured. But their organizers all recognized the problem and tried to solve what has been a systemic health quandary for decades.

One of those projects, the Cuyahoga Health Access Partnership in Cleveland grew out of an effort that began in 2008 when all the major medical systems, federally qualified health centers and free clinics there came together to talk about access.

"We had all the players gathered around the table and said, 'We've got some of the highest quality healthcare available in the country here, we need to find a way to get uninsured people access,'" said Sara Hackenbracht, the program's executive director since 2011.

The result was that the major hospital systems, with the exception of University Hospital, agreed to make their specialists and diagnostic services available to patients who were qualified for charity or discounted care through the program.

The program takes any uninsured adult, 19 to 64 years old, who made 200 percent or less than the federal poverty guidelines.

By the end of 2012, 3,088 residents had been qualified through CHAP, and the program had made 4,035 specialty care referrals for them.

Perhaps most importantly to the hospitals, Ms. Hackenbracht said that surveys of CHAP patients show that 57 percent of them reported using emergency rooms less than before they were in CHAP, and 75 percent of those patients said they had not used the emergency room at all.

The program continues to grow, despite Ohio having adopted Medicaid expansion under the Affordable Care Act, meaning that fewer patients are without insurance coverage.

And now, Ms. Hackenbracht said, CHAP's board is talking about a new challenge: Underinsured patients who got their high-deductible or high co-pay insurance through the Affordable Care Act marketplace.

"I think we're going to have to move in that direction" and take on underinsured patients, she said.

Community health centers have long kept their own lists of specialists who were amenable to helping disadvantaged patients, and some had unwritten agreements with some hospitals that they could refer patients to.

But the Health Resource and Services Administration, which oversees federal health centers, recently began pushing health centers to get such agreements in writing to build more access for their patients.

In this region, only the Theiss health center and UPMC have such a formal relationship, though others have some ties.

Mr. Payne, whose struggling network of 11 health centers in some of the poorest areas of Allegheny County, is in conversation with UPMC to create an affiliation that would help support Primary Health Care Services.

"It would help us both," Mr. Payne said. "We'd be more financially secure and we'd be able to keep more people out of the emergency room."

Will Cook, president of UPMC Mercy, said he couldn't comment on the discussions, but said such an affiliation might happen.

"We are eager to talk to him because having FQHCs in neighborhoods is the future of health care, in my mind," he said. "They're already in the neighborhoods, which overcomes the transportation issues the poor deal with, and they're part of the neighborhoods."

Even with formal affiliations, problems persist. The executive director at an Indianapolis network of clinics affiliated with a health system says he too struggles with getting access for poor patients.

Jimmy Brown, head of HealthNet, said the ties his network of FQHCs has with IU Health are beneficial but still do not guarantee that his clients will be able to see specialists.

His physicians have deal with the fact that some specialist won't take Medicaid patients, he said, and some specialties just have a very limited numbers of physicians.

Even when patients get to see specialists, the wait times are long.

"The uninsured and underinsured do have a difficult time getting specialty care. We're constantly trying to find a place for our patients to get specialty care.