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American Academy of Emergency Medicine

Finding a Deep Pocket to Pay for Indigent Care

by Robert V. West, MD JD FAAEM

The financial responsibility of providing health care for indigents has traditionally rested on local governments. Despite the premise, many physicians are professionally obligated to render care to many patients irrespective of financial reward or county support. In an emergency room practice such as mine, every individual who walks through the door has to be evaluated and screened. Those suffering a medical emergency require treatment in order to comply with State and Federal statutes mandating care for emergency services. The issue of reimbursement for the care we provide to those individuals who cannot pay their bill is rarely resolved at the time services are rendered, whether emergent or not. Futhermore, Federal and State laws also obligate in-patient care by attending physicians and prohibit transfer of these patients until stable.

To complicate these legislative mandates, there is a disturbing trend by other segments of our society to further shift these costs back to the health care providers, including the county governments of this State. Cost driven policies by employers have brought us a "medically indigent" working class. Third party payors are reducing reimbursement for their insured subscribers. Government programs to "reform" and reduce welfare payments are reducing Medicaid monies. Accordingly, for many Texas indigent and Texas physicians practicing in Texas, the buck now stops at the door of their local hospital ED.

For example, as I was preparing for a recent night shift at one of the downtown hospitals, I was jogging with an acquaintance who owns a trendy restaurant on the River Walk. He was applauding my efforts in treating "those people" of the inner city, affirming the fact that somebody has to do it. Later that night one of his kitchen workers presented with appendicitis. The patient was a recent immigrant who did not qualify for Medicaid and as you might expect and had no benefits from my friend's restaurant. The general surgeon was called and the patient was admitted for an appendectomy. My collection rate for private payors is 8%, less than the gratuity I leave the wait staff at my friend's restaurant.

In my state as well as others, there are three sources of legal authority to empower a health care provider to seek reimbursement from their local governments.

State Constitutional Duty
Counties that opt to create public hospital districts are legally liable for medical services provided to indigent residents of their respective county. According to Texas Constitution, Texas counties are empowered to create legal entities or hospital districts with the authority to tax the property owners in order to provide health care to the indigent inhabitants of their county. Article IX which provides for the creation of hospital districts by Texas counties, states in plain terms, "that any district so created shall assume full responsibility for providing the medical and hospital care for its needy inhabitants." Counties and their governing bodies (the county commissioners) are empowered to tax up to 75 cents on every $100 valuation on all property within their boundaries to fund the care of indigent residents, an ad valorum tax.

County Statutory Duty: County Indigent Health Act
The Texas Constitutional duty imposed on certain counties who opt to provide health care through the creation of a hospital district has been supplemented and in effect extended to all counties in the state by the Indigent Health Care and Treatment Act (IHCTA). In effect, this law requires each and every county in Texas to provide for preventative and emergency care to county residents who are indigent and not otherwise covered by another source. That means that health care providers are entitled to reimbursement from the county for services rendered to "eligible residents." The Indigent Health Care Act steps in to fill the void where other federal and state programs do not provide medical coverage to indigents. The Texas Department of Health has established the minimal eligibility restrictions. Most Texas physicians should seek reimbursement for the indigent care they provide directly from the county government by completing and submitting a Form 100 available from the Texas Department of Health at (512) 338-6461. While it is the county government, not the TDH, that is responsible for generating the tax revenues and making the disbursements to health care providers up to a ceiling of 10% of their general tax revenue, whether or not a physician receives his payment will in most cases depend on physician compliance with the procedures and patient eligibility which will be determined on a case by case basis by the county.

Federal Statutory Duty
According to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. §§ 1601 -1646 (1994 & Supp. V 1999), undocumented aliens are ineligible for state or local health benefits "for which payments or assistance are provided to an individual, household, or family eligibility unit by an agency of a State or local government or by appropriated funds of a State or local government." Id, § 1621 © (1)(B). This eligibility restriction does not apply to:

(1) Assistance for health care items and services that are necessary for the treatment of an emergency medical condition (as defined in section 1396(v)(3) of Title 42) of the alien involved . . .