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Unwillingness Vs. Inability to Pay

October 21, 2013

All CHCs struggle to balance the provision of unmitigated access to under- or un-insured patients while maintaining the fiscal solvency of the organization. PMG has discussed for more than a decade the critical need to discern between an inability to pay (i.e., those with true, demonstrated need) vs. an unwillingness to pay (i.e., they make enough money but are too stingy or don’t think your CHC work product is worth it to them). So what do you do? If you’re like most CHCs, you keep seeing those “unwilling” patients ad nauseum despite the mounting losses never mind the demoralization of the staff. (NOTE: It is imperative that any health care provider, CHCs included, have a triage process in place to evaluate patients they refuse to see to assure their issues are non-emergent).

Some CHCs have tried over the years to dissuade these patients from non-payment through a variety of methods. Some send patients to collections, others make the patient reschedule, and still others actually “fire” patients redirecting them to another organization for service. All these actions stem from a patient’s unwillingness to pay ANYTHING… not a modest amount, not a payment plan, nothing. Working with CHCs across the country, literally hundreds over the years, PMG has witnessed countless CHCs accepting of almost any payment effort. Make a bi-weekly payment of $5 on a $200 bill at no interest… fine, the patient is considered in good standing, at least enough so to continue being seen. Too many CHCs, though, continue to see patients who refuse to pay and typically they think they have no choice… that it is just part of their CHC mandate.

HRSA has been conspicuously silent on this topic… at least in statute/policy. Opinions vary across the various regions of the country depending on which HRSA officer is overseeing a particular situation. Certainly, a CHC’s acceptance of the 330 grant income does come with some expectation that the CHC will see the marginalized, afford a sliding fee scale based on Federal Poverty Level (FPL) guidelines, and assure adequate access to a specific scope of services. Certainly, other commitments also exist but the focus on assuring access to the disenfranchised can be so all encompassing, it occurs at the financial detriment of the organization.

CHCs tell PMG it is “illegal” for them to “fire” or refuse care to a patient who does not pay. First and foremost, there is no “law” or statute stating such. Well, more accurately, PMG has asked for ANYONE to produce such a law/statute in this regard and to date… nothing. Further, HRSA (and us taxpayers) expect a CHC to maintain significant fiduciary controls over the financial well-being of a CHC. Certainly, part of this well-being must be to disallow patients from taking unjustified advantage of the generous policies attempting to assure “unmitigated access.” Yet, CHCs have expressed outright fear, or at least significant concern, of repercussions from HRSA or other governmental authority (not ever certain which one) for creating and enforcing a policy that requires patients to pay their “fair share.” A CHC is NOT a free clinic… it is subsidized. How can anyone expect a CHC to truly compete in the open market (think healthcare reform enacted) or realize actual “surplus” margins if they are compelled against their will to continue seeing patients who refuse to pay their fair share?

In the end, CHCs need to demand control over their business process around non-compliant patients AND when necessary see written clarification of policies in this regard. Releasing patients who consistently refuse to pay is one issue but how about charging for “no-shows/DNKAs,” assessing a financial penalty for not paying anticipated co-payments, charging for completion of the myriad of forms providers are coerced into completing… the list could go on. CHCs can run in the black but they need to follow their good business instincts and create an expectation in their community that their service is as valuable as any other non-healthcare commodity for which patients willingly pay (e.g., cell phones, internet, cable or satellite TV, fast food, movies, etc.). Remember, a CHC exists to serve the marginalized, not to be a patsy to the minority of patients who simply won’t be accountable for paying their own way. Keep your CHC financially viable as it is the only way to assure your ongoing mission.

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