By mid-2003, the nation's hospitals were knee-deep in congressional investigations and bad publicity over their aggressive billing and collection practices.
The American Hospital Association responded, calling on hospitals to adopt a detailed set of principles designed to help them better serve poor and uninsured patients. Since then, more than 80% of its 5,000 members, or some 4,200 hospitals nationwide, have pledged to abide by the voluntary guidelines.
But a report released last week questioned whether this self-policing effort has actually led to improvements in charity-care practices. The study, conducted by the Access Project, a Boston-based consumer group, found that many hospitals remain reluctant to share their policies, despite the AHA's explicit call for members to do so.
"The burden of proof is on hospitals to show that their signatures on the letter of commitment reflect their actual practices," said Access Project Director Mark Rukavina. "Frankly, it's been frustrating. We found little evidence that hospitals have really altered their procedures."
Carmela Coyle, senior vice president of policy at the AHA, defended hospitals' commitment to the uninsured and said the study was far too small to produce reliable data.
In recent years, hospitals have come under intense scrutiny for charging uninsured patients high rates for services and then resorting to heavy-handed collection efforts. In June 2004, Congress held hearings to discuss whether legislation was required.
Partly to ward off such mandates, the AHA urged members to adopt its guidelines, which call on hospitals to provide financial counseling to needy patients; develop written policies to help patients determine their eligibility; and share these policies with the public and community agencies, among other things.
To gauge the impact of the effort, the Access Project attempted to randomly survey 61 hospitals about their policies and efforts to meet the AHA's guidelines. Despite repeated phone calls, only 12 executives representing 13 not-for-profit and two for-profit hospitals agreed to participate. Twelve declined and 34 others did not respond.
Five of the not-for-profit executives said their hospitals had signed the AHA's commitment form and already met or exceeded its guidelines. Three other not-for-profit executives said their hospitals had claimed to be in the process of evaluating their policies. The remaining four either were unsure whether their hospitals had signed the form or didn't know which option they'd chosen.
Moreover, the survey found wide variation in the hospitals' efforts to meet the AHA guidelines.
Rukavina admitted the small response rate makes generalizations difficult. But the fact that so few hospitals were willing to cooperate is noteworthy in itself, he added, "since increasing the transparency of hospitals' charity-care policies is a key focus of the AHA's guidelines."
"You would think that with all the attention being given to this issue, hospitals would be eager to share their progress with us," Rukavina said
The AHA's Coyle, however, said that the continuing threat of litigation might have contributed to hospitals' reluctance to discuss their efforts over the phone. "It's important not to confuse how hospitals respond to a survey with the energy and commitment they show in helping patients," she said, noting that the report highlighted several positive changes hospitals had made.
Coyle said it was never the AHA's intent to police its members' charity-care efforts, nor does it see a need to publish data from the commitment statements as the Access Project and other consumer groups have demanded. "When we started this effort, it wasn't about gathering data or slicing and dicing hospitals' practices to say which ones are doing this and which ones are doing that," she said. "Our objective is to engage the entire hospital field in an ongoing process of change."
The Association of Community Organizations for Reform Now, or ACORN, says the AHA could do more. When ACORN's members recently phoned hospitals in 10 cities to ask about their charity-care policies, most received little help. In Cleveland, members made 18 phones calls to five hospitals; in each instance they were referred to a free clinic, told to contact Medicaid or otherwise left without answers, said Liz Wolff, national research director for ACORN.
"With that kind of response, people may not go to the hospital for necessary care because they're afraid of receiving huge medical bills they may not be able to pay," Wolff said.
Hospitals have shouldered part of the cost. In 2003, hospitals spent $24.9 billion on care for patients who couldn't or wouldn't pay their medical bills, an 11.7% increase from 2002, according to the AHA. Still, those figures accounted for just 5.5% and 5.4% of all hospital expenses in 2003 and 2002, respectively, or the second-lowest and lowest percentages since 1983.
"We appreciate the financial pressures facing hospitals," Rukavina said, "but we're asking them to appreciate the financial pressures facing the average low- and middle-income family."