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Patient Advocates are Not the Enemy

 |  By Philip Betbeze  
   April 05, 2013

If you're a nonprofit hospital or health system leader, it may seem that no matter what you do to benefit your community, someone's always pointing out your shortcomings and how you could do more. Some examples are more egregious than others, of course.

Much of this bad publicity surrounds efforts promoting healthcare access and finance for the most vulnerable people in the community. Time magazine may have just discovered this problem, but we and others in the trade press have documented over the years instances when nonprofit hospitals and health systems have gotten into trouble with their nonprofit status.

Most often, it's because some of them have aggressively pursued payment from the so-called "self-pay" population after charging them full price for services, that is, without the benefit of discounts available to government or commercial payers. Those problems have been addressed by many as hospitals and health systems have built detailed financial assistance policies, but nonprofit status must continually be justified as the healthcare marketplace undergoes dramatic change.

The IRS has instituted new rules regarding community benefit reporting, although many see it as an information-gathering exercise to develop more precise rules on what hospitals and health systems need to do to justify their nonprofit status in the future. The PPACA itself contained several provisions concerning tax exemption.

Yet still hospitals tend to get themselves in trouble. Just last year, a CEO ultimately lost his job after efforts to collect on such patients that got out of hand.

Patient advocates have long been a thorn in the side of hospitals and health systems with respect to healthcare access and issues of overcharging the poor. They've done good work. Without them, many of the most egregious examples of hounding poor and sick patients for payment might have gone unnoticed or underreported.

But hospital and health system leaders are in a difficult position as well. Healthcare payment is complex and certainly hospitals deserve compensation for their work, but with rules and regulations so murky, how do you know how much is enough? The labyrinthine flow of money through hospitals and health systems that culminates in an often meager bottom line makes this work difficult as well, and offers plenty of opportunities for obfuscation surrounding where the money is really flowing.

As important: How do you protect yourself and your system from charges that you are taking advantage of people least able to afford care?

First, you could start listening to what some of these groups have to say instead of treating them as enemies. Piedmont Healthcare in Atlanta went one step further by hiring one of the dedicated people who has been pushing it and other hospitals in Georgia to do better.

Piedmont hired Holly Lang a year ago as the director of community benefits for the health system. Seven months later, it promoted her to deputy director for a new community benefit initiative called the Georgia Center for Healthier Communities. Partly a lobbying organization on the local and state level, more important, says Lang, is its mission to improve health and healthcare throughout Georgia's communities.

Lang gives that statement gravitas by her own reputation, which, she recognizes, is at risk if the organization doesn't live up to its lofty goals.

Over the years, predominantly in Georgia, Lang has been a thorn in the side of nonprofit hospitals as both a reporter and a patient advocate. She grew up poor in rural Georgia, and, after college, became a health policy reporter for Scripps-Howard and later, the Associated Press.

"I was very unpopular," she says. "Everyone just hates you."

She was frustrated as a reporter, but not because of the haters.

"I always had health in mind and was concerned with issues around health access," she says. "I was assigned to that beat and covered it with enthusiasm, but I was frustrated with seeing the issue as a reporter and not doing the actual work."

So she left reporting, to the relief of many senior executives at the nonprofits she covered, but that relief would be short-lived. She quickly resurfaced at Georgia Watch, a nonprofit consumer advocacy organization in Atlanta.

There, she headed the Georgia Hospital Accountability Project, in which she worked closely with state and national stakeholders and federal policymakers in establishing standards for the community benefit obligations of nonprofit hospitals.

"At Georgia Watch, we took the viewpoint that healthcare is a finance issue for many," she says. "For the uninsured, the underinsured, and those unable to fully self-manage complex care, the role that hospitals play in people's lives surrounding healing, but especially surrounding bankruptcy, was and is huge."

About 85% of the hospitals in Georgia are nonprofits. They are some of the biggest employers and landowners in their local areas, and are tax-exempt because of the role they are supposed to play in helping the poor receive care that they can't necessarily pay for.

"Some do a tremendous job in how they approach the poor in their communities, but not all demonstrate that obligation to their community," she says of Georgia nonprofits.

She feels now is an exciting time in community benefit because the provisions in the PPACA dovetail nicely with the idea of healthcare instead of sick care.

"It's kicking off the external focus hospitals are now beginning to have, and given how seriously they're taking it, it's truly an opportunity to benefit these populations," she says. "With penalties for preventable readmissions and value-based purchasing, it's shifting in such a way that it's all helping us refocus our efforts on the community into keeping folks healthy. This different economic model can work for everyone if it's done well."

Lang came to Piedmont at the request of the chief marketing officer and director of external affairs, who had previously worked at Grady Hospital, Atlanta's safety-net system. "I'll be honest and say I was a little hesitant because I was used to being on the other side of things," she says. "I was afraid I couldn't truly work for the community and I felt strongly my obligation was to the people and I didn't want that to shift. When I realized that the ultimate goal was the same, I decided to try."

Lang's role is not hospital- or even Piedmont-specific. Her job is to analyze policies that promote or hinder progress in the area of healthcare help for the poor, period.

The center is looking at access to proper care, mental health and inpatient-outpatient transition issues, self-management issues and obesity and heart care. This should, she notes, help with preventable readmissions and access to care.

The center is working to develop a low-income patient navigator program with funding from the Kaiser Foundation of Georgia targeting patients at or below 200% of poverty level. They're also working on transportation to doctor visits and for the uninsured, helping fund the doctor visit. Child care issues, prescription access issues, and durable medical equipment needs are all important aspects of keeping patients out of the hospital.

Lang is heartened at the way fiscal incentives are forcing hospitals to have this focus. "I'm not sure if this could have happened in the past because it's hard for hospitals and others to accept the positive role that advocacy can have," she says. "I would never have been in this role a few years back."

While the proof will be in the progress the center makes in the next few years, Lang is encouraged because she feels many of the problems with the poor population and healthcare can be solved much less expensively than many assume.

"I emphasize the win-win all the time, because it's there for hospitals and patients," she says. "Often what [the poor] need is not very expensive."

Philip Betbeze is the senior leadership editor at HealthLeaders.

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