Mission matters?

Are we making money to provide care or are we providing care to make money? In few minds is the trade-off that stark. And it's probably also true that in few board rooms of non-profit healthcare organizations that the trade-off is that stark. But it's easy enough to lose ones way. And it's particularly easy to lose ones way when operating in an environment that routinely pressures us to move in a particular direction.

As survival has become more challenging, as competition has become more fierce, the pressures to favor the money-making side of the equation increase.

And regulatory systems are part of the environment, part of the system structure that conspire to make things worse as well as better. EMTALA and state regulations push toward providing care. New York has long had a law requiring that hospitals provide care to those in need.  But in return for sharing funds from its Indigent Care Pool, New York  requires hospitals to pursue payment.

The stories started with a string of articles in the Wall Street Journal and a story about Yale-New Haven's lawsuit that left an elderly widower broke as a result of his wife's hospital care. The issue's been bubbling since. (Click here, here, and here.) For example, Lucette Lagnado, who's written many of these stories, wrote this article in June (subscription required)  about Provena Covenant Medical Center in Urbana, IL that lost its local property tax-exemption due to its profit making entities, its debt collection tactics and the amount of charity care it provides. (Provena has reportedly changed policies since then and is attempting to regain its tax exempt status.)

The AHA (PDF) and HANYS moved quickly to stem the damage.

Now the Times has picked up the issue with a lengthy article its magazine, Uncharitable, by Jonathan Cohn.

When a faith-based hospital sues a grieving widow over medical debt, plunging her family deeper into poverty, some part of the health care system has clearly failed. But which part, exactly?

While the press coverage is relatively new, the issue isn't and perhaps its time to give up the pretense. As a current and former Board member of non-profit healthcare organizations, I have decidedly mixed feelings about this idea but it may be time to reexamine what we expect. Let's pose some questions:

1. Are social expectations of hospitals are generally greater than those for other non-profit healthcare organizations? Should they be? Should there be a standard? For example in New York, certified home health agencies are required to provide a fixed percentage of charity care. Nursing homes are not.
2. What is the best means of defining those social expectations? Is tax exempt status an optimal means of rewarding performance of  socially desirable behavior? Tax exempt status is binary. Organizations either have it or they don't. But organizational behaviors fall across a very wide spectrum. Thus, the "rewards" (different tax savings for different organizations) for socially desirable organizational behaviors probably doesn't match up well with actual behaviors.
3. Do social expectation and legal requirements to provide uncompensated care provide a ready-made excuse for hospital managers to offer to their boards and to public policy makers when they don't perform well financially? How can we effectively differentiate between genuine charity and sloppy administration?
4. Isn't the real issue here that while society expects providers, particularly hospitals, to provide care, our society is unwilling to face up to the challenge of universal coverage? We don't want people "dying in the streets." Press coverage of hospitals pursuing payment from low income people for care provided is per se bad press. And press coverage of lack of care is even worse. But we won't face our own responsibilities nor our role in creating and maintaining a system where such contradictions are inevitable.
5. Don't we really have a system here that wants a form of socialized care, but wants to pay for it with a market system?
6. Considering the imbalance of power between institutions and patients, which is better: attaching money to institutions and expecting patients to chase care, or attaching money to individuals and families and expecting institutions to chase patients?

Enough. The real issue is not aggressive billing and collection practices. The real issue is the lack of coverage by 15 percent of the nation's population in an economic system that is coverage based.

This is politically the worst time imaginable to try to re-start a debate on universal coverage, but the pendulum always swings. How does that tie to a debate on the obligations of non-profit, tax-exempt institutions? Cover everyone and drop the awkward, unexacting and hard-to-enforce regulatory requirements.

After the holidays, we'll get into it.