Hassles stymie physician pay for care of illegal immigrants

Washington -- The federal government has established a new pot of money to pay for uncompensated emergency care for illegal immigrants, but many physicians could find that bureaucratic hurdles put that money just out of reach.

Federal officials recently published final rules on the distribution of $1 billion over the next four years to compensate hospitals, doctors and ambulance services to provide emergency care to illegal residents.

But accessing that money requires hospitals to ask patients for various forms or documents that directly or indirectly indicate their immigration status. Many hospitals currently don't collect and are unlikely to start gathering this information.

Without the hospitals' cooperation, emergency department physicians might have to forgo the new government money, said Gordon Wheeler, a spokesman for the American College of Emergency Physicians.

Program participation presents significant hurdles, he said. Compliance is complicated and not without cost for the hospitals, and the funds are fairly limited, covering only a fraction of what hospitals and physicians provide in uncompensated care to these patients.

"If it's not worth it to hospitals, physicians are not likely to have the capacity to do so," he said.

The Centers for Medicare & Medicaid Services addressed the hospital community's comments and concerns in the final rule, said agency spokeswoman Mary Kahn. "The program is voluntary. If a hospital thinks the paperwork burden is too much, they don't have to participate," she said.

Although the rules allow physicians to make claims on the federal funds themselves, they still would need the hospital to collect the required information, said Seth Guterman, MD, president of Emergency Care Physician Services, which contracts emergency services for two Chicago hospitals. "We have tried to encourage our hospitals to participate in the program, but they don't want to do it," he said.

About 20% of patients that ECPS serves are uninsured, and the majority of those are illegal immigrants. The group racks up more than a $1 million a year in uncompensated care.

American Medical Association policy calls for Congress to provide adequate funds for programs that reimburse doctors and others for illegal immigrants' uncompensated care.

Is it enough?

The new federal funds have been made available as part of the Medicare Modernization Act of 2003. The final rule, published in May, establishes how and to whom those funds are to be distributed. The $250 million annual kitty is divided into two pools.

Two-thirds of the money, $167 million, is to be split among all 50 states and Washington, D.C., in proportion to their illegal immigrant populations. The remaining one-third, $83 million, is reserved for the six states with the largest numbers of illegal immigrants: Arizona, California, Florida, New Mexico, New York and Texas.

Claims and payouts will be made on a quarterly basis. If there is not enough money to cover all claims, the government will reduce the payout on a pro rata, across-the-board basis.

That arrangement has some hospitals, especially those in the border states, worried that there will not be enough to go around. "The original intention was just to cover the border hospitals," said Bill Burns, CEO of Rio Grande Regional Hospital in McAllen, Texas. "It's going to be diluted."

There is little question that those hospitals carry the largest burden of care for these patients, he said.

Burns gave the example of an undocumented immigrant who is in end-stage renal failure. Because the patient doesn't have insurance, the local dialysis facility won't take him. So the hospital has to admit him every few months for emergency dialysis to the tune of about $300,000 a year, he said.

"You get a few of those patients and it adds up fast," he said.

Legal status a sensitive issue

Beyond the hassle of collecting more information on undocumented immigrants, hospitals are afraid that local Hispanic communities will not look kindly upon such activities, Dr. Guterman said.

"They're afraid of the political statement. There is a lot of hospital competition here, and patients have the choice of going elsewhere," he said.

Some hospitals have other objections. "We are not in the business of doing the work of the Homeland Security Dept.," said Elio Montenegro, vice president of corporate and support services for Norwegian American Hospital in Chicago.

In the final rule, CMS removed the requirement that hospitals ask patients directly about whether they are illegal immigrants, but kept some documentation requirements that still could pose an obstacle.

There is a delicate balance between the government's requirements and the need to be sensitive to the implicit threat of deportation, said John Gates, chief financial officer for Parkland Hospital in Dallas. "Our job is to get enough information so that we can bill for these people without scaring them away," he said. "That's a difficult task on a good day."