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How Northeast Georgia Health System provides indigent care - and what it costs
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Northeast Georgia Medical Center Registered Nurse Liz Ratliff prepares to get medicine for patients inside the hospital's emergency room Thursday, Oct. 17, 2019. - photo by Scott Rogers

The Northeast Georgia Health System spent $63.9 million on indigent and charity care between its Gainesville and Braselton locations in the fiscal year ending September 2018.

All hospitals must stabilize patients who need emergency care, regardless of whether they can pay, under a mandate from the federal Emergency Medical Treatment and Active Labor Act. 

Not-for-profits like NGHS go beyond that requirement, Brian Steines, the system’s chief financial officer.

Patients can fill out a form, available on the NGHS website, to apply for indigent and charity care, or they can have a conversation with their provider.

That care is provided on a sliding scale and up to three times the poverty level. The poverty level for a family of four is $25,750.

According to NGHS policy, family income of 150% or less than the federal poverty guideline qualifies for 100% financial assistance, while a family with income 2.3 to three times the poverty level qualifies for a discount of 5-10%.

Providing that care comes at a cost to NGHS — one providers and administrators are looking to reduce while still serving patients.

The state helps cover some of the cost. Last year, the system received $8.8 million from the state’s Indigent Care Trust Fund, which most Georgia hospitals are required to pay into quarterly, based on percentage of annual net patient revenue, according to the Georgia Hospital Association. In 2018, the system contributed a little more than $4 million and received a total of $12.8 million, or a net gain of $8.8 million from the fund, according to NGHS spokeswoman Beth Downs. Other sources for the fund include nursing home provider fees and federal matches.

The system’s overall  budget needs to take that remaining financial loss into account, Steines said.

As the system plans its budget, it projects indigent care numbers by looking at population growth and previous volumes, he said. 

“If someone comes into the organization and they’re paying us zero, we obviously know that if somebody else comes into the organization and they’re paying $100, you take those two patients, add it together, it’s an average of $50,” Steines said. “That’s how health care systems kind of build their budget. Part of the commercial, Medicare, Medicaid, self-pay — eventually you blend all that revenue together and then you work your expenses to be able to make sure that you can take care of all the patients in your community.”

In 2018, of the 38,902 patients seen at NGMC Gainesville and Braselton, 49.75% of those were Medicare patients, 13.7% were Medicaid, 28.3% used third-party insurance, and 8.25% were self-pay.

Jamie Cleverley, an Ohio-based health care finances consultant who works with NGHS, said hospitals also keep indigent and charity care in mind when working with insurers.

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The patient drop-off area at the Northeast Georgia Medical Center's emergency room in Gainesville, pictured Oct. 17, 2019. - photo by Scott Rogers

“The hospital, in terms of looking at its overall financial picture, tries to look across and say, ‘OK, our mission is to provide care for our community, and our community is representative of folks from all different walks of life and different kinds of coverage,’” Cleverley said. “So, the hospital wants to provide those services for those that at the moment might not have coverage and those that do. In looking at those, they’ll work it with their payment rates for the commercial payers, such that it’s respectful of those needs.”

Cleverley said being efficient when providing care can keep costs down for everyone.

“There could be a situation where maybe there are additional tests or services that are being utilized that might not be most efficient. … Within the course of a treatment, it’s the cost of the underlying service as well as the intensity of the service,” Cleverley said. “Northeast Georgia has struck a really good balance. .. to make sure the right services are provided at the right time to treat the right things.”

Steines said offering indigent care at physicians offices and urgent care facilities also keeps indigent care spending down by reducing unnecessary emergency department visits, which are more costly.

“What often ends up happening, is if somebody does not have health insurance and they get an earache or a runny nose, they present to the emergency department because that ends up being their primary care provider, when it would be much better for them to be seen in a lower cost-of-care setting, which is an urgent care or a primary care physician’s office,” Steines said.

Steines said staff also work to identify people who may be eligible for Medicaid but are not receiving the benefits.

“You’d be surprised how many people present to our facility who are eligible for Medicaid, and they just haven’t signed up yet,” Steines said. “... We have people on site that will help them and walk them through that application. That will help us, it will at least give us some revenue if they qualify for that.” 

Medicare pays on average 7.5% less than the cost of care. Medicaid pays about 25% less than the cost of care on average nationally, according to Jamie Cleverley, an Ohio-based consultant who works with NGHS.

Lives on the line

This special weeklong series explores how cost and bureaucracy stand between local residents and their health care. Times reporters pored through the latest Community Needs Health Assessment, conducted numerous interviews with those in the local health care industry and those affected by it and examined the latest efforts by state government and politicians to remedy problems in our health care system. Read other stories in the series at