Editorial: One more sign of a broken health system

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In yet another disturbing sign that America’s health care system is broken, the urgent-care centers operated by Manchester’s Elliot Hospital now require a $150 advance payment before treating patients who lack health insurance and whose medical problem isn’t an emergency. Patients with insurance must hand over their co-pay up front.

The “pay-first” rule is becoming more common as hospitals struggle to reduce losses from uncompensated care and offset low payments by Medicaid and Medicare. Charging in advance may be good for a hospital’s bottom line, but it shifts costs to institutions that don’t require pre-payment – Catholic Medical Center in Manchester, for example, or community health centers. It also means that some people will go without care. When they do, the medical problems of some of them will worsen and require expensive emergency room treatment or hospitalization.

Federal law requires that hospital emergency departments assess the condition of every person who requests care and provide enough treatment to stabilize the patient. Hospitals and clinics are not, however, required to provide treatment for medical problems that are not an emergency – a sprained ankle or bad cold, for example. They’re free to tell those people, if they can’t pay, to seek care elsewhere.

It’s not hard to understand why Elliot Hospital adopted its new policy. Its losses from uncompensated care are growing rapidly, swollen in part by the growing percentage of insurance coverage that comes with co- payments bigger than many can pay. Elliot lost millions more when the state cut its payments to hospitals that care for a disproportionate share of patients on Medicaid. Its fee policy, however, is a Band-Aid on a bullet wound, and it’s dangerous. Emergency rooms and urgent care centers that turn away people who can’t pay gamble that the person’s problem was correctly diagnosed as one not threatening to life or limb. A misdiagnosis could mean a fine and a lawsuit.

If other hospitals and clinics emulate Elliot and adopt a pay-at-the-door policy, the waiting rooms of the state’s public health centers will be standing room only. To prevent a proliferation of up-front fees and other measures that make it more difficult for the uninsured to receive care, the governor and Legislature should accept the federal offer to expand Medicaid to cover tens of thousands of additional New Hampshire residents. Medicaid doesn’t pay providers well, but it pays. The state should also partner with the federal government to create a health care exchange, which will give people who aren’t poor enough to be covered by Medicaid a way to purchase coverage with the aid of a federal subsidy. Doing so will reduce the rolls of the uninsured and take some of the financial pressure off hospitals.

As for urgent-care centers, they play an important role in the delivery of health care and they reduce costs when they keep people with minor problems out of hospital emergency rooms. But they are no substitute for a primary care doctor, preventive health services and follow-ups. Neither are the “Doc in a Box” walk-in clinics that Walmart an other retailers have begun opening, nor the for-profit urgent care centers like the one slated to open on Loudon Road in Concord.

To control health-care costs and create a healthy populace, everyone should have health insurance and a medical home, a place whose staff’s first order of business is to keep their patients healthy and to treat them when they’re not. Up-front clinic and hospital fees and urgent-care centers that aren’t true medical homes aren’t the answer. They should go the way of the cassette tape and the floppy disk, only faster.