Uncompensated Care

Maryland AAHAM

December 19, 2014

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• UCC History• Summary of FY 2015 UCC Policy

Prospective reduction• FY2015 Experience• Changes to financial assistance policies

(Discussion)• Future Considerations• Q&A

Overview

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• By statute, funding uncompensated care is a cornerstone of the Maryland system

• HSCRC statute requires a “reasonable” amount of UCC rate funding Staff has wide latitude to determine “reasonable”

• Hospital rates include an amount for UCC that is pooled in a state fund and redistributed

• Hospital position relative to the state average determines what they pay into, receive from, the pool.

UCC History

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UCC History

• UCC policy has long included concepts to fund individual hospitals based on their: Actual UCC from audited financial statements “Predicted” UCC, as determined by a regression Incentive to collect from patients who can pay

• Several policy modifications, particularly on defining the independent variables to be used as predictors of UCC in regression

• Discussion of the number of years of data to use--responsiveness vs stability

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• Revised predictive regression variables

• Two years of actual UCC

• Hospital-specific, prospective UCC reductions for the projected expansion of Medicaid

Rate Year 2015 Policy

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• Four regression variables (p. 5) replaced with five variables (still proportion of total charges): Inpatient Medicaid ED admissions

Inpatient commercial insurance admissions

Inpatient self pay and charity admissions

Outpatient self pay and charity admissions

Inpatient self pay and charity ED admissions from 80th percentile of Medicaid undocumented zip codes

Rate Year 2015 Policy

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• Inpatient self pay and charity ED admissions from zip codes with 80th percentile and above of Medicaid undocumented beneficiaries HSCRC staff used Department of Health and Mental

Hygiene data summarizing Medicaid undocumented enrollment by zip code (pregnancy or ED coverage)

Included self pay and charity charges from ED admissions, by hospital, from zip codes with 80th percentile or higher of Medicaid undocumented enrollment

Rate Year 2015 Policy

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• As part of the 2015 UCC Policy, the HSCRC prospectively reduced UCC provisions to reflect January 1, 2015 Medicaid expansion and the expected associated UCC reduction.

1.08% statewide reduction

• The prospective reduction was limited to the conversion of the Primary Adult Care (PAC) program to Medicaid.

• Did not include anticipated reductions in UCC as a result of additional Medicaid expansion (116% - 138% FPL)

• Did not include anticipated reductions in UCC as a result of private insurance expansion

Rate Year 2015 Policy

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• Since PAC covered only ED services, staff summarized PAC non-ED hospital charges that would be covered under Medicaid

• Staff reviewed the data and shared with hospitals Certain cases were determined to have coverage and

were excluded

• Remainder was prospectively reduced from UCC provision

Rate Year 2015 Policy

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Change in UCC Rate Funding: FY2015 vs. FY2014, including related comparisons

A B C D = Avg (B+C) E = B-C F = B - A G H = D - G I J = D + I K = J - G

* Rev Neu

Predicted UCC Over / (Under)

Hospid Hospital Name

FY2013 Actual UCC

Predicted UCC

FY '12- FY '13 UCC Average

Policy Result Prior

to PAC (50/50 Blend)

(1)

FY2012 / FY2013

Avg ActualFY2013 Actual

FY2014 In Rates

FY2015 Policy (pre PAC) Over / (Under) FY2014

PAC Adjustemnt

Policy Results

with PAC Adjustemnt

FY2015 Policy Over /

(Under) FY2014

210001 Meritus Medical Center 7.20% 8.17% 7.40% 7.83% 0.77% 0.98% 7.46% 0.37% -1.66% 6.17% -1.29%210002 Univ. of Maryland Medical Center 5.40% 7.04% 5.87% 6.50% 1.17% 1.64% 7.39% -0.89% -1.85% 4.65% -2.74%210003 Prince Georges Hospital 15.51% 16.60% 15.34% 16.07% 1.26% 1.09% 14.43% 1.64% -1.09% 14.98% 0.55%210004 Holy Cross Hospital of Silver Spring 9.26% 8.17% 9.41% 8.84% -1.24% -1.09% 8.10% 0.74% -0.31% 8.53% 0.43%210005 Frederick Memorial Hospital 6.03% 6.47% 6.11% 6.33% 0.36% 0.45% 5.82% 0.51% -0.90% 5.43% -0.39%210006 Harford Memorial Hospital 12.44% 9.32% 12.04% 10.75% -2.72% -3.12% 9.95% 0.80% -1.51% 9.24% -0.71%210063 Univ. of Maryland St. Josephs Medical Center 5.13% 4.49% 4.71% 4.63% -0.22% -0.63% 4.10% 0.53% -0.72% 3.90% -0.20%210008 Mercy Medical Center, Inc. 8.29% 5.69% 7.70% 6.74% -2.01% -2.59% 6.93% -0.19% -1.34% 5.40% -1.53%210009 Johns Hopkins Hospital 4.27% 4.58% 3.98% 4.31% 0.60% 0.31% 4.42% -0.11% -0.78% 3.53% -0.89%210010 Univ. of Maryland Shore Medical Center at Dorchester 6.99% 10.12% 6.27% 8.25% 3.85% 3.13% 7.36% 0.89% -2.67% 5.58% -1.78%210011 St. Agnes Hospital 7.96% 8.85% 7.31% 8.13% 1.54% 0.90% 6.87% 1.26% -1.45% 6.69% -0.18%210012 Sinai Hospital 5.41% 6.30% 5.29% 5.83% 1.02% 0.89% 5.78% 0.05% -1.10% 4.73% -1.05%210013 Bon Secours Hospital 19.09% 17.17% 17.79% 17.59% -0.62% -1.93% 15.77% 1.82% -5.80% 11.79% -3.98%210015 Franklin Square Hospital 7.06% 8.27% 7.12% 7.74% 1.14% 1.21% 7.50% 0.24% -0.95% 6.80% -0.70%210016 Washington Adventist Hospital 14.08% 12.89% 13.66% 13.36% -0.77% -1.19% 9.94% 3.42% -0.59% 12.78% 2.84%210017 Garrett County Memorial Hospital 10.86% 8.98% 11.10% 10.10% -2.12% -1.88% 9.12% 0.98% -0.75% 9.36% 0.24%210018 Montgomery General Hospital 6.59% 7.42% 6.54% 7.02% 0.88% 0.83% 6.23% 0.79% -0.78% 6.25% 0.02%210019 Peninsula Regional Medical Center 6.87% 6.48% 6.85% 6.71% -0.37% -0.39% 6.05% 0.66% -1.30% 5.41% -0.64%210022 Suburban Hospital Association,Inc 5.07% 5.81% 4.79% 5.33% 1.03% 0.75% 4.27% 1.06% -0.28% 5.05% 0.78%210023 Anne Arundel General Hospital 5.21% 4.67% 4.92% 4.82% -0.25% -0.54% 4.25% 0.57% -0.54% 4.29% 0.04%210024 Union Memorial Hospital 8.13% 7.27% 7.61% 7.49% -0.35% -0.87% 5.81% 1.68% -1.45% 6.03% 0.22%210027 Braddock Hospital 6.89% 6.35% 6.54% 6.49% -0.19% -0.53% 5.26% 1.23% -1.06% 5.43% 0.17%210028 St. Marys Hospital 8.47% 7.33% 7.39% 7.41% -0.07% -1.15% 7.37% 0.04% -1.09% 6.32% -1.05%210029 Johns Hopkins Bayview Med. Center 9.28% 8.13% 9.17% 8.71% -1.04% -1.15% 7.75% 0.96% -1.73% 6.98% -0.77%210030 Univ. of Maryland Shore Medical Center at Chestertown 10.13% 8.08% 9.84% 9.01% -1.76% -2.06% 8.03% 0.98% -0.77% 8.24% 0.21%210032 Union Hospital of Cecil County 8.69% 8.11% 8.29% 8.25% -0.18% -0.58% 8.79% -0.54% -1.82% 6.43% -2.36%210033 Carroll County General Hospital 4.70% 5.66% 4.73% 5.23% 0.93% 0.96% 5.14% 0.09% -0.69% 4.53% -0.61%210034 Harbor Hospital Center 8.59% 9.84% 8.28% 9.12% 1.56% 1.26% 9.07% 0.05% -1.47% 7.65% -1.42%210035 Univ. of Maryland Charles Regional Medical Center 7.46% 8.91% 7.30% 8.15% 1.61% 1.45% 8.14% 0.01% -0.80% 7.35% -0.79%210037 Univ. of Maryland Shore Medical Center at Easton 5.86% 7.18% 5.53% 6.40% 1.65% 1.32% 5.42% 0.98% -0.83% 5.56% 0.14%210038 Univ. of Maryland Medical Center Midtown Campus 15.22% 11.38% 13.76% 12.65% -2.38% -3.84% 12.33% 0.32% -3.52% 9.14% -3.19%210039 Calvert Memorial Hospital 6.16% 7.09% 5.93% 6.55% 1.16% 0.94% 6.60% -0.05% -1.05% 5.51% -1.09%210040 Northwest Hospital Center, Inc. 8.41% 9.22% 7.62% 8.47% 1.61% 0.81% 7.25% 1.22% -0.93% 7.54% 0.29%210043 Univ. of Maryland Baltimore Washington Medical Center 9.78% 8.33% 9.20% 8.82% -0.87% -1.45% 7.70% 1.12% -1.02% 7.80% 0.10%210044 Greater Baltimore Medical Center 3.12% 4.44% 3.09% 3.79% 1.35% 1.32% 3.40% 0.39% -0.38% 3.42% 0.02%210045 McCready Foundation, Inc. 8.32% 10.47% 8.55% 9.57% 1.93% 2.16% 10.10% -0.53% -2.76% 6.81% -3.29%210048 Howard County General Hospital 5.99% 6.43% 6.15% 6.33% 0.28% 0.44% 6.70% -0.37% -0.61% 5.72% -0.98%210049 Upper Chesepeake Medical Center 6.08% 5.34% 6.01% 5.71% -0.68% -0.75% 5.86% -0.15% -0.59% 5.12% -0.74%210051 Doctors Community Hospital 9.29% 9.47% 8.61% 9.10% 0.86% 0.19% 7.75% 1.35% -0.61% 8.49% 0.74%210062 Southern Maryland Hospital 6.84% 8.66% 6.32% 7.54% 2.34% 1.82% 7.81% -0.27% -0.94% 6.60% -1.21%210055 Laurel Regional Hospital 14.23% 12.21% 14.11% 13.24% -1.89% -2.02% 11.25% 1.99% -0.94% 12.30% 1.05%210060 Fort Washington Medical Center 13.63% 13.00% 13.01% 13.09% -0.01% -0.62% 13.69% -0.60% -0.86% 12.23% -1.46%210061 Atlantic General Hospital 7.68% 8.62% 7.00% 7.86% 1.62% 0.94% 6.59% 1.27% -1.42% 6.43% -0.16%210058 Univ. of Maryland Rehabilitation and Orthopaedic Institute 5.20% 5.77% 5.77% 5.80% N/A N/A 6.95% -1.15% -1.13% 4.67% -2.28%210056 Good Samaritan Hospital 6.60% 8.31% 6.25% 7.33% 2.06% 1.71% 5.77% 1.56% -0.90% 6.43% 0.66%210057 Shady Grove Adventist Hospital 6.76% 7.67% 6.71% 7.24% 0.96% 0.91% 6.78% 0.46% -0.53% 6.71% -0.07%218992 Univ. of Maryland (MIEMSS) 22.32% 21.22% 21.22% 21.36% N/A N/A 22.82% -1.47% -0.25% 21.11% -1.72%212005 Levindale Geriatric Center and Hospital 1.82% 1.82% 1.82% 1.83% N/A N/A 1.83% 0.00% 0.00% 1.83% 0.00%

STATEWIDE 7.23% 7.32% (2) 7.04% (2) 7.23% 0.28% 0.09% 6.84% 0.39% -1.09% 6.14% -0.69%

(1): Includes Revenue Neutrality Factor of 1.00645(2): Totals may not add due to rounding.

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• In FY2015 Staff collected data on individual patient write offs, net of recoveries Most hospitals have submitted, though many

found difficult

• May be used to reconcile prospective reduction and other purposes

FY2015 Experience

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• HSCRC evaluating a further prospective UCC reduction CY2014 YTD September data reflect a

$252m reduction from CY2013 September data− $328m annualized impact

• $328m impact is double the original prospective reduction

FY2015 Experience

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• HSCRC Staff has also accumulated the Medicaid expansion dollars by hospital, suggesting this amount is greater than $328m Assumed to be matched use MPI from CRISP

• Staff provided data to hospitals on 12/16 to begin reviewing the potential UCC impact

• Monthly data reflect a lower impact

FY2015 Experience

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Summary of FY2015 Rate Provisions versus FY2015 YTD Actual(Source: Monthly FS Schedules)

FY2015 UCC Funding

ID Hospital2015 Rate Funding

PAC Adjustment

2015 Rate Funding less

PAC

FY2015 YTD Actual

October

Rate Provision Over / (Under)

Actual1 Meritus Med. Ctr. 7.83% -1.66% 6.17% 8.48% -2.31%2 Univ of Maryland 6.50% -1.85% 4.65% 5.01% -0.36%3 Prince George's 16.07% -1.09% 14.98% 14.65% 0.32%4 Holy Cross 8.84% -0.31% 8.53% 7.93% 0.60%5 Frederick Memorial 6.33% -0.90% 5.43% 3.07% 2.36%6 Harford Memorial 10.75% -1.51% 9.24% 10.68% -1.44%8 Mercy Medical Ctr 6.74% -1.34% 5.40% 6.95% -1.55%9 Johns Hopkins 4.31% -0.78% 3.53% 3.80% -0.27%

10 UM Shore Dorchester 8.25% -2.67% 5.58% 5.92% -0.34%11 St Agnes 8.13% -1.45% 6.69% 5.07% 1.61%12 Sinai 5.83% -1.10% 4.73% 3.39% 1.34%13 Bon Secours 17.59% -5.80% 11.79% 9.59% 2.19%15 MedStar Franklin Square 7.74% -0.95% 6.80% 4.04% 2.76%16 Washington Adventist 13.36% -0.59% 12.78% 13.59% -0.82%17 Garrett County Memorial 10.10% -0.75% 9.36% 8.68% 0.68%18 MedStar Montgomery 7.02% -0.78% 6.25% 3.64% 2.61%19 Peninsula Regional 6.71% -1.30% 5.41% 5.71% -0.30%22 Suburban Hospital 5.33% -0.28% 5.05% 4.55% 0.50%23 Anne Arundel 4.82% -0.54% 4.29% 3.67% 0.62%24 MedStar Union Memorial 7.49% -1.45% 6.03% 3.52% 2.52%27 West.Md.Reg.Med. 6.49% -1.06% 5.43% 5.28% 0.16%28 MedStar St Mary's 7.41% -1.09% 6.32% 4.05% 2.27%29 Hopkins Bayview Med Ctr 8.71% -1.73% 6.98% 5.94% 1.03%30 UM Shore Chestertown 9.01% -0.77% 8.24% 8.85% -0.61%32 Union Hospital 8.25% -1.82% 6.43% 4.55% 1.88%33 Carroll Hospital Center 5.23% -0.69% 4.53% 3.26% 1.27%34 MedStar Harbor Hospital 9.12% -1.47% 7.65% 5.04% 2.62%35 UM Charles Regional MC 8.15% -0.80% 7.35% 6.79% 0.56%37 UM Shore Easton 6.40% -0.83% 5.56% 5.45% 0.11%38 UMMC Midtown Camp. 12.65% -3.52% 9.14% 8.60% 0.54%39 Calvert Memorial 6.55% -1.05% 5.51% 3.50% 2.01%40 Northwest Hospital Ctr 8.47% -0.93% 7.54% 9.73% -2.19%43 UMMC BWMC 8.82% -1.02% 7.80% 6.36% 1.44%44 GBMC 3.79% -0.38% 3.42% 2.14% 1.27%45 McCready Memorial 9.57% -2.76% 6.81% 5.42% 1.39%48 Howard County 6.33% -0.61% 5.72% 4.76% 0.96%49 Upper Chesapeake Medical 5.71% -0.59% 5.12% 6.81% -1.69%51 Doctors Community 9.10% -0.61% 8.49% 2.39% 6.10%55 Laurel Regional 13.24% -0.94% 12.30% 12.03% 0.28%60 Ft Washington Med Ctr 13.09% -0.86% 12.23% 9.14% 3.09%61 Atlantic General 7.86% -1.42% 6.43% 5.96% 0.47%62 MedStar Southern Maryland 7.54% -0.94% 6.60% 7.56% -0.96%63 UofMD St. Joseph 4.63% -0.72% 3.90% 5.62% -1.72%

2001 UM Rehab-Ortho 5.80% -1.13% 4.67% 7.56% -2.89%2004 MedStar Good Samaritan 7.33% -0.90% 6.43% 4.33% 2.10%5033 Levindale 1.83% 0.00% 1.83% 3.20% -1.37%5050 Shady Grove 7.24% -0.53% 6.71% 6.37% 0.34%8992 University - MIEMS 21.36% -0.25% 21.11% 17.41% 3.70%

99 Total 7.23% -1.09% 6.14% 5.69% 0.46%

FY2015YTD Annualized Charges (October) 15,425,109,969$

FY2015 "Savings" 70,701,933$

15

• Expansion of Medicaid has affected financial assistance policies Coverage eligibility under Medicaid

Plan enrollment, service use and premium non-payment

Other potential scenarios

Changes to Financial Assistance Policies

16

• UCC policy issues likely to be addressed in FY 2016: Treatment of Medicaid-pending patients

Review of undocumented UCC variable

• FY 2016 UCC policy review process TBD

Future Considerations

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• Q&A