Data show hospitals bear burden

At the county's University Medical Center last year, three out of every four patients who did not provide a Social Security number were Hispanic. But nobody knows how many were illegal immigrants.

"We are a health care agency," said Kathy Silver, interim director at UMC. "We are not the INS, the police or the FBI. We are in the business of providing health care. We are not in the business of determining whether people are in the country illegally."

Even so, the hospital's billing data suggest many of those patients are illegal immigrants, and, since nearly half don't have private insurance or Medicaid coverage, that many won't pay their bill.

As a result, they have contributed to the growing budget burden at the public hospital, which recently received a $60 million transfusion of county funds diverted from parks.

Similar inferences can be drawn from the following facts:

• Among Clark County children who qualify for low-cost health coverage through the state, most are Hispanic, but nobody knows whose parents came to the country unlawfully.

• At low-cost clinics operated by the federally funded Nevada Health Centers, administrators know that as many as 70 percent of the patients are Hispanic and that many do not have insurance, but they don't know who is illegal.

Federal law not only prohibits hospitals from denying emergency medical care to illegal immigrants, it also forbids them from asking whether patients are legal U.S. residents.

"Hospitals are bound by (federal) laws. They're not interested in determining citizenship status. They just want to get paid," said Charles Duarte, who oversees Medicaid for the state Department of Health and Human Services. "If (elected officials) want us to get involved in that, they have to make that a priority of our program."

Therefore it is unknown how many illegal immigrants use government-subsidized health care services in Southern Nevada, but billing and collection data at UMC and other information provide a glimpse into the potential costs.

COUNTY HOSPITAL

At Clark County's University Medical Center last year, 42,794 Hispanics did not give Social Security numbers, comprising 77 percent of all Southern Nevada patients who did not give them, according to figures delivered by county officials at the request of the Review-Journal.

The Hispanics accounted for $146.1 million, nearly 68 percent, of the $215.8 million billed to patients without numbers. Caucasians accounted for $37.3 million, about 17.3 percent, and black patients $22 million, about 10.2 percent.

The hospital was able to collect small but proportional amounts from each of the three ethnic groups; some 20 percent of the totals for Hispanic or black patients and 24 percent among Caucasians. Only a fraction of the charges collected were paid by the patients themselves; more than 95 percent were paid by Medicaid and, in a few cases, private insurance.

While the patient is expected to pay the billable charges, administrators at a hospital running in the red are mindful of costs, Silver said. The costs are typically between 30 percent and 40 percent of the billable charges, she said.

Last year, the hospital's cost of serving those who did not provide a Social Security number was $68.6 million, about 32 percent of $215.8 million billable charges.

Wanting to clear up any unfair assumptions, Silver explained that people other than noncitizens might not provide a Social Security number for several reasons, such as avoiding debt collectors, a former spouse or the police.

But Silver said she was surprised by the number of Hispanic patients who did not provide a Social Security number, in part because the hospital had never examined the patient mix from that perspective until the Review-Journal requested the billing data by ethnicity.

"I think the size of the number is somewhat surprising," Silver said.

In looking at only Hispanic patients who in 2006 provided a Southern Nevada zip code but did not provide a Social Security number to UMC, the following was found:

• 19,802 cases involved patients with no health coverage; 17,488 cases qualified for Medicaid payments; 2,463 cases received assistance from the state or county; and 3,107 cases had private insurance, according to UMC statistics.

• Of the $146.1 million in billable charges, $29.6 million had been paid before June. The payments are about 20 percent of the charges and 64 percent of the actual costs of services.

Typically, the hospital collects about 10 percent of the bill for uninsured patients, Silver said.

Although Hispanics are the majority of UMC patients who do not give their Social Security numbers, immigrants interviewed in Las Vegas and North Las Vegas recently said illegal family members usually steer clear of hospitals and clinics. Medical care is expensive, and they are usually uninsured. Also, they fear they will be detected and deported if they have an outstanding bill.

Jorge Guerrero, 35, a legal Mexican immigrant, said his illegal cousin Javier had gone years without health insurance for his family. But recently, Javier landed a union job as a plasterer in Las Vegas using fraudulent employment documents.

"He has two kids now and one on the way," Guerrero said of his cousin. "His wife is six-months pregnant, and she hadn't had any prenatal visits. She didn't want to go to a doctor without having health insurance. She didn't want any help from the government because she doesn't want that on her record."

He said his cousin's wife thinks that if she has a chance at obtaining legal status, she wants a clean record that shows she has never been a burden on taxpayers.

Lilian Rosmen, a 42-year-old legal immigrant, said that although access to health care and health insurance has been easier for her than for her illegal relatives, the cost of care is expensive for both.

"When it comes to getting health care, going to a doctor or a clinic, it's going to cost money," Rosmen said. "They take your money either way, out of your paycheck or they charge you when you go. It's expensive either way."

Fernando Gonzalez, 34, a legal resident for two years, said that he has insurance through his construction job and that his brother, an illegal immigrant, recently got a job at a music store where he pays $80 toward his monthly premium.

Because federal law dictates that hospitals care for the poor, whether they have documents or not, UMC would risk bankruptcy if it simply stopped providing care for them, Silver said.

If the hospital violated federal law, she said, it would lose Medicare and Medicaid patients and the insured patients who can get coverage for care only at a Medicare-eligible hospital, Silver said.

"I don't think we have that option. There are federal laws that say we must care for people in an emergency," she said.

SUGGESTING ANOTHER OPTION

Since May, when Silver first saw the figures requested by the Review-Journal, she and her staff have worked on a proposal that she expects to present to the Clark County Commission later this summer.

With tens of millions of dollars lost each year on charges billed to uninsured, poor residents who cannot pay their bill, the hospital is considering a separate set of rates for residents who do not qualify for Medicaid or Medicare but cannot afford private insurance.

"We have been taking a closer look at our charity care," Silver said.

Uninsured patients are billed a rate for services that is higher than the rate paid by some patients whose managed-care companies have contracts with UMC, but lower than a rate paid by other managed-care patients, Silver said.

By reducing rates for the uninsured, hospital officials think those patients would be more likely to pay all, or a greater portion, of the smaller bill. By charging them less, the hospital hopes to cover more of its costs rather than lose money on patients skipping out entirely on a bill they could never afford to pay, Silver said.

"We would rather have people make an attempt to cover their bill, and cover our costs, rather than hold out for billed charges," Silver said. "What we would endeavor to do is set up a program where we can cover our costs and a small (profit) margin."

With the hospital's costs representing 30 percent to 40 percent of the billable charges for an uninsured patient, the reduced rate would be set so that UMC can cover its costs while making a marginal profit between 5 and 10 percent, Silver said.

The proposal would require applicants near the poverty line to prove their income to qualify, and illegal immigrants and other "working poor" would be eligible, Silver said.

As part of the Medicare Prescription Drug Improvement and Modernization Act of 2003, the federal government set aside about $250 million a year for the emergency care of illegal or new immigrants across the United States, but Nevada's portion of the "1011 program" funding was $2.4 million, less than 1 percent, last year, said Dwight Hansen, financial analyst for the Nevada Hospital Association.

Although hospital staff members must not ask patients for their citizenship or immigration status, they ask several other questions to determine whether a patient might be an illegal immigrant whose treatment qualifies for the funding. Besides asking whether the patient has a Social Security number, they ask the patient's country of birth and whether he or she qualifies for veterans benefits, Medicare or Medicaid.

Silver said that the 1011 funding pays pennies on the dollar for the handful of cases it helps cover and that it's frustrating larger states such as California and Texas get so much more of the federal money though nobody knows whether they're treating a proportionally large number of immigrants.

NONPROFIT CHIPS IN

Helping offset the demand for emergency services at UMC and other Southern Nevada hospitals are the nine health centers and two homeless clinics operated by the nonprofit Nevada Health Centers.

Patients must provide proof of their income, but the federally funded organization does not ask patients about their citizenship or immigration status, said Steve Hansen, chief executive of the agency, which also operates another 11 health centers in Northern and rural Nevada.

Patients typically can be seen for about $25. With prescription medication, the average visit costs about $40.

"Our mission is to see everybody regardless of their ability to pay," Hansen said. "To be asking about citizenship and things similar to that puts up barriers (to health care) and we don't do that."

At some of the health centers, up to 70 percent of the patients are Hispanic, and many of the Hispanic patients do not have health coverage. But very few Hispanics are seen at the agency's homeless clinics, Hansen said.

In Las Vegas, about 68 percent of all Health Center patients seen in 2006 did not have health coverage, Hansen said. Over the past several years, the number of uninsured patients has risen between 3 percent and 5 percent a year.

"A lot of the uninsured patients are Hispanic," Hansen said.

About half of the patients are women, with the other half being children or men, and the agency handles between 90 and 126 births a month, Hansen said.

Federal funding last year paid about 27 percent of the agency's $20 million annual, statewide operating budget, Hansen said. About 23 percent of the agency's revenue comes from government grants and private fundraising, and the remaining 50 percent comes from patients who pay fees up front, Hansen said.

The centers provide outpatient, nonemergency medical services, such as family practice, prenatal care, internal medicine and pediatrics.

"We are just like a doctor's office," he said. "It's obviously a lot cheaper to provide care in a primary-care setting than in an emergency-room setting."

The statewide agency handled approximately 120,000 office visits last year, and roughly two-thirds of the visits were in Southern Nevada. Patients might wait a week or longer for a doctor's visit, Hansen said.

"We could easily have double that with our demand, but there is not the revenue sources to meet that need," Hansen said.

Maria Ochoa Silva, 35, an illegal immigrant from Jalisco, Mexico, said that her family has never been treated at a Nevada Health Center facility and that her family goes to a private clinic because no one is insured.

"We always go to private clinics, and we always pay," she said. "For the routine consultation, it's usually $100 and more if additional tests or prescriptions are needed. It just depends."