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Texas counties struggling to help indigent population
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Texans who can't afford health care still get sick--and that has counties scrambling to fund health care for the state's poorest residents.

In 2004, Texas counties reported spending nearly $5.6 million on the state's County Indigent Care Program, according to the Texas Department of State Health Services (DSHS).

Only counties that apply for state funds have to report the spending, so the actual figure could be much higher, said Jan Maberry, program manager.

When uninsured people who don't live in a hospital district need health care, Texas counties are legally bound to pay for their care if they are at or below 21 percent of the federal poverty level, according to DSHS. In Texas, that means residents making less than $168 per month who do not qualify for other programs such as Medicaid.

After a county spends 8 percent of its general revenue tax levy on indigent care, Texas' County Indigent Care Program begins reimbursing 90 percent of counties' additional indigent health care costs.

Texas requires counties to pay up to $30,000 per client per year, but counties can increase this requirement, Maberry said.

E for emergency
Texas counties aren't rushing to increase spending on indigent health care, since many struggle to meet the minimum requirements. Several counties have found ways to stretch limited budgets.

Fannin County in Northeast Texas, population 32,620, found that its clients were burning through their $30,000 allotment with unnecessary emergency room visits, so the county started teaching clients how to use their funds more wisely, said Rebecca Shirley, the former indigent health care director for Fannin County.

"People were going in [the emergency room] for a cold or a sinus headache," Shirley said. "These people had to be educated. Being an old-school teacher that I am, I thought, 'If I can make the clients understand why they need to go to their primary care physician first, then maybe they'll understand.'"

She created a mandatory meeting for all people enrolled in the county's indigent health care program, which usually has between 100 to 120 clients, she said.

Shirley told the clients that they had a set amount of $30,000 they could spend in a year, and while that sounds like a lot of money, it isn't. One big event, like a heart attack, would wipe it out, she said.

"I also explained that you don't get the diagnostic work [in the emergency room] that you would get in a physician's office," she said.

Since the county's first meeting in May 2004, Shirley noticed a decrease in the number of people using the emergency room. The county now holds the mandatory meetings each quarter, in addition to an orientation meeting held when each client is first enrolled.

Good gatekeepers
When clients use a primary care physician (PCP) instead of an emergency room, they save the county money even when the physician refers the patient to someone else, Maberry said. When a PCP refers a client, the procedure becomes a scheduled surgery rather than an emergency room visit, and the hospital bills scheduled surgeries at a lower rate, Maberry said.

"If it's scheduled, then we know the patient will just be charged for the surgery rather than for the emergency room fees," said Genny Fernandez, indigent claims auditor for Cameron County in South Texas.

A PCP also can refer a client to an ambulatory surgical center instead of a hospital, which can save the county hundreds of dollars per surgery. For example, a retinal detachment surgery costs the county $808 at an ambulatory surgical center, but would cost more than $1,000 at a hospital, Fernandez said.

Out of money
Educating patients may cut down on the number of costly, often unnecessary, emergency room visits, but some counties still come up short before the end of the year.

Cameron County, population 371,825, paid $2.25 million in 2004 for its indigent health care program, and the state kicked in another $1.9 million, said Mark Yates, county auditor for Cameron County. The county averages about 1,500 clients who participate regularly in the program.

"We're on the border here, and undocumented people can qualify for the program," Yates said. "I think it's a substantial percentage, something that most counties don't have."

Yates said Cameron County pays about half a million dollars each month for the program.

"The problem is that if we follow the traditional expenditures, I can pay everything out in about eight months," Yates said. "The need is growing faster than the resources."

Cameron County is considering outsourcing its indigent care program to a local hospital if the hospital can provide a 12-month managed care program, Yates said.

The county would give the hospital the 8 percent of its general revenue tax levy budgeted for the indigent health care program plus any funds it receives from the state if the hospital will provide health care for the county's indigent population for the entire year.

Yates said hospitals have an incentive to help the county manage the program more effectively.

"Hospitals say, 'When y'all run out of money, we start picking up the cost,' because hospitals can't deny emergency care," Yates said.

Indigent faces
Fannin County also ran short of funds and had to shut down payments for everything except medications from May 2004 to September 2004, when the new fiscal year began, Shirley said.

"The law says that you have to provide this [care], but it gets to the point where you don't have any money," Shirley said.

Maberry said the state requests that counties report the five most common diagnoses they treat when they apply for state matching funds.

"That will help us put a face on the indigent population," Maberry said. "What we hope to do is help the counties see across the board what the five top reasons are. I think it will help us [work] with our community partners as best we can."

Angela Freeman