Chapter 05: The Charity Care Program
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Description
Dr. Foxhall describes MD Anderson’s work with indigent patients and the Charity Care Program.
He notes that MD Anderson was founded as a charity care institution and sketches the later history of this obligation. He explains the financial stresses this caused the institution. He explains that he worked with the Charity Care Program to reduce costs while paying for care, helping to stablilize the financial situation. He notes the partnership with the Lyndon Baines Johnson Community Hospital to serve charity cases.
Dr. Foxhall observes that patients at MD Anderson in general represent the cancer levels in the general population, though MD Anderson sees insured patients and the rates of the uninsured in Houston are very high (1/3 of population). He explains why the level of uninsured is so high.
Identifier
FoxhallLE_01_20140205_C05
Publication Date
2-5-2014
City
Houston, Texas
Interview Session
Lewis Foxhall, MD, Oral History Interview, February 05, 2014
Topics Covered
The University of Texas MD Anderson Cancer Center - An Institutional Unit; MD Anderson History; Institutional Mission and Values; The Business of MD Anderson; MD Anderson and Government; Fiscal Realities in Healthcare; Building/Transforming the Institution; The History of Health Care, Patient Care
Transcript
Tacey Ann Rosolowski, PhD:
So tell me how your role expanded next.
Lewis Foxhall, MD:
Well, the Physician Relations operation continued for some time, and so we built that up over time and continue to operate that. The next area of responsibility that I took on was in relation to our Charity Care Program. So we had some opportunities that presented themselves in managing that challenge. We had switched back in 1995 out of the Charity Care portion of the state health laws.
Tacey Ann Rosolowski, PhD:
Can you tell me a little bit about that? I’m not familiar with that background.
Lewis Foxhall, MD:
So MD Anderson was founded as a charity hospital, so it was 100 percent charity care. It was 100 percent supported by the state. And over time, that gradually changed and it began to develop its own—or to attract patients who had some insurance coverage or some resources and was able to develop a more prominent side of people actually being able to pay for their care. So it wasn’t limited to only charity care, but over time that ability to attract patients with other resources increased. So the changes then did not really do away or eliminate all of our charity care, so it’s always been a tradition. We’ve always had some opportunities there, and up until ’95 it was really the obligation of the institution to take patients who were unable to pay. So in ’95, in addition to changing self-referral, we were switched under to the health and safety part of the regulations, at which point as a state hospital we really had no statutory responsibility to take care of funding patients. So, however, we respected our previous tradition and respected out obligations socially and morally to care for the underserved, so that continued. Our charity program is one which is open-ended, so individuals who met the income and residency requirements came in and said [unclear] we had a certain amount of money we would spend or a certain number of people we’d take care of. So there was a period of time there largely driven by the economic climate in the region, in the state, that resulted in a large increase in our charity care population. So we were glad to take care of all those patients, but it became clear that the trend was challenging, and we were concerned that it would adversely impact the rest of the operation. So in attempt to find a more reasonable balance of being able to care for patients and being able to pay for that care through other remedies, we implemented a number of programs at that time to try to address some of those increased costs, either by helping reduce those costs in a way that we could through finding pharmaceutical coverage for people through charity programs, from industry, or better utilization management or more careful application of our eligibility rules, we were able to stabilize that, so those huge increases stabilized and we’ve been able to maintain that since that time. But that took a few years to get that settled out.
Tacey Ann Rosolowski, PhD:
So during this very stressful period, what was the percentage of patients?
Lewis Foxhall, MD:
Yeah, it could have been up over 10 percent at that time.
Tacey Ann Rosolowski, PhD:
Oh, really?
Lewis Foxhall, MD:
Yeah. So it was going higher and higher every year, so we were concerned.
Tacey Ann Rosolowski, PhD:
This was in the eighties?
Lewis Foxhall, MD:
No, this was back in the early 2000s.
Tacey Ann Rosolowski, PhD:
Oh, okay.
Lewis Foxhall, MD:
There was a big recession back in there, and a lot of this comes from, you know, the economic situation.
Tacey Ann Rosolowski, PhD:
Right, right.
Lewis Foxhall, MD:
Some people have a hard time when they get cancer anyway, and they need care. So we didn’t turn anybody away, but we were able to try to moderate our cost and to help better manage the caseload. It was at that point in time we developed or began to really foster our program at the LBJ Hospital.
Tacey Ann Rosolowski, PhD:
Tell me about that.
Lewis Foxhall, MD:
So that was implemented in ’95, during that time when the law was changed, with one physician, Dr. Valero, who’s out there, and it became evident that by better supporting that program, growing that program, we’d be able to use our faculty to take care of more patients who were low-income that we could care for there as well as here. So it was really a kind of win-win situation where we were able to grow the program. We had a number of faculty that were very interested and have been very interested in working in that environment, and [unclear] help them provide care for their patients. So we supported the salaries of all the physicians out there, and still do, and have collaborated with the hospital district to help [unclear] provide the facilities and other services, and we provide the faculty and get to take care of lots of patients that way.
Tacey Ann Rosolowski, PhD:
When I was doing some of the background research for this interview, I read a little Q&A you did for one of the in-house publications that talked about the demographics issue, I mean who gets cancer in Texas, in Houston, and then who’s treated at MD Anderson, who’s treated at other facilities. Could you characterize that for me now, just for the record, so we can kind of get a sense of that breakdown?
Lewis Foxhall, MD:
Sure. Well, you know, the patients we care for are not that dissimilar from the general cancer population, but we tend to be a little low on the percentage of Hispanic persons who are cared for here in the institution. The numbers of—you know, related to their income levels, then, you know, we see primarily patients who are insured, patients who have Medicare or Medicaid government programs, but there are still large numbers of patients who also have cancer who have no insurance. So that’s a big challenge for us here in Texas, and about a fourth of the population has no insurance. That’s even higher here in Houston.
Tacey Ann Rosolowski, PhD:
Really? I didn’t know that. Huh.
Lewis Foxhall, MD:
Yeah, it’s almost a third.
Tacey Ann Rosolowski, PhD:
Really? And in an urban area, that surprises me. What would be the cause of something like that?
Lewis Foxhall, MD:
Well, there are a number of factors that are involved, but one big factor is the number of small businesses here in Texas, and Houston is relatively low compared to the rest of the country. Large employers, for the most part, offer all of their employees insurance coverage. Small employers do so much less frequently. So just by the economic mix that we have here in the community, that plays a big role. So a lot of people who are uninsured are working poor. They have low incomes, but they have some member in the household who’s working. It’s just they often work for small companies that don’t offer insurance. So as a result, none of the family members are covered. So the low-income government program, Medicaid, here in Texas is extremely limited compared to other parts of the country. So we cover pregnant women and children and we cover anyone that’s disabled and not much else in between, so adults and parents of kids in the program or single adults are not covered beyond just the very small bit of income.
Tacey Ann Rosolowski, PhD:
Have the percentages of the uninsured increased dramatically over time? I’m thinking about your situation, your experience growing up in a rural area. Were there many, many uninsured people at that time when you were growing up?
Lewis Foxhall, MD:
I have no clue. But uninsured has generally increased over time. In those days, insurance was generally pretty affordable, so there was things called a major medical insurance policy, so people could buy or their companies could buy, and they were relatively inexpensive. So, over time, healthcare costs have increased dramatically, insurance premiums have increased along with it, and it’s become unaffordable for a lot of individuals and a lot of small companies to have that sort of coverage. So I’m sure it existed, we just didn’t—I wasn’t particularly aware of it at that time. So, anyway, it’s still a big problem.
Tacey Ann Rosolowski, PhD:
We have a few minutes left. Do you want to stop now or do you want to go until twelve-thirty?
Lewis Foxhall, MD:
Whatever is good for you. I’ve got to dash over to 1MC [phonetic] here in a moment, so—
Tacey Ann Rosolowski, PhD:
Okay. Well, maybe it would be—
Lewis Foxhall, MD:
—we could pick up next time [unclear].
Tacey Ann Rosolowski, PhD:
Sure. That sounds great. Well, thank you for your time.
Lewis Foxhall, MD:
Sure. You bet.
Tacey Ann Rosolowski, PhD:
And I’m turning off the recorder at 12:25. (end of session one)
Recommended Citation
Foxhall, Lewis E. MD and Rosolowski, Tacey A. PhD, "Chapter 05: The Charity Care Program" (2014). Interview Chapters. 854.
https://openworks.mdanderson.org/mchv_interviewchapters/854
Conditions Governing Access
Open
