COUNTY OF SAN MATEO

Inter-Departmental Correspondence

San Mateo Medical Center

DATE:

July 12, 2004

BOARD MEETING DATE:

July 27, 2004

TO:

Honorable Board of Supervisors

FROM:

Nancy J. Steiger, Chief Executive Officer

SUBJECT:

WELL Program Co-Payment and Annual Fee Increase

Recommendation

Adopt a resolution, effective August 1, 2004, increasing the annual fees and co-payments for services provided to patients covered by the WELL Program at San Mateo Medical Center.

Background

Since July 1996, San Mateo County patients covered under Section 17000 of the California Health and Welfare Code that mandates medical care coverage for the indigent population, moved from a sliding fee type to an annual and co-payment fee schedule for determining out-of-pocket responsibility for their health care. These fees promote a small amount of cost sharing while not presenting an undue barrier to compliance or the appropriate level of medical care.

No increase to these fees has been made since 1997. Co-payments are expected to be paid at the time the service is provided.

Discussion

This increase is being requested in order to help offset the costs associated with providing care to the indigent population. Balancing next year’s budget for SMMC will be very challenging given the County’s mandate to keep funding for the WELL Program patients at the same level as this year while salaries and medical supply expenses are expecting a 5-7% inflationary increase. Even though this increase represents a very small portion of the Medical Center’s revenue stream, it is nevertheless an essential contribution towards its financial stability. In addition to an increase in the co-payments, and prior to implementation of the increases, the SMMC shall adopt a policy and procedure for a waiver process for those patients who are unable to afford the co-payments. The policy and procedure shall be approved for legal sufficiency by the County Counsel.

Vision Alignment

This recommendation helps keep the commitment to Ensure Basic Health and Safety for All and goal number 8: Help vulnerable people – the aged, disabled, mentally ill, at-risk youth and others – achieve a better quality of life.

Fiscal Impact

Based on the recommended increases reflected in the exhibit, the Medical Center can expect to receive approximately $600,000 to $700,000 additional revenue. This is based on the current enrollment levels of approximately 11,500 WELL patients, which generate an average of 4,200 outpatient visits per month. There are many variables related to the estimated increase in revenue including outpatient utilization rates and the Medical Center’s success in collecting co-pays.

Exhibit A

“WELL Program Member Annual Fee and Co-Payment” *

Initial and Annual Enrollment Fee:

$250

Per individual member

Co-Payments:

Clinic Visit,

Office Visit,

Infusion Center

$10

$20

Per visit if paid at time of service.

Per billed visit

Home Care

$10

Per visit

Emergency Room Visit

$40

Per visit

Outpatient Prescriptions

$10

Per 90-day prescription

Orthodics, Glasses,

Outside DME Supplies

$10

Per item

Radiology – Diagnostic

$25

Per visit

Radiology – CT & Nuclear

Medicine, Ultra-Sound, Echo

$50

Per visit

Special Procedures,

Cardiac Caths

$550

Per procedure

MRI

$150

Per exam

Outpatient Ancillary Procedures **

$150

Per procedure

Ambulatory Surgery

$550

Per surgery

Inpatient Admission

$550

Per admit

* Applies to both internal or external services

** Example – Eye Laser, Endoscopy, Radiation Therapy