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9:35 AM Sat, Sept. 22nd

Through different eyes: Doctors, health center director see insurance problem, solutions

Les Stukenberg, photo illustration/The Daily Courier

Les Stukenberg, photo illustration/The Daily Courier

PRESCOTT - The health care system has been broken for years, said Jay Crutchfield, a surgeon who has practiced in Prescott for six years.

"The answer to that question (fixing the system) depends on who you are asking," Crutchfield said. "If you ask the patient who has to pay the bills, you will get a different answer than someone who has insurance. It is broken on several levels (for doctors)."

Health care is not a right, said Crutchfield, who took out $200,000 in loans to pay for medical school at the City University of New York.

Younger doctors face huge debt for financing medical school, said Dr. Stephen Linn, a Prescott gynecologist.

"That is part of the reason that a lot of them do not go into primary care," he said. Linn has practiced gynecology for about 20 years - five years in Prescott.

Linn and Crutchfield cite a variety of causes of why they believe the nation's health care system is broken. Linn cited problems that triggered the national health care reform movement in the first place: people lacking health insurance, costs for medical care and insurance companies denying coverage for treatment based on so-called pre-existing conditions.

Crutchfield mentioned a restrictive federal law, consumers without insurance who skip out on bills in the emergency room and costly malpractice insurance ($49,119 a year for him).

An estimated 17 percent of the population in Yavapai County lacks health insurance, said Peggy A. Nies, director of Community Health Center of Yavapai. The center operates clinics in Prescott, Prescott Valley and Cottonwood, and provides primary medical and dental care to both insured and uninsured patients, she said.

Nies furnished estimates that indicated 36,636 of Yavapai County's 215,503 residents in 2008 lacked health insurance.

Nies, Crutchfield and Linn provided analyses of the health care problem that differs in part from the rhetoric in Congress as well as the lobbying efforts by reform advocates and conservative-led opposition.

Crutchfield has proposed reform measures of his own that are unlikely to appear in the final package that Congress approves and President Barack Obama signs into law.

Crutchfield, a native of Snowflake, considers the Emergency Medical Treatment & Active Labor Act, or Emtala, as the "biggest, most voluminous constraint" on doctors. Congress enacted the law in 1986 to prevent "patient dumping."

He said Emtala was designed to prevent patients who lack health insurance or have no way of paying for medical care from being transferred to community or county hospitals. It is also designed to prevent the transfer of pregnant women who cannot afford medical care.

The federal government created Emtala to do "what is ethically and morally correct," Crutchfield said. "They forgot somebody: the MDs.

"It has created a legal mandate for physicians to take care of patients who may or may not be able to pay the bill, and it punishes doctors and hospitals who don't," Crutchfield said.

Emtala penalizes every doctor who sees patients in emergency rooms, Crutchfield said. "The law does not (say) you can only treat American citizens."

He estimates 20 percent of the patients whom he treats in the emergency room at Yavapai Regional Medical Center do not pay the bills he directly sends to patients. Illegal immigrants, meanwhile, constitute 20 percent of those who do not pay their bills, he added.

Robbie Nicol, director of development and community relations at YRMC, said, "We don't have the percentage right now" of illegal immigrants using the ER. However, she speculated their numbers have dropped because of the sluggish economy and Arizona's employer sanctions law.

Illegal immigrants make up about one out of every five emergency appendectomies, Crutchfield said, adding they are one of the most common surgeries in the ER. Using www.healthcarefee.com as his source, Crutchfield said appendectomies cost an average of $15,850 apiece (hospital and surgeon bills).

The overall bill for an appendectomy performed in an ER costs around $6,000 if the patient has insurance, Linn said. However, he added uninsured patients could face bills three to four times as high for the same medical procedure in an ER.

Uninsured ER patients at YRMC are eligible for financial aid if they are American citizens and legal residents, Nicol said.

Nicol said YRMC eligibility workers offer applications for the Arizona Health Care Cost Containment System (the state's Medicaid program) as well as applications for YRMC's patient financial assistance program.

She said AHCCCS recipients make up about 20 percent of the patients in the ER in the Prescott and Prescott Valley campuses of YRMC.

A number of people who are uninsured and do not pay the bills appear to be affluent but are too young to qualify for Medicare, according to Crutchfield.

"Nobody is talking about the deadbeats, the people who choose not to pay the bill," he said. "The image of the rich doctor is one that is very hard to break."

Taxpayers end up paying for deadbeat patients through their taxes and higher insurance premiums, Crutchfield said.

Uninsured and underserved clients of Community Health Center must meet federal income requirements, and supply proof of income and residency, Nies said. The center had about 10,000 patients as of October.

The center's clinics also serve AHCCCS (31,315 people) and Medicare (38,791) recipients and patients who cannot find a provider elsewhere because of the shortage of primary care doctors, Nies said.

Patients pay the center on an income-based sliding scale for doctor visits, lab work and radiology fees, Nies said. She estimated 33,000 or more county residents are eligible for using the sliding scale.

"We are going to be part of the solution of health care reform because we have always been the safety net," Nies said. "I do know community health centers will be part of it because there is not enough private infrastructure to care for the number of folks that are out there."

Crutchfield said, "I think there are several solutions. I think Medicare should be based on a fee basis and ability to pay. There should be an income cutoff" - but he is not sure what amount.

He said he does not accept Medicare patients because of the low reimbursement rates from the federal government.

"A family doctor would go bankrupt" if he or she accepted Medicare patients exclusively, Crutchfield said.

Crutchfield also called for tort reform by freeing doctors from liability for patients who have taxpayer-sponsored medical plans.

While agreeing with Crutchfield on the need for tort reform, Linn said no "simple answer" exists for fixing the broken health care system.

"I don't think anybody has got a good answer," Linn said.

Linn said he would prefer fixing one problem at a time instead of an ambitious plan to overhaul the entire health care system.

He said eliminating the pre-existing condition clauses in insurance policies "could be a good start."