The Financial Considerations Behind Medical Repatriation

ISSUES OF IMMIGRATION AND HEALTHCARE IN THE UNITED STATES

Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM160 special series – Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.

Legal immigrants across the United States pay taxes to be sure, but those who have spent less than 5 years in the country are often not able to qualify for any healthcare coverage under the states Medicaid program. If a patient in this situation develops an illness that requires long-term care, who pays and how might this scenario financially impact a hospital's capacity to maintain cost-effective strategies for care. You are listening to ReachMD, The Channel for Medical Professionals. Welcome to a special segment – Focus on Global Medicine. I am your host Dr. Mark Nolan Hill, Professor of Surgery and practicing general surgeon and our guest is Dr. Steven Larson, Assistant Dean of Global Health at the University of Pennsylvania School of Medicine. Dr. Larson is also an Associate Professor of Emergency Medicine at the hospital of the University of Pennsylvania and an expert on migrant health.

DR. MARK NOLAN HILL:

Welcome Dr. Larson.

DR. STEVEN LARSON:

Thanks for having me.

DR. MARK NOLAN HILL:

Dr. Larson, how long are we seeing immigrant patients stuck for extended periods without recourse for hospitals to transfer to? Are we talking about days, weeks, months?

DR. STEVEN LARSON:

In terms of a situation where it becomes obvious that they need to be repatriated, my experience in talking with folks who have been involved in this is that they exhaust all different avenues, everything from discussions with the consulate to social services people getting on the phone with the government. I mean, I don’t think it is something that people embark on lightly, I think and that can play out over weeks to months, as it becomes apparent that the chronicity and the acuity is going to make it impossible to move the person beyond a skilled nursing facility, then the challenge arises because there is no reimbursement to those skilled nursing facilities and the transition from the hospital to that level of care is that there is a breakdown.

DR. MARK NOLAN HILL:

I believe that federal regulations state that the hospital must arrange post hospital care. Is that correct and is it always happening or isn't it happening?

DR. STEVEN LARSON:

I don’t know nation-wise. I think the article that Ms. Sontag puts out there has questioned those plans and the feasibility and the reliability of them in my experience with patients that had been hospitalized. In the hospitals where I work, there has been every effort to ensure that the transition has been smooth.

DR. MARK NOLAN HILL:

I believe that there is a minimum time that a legal immigrant has to be in the United States before they get some federal benefits. Is that correct?

DR. STEVEN LARSON:

Yeah, the welfare reform in the mid 1990s, 1996 I believe, the public PRWOA (Public Responsibility Work Opportunities Act), which was welfare reform essentially, has embedded in it a tremendous volume of anti-immigrant kind of legislation. A lot of that sort of came out of Southern California during the early 1990s in what was noticed Proposition 187 and you know there were a lot of restrictions in terms of accessing Medicaid, Medicare for legal immigrants, people with papers and 5 years was the sort of said upon agreed number of years that one had to sort of stand on their own before the system would back them up. I do think, however, that many states, when the government passed welfare reform in terms of healthcare, their block grants were given and the states were basically at their own choice to decide how that money gets spent. There is no standard approach to it, to my knowledge, across the country. Some states for instance will allow prenatal care to be administered, some will allow SCHIPs, some won't. It's hit or miss.

DR. MARK NOLAN HILL:

Dr. Larson, certainly you as a professor of Emergency Medicine would know this, do you some times find in the emergency room that's the place where money is lost as well.

DR. STEVEN LARSON:

I believe most ERs are money-losing proposition, at least that's what I have been told.

DR. MARK NOLAN HILL:

In these situations, do you think that would be somewhat heightened?

DR. STEVEN LARSON:

Well, when welfare reform was passed and the PRWOA was put in place, there were some exceptions to the rule and that gave recourse for instance to hospitals to retroactively recoup some of the losses in terms of what were considered emergency medical care and the criteria for instance were active labor, life-threatening process, limb threatening, organ threatening and I think the fifth was pain. So, in those situations, the hospital has re-coursed to recoup from medical assistance emergency medical funding for both documented and undocumented.

DR. MARK NOLAN HILL:

Dr. Larson, I read about the repatriation company that offers a network of connections to hospitals in the Latin America. What exactly is this all about?

DR. STEVEN LARSON:

I would imagine that there are probably contractual agreements to be recipients of patients sort of guaranteeing upfront a level of care to those individuals that sufficiently satisfies the US side of the issue, very similar to the COBRA law that are enacted. Patient dumping, I think, is generally frowned upon in our profession and by guaranteeing a level of care on the repatriation, you know, side of it on the country that's we are recipient would satisfy, I think, many of the questions and concerns that the providers on our side would feel. That having been said, once the repatriation takes place and that individual sort of disappears into the night, I think it would be cautious to assume the best outcomes that are going to happen because limited resources exist and those hospitals are going to be pushed to provide care to an individual who is already, you know, on the lowest rung of the socioeconomic ladder. I mean that's what drove them up in economic gradient to come to the United States to work in the first place. So, those hospitals are I would imagine going to be, you know, driven by dollars in a sense to, you know, make a decision on how they are going to care for that patient.

DR. MARK NOLAN HILL:

Now, you mentioned before that some states are setting aside large amount of money to deal with this cause, such as California or New York. Are all states beginning to do this?

DR. STEVEN LARSON:

You know, California and New York are 2 of the 5 original main destinations for undocumented immigrants and so I think that their sensitivity to this issue is probably heightened. I would imagine especially in the setting of recent immigration trends and the fact that undocumented immigrants were being found in Bangor, Maine, for instance in the lumbar industry, but these are going to be issues that the nation is going to have to wrestle with.

DR. MARK NOLAN HILL:

What is the responsibility once a hospital in United States sends someone to their home country? Does that responsibility at least from their aspect of financial end?

DR. STEVEN LARSON:

I think, that's going to be a situation that the lawyers are going to have to sort through and resolve. I don’t know that there is any responsibility. Honestly, if we can take a prisoner and put him in Guantanamo Bay where our laws don’t reach and you know keep him sequestered for 7 years without due process, I think once you have exited the 48 contiguous states, you are outside on the law. I don’t know what responsibilities there are, honestly.

DR. MARK NOLAN HILL:

Is there a broad range of care facilities offered? Let's say in Guatemala or El Salvador or other countries.

DR. STEVEN LARSON:

When you explore the healthcare systems and in fact it was fascinating I am working with some trauma friends in Guatemala City right now on a project and know with the decline in the economy all of a sudden that economic gradient that moves people to try to find ways to survive is suddenly being reversed and they are anticipating and even beginning to see a return of immigrants from the United States back to those countries and they shudder at the thought of the volume, the unemployment, and the issues that that's going to, you know, create. As far as the infrastructure and their capacity to provide care, many countries, for instance in Guatemala, you have almost 3 tiers of healthcare delivery. You will have a public health system that by and large provides care for everybody as you can imagine it's pretty stripped down, pretty basic. Once you leave major urban areas, it drops off to little posts, which are staffed often times by a nurse, very basic rudimentary resources and skills. That's in general the public system. What they have is it's almost like an equivalent of a VA System. Many countries, you know the Dominican Republic, Guatemala, Mexico, has a social security system, which employers put money into and guarantees healthcare for the worker and their family up to a certain age. That level of care can be a little bit more sophisticated and more consistent and then if you are in the upper echelon of the society, the top 5%-10%, then you can have just about any procedure that you would get in the United States at your, you know, . So, there are several different ways this could go and it would all depend on the resources of that individual as well as their status, you know. Obviously, if they are not working in Guatemala, then the social security system isn't going to be applicable and they are going to default to the public health system.

DR. MARK NOLAN HILL:

I am sure some of the listeners are thinking, well if one of our citizens meaning from another country decides to go to the United States and live there illegally or legally and work there and make money and even set up a home there and then they get into trouble and want to come back to their home country, do they some times, do you think, look at them as disloyal and they say well, you decided to go to the United States, well you are in the United States now.

DR. STEVEN LARSON:

No, you know, funny, I said in on a conference about 5 years ago it might take home lesson from this whole discussion on immigration and with an aspect that I really hadn’t considered, these guys and back then it was a predominantly male population that left their families behind, they are considered heroes in a way.

DR. MARK NOLAN HILL:

What do you mean by that, sir?

DR. STEVEN LARSON:

Well, you know, they venture 2000-3000 miles north into climates that are not familiar to them, to cities where they are not really welcome there, that sort of Steinbeck's Grapes of Wrath, we want you to pick our crop, but don’t be a part of our community, just a real entity and don’t make yourself too visible and you know that hostility is, you know, to take that on just head-on into that. These guys are considered heroes.

DR. MARK NOLAN HILL:

Do you think that's changing in terms of our perception of that?

DR. STEVEN LARSON:

Well, I don’t think we have ever looked upon it in that sense. You know, we have looked upon it in a very black and white, they are illegal and they broke the law and therefore, I mean it's very easy for a person to assume that. I think if we look back historically to our own origins in terms of the immigration patterns to the United States, you know whether you are coming out of Ireland or Italy or Sweden, those are often times precipitated by economic hardship, famine that moved you in that direction and you know, so this is not something that is just arrived and being created. This is the history of our immigration into our country.

DR. MARK NOLAN HILL:

And has that increased or decreased or stayed the same in recent years?

DR. STEVEN LARSON:

In terms of the immigration pattern?

DR. MARK NOLAN HILL:

Yeah.

DR. STEVEN LARSON:

Well, I think it's very clear when you look at the numbers and the volume that beginning in the 1990s up until around 2006 when it peaked that the numbers were just off the chart in terms of undocumented immigration. We are talking millions and millions, growing from the 1990s when there were a couple of million to current times when there are 11 millions.

DR. MARK NOLAN HILL:

I want to thank our guest, Dr. Steven Larson. We have been discussing issues of immigration and healthcare in the United States.

I am Dr. Mark Nolan Hill and you have been listening to a special segment – Focus on Global Medicine on ReachMD, The Channel for Medical Professionals. Be sure to visit our web site at www.reachmd.com featuring on-demand pod casts of our entire library and thank you for listening.