Charity Care Report FY 2016

Charity Care Report FY 2016 Full Health Commission - May 15, 2018 San Francisco Department of Public Health Office of Policy & Planning

Agenda 1 Charity Care Overview and Background 2 FY 2016 Charity Care Annual Report - City-Wide Charity Care Trends 3 FY 2016 Charity Care Report - Hospital-specific charity care data 5/15/2018 Office of Policy & Planning 2

Charity Care Ordinance and Reporting Hospitals San Francisco Charity Care Ordinance 163-01 passed in 2001 Requires hospitals to notify patients about free and discounted services Requires hospitals to annually report charity care data to DPH Charity Care is emergency, inpatient, and outpatient medical care, including ancillary services, provided to those who cannot afford to pay and without expectation of reimbursement * Reports voluntarily * Reports voluntarily * Reports voluntarily 5/15/2018 Office of Policy & Planning 3

Charity Care Landscape: Timeline 2001 2007 2010 2011-2013 SF Charity Care Ordinance passed 2011 Healthy San Francisco program started ACA signed into law by President Obama ACA Preparation Period 1. Healthy San Francisco 2. SF PATH 3. Get Covered! SF 2014-2016 2017-2018 ACA-initiated health insurance 1. Medi-Cal Expansion up to 138% FPL 2. Covered California Health Exchange Federal Uncertainty with the ACA 1. Repeal of Individual mandate 2. Elimination of cost-sharing reductions 2014 5/15/2018 Office of Policy & Planning 4

Charity Care Report Overview Goal: Understand and present trends related to charity care in San Francisco Tracks traditional charity care and HSF populations Showcases City-wide trends and hospital-specific data Engages representatives from the mandatory and voluntary reporting hospitals for development and review Completed and presented to the Health Commission annually 5/15/2018 Office of Policy & Planning 5

City-Wide Charity Care Trends As expected with continued implementation of the Affordable Care Act, Charity Care has declined in San Francisco. The charity care declines continue to be greater for Healthy San Francisco, likely because program participants are accustomed to actively participating in their health care and have greater support to transition onto ACA-sponsored health insurance. Traditional Charity Care will continue to be essential for the hard-to-reach population and for those who cannot access insurance. 5/15/2018 Office of Policy & Planning 6

As expected with continued implementation of the Affordable Care Act, Charity Care has declined in San Francisco. Unduplicated Charity Care Patients, FY 2012-2016 Charity Care Service Utilization: Emergency, Inpatient, and Outpatient 87,660 90,000 113,105 110,272 97,210 75,000 60,000 60,761 51,569 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 45,000 30,000 15,000 0 46,778 37,839 20,371 15,372 15,792 5,932 4,105 3,611 Emergency Inpatient Outpatient Charity Care Patients declined in San Francisco Utilization of charity care services overall has declined in San Francisco 5/15/2018 Office of Policy & Planning 7

As expected with continued implementation of the Affordable Care Act, Charity Care has declined in San Francisco. Charity Care Expenditures and Medi-Cal Shortfall, in Millions $652.2 $660.7 Total $536.5 $582.0 $566.4 $575.2 Medi-Cal Shortfall $382.9 $474.2 $482.2 $332.8 $203.7 $199.2 $178.0 $84.2 $85.5 Charity Care FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 Medi-Cal Shortfall continues to increase; Charity care expenditures are stable 5/15/2018 Office of Policy & Planning 8

The charity care declines continue to be greater for Healthy San Francisco, likely because program participants are accustomed to actively participating in their health care and have greater support to transition onto ACAsponsored health insurance. HSF and Traditional Unduplicated Charity Care Patients HSF and Traditional Charity Care Expenditures, in Millions 59,053 61,360 54,052 48,912 51,654 45,556 42,032 18,729 39,583 11,986 Traditional HSF $118.0 $85.6 $126.3 $72.9 $94.8 $83.1 Traditional $60.1 $63.5 HSF $24.1 $22.0 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 HSF charity care patients continue to decline more significantly HSF expenditures continue to decline, while traditional charity care expenditures increased slightly 5/15/2018 Office of Policy & Planning 9

Traditional Charity Care will continue to be essential for the hard-toreach population and for those who cannot access insurance. Proportion of all services for HSF and Traditional, FY 2014-2016 14.1% 12.2% 10.5% 21.7% 28.0% 32.1% 83.0% 85.6% 88.5% 70.8% 64.0% 60.0% 2.9% 2.2% 1.0% 7.5% 7.9% 7.8% FY 2014 (n=57,228) 2015 (n=20,198) 2016 (n= 13,040) FY 2014 (n=56,735) 2015 (n=46,057) 2016 (n=44,202) HSF HSF Traditional Traditional Charity Care HSF Inpatient Outpatient Emergency There is a steadily increasing dependence on emergency care for traditional charity care patients. 5/15/2018 Office of Policy & Planning 10

Traditional Charity Care will continue to be essential for the hard-toreach population and for those who cannot access insurance. Traditional Charity Care Patients by Reported Residence Traditional Charity Care Patients by Supervisorial District 6% 1% 3% 1% 3% 1% 8% 8% 3% 1% 7% 3% 1% 11% 9% 12% 13% 12% 12% 16% 76% 76% 77% 71% 70% 7642 7564 6323 4171 6777 6342 5130 3555 6168 5609 4657 3322 6,317 6,009 4,318 3,108 5655 5454 3518 2788 District 6 District 10 District 9 District 11 FY12 FY13 FY14 FY 15 FY 16 FY 12 FY 13 FY 14 FY 15 FY 16 San Francisco Homeless/Unknown Bay Area California Out of State District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 District 9 District 10 District 11 Traditional Charity Care remains relatively consistent, and continues to cover 1) majority San Franciscans concentrated in districts with lower income neighborhoods and 2) homeless residents. 5/15/2018 Office of Policy & Planning 11

Hospital-Specific Data Charity Care Patients across San Francisco Hospitals City-wide trends in charity care patients, service utilization, expenditures, and Medi-Cal Shortfall varied among the eight reporting hospitals. 2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015 5/15/2018 Office of Policy & Planning 12

Hospital-Specific Data Charity Care Expenditures across San Francisco Hospitals, in millions Percent of total charity Care expenditures, by San Francisco Hospitals, FY 2016 CPMC, 8.0% St. Luke's, 2.8% Chinese Hospital,0.3% Kaiser, 2.9% ZSFG, 68.4% Saint Francis, 5.1% UCSF, 10.7% St. Mary's, 1.9% 5/15/2018 Office of Policy & Planning 13

Charity Care Moving Forward The federal administration has made changes to dismantle the ACA that may impact the health insurance and charity care landscapes for the City. Impacts for San Francisco are still uncertain. San Francisco s charity care ordinance and reports provides strong mechanisms for tracking and understanding the impacts on charity care. 5/15/2018 Office of Policy & Planning 14