Charity Care Report draft FY 2017

Charity Care Report draft FY 2017 Health Commission Finance and Planning Committee April 2, 2019 San Francisco Department of Public Health Office of Policy & Planning

Agenda 1 Charity Care Overview and Background 2 FY 2017 Charity Care Annual Report - City-Wide Charity Care Trends 3 FY 2017 Charity Care Report - Hospital-specific charity care data 4/2/2019 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 4/2/2019 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 3. Proposed changes to public charge 2014 4/2/2019 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 4/2/2019 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. For the first time since ACA implementation, charity care declines in the number of unduplicated patients were greater for traditional charity care compared to Healthy San Francisco (HSF). The number of HSF patients remained stable between FY 2016 and FY 2017, suggesting that Healthy San Francisco remains an important health care access option for San Franciscans. Traditional Charity Care will continue to be essential for the hard-to-reach population and for those who cannot access insurance. 4/2/2019 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 2013-2017 Charity Care Service Utilization: Emergency, Inpatient, and Outpatient 50,000 46,778 110,272 40,000 37,839 97,210 30,000 28,074 60,761 51,569 20,000 15,372 15,792 13,498 40,617 10,000 4,105 3,611 4,223 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 Charity Care Patients declined in San Francisco 0 2015 2016 2017 2015 2016 2017 2015 2016 2017 Emergency Inpatient Outpatient Utilization of charity care services overall has declined in San Francisco 4/2/2019 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 $738.1 Total $652.2 $660.7 Medi-Cal Shortfall $582.0 $566.4 $649.2 $575.2 $474.2 $382.9 $482.2 $199.2 $178.0 $84.2 $85.5 $89.0 Charity Care FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 Medi-Cal Shortfall continues to increase; Charity care expenditures are stable 4/2/2019 Office of Policy & Planning 8

Healthy San Francisco continues to be an important health care access option for uninsured San Franciscans ineligible for ACAsponsored health insurance. HSF and Traditional Unduplicated Charity Care Patients HSF and Traditional Charity Care Expenditures, in Millions 61,360 51,654 $126.3 $94.8 48,912 45,556 42,032 39,583 28,683 Traditional $72.9 $83.1 $60.1 $63.5 $67.8 Traditional 18,729 11,986 11,934 HSF $24.1 $22.0 $21.2 HSF FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 Traditional charity care patients continue to decline; HSF remained stable HSF expenditures continue to decline, while traditional charity care expenditures increased slightly 4/2/2019 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 2015-2017 12.2% 10.5% 12.2% 28.0% 32.1% 41.5% 85.6% 88.5% 86.7% 64.0% 60.0% 51.0% 2.2% 1.0% 1.1% 7.9% 7.8% 12.5% 2015 (n=20,198) 2016 (n= 13,040) 2017 (n= 13,251) 2015 (n=46,057) 2016 (n=44,202) 2017 (n=32,543) HSF HSF Traditional Traditional Charity Care HSF Inpatient Outpatient Emergency There is a steadily increasing dependence on emergency care for traditional charity care patients. 4/2/2019 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 3% 1% 3% 1% 3% 1% 3% 1% 6% 1% 8% 8% 7% 9% 9% 12% 13% 12% 16% 16% 76% 76% 77% 70% 69% Traditional Charity Care Patients by Supervisorial District 6,777 6,168 6,317 5,655 6,342 6,009 5,609 5,454 5,130 4,318 4,657 3,518 3,322 3,108 3,555 2,788 4,809 4,711 District 10 District 6 3,157 District 9 2,448 District 11 FY 13 FY 14 FY 15 FY 16 FY 17 FY13 FY14 FY15 FY 16 FY 17 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. 4/2/2019 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. 2013 2014 CPMC 2015 2016 2017 St. Luke's Chinese Kaiser Saint Francis 333 227 228 225 213 1,469 1,177 1,128 1,293 2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015 2,544 2,401 2,500 2,442 3,281 3,238 4,027 3,472 4,596 3,574 4,104 3,747 3,769 5,216 5,540 5,144 St. Mary's 1,313 1,919 1,893 2,556 2,818 UCSF 1,772 2,146 2,303 3,167 3,387 ZSFG 45,347 36,535 25,957 86,648 76,780 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 4/2/2019 Office of Policy & Planning 12

Charity Care Moving Forward The federal administration has made policy changes that may impact the health insurance and charity care landscapes for the City. federal tax reform repealing the ACA individual mandate eliminating ACA cost-sharing reductions proposed changes to public charge policies San Francisco s charity care ordinance and reports provides strong mechanisms for tracking and understanding the impacts on charity care due to ACA-related changes. Charity care has an important role in protecting patients from high medical bills and balance billing 4/3/2018 Office of Policy & Planning 13