Hospitalito Atitlán Patient Charges
The subject of patient charges has always been a hot topic at the Hospitalito Atitlán. A year ago administration and physicians decided to offer a sliding scale of fees. The discount from full fees is based on measurable criteria—number of persons living in the home, total income, type of housing, water access, cooking arrangements, and number of children under the age of 13 who were not in school but were working. A social worker interviews patients and assigns points based on these criteria. A patient’s points determine a reasonable amount of payment.
On my site visit in August, I talked about patient charges with local residents of Santiago Atitlán, the volunteer physicians, and K’aslimaal—the governing board of the Hospitalito. Perspectives differ widely.
I asked several T’zutujil friends, acquaintances, and strangers about the reputation of the Hospitalito. One family had taken their daughter to the Hospitalito for the birth of their granddaughter. At first they told me that the delivery was too expensive…Muy Caro! In discussing her hospital stay, it became clear that she had had a complicated caesarean birth. At the end of the conversation, grandmother admitted that only excellent care could have given them a healthy mother and baby.
Another man I queried about the reputation of the Hospitalito told me he had heard it was expensive. He added a new twist—“Listen, people in Santiago Atitlán are not used to paying foreign doctors. For years, groups of doctors have come to Santiago Atitlán for short visits to provide medical care….this was always free.” A woman weaver told me her neighbor had gone to the Hospitalito and she was charged what seemed a fair amount.
Given Santiago Atitlán’s overwhelming health problems, why isn’t everyone taking advantage of the western medical expertise available at the Hospitalito? Cost is clearly the major factor but not the only one. There is a long tradition of local practitioners and practices available for health problems. When people break a bone they go to a T’zutujil Bonesetter. Lay mid-wives with varying levels of expertise offer prenatal care and delivery. These mid-wives may be reluctant to refer their patients to another healthcare provider. Entering a hospital by many is seen as giving up hope as they are convinced that only those who are dying are admitted. Often people with health problems bypass all providers and visit the Mayan God Maximon to pray for a cure. Many factors determine if, where, and from whom a sick T’zutujil decides to seek health care. K’aslimaal and the Hospitalito need to build relationships with traditional providers and persuade the community that western medicine can provide benefits that all can afford.
Remember the man who said the T’zutujil expect foreign physicians to provide free care? To some extent the foreign physicians have the same expectation. They generously donate their expertise and their time and want to provide care for the neediest people in Santiago Atitlan. They fear that “high” fees keep the poor from seeking care except in emergency situations. They suspect that the financial evaluation system is not working efficiently and that some patients may be charged beyond their means, lending credibility to the rumors that care is expensive at the Hospitalito Atitlán. They are frustrated by the lack of the technology and medicines they were trained to use.
The members of K’aslimaal and the local doctors have a different view on charging patients. Where the foreign physicians see mainly poverty, the locals see all of their townspeople as having some resources to care for themselves. For the short- term, K’aslimaal believes patients need to take responsibility for their own health care. This responsibility includes paying for care at the Hospitalito. If a patient can only afford one quetzal for hernia surgery, they should pay that one quetzal. Paying for services—paying the hospitalito—helps make it THEIR hospital. Patient families can volunteer to work a number of days doing construction or maintenance work at the facility in lieu of money payment. The local providers feel that paying for service is critical to changing local attitudes towards health care.
K’aslimaal and the indigenous providers also believe that local support—especially local financial support—is necessary to ensure the Hospitalito is a permanent part of Santiago Atitlán. The original Hospitalito in Panabaj was run by a
When local leaders began discussing reopening the Hospitalito, they felt that local support and local control would be crucial for long-term sustainability. With the temporary hospital operating and as plans move ahead for the permanent Hospitalito, K’aslimaal wants to control its future by relying as much as possible on local resources. Patient charges are a part of those local resources that can help the T’zutujil sustain their own Hospitalito. We are currently discussing the feasibility of a pre-paid healthcare plan that would both reduce the financial barrier to care, encourage early and less costly care and provide a predictable stream of income for the Hospitalito. Policyholders would include, schools, businesses, churches, finca owners and individuals.
The tensions between medical providers and medical administrators are found everywhere. Providers want to give the best care they can today. Administrators want a hospital that will be financially viable as long as people need health care. Building a hospital, while providing care increases these tensions. Decisions on how to use limited resources are painful. Does one purchase construction materials or medicines? How do physicians feel when they lose a patient for lack of that medicine?
While I applaud K’aslimaal’s push for a locally controlled and locally financed health care facility, no hospital sustains itself on patient charges alone. Given the medical needs of a community this poor, it is only realistic to assume that the Hospitalito finances will require subsidies into the future. And given the local poverty, it is reasonable for the foreign physicians to want a working sliding scale payment system.
The current sliding scale payment system was designed to address these issues. It didn’t seem to be working. I asked a group of Harvard medical student volunteers to get some data about charges. They reviewed hundreds of patient charts. They found that the majority of patients were not financially evaluated. There is no policy that all patients need to be evaluated. Indeed, the social worker may have too many responsibilities to evaluate everyone. Apparently the patient or the provider must request a financial assessment. The availability of a sliding scale payment system is not advertised in the Hospitalito. Even when a patient had an evaluation, they were not consistently charged the price their points indicated. Some patient overcharges were documented. Most of the variance from sliding scale charges occurred among low income patients; those with more income were usually charged the correct amount.
As representatives and stewards of donors’ contributions and intentions,
The Board of Pueblo a Pueblo knows that documenting and implementing a sliding scale payment policy will require much time and resources. We feel strongly that the sustainability of the Hospitalito depends on meeting all constituents’ interests. Consistent use of a fair sliding scale will encourage physicians to volunteer as the hospital attracts more needy patients. The reputation of the Hospitalito will improve as patients pay charges that are consistently within their financial capabilities. Donors will continue to support a medical facility that can demonstrate that it is providing care to the entire T’zutujil community. Lastly, K’aslimaal will strengthen its control over the Hospitalito and ensure long-term sustainability by building strong partnerships with volunteer physicians and donors.
In working through these issues, I felt admiration for everyone working for the Hospitalito. I admire K’aslimaal for working hard to support itself by generating local income….by paying their staff with earned income rather than donations. And I respect the physicians desire to provide care to more needy patients. Both these goals are good. I believe the Hospitalito can achieve both these goals by further developing and implementing a working payment system.
Despite the obvious shortcomings of the payment system and its to-date poor implementation, simply raising these issues and presenting the data from the study has created some effect. Tensions seemed a bit relieved as folks began to voice their perspectives. I recently got an email from Lyn Dickey saying that the Social Worker had evaluated a patient family and determined that they should receive a 90% discount for a surgery. That is what they paid. The social worker was ecstatic. Presumably the patient was, too. This anecdotal report was heartening and we look forward to systematic changes and the November report.
Kenneth Wood
Executive Director
