Copays mean no treatment for some

Practically every week, the surgeon waits -- but knows all the same that the patient won't be coming.

Dr. Fernando Garcia is ready to operate. Sometimes he has even offered to waive his own fees to save a life or take away pain.

Nevertheless, some operations don't proceed. The patients are scared off -- or warned off -- by their potential hospital bill, he said.

"My patients get canceled because they haven't come up with a copay," Garcia said. "You feel terrible for that patient, and, I mean, it's horrible."

The difference between removing a tumor or living with it? Perhaps $200.

JPS Health Network is supposed to be a safety net for the poor, the healthcare provider they can turn to when there is nowhere else to go. But the system has formidable barriers for some of the poor and uninsured, critics say.

Even people enrolled in JPS' poverty program, Connection, can struggle with copays that add up over multiple visits.

For others without health insurance -- including the swelling ranks of middle-class families priced out of coverage -- required down payments can be insurmountable.

Need chemotherapy? Pay $20,000 to get started.

David Cecero, president of JPS, said that, far from limiting access, the health network has reached out to the community, investing millions in opening new locations, adding physicians and other personnel, and purchasing state-of-the-art technology. JPS also started a new discount program in October, so more people would be eligible.

"We have not done anything that has directly, negatively impacted access to healthcare," Cecero said.

He acknowledged that uninsured patients who don't qualify for Connection or the new discount program are on their own unless they reach a medical crisis.

But Connection patients who cannot afford their copays can still be treated, JPS officials said; the payments will be waived.

"If the doctor appoints the patient, they get seen," Cecero said. If they don't, he said, that would be "the doctor choosing on his or her own not to see the patient. I don't know why. There's no barrier."

Many critics see the situation differently.

JPS can afford to lower its copayments and down payments and make sure patients who can't afford them know how to get waivers or discounts, given its enviable financial position, they said. JPS owes the community that much, they say, because taxpayers have paid billions to serve the needy.

"I could see it if we were in the red and we all had to pinch and doctors had to take a cut and nurses had to take a cut," Garcia said. "But we're fortunate in Tarrant County to have an area where property values have remained stable even with the housing market declining across the country."

Physicians said that patients often do not return for follow-up appointments after surgery, even to learn results of tests for cancer.

"Some of the patients have been reluctant to come back for their follow-up because they have to pay another copay," said Dr. Chuck Webber, a surgeon who has worked at JPS for three decades.

Garcia remembers one of his patients with late-stage breast cancer who couldn't qualify for JPS Connection. For hospital treatment, she would have to make a down payment and agree to an installment plan.

She stopped showing up at Garcia's office. He suspects she is dead.

When the Star-Telegram told Cecero about the case, he said the relevant question to ask is whether the woman was financially needy. "Do you think our board has an unlimited prerogative to approve all patients for all services, regardless of their income or assets?" he asked.

Forty-five million Americans are uninsured, he said, but added, "How many are uninsured because they choose to be uninsured, versus truly can't afford health insurance?"

Another issue is whether patients are limited on how many health problems they can discuss per visit.

JPS' own consultants and employees say restrictions apply.

At JPS' Urgent Care Center, patients must agree to the limit in order to receive rapid assessment and treatment, consultants for InSight Advantage reported in a 2007 assessment. And at Family Health Center, walk-in patients can be seen only for one health concern, no matter how many they have. (See supporting document as PDF.)

A similar policy existed at the JPS' Family Medicine & Surgical Specialty Clinic in Arlington, said former manager Sharon Delso.

"It was emphasized that patients only make appointments for one problem per visit," she said in an interview.

The policy forces the poor, who often delay healthcare until a crisis, to return and be charged repeatedly, Delso said. (See supporting document as PDF.)

Another hurdle: New patients who wanted appointments were instructed to call back the first day of the next month, she said. Many could not be scheduled for up to three months.

Some patients come in with undiagnosed cancer, she said, "and by the time they get treatment, it's too late."

Chief Operating Officer Ron Stutes said he knew of no policy limiting patients to one problem per visit. "Our patients usually come in with one complaint, and doctors say they find more than one thing wrong," he said.

What may be happening at the clinics, he said, is that patients have been scheduled for the wrong kind of appointment, such as a follow-up.

JPS board Chairman Steve Montgomery said he was unaware of any restriction. Such a system, he said, would obviously be inefficient.

"The board has wanted to remove these kind of barriers, artificial or unintended," he said.

But he added that JPS has taken other steps to enhance access in the face of phenomenal growth in demand. "I think we are trying to drink out of a fire hydrant. It is a rush of need and us responding to the need."

Garcia agrees that the need is great. "I love JPS ...," he said, "but the system is taxed."

Online: www.jpshealthnet.org

A BREAKDOWN OF JPS COPAYS

Selected copayments for JPS Connection patients and those on the network's discount program as of October.

ABOUT THIS SERIES

Star-Telegram reporters Darren Barbee, Yamil Berard and Anthony Spangler spent four months examining the JPS Health Network using a variety of public records and data, including financial and tax documents, reports to state and federal agencies, and correspondence. Sources also provided the Star-Telegram with confidential documents and with reports by InSight Advantage, which JPS had not publicly discussed or released.

The articles are also based on interviews with dozens of experts, patients, healthcare advocates, and former employees and physicians, along with JPS administrators and board members and county commissioners. Jeff Claassen created the online map of JPS facilities. The videographer was M.L. Gray and the photographer was Ron T. Ennis. Copy editors were Ehren Meditz and Tim Sager. Meredith Poldrack-Segrist designed the pages. Arthur Lopez provided Web design. Marcia Melton provided research assistance. Lois Norder was project director, and Danny Robbins assisted with editing.

What do you think?

Post a comment about the series at star-telegram.com/jps

At star- telegram.com/jps

Outrageous charges await those without insurance. A look at a few hospital bills.

Miss a day? Catch up on previous days' stories, videos and more.

Series at a glance

Sunday: Cash surpluses

Monday: Barriers to access

Today: Pinched by high prices

Wednesday: What JPS says, what the records show and competing for the insured

Thursday: Gaming the system

Friday: A Q&A with JPS administrators