Caring For The Uninsured Final 050510


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Caring For The Uninsured Final 050510

  2. 2. TABLE OF CONTENTSINTRODUCTION .......................................................................................................................................... 1THE UNINSURED POPULATION: NOT HOMOGENOUS ..................................................................... 1UNINSURED HEALTH SERVICES UTILIZATION .................................................................................. 2OUTPATIENT SERVICE USE DIFFERS BY PAYER GROUP ................................................................. 3INPATIENT SERVICE USE DIFFERS BY UNINSURED PATIENTS ..................................................... 3USING MARKETING TO INFLUENCE BEHAVIOR OF THE UNINSURED ........................................ 4STRIVING FOR BALANCE: TACTICS FOR CONSIDERATION ............................................................ 6MARKETING TACTICS ............................................................................................................................... 6FRONTLINE TACTICS .................................................................................................................................7CONCLUSION...............................................................................................................................................7APPENDIX ................................................................................................................................................... 8REFERENCES .............................................................................................................................................. 9
  3. 3. INTRODUCTIONAcross all political affiliations, industries, andsocioeconomic backgrounds, healthcare reform ranksamong today’s most discussed topics. But in the midst ofthe debate, one fact remains clear: providing care to theuninsured segment of the population is a monumental taskof paramount importance.The total uninsured population now includes one out of every six Americans. Estimates of the total numberof uninsured individuals ranges from roughly 46.31 to 49.72 million. The uninsured population now exceedsthe total number of Medicare beneficiaries by roughly 22 percent. Furthermore, forecasts indicate that thenumber of uninsured will reach 58 million Americans by 2014.3The cost of continuing to provide care as we do today will translate into billions of dollars in unpaid medicalbills for patients with little or no coverage. But the more hospitals and healthcare providers know abouttheir patients – notably the uninsured – the better equipped they will be to meet their missions, maintain arobust community benefit, and contain costs as components of financial viability. Regardless of the future ofhealthcare reform, hospitals and healthcare providers are well served to assess utilization and care patterns,examine their patient rosters, and develop strategies to lower expenses without sacrificing quality of care.In supporting this need, Thomson Reuters experts explored the topic of caring for the uninsured byexamining national hospital data and consumer healthcare information to articulate the uniquecharacteristics and behaviors of this growing population. This paper identifies distinct segments withdifferent utilization trends/behaviors, as well as channels and receptiveness to marketing. In addition,Thomson Reuters developed recommendations to hospital leadership on how to provide the right care at theright site of service to help better manage the rising costs of serving the uninsured.The research presented here draws upon multiple sources, including the Thomson Reuters OutpatientProcedure Estimates and consumer research from the annual Thomson Reuters PULSE™ Healthcare Survey.THE UNINSURED POPULATION: NOT HOMOGENOUSUninsured – Not Necessarily Low Income or UnemployedFor many Americans, the “uninsured” – when viewed as a single group – often means those withoutemployment or those who cannot afford individual healthcare coverage. The uninsured are not ahomogenous group and include both unemployed and employed individuals, at various income levels, aswell as their children and other dependents. Thomson Reuters experts have found significant differencesamong the various subgroups of the uninsured, including site of service preferences and health conditions.Thomson Reuters defined four mutually exclusive segments for the uninsured, based on employmentstatus and income level. Key differences in behaviors of the various segments are described as follows.• Uninsured, employed with incomes under 300 percent of the Federal Poverty Level• Uninsured, employed with incomes above 300 percent of the Federal Poverty Level• Uninsured, unemployed with incomes under 300 percent of the Federal Poverty Level• Uninsured, unemployed with incomes above 300 percent of the Federal Poverty Level Caring for the Uninsured Amid Financial Pressures 1
  4. 4. Uninsured – Low Income, not Medicaid Not all low-income individuals qualify for government coverage through Medicaid.4 Medicaid eligibility is based on considerations of income as well as other characteristics. Among the population groups that generally qualify for Medicaid are children, parents of dependent children, pregnant women, the disabled, and the elderly. The income levels at which these groups qualify differ from state to state, and group to group. Generally, coverage for children and pregnant women is available at higher income levels, followed by the disabled and elderly, and lastly, parents of dependent children. Childless adults who are not disabled or elderly do not qualify for Medicaid, even at the lowest income levels.5 Uninsured Workers Across All Industries – Variations Within The uninsured are present and working across nearly all segments of American business, even at moderate income levels. There is a significant presence of uninsured/employed at greater than 300 percent of the Federal Poverty Line (FPL), with high concentrations in the financial services, information technology, transportation, and utilities industries. These individuals are often the recipients of direct marketing targeted toward the purchasing individual for self-pay insurance plans. The construction industry, and the leisure and hospitality services industry, have the highest percentage of uninsured/unemployed individuals below 300 percent of the poverty level. While these industries have lower employee retention rates and may have higher incidences of on-the-job injuries, this group of individuals also moves between employed and unemployed status more frequently. This group is often unable to access quality health insurance given the number of workplace-related injuries that occur in these lines of work. Table 1: Uninsured Workers by Industry EMPLOYED EMPLOYED UNEMPLOYED UNEMPLOYED GRAND TOTAL UNINSURED UNINSURED UNINSURED UNINSURED INDUSTRY PERSONS: PERSONS: PERSONS: PERSONS: 0-FPL300 FPL300+ 0-FPL300 FPL300+ Financial Activities 43% 35% 17% 6% 1,098,728 Information 41% 30% 20% 9% 456,213 Transportation and 44% 29% 22% 5% 1,340,292 Utilities Educational and 46% 28% 22% 4% 3,576,886 Health Services Professional and 40% 26% 28% 6% 3,149,590 Business Wholesale and 46% 24% 25% 4% 4,499,978 Retail Trade Manufacturing 49% 23% 24% 5% 2,264,383 Construction 41% 22% 33% 5% 3,950,430 Agriculture, 56% 18% 24% 3% 626,562 Forestry Leisure and 50% 18% 28% 4% 4,756,268 Hospitality Source: Bureau of Labor Statistics, Current Population Survey, March 2008 Supplement UNINSURED HEALTH SERVICES UTILIZATION Physician Office Visits Lower; Self-Reported Conditions Higher For the employed and unemployed uninsured, office visits occur infrequently. Regardless of employment status, the uninsured average 2.5 physician office visits per year – approximately half the rate of those with insurance. However, despite a lower number of visits to physicians’ offices, the uninsured population has below- average health status and experiences complicating factors that negatively impact health. Unemployed, uninsured individuals self-report heart problems, hypertension, and lung cancer at extremely high rates, and show a high prevalence of chronic conditions. Risk factors among unemployed, uninsured patients include: obesity, poor diet, extreme stress, depression, and anxiety.2 Caring for the Uninsured Amid Financial Pressures
  5. 5. As a result, it’s not surprising that the uninsured often seek other locations and venues of care, includinginpatient and hospital emergency department settings.OUTPATIENT SERVICE USE DIFFERS BY PAYER GROUPMedicaid Usage Higher Than UninsuredMedicaid outpatient utilization across all delivery settings, including high-cost surgical procedures,invasive procedures, and deliveries, ranges from two to three times greater than that of the uninsured.Uninsured Patients Seek Lower Cost Medical Therapies, Minor Procedures, and VisitsThe uninsured population frequently accesses lower cost medical therapies, minor invasive procedures,and visits (often paid directly by the patient) at hospital outpatient or non-hospital clinic settings. In thiscase, the uninsured take advantage of the various charity care and community benefits provided by areahospitals that treat patients of all payer coverage categories or those without coverage at all. It’s alsocommon for the uninsured to use the Emergency Department for non-emergent visits at a much higherrate than those with private insurance. But the use of Urgent Care centers, a lower cost-of-service site,shows below average usage rates for the uninsured population.To have an impact on this cycle of high-cost behavior across payer groups, hospital providers and theirmarketing teams could benefit from developing and delivering targeted messaging regarding the varioussites of services, and clarifying the key situations for use.Further insights on how frequently the uninsured population accesses healthcare services are revealed inthe chart below. For all outpatient services, the uninsured access care through a physician office at a rate67 percent lower than the Medicaid population and 53 percent below the privately insured population. Table 2: Outpatient Visit Use Rates DIFFERENCE IN USE RATE FOR OUTPATIENT VISITS Visit Type % Difference - Uninsured vs. Medicaid % Difference - Uninsured vs. Private Emergency department visit, emergent -25 -22 Emergency department visit, urgent -4 26 Office medical visit, established patient -52 -32 Office medical visit, new patient -55 -44 Source: Thomson Reuters Outpatient Procedure Estimates, 2009INPATIENT SERVICE USE DIFFERS BY UNINSURED PATIENTSPostponement of Care a FactorThe uninsured that are unemployed with incomes above 300 percent of the Federal Poverty Level usehospital inpatient services at a rate of nearly three-to-one, compared to other uninsured segments.The difference between the inpatient usage rates of these groups likely stems from the fact that theunemployed are more likely experiencing either chronic or disabling illnesses that prevent them fromworking or pursuing employment.In addition, this segment of the uninsured is the most likely to delay or postpone care for at least 12months, creating a vicious cycle that further exacerbates chronic conditions and leads to increasedinpatient visit rates.The situation is complicated by the fact that the uninsured, and in particular this segment of theuninsured, are more likely to avoid receiving the recommended screening services to maintain health.In short, the segment that needs the most care is the one most likely to use the costliest form of caredelivery (inpatient services) rather than accessing other, less-costly sites of services capable of managingconditions. Caring for the Uninsured Amid Financial Pressures 3
  6. 6. Chart 1: Physician Office vs. Inpatient Encounters 60 n Employed Uninsured Persons: 0-FPL300 50 n Employed Uninsured Persons: FPL300+ 40 Encounters n Unemployed Uninsured 30 Persons: 0-FPL300 n Unemployed Uninsured 20 Persons: FPL300+ 10 0 Physician Visits Inpatient Discharges Inpatient Nights Source: Bureau of Labor Statistics, Current Population Survey, March 2008 Supplement USING MARKETING TO INFLUENCE BEHAVIOR OF THE UNINSURED A hospital’s marketing programs and targeted messages can be an effective means of directing the various uninsured segments to appropriate and cost-effective settings of care. In fact, well-executed marketing and communications campaigns can positively impact the overall profitability of the entire healthcare organization. However, there are significant differences in preferred communication channels and messages to reach the targeted uninsured audience. In comparing the uninsured with the insured population, the uninsured segment, on average, has less information at hand when selecting a hospital. This information disparity suggests that concerted efforts to direct and channel care for the uninsured to specific services or sites must be precisely designed for the intended audience. A look at distinct marketing messaging opportunities, patient segmentation and clustering techniques, and marketing vehicles will help illustrate how these unique groups can be best reached. For example, the uninsured audience with incomes under 300 percent of the Federal Poverty Level, without differentiation to employment status6, is more likely to respond to traditional methods of communication about pursuit of services (e.g., radio, direct mail) than to Internet campaigns or information from employers. Chart 2: Preferred Communication Channel Compared to the Average Preferred Info Channel: Word of Mouth n Less Than $50k Preferred Info Channel: Employer n Greater Than $50k Preferred Info Channel: Physician Office Preferred Info Channel: Internet Preferred Info Channel: Phone Preferred Info Channel: Direct Mail Preferred Info Channel: Newspaper Preferred Info Channel: Radio Preferred Info Channel: TV Heard/Saw Healthcare Advertising Use Internet For Health Info Lookup Have Internet Access -18% -12% -6% 0 6% 12% 18% Percent Difference from Average Source: Thomson Reuters PULSE™ Healthcare Survey, 20094 Caring for the Uninsured Amid Financial Pressures
  7. 7. While hospitals have shifted their budget allocations to create a host of scalable, efficient, online health resources (e.g., hospital Web sites, health content) that serve as patient education materials, they may miss the targeted audiences that need these resources most. A traditional target audience analysis, based on the HouseholdView® segmentation system, provides a window into the need to craft specific messages for the uninsured market. The chart below demonstrates that within the uninsured population, there are additional differences driven by demographic details, such as age, that may be leveraged for marketing success and cost containment. Chart 3: Likelihood to Postpone Care 20.0% n Postponed Care: 15.0% 1 yearPercent Difference from Average 10.0% n Have PCP 5.0% 0.0% -5.0% -10.0% -15.0% -20.0% -25.0% -30.0% Over-55 Segments Under-55 Segments t en s s em er ck o ng pp s he ng tir er rl ivi ho Re C lo Bi av Gi ls eL So ly tS S g l n il th tfu yin ny Fr pl de le g on n es ut im en la ol o lyi .M .N .R .O .P .G .S .P .F 29 54 55 46 38 47 33 37 17 Source: Thomson Reuters PULSE™ Healthcare Survey, 2009 Messaging to Uninsured Greatest/Silent Generation – Get the Doctors on Board HEALTHCARE The Greatest/Silent Generation segment of the uninsured population, is more likely than their younger ATTITUDES counterparts to have a primary care physician (PCP). And despite being concerned about the cost of OF FOUR medical services, they are more likely to seek care. GENERATIONS7 In the Thomson Reuters PULSE™ Healthcare Survey, the age 55+ generations reveal strong physician Greatest/Silent Generation alignment and consider “Physician Referral” and “Physician Affiliation” as the most important drivers (born before 1942) in selecting a hospital for care. Correspondingly, strengthening physician relationships, rather than increasing direct-to-consumer outreach, may ultimately be more advantageous in influencing individuals’ Baby Boomers hospital selection process. Stronger physician relationships can foster paths of communication, with (born 1943–1960) the intent of shifting use of healthcare services to the appropriate settings and thereby improving care Generation X management. The behavior of the over-55 uninsured population is consistent across the segment and can (born 1961–1981) be messaged accordingly. Millennials (adults Messaging to Uninsured Baby Boomers and Gen Xers – Use Direct Mail or Phone Campaigns born since 1982) Crafting effective messaging for the under-55 populations is a more difficult task, even for those with significant health issues, including younger uninsured segments that are at risk for hypertension, depression, and diabetes. As the chart Likelihood to Postpone Care indicates, these individuals are less apt to have a PCP and therefore are unable to be directed by their physician to appropriate sites of care. Even within the under-55 uninsured population, the Baby Boomer and Gen Xer groups prove to be two distinct populations: • Those who would act on healthcare advertising, but do not often see it (These segments make up the majority of the uninsured population.) • Those who are aware of healthcare advertising, but would not act on it Caring for the Uninsured Amid Financial Pressures 5
  8. 8. Focusing on the former, those who would act on healthcare advertising, helps marketers to connect with a willing and receptive population. The dilemma comes in deciding which media and messages are most important and effective. The goal in developing a strategy that best suits this audience is to identify the most appropriate media to reach them, avenues that will draw upon their penchant to respond positively to any form of healthcare advertising. The two strongest media formats for this population are standard direct mail and telemarketing. Of these two mediums, direct mail is usually the most cost-effective communication channel to connect with the uninsured, under-55 population. In order to impact site of service selection, the goal of these mailings should be to direct individuals to a primary care physician and encourage them to pursue necessary care. Another tactic that has been effective with this audience is to develop a health lecture on a topic relevant to their lives. Since many uninsured individuals in this segment struggle with chronic stress and anxiety, health lectures on these topics are likely to resonate. Directing this population could utilize a strategy such as: Table 3: Potential Outreach Strategy CALL TO ACTION MEDIA HOSPITAL GOAL Attend a health lecture Direct mail Help establish relationship with PCP Potential Topics: Anxiety, Depression, Phone number provided for follow-up Provide reason to see a PCP Stress Management questions Follow-up call after attending to make Identify critical health conditions that an appointment with a primary care require treatment and management physician (PCP) Source: Thomson Reuters crmView™ Marketing Solutions, 2010 Successful efforts require consistent messaging through preferred media channels to help achieve the goals of identifying the most appropriate site of service and disease management program. STRIVING FOR BALANCE: TACTICS FOR CONSIDERATION While everyone from Washington to your hometown critiques and debates the tactics for healthcare improvement, hospitals continue to face the critical onus of delivering uncompensated care.8 There is an immediate need to identify and achieve real solutions. Regardless of the system-wide healthcare changes that may be on the horizon, most individual hospitals and healthcare systems face faltering business models that are forcing reductions in services and staff. This research raises plausible considerations for achieving a balance between meeting the mission of serving the uninsured, benefitting the community, and also addressing healthcare budgetary constraints while delivering a significant return to the board and other key stakeholders. Simple solutions may not exist. However, by guiding and transferring care to more appropriate care settings, healthcare providers have an opportunity to address the cost of care, while concurrently increasing quality of care, patient throughput, efficiency, and ultimately reimbursable care. To chart the roadmap toward these achievements, consider the following tactics: MARKETING TACTICS Focus on Patients Who Drive the Costs A small number of patients usually drive the majority of costs. Target these patients at the right time with the right message. Then, measure the impact of your efforts through response rate analysis and reporting, and support continuous improvement based on your successes. Mine the Customer Information to Gain Key Insights Mining, modeling, and measurement are vital steps in understanding your current and anticipated patient populations. Organizations without the internal talent or tools to achieve a comprehensive analysis can consider partnering with healthcare-focused strategic intelligence and consulting firms and/or purchasing market intelligence tools.6 Caring for the Uninsured Amid Financial Pressures
  9. 9. Periodically Reevaluate Tactical Plans Oakwood AnnapolisThe tactics provided above are recommended as ongoing efforts, in lieu of one-time, evaluation processes. Hospital, part of theThough characteristics and utilization behaviors of patients continually change, patterns emerge and Oakwood Healthcaremeasurement will provide key insights in determining the effectiveness of the aforementioned tactics. System in Wayne, Michigan, receivesThese marketing tactics can help your organization gain a greater understanding of your audience, the over 70 percent of its admitted patientsbest way to reach them, and how their behavior changes over time. The frontline tactics below offer from the emergencyadditional suggestions for providers to consider. department (ED). The facility identifiedFRONTLINE TACTICS patterns of its ED “frequent fliers” through the use ofPartner With Physicians for Continued Patient Education and Direction Thomson ReutersEnsure information is shared with patients on appropriate care settings. For example, emergency crmView™ Marketingdepartment (ED) physicians may be able to share literature on other facility resources, including primary Solutions andphysicians, urgent care locations, and clinics. employed direct mail to generate awareness within theirReview Increased Collection Efforts (at the Time of Service) target audiences.Increased collection efforts may discourage the uninsured from seeking care at expensive sites of servicewhen less expensive sites provide equally appropriate care. Yet it is important to study both the short-term They stressed theand longer-term effects of such an effort. While the target audience may seek care at your ED much less importance of seeing afrequently, a patient’s disease or condition may worsen, and require acute inpatient services.9 primary care physician for non-life threatening conditions and sharedExamine Success Stories information regardingIdentifying organizations that have successfully addressed the right care at the right site helps generate federally qualified careideas on what to do and who to leverage for support. centers. Among their achievements, cost of care decreased by $35CONCLUSION per ED visit; improper utilization declined byThe challenges the medical community faces in meeting the needs of the uninsured while also remaining 72 percent; physicianfiscally responsible to their own organizations are great. Although the landscape of healthcare politics referrals for patientsremains in flux and is likely to continue so for the foreseeable future, healthcare organizations can take a to more appropriate health centersnumber of practical steps to alleviate some of their most vexing financial challenges while improving their increased by 12 percent;ability to care for the uninsured. and the ordering and prescribing of narcotics in the ED declined Table 4: HouseholdView® Segments by 10 percent. 10SEGMENT NAME AGE MARITAL STATUS GENERATION55. Restful Retirement 75+ Married/Married with Kids Greatest/Silent54. Monthly Checks 75+ Married/Married with Kids Greatest/Silent47. Golden Girl 65+ Single Female/Single Female with Kids Greatest/Silent46. Playing Bingo 65+ Single Female/Single Female with Kids Greatest/Silent38. Outlet Shoppers 55-64 Single Female/Single Female with Kids Boomers37. Penny Savers 55-64 Single Female/Single Female with Kids Boomers29. No Frills 45-54 Married with Kids Boomers33. Simple Living 45-54 Married Boomers17. Flying Solo 35-54 Single Female Gen X/BoomerSource: Thomson Reuters HouseholdView® Caring for the Uninsured Amid Financial Pressures 7
  10. 10. APPENDIX HEALTHCARE ATTITUDES OF FOUR GENERATIONS7 THOMSON REUTERS PULSE HEALTHCARE SURVEY Thomson Reuters delivers unique insights into consumer healthcare behavior GREATEST/SILENT GENERATION (BORN BEFORE 1942): and attitudes with the proprietary PULSE™ Healthcare Survey – the largest Attitude toward gathering healthcare ongoing, privately funded telephone healthcare survey in the United States. information: Physician Directs Me Through the PULSE Healthcare Survey, Thomson Reuters has compiled • Rely on personal doctors, defer to more than 100,000 household interviews annually since 1988. The survey is physicians’ preferences conducted by telephone throughout the entire year to account for seasonality. • Rigid definitions of good service: Each year, Thomson Reuters clients help to determine the PULSE Healthcare the customer is always right Survey topics, ensuring the questions asked reflect the most important • Consider only physicians and nurses industry topics. The questions are both behavioral and attitudinal in nature as health professionals and are modeled to reflect the larger population. The PULSE Healthcare Survey is unique in that it ties results to two proven lifestyle segmentation BABY BOOMERS (BORN 1943–1960): Attitude toward gathering healthcare information: systems: PRIZM® by Nielsen and HouseholdView®, a Thomson Reuters Engage Me methodology. The use of lifestyle segmentation gives healthcare clients better • Prefer individual engagement in healthcare insights into who is using which services and where similar households are located within their markets. • Seek counsel from and bring information to the physician, and then research physician recommendations HOUSEHOLDVIEW • Consider only physicians and nurses as HouseholdView® is a dynamic, proprietary segmentation system for the health professionals next generation of healthcare consumer insights. The 56 segments paint a • Often involved in decision-making for their aging comprehensive picture of how healthcare consumers use health services, parents, while also informing the health needs of select providers, define quality, obtain healthcare information, and respond their own children to healthcare advertising. With a high level of sophistication for today’s complex healthcare market place, each of the customer segments within GENERATION X (BORN 1961–1981): Attitude toward gathering healthcare information: HouseholdView is a unique combination of the variables determined to be the Educate Me most predictive of consumer healthcare behavior. HouseholdView segments • Desire to be educated and involved align with the strategic planning and marketing challenges that face the healthcare industry today. • Relatively healthy compared to older generations • Curious and actively seek information THOMSON REUTERS OUTPATIENT PROCEDURE ESTIMATES • Assume physicians and staff are knowledgeable Thomson Reuters Outpatient Procedure Estimates predicts the total annual • Strong interest in amenities volume of ambulatory procedures performed by ZIP code, age group, sex, site • Likely to switch physicians and hospitals based on of service, and payer for every market in the United States. Procedures are recent experience defined and reported by 591 categories of CPT® and HCPCS codes, which are • More in common with the Millennial adults than with further grouped into clinical service lines as well as broad technical groups. the Boomers To construct population-based use rates for all payers and all ambulatory • Definition of health professionals is broad and care settings, Thomson Reuters uses proprietary and public claims, as well as includes nurse practitioners, physician assistants, Federal surveys. The rates are adjusted to reflect local utilization patterns and insurance companies, and pharmacies are then applied to demographic and insurance coverage projections by ZIP MILLENNIALS (ADULTS BORN SINCE 1982): code to estimate outpatient utilization for 2009 and 2014. Attitude toward gathering healthcare information: Connect with Me • Access healthcare system through primary care providers (PCP), urgent care centers, and Ob/Gyns with a higher likelihood to use Ob/Gyns as PCPs • Relatively low utilization of inpatient and outpatient services • When using inpatient services, most come through maternity and emergency departments • Enjoy and use technology • Maintain positive, personal relationship with physician • Seek health information from multiple sources • More likely to switch providers if confidence in care lost based on recent experience8 Caring for the Uninsured Amid Financial Pressures
  11. 11. REFERENCES1 DeNavas-Walt, Carmen, Bernadette D. Proctor, Jessica C. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2008.2 2009 Thomson Reuters, Insurance Coverage Estimates.3 Abelson, Reed. Bills Stalled, Hospitals Fear Rising Unpaid Care, February 8, 2010. ( ( Retrieved on March 2, 2010.5 ( Retrieved on March 2, 2010.6 For the purposes of the following analysis, Thomson Reuters is comparing and contrasting the behaviors of the below $50,000 and above $50,000 income households. The $50,000 line is close, but not exactly comparable to 300 percent of the Federal Poverty Line for a family of three in the contiguous 48 states. As such, we are using household income for approximating behavior of the uninsured population 300 percent FPL compared to the above $50,000 household population as an approximation for the insured segment.7 Matching the Market: Using Generational Segments to Attract and Retain Consumers. Thomson Reuters, 2009. pgs. 2-3.8 Guggenheim, Ricardo, MD. Uncompensated Care is a $31 Billion Problem Waiting to be Solved. HealthLeaders News. September 26, 2008.9 Ibid, Guggenheim.10 Patient Marketing Addresses E.D. Over-Utilization and Lowers Cost of Care. Thomson Reuters, 2009. Caring for the Uninsured Amid Financial Pressures 9
  12. 12. aBOUt tHOMSON reUterSThomson Reuters is the world’sleading source of intelligentinformation for businesses andprofessionals. We combine industryexpertise with innovative technologyto deliver critical information toleading decision makers in thefinancial, legal, tax and accounting,healthcare and science and mediamarkets, powered by the world’smost trusted news organization.With headquarters in New Yorkand major operations in Londonand Eagan, Minnesota, ThomsonReuters employs more than 50,000people and operates in over 100countries. Thomson Reuters sharesare listed on the Toronto StockExchange (TSX: TRI) and New YorkStock Exchange (NYSE: TRI).thomsonreuters.comThomson Reuters777 E. Eisenhower ParkwayAnn Arbor, MI 48108 USAPhone +1 800 366 7526©2010 Thomson Reuters.All rights reserved.MDS-7808 05/10 MC