How avoiding an awkward waiting room conversation can contribute to better health among transgender people

Rodrigo Heng-Lehtinen: In our U.S. Transgender Survey, the USTS, we found that nearly a quarter of our respondents reported that they did not even seek the healthcare that they needed in the last year due to fear of being mistreated.

Erika Grotto: The financial risk of discrimination in healthcare, today on HFMA’s Voices in Healthcare Finance podcast, sponsored by Red Dot.

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Grotto: Hello and welcome to the podcast. I’m your host, Erika Grotto. Today, we’re discussing the barriers to healthcare for the transgender community with Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality. We’ll get into that interview in just a few minutes, but first, let’s see what’s happening in the news with HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.

Nick Hut: Hey, everybody. Our topic today is federal vaccine mandates for clinical and non-clinical staff who work at hospitals and many other healthcare settings. I’m going to give a news update to start. Right now, it’s the morning of January 11, and any day now—possibly even before this episode airs—there could be a Supreme Court decision handed down on whether the mandate will apply across the country or whether injunctions will remain in place that block it in 25 states. I had a chance the other day to listen to arguments that took place at the Supreme Court, and it sounded like there might be enough votes on the side of the Biden administration, meaning a majority of the justices would rule that the injunction should be lifted and the mandate could apply nationwide while the cases challenging the mandate work their way through the federal court system, and that could easily take a matter of months. Now, reading the tea leaves as to what the Supreme Court will decide is dicey, to say the least, but if nothing else, we know that CMS has said the mandate will take effect in late January for the 25 states for which federal courts have not issued injunctions. So, Shawn, what’s your impression of providers’ frame of mind in terms of trying to abide by these regulations?

Shawn Stack: I agree. I think the courts seem to be moving toward upholding the CMS vaccine or test mandates. You know, those are tailored to certain workplaces, including healthcare facilities. CMS’s conditions of participation stance regarding the vaccine mandate is not a reach for the agency’s oversight regarding federal healthcare facilities. And as always, the agency’s already come out and said that it will be providing some flexibility in that, it has stated that if healthcare facilities show they are working in good faith to get their workforce fully vaccinated, the agency will continue to work with the facilities and continue funding. But I do think that while the CMS mandate was more tailored to addressing risks at high-risk workplaces, the OSHA mandate is not focused on workforce hazards and appears to be more blanketed in its approach, pushing for general population vaccination. So I think the arguments on the OSHA side are a little bit more grounded and we can see some movement or shifts in that policy, because a lot of the legal experts are saying that the Occupational Safety and Health Act doesn’t support the power of OSHA requiring those vaccinations. So I think we’ll see a decision from the Supreme Court shortly, at least by the end of the month, and then that decision will most likely dictate the playbook in the lower court of appeals.

Hut: Alright. Well, great stuff as always, Shawn. We will be covering this story as it continues to unfold. Be sure to check out our coverage at hfma.org/ news.

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Grotto: The cover story on the Winter 2020 issue of hfm magazine, “Where did our sickest patients go?” had a real impact on me. The article, written by Rich Daly, discussed pandemic-driven delays in care and what the consequences would be for the industry. But the more I thought about the issue of deferred care, the more I kept coming back to the idea that it’s not just a pandemic problem, that there are people who routinely defer or resist care because they fear discrimination by the healthcare system. One group of people this applies to is the transgender population, so I invited Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality, to discuss the barriers transgender people face in healthcare. And I was surprised to hear that the first thing he wanted to talk about wasn’t what happens in the exam room, but something that comes up much earlier in the process: the paperwork.

Heng-Lehtinen: There are so many barriers that trans people face. One of the ones that is not really obvious to a lot of non-trans people is identity documents. So that’s things like driver’s licenses, birth certificate, passport. To most of us, these are just bureaucratic documents. These are paperwork matters. But if you really think about all of the places in your life, all of the times in your life that you have to show these documents, they’re really critical moments. It’s things like applying for a job or enrolling at a new job, starting at a new school. If you have a child, if you’re a parent, you’re often having to show your driver’s license or birth certificate that lists you to enroll your child in services. So you use these documents at really important times of your life. For trans people, we often aren’t able to accurately update these documents, so it opens us up to discrimination at these critical junctures like just trying to move into a new apartment. So that’s another barrier that a lot of people don’t really think about if they’re not trans but is really important to those of us who are trans so it’s one of the things NCTE works on.

Grotto: I would imagine that in healthcare specifically too, when it comes to health records, could be confusing at best for a provider, and if they don’t handle that well or have a conversation in a way that makes the person feel comfortable, that can be a really difficult situation.

Heng-Lehtinen: Exactly. Identity documents come up all the time in healthcare. Counterintuitively, you may, as a transgender person, you may have different names or information listed on different documents. So you could very well have one name and gender on your driver’s license but a different name and gender on your health insurance card. And it’s not a mistake, it’s not fraud. It’s simply that every single—and I truly mean every single—different document that you have is governed by a different set of rules. The DMV, or whatever you call it in your state, the place where you get your driver’s license, has its own set of rules for name and gender that is totally separate from the rules that your health insurance provider has, which is also totally separate from the rules of the Social Security Administration, for example. So it leads to this situation where actually, most transgender people don’t have fully accurate documents. To use myself as an example, I am a transgender man. I’ve been able to update most of my documents, but I am not able to update my birth certificate, because the state that I was born in has archaic laws that essentially ban me from being able to accurately update my birth certificate. I really bring myself up as an example because, you know, my whole job is transgender rights. I literally work at the National Center for Transgender Equality. If even I can’t update all my documents, you can imagine what it’s like for an everyday person who has a more normal job. And just to put into context how widespread this is, actually, only 11% of transgender people have 100% across the board updated documents. So that means the majority—almost 9 out of 10 transgender people—are not able to fully update all of our documents. So healthcare providers and administrators need to be really aware that transgender people often operate under a patchwork, and it is not fraud. It is actually how the government is set up.

Grotto: A 2017 study of 417 transgender adults in the Rocky Mountain region of the United States found that “transgender individuals who delayed healthcare because of discrimination had worse general health than those who did not delay or delayed care for other reasons.” That doesn’t sound all that surprising, but they also had 3.08 greater odds of depression, 3.81 greater odds of a past-year suicide attempt and 2.93 greater odds of past-year suicidal ideation. We’re really talking about, you know, risking lives if people don’t feel comfortable getting the care they need.

Heng-Lehtinen: Yeah, exactly. I mean, this issue of deferred care is staggering. A lot of times when we’re talking about healthcare for transgender people, folks assume that this is about transition-related procedures, you know, medical procedures that are squarely because you are transitioning your gender. And certainly there are barriers to that, and those are significant. But as you’re pointing out, there’s also just the fact that transgender people get illnesses just like non-transgender people do. If I break my leg—again, I’m a transgender man—if I break my leg, that probably had nothing to do with the fact that I’m transgender. It’s just that I fell on my leg. So any given health issue that a human being could face, a trans person is going to face it at some point as well. What is unique to transgender people, however, is the discrimination that we face, and importantly, the fear of it that leads us to avoiding trying to go to the doctor in the first place. So many people have negative experiences in healthcare for being trans. At NCTE, we run the largest and most comprehensive study of transgender people’s experiences around the country. It’s called the USTS, the U.S. transgender survey. We found that one-third of trans people who had seen a healthcare provider in the last year had a negative experience related to being trans. So that’s 1 out of 3 patients having a negative experience. Then imagine, for those other 2 out of 3 patients who didn’t have a negative experience, they were probably really scared of it, even if they didn’t experience it. So many people avoid going to the doctor in the first place out of concern for that discrimination, and then it makes our other conditions worse.

Grotto: What can we be doing, from a systemic point of view, to improve things, to make people feel welcome when they go to get care, to help overcome maybe some of the paperwork barriers, to let our front office people know, this is something that could come up for you, and here’s how you deal with this specific paperwork issue? What can healthcare leaders do to educate and to make processes better and easier for their patients?

Heng-Lehtinen: Well, one really concrete thing that people can do is to look at all your places where you capture data about patients and separate gender fields, where there’s one field that you ask patients, “What is the name and gender on your health insurance card?” Now, obviously this only applies to patients who are using insurance, and that is not everyone. But it’s the majority of people accessing healthcare are doing so using some sort of insurance provider. So it is really, really handy to allow that information to stand alone. So you ask, “What is the information on your health insurance card?” A lot of transgender people may have one set of information on their health insurance card and a different set of information somewhere else, on other IDs, or may have documents, including health insurance card, that say a certain name and gender when really they go by a different one. So it goes a really long way if you just add a few fields to your health information system or patient tracking or whatever you use in your role, to capture that complexity. It is literally just about adding fields so that those of us, many of whom are transgender, who have more complex situations, there’s a way to capture that in the data. Now, that does cost money up front in that you probably would have to bring in your IT folks, your contractors to update that. So it is a lot of work on the front end, but then it streamlines the rest of the process and makes it way more efficient. Right away, you’ll see it become more efficient because you’ll just have so much more straightforward information instead of this burdensome amount of back and forth trying to clear up some paperwork confusion. So whenever you’re able, really separate out that data and at the very least, allow a patient to indicate what is the information on their health insurance card in case it’s different from on their documents already.

Grotto: That definitely seems like a pretty—as you said, definitely some expense there, but it seems like a fairly simple solution that would solve a lot of problems.

Heng-Lehtinen: Yeah, it’s so powerful. It’s such a straightforward thing, but it makes a tremendous, tremendous difference. And you know, this also would help with all sorts of patients who have other kinds of name change situations going on. Another, more trans-specific example here, to use myself again as an example, I go by Rodrigo, and that now is the name on my health insurance card and on my driver’s license, but I did not have that name on any of my documents for years because I couldn’t afford the $450 fee that California was charging at the time. They do not charge that anymore, which is fantastic—thank you California—but this was years ago when they did, and it’s still the case in many states that it’s expensive. And I also did not have all the health documents like a letter from a therapist and things like that that were necessary for me to be able to update my other documents down the line. So all that to say that for years and years, I had that name on all of my documents, but I very obviously did not use that name. I very obviously was not living as a woman, and I used the name Rodrigo at my job. All my coworkers knew me as Rodrigo. My business cards said Rodrigo. My family knew me as Rodrigo. My friends knew me as Rodrigo. What I’m trying to demonstrate here is, just because something might not be the name on our documents doesn’t mean that we’re not using it every single day of our lives. There are a lot of transgender people who are trapped in this circumstance, where our documents don’t yet reflect the name that we actually go by every single day. And that’s important to keep in mind for things like when a patient is waiting in a waiting room. You know, during that phase in my life, if I was sitting in a waiting room, often the nurse or whoever would call out a woman’s name because that’s the name that was on my paperwork. And then I would stand up, and everyone would stare. The nurse or receptionist would question if I was the right person. I would have to out myself as transgender in front of literally every single person, including strangers, in the waiting room. And it was a whole process just to be able to justify that I really was that person. So having a separate field makes such a difference. Even as simple as it is, it’s a powerful tool.

Grotto: As you were talking about that, I was thinking, it must be so exhausting to have that conversation everywhere you go. I can’t imagine having to explain my name and gender everywhere I went.

Heng-Lehtinen: Exactly. You can imagine what a deterrent that is to people going to the doctor. This is part of why a lot of transgender people almost don’t want to even bother going to the doctor until they’re very, very sick and it’s unavoidable. That is an unsustainable situation for all of us. Patients and providers both are better served if the patient goes to the doctor at the start of an illness as opposed to when it’s totally spiraled out of control. So the more we can make everyday medical interactions easy and respectful, the simpler they become in the long run because then you’ll have patients who happen to be trans coming in at the start of an illness instead of when it’s already gotten so much worse and more costly. Another concrete thing that providers can do to create that better environment and lower the barrier to entry is to train the front-line staff, people who work on the administrative side or reception, to be mindful about what information is shared publicly or in the waiting room. So for example, just yesterday, actually, I saw a new endocrinologist, and I really appreciated that the receptionist was handing me the first-time-patient paperwork, and he said, “first two pages are this, this and that. The last page is for the reason you’re here today.” And I saw when I opened it, that last page was the transgender intake form for questions an endocrinologist would have specifically in the event of—quote, unquote—“gender identity disorder,” which it’s technically classified as. But what was so fantastic about it was that the receptionist did not say it in front of the other people in the waiting room as, “The last page is because you’re trans.” Instead, he simply said, “The last page is for the reason you’re here today.” So any other patient that overheard him didn’t know what that was about, didn’t think twice about it, it was totally innocuous. I was not outed to everyone else in the room. That was so thoughtful, and I, as a patient, appreciated that so much. It was so helpful. And it only took a second of time, and it was totally free. It did not require IT coming in and overhauling your database, right? It was such a simple, easy, free thing for that medical practice to do, and it made a world of difference for me as an individual transgender patient. So being really thoughtful about what information you share in front of others can make a really big positive impact.

Grotto: Yeah. Absolutely.

Heng-Lehtinen: It helps so many patients. Even if the first motivation of doing it is to support transgender patients, which is great, you never know how many other patients could be supported by that practice as well, because it is consistent with best practices. It is not particularly unique to being trans. It’s maybe a heightened need because the patient is transgender, but it could come in handy for a lot of patients that you don’t even realize how.

Grotto: Yeah, absolutely. Who wants to go in anytime that they’re not feeling well and talk to the doctor, and you get this, well, why are you here today? Do you want to be standing at the front desk saying, “Well, I’ve had diarrhea for five days”? This isn’t a conversation you should have to have. Just give me a piece of paper and I’ll write it down, and then I’ll talk to the doctor in private about it or whatever the case may be. It feels like this is just best practice no matter what, but like you said, a very good and welcoming thing for someone who is transgender.

Heng-Lehtinen: Exactly, exactly. The more medical practices start adopting these tips, the more that we will see transgender health improve across the board. As medical practices become more welcoming, transgender people are inevitably going to seek medical care earlier on, and so we’ll see all of these other outcomes improve. You know, the healthcare deterrents is such a big issue that affects so many people, right? And in our U.S. transgender survey, the USTS, we found that nearly a quarter of our respondents reported that they did not even seek the healthcare that they needed in the last year due to fear of being mistreated. So that is that fear of discrimination being borne out in the data. That is almost one out of four people avoiding going to the doctor out of worry, and that was just in the last year.  That’s nearly one out of four transgender people avoiding going to the doctor in the last year. It is staggering then to think about what does that mean over years and years and years of accumulated health effects. Now, realistically, it will take some time for that trend to reverse, but it absolutely will reverse the more that medical practices start implementing this kind of guidance. It will have a really positive snowball effect as transgender people start feeling welcome and affirmed in medical care. They’ll go more often. Diseases will be caught earlier—diseases that have nothing to do with being trans, they’re just part of being human sometimes—those will be caught earlier, interventions can be implemented earlier, and we’ll see transgender people be healthier overall.

Grotto: This has been so great. I have so enjoyed this conversation. There’s a lot of very upsetting information out there about the way that transgender people are treated out here in the world, but this has been really uplifting, so I have enjoyed it. Thank you so much for joining me.

Heng-Lehtinen: Yeah, thank you so much for having me. As much as there’s a lot of discrimination out there in the world, there’s also a lot of people with open minds learning about transgender topics and really hungry to do the right thing, so I really appreciate you covering this, and happy to be a resource anytime.

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Grotto: Let’s take a moment now to get a word from our sponsor, Red Dot, and CEO Michael Bumann. Welcome back, Michael.

Michael Bumann: Thank you, Erika.

Grotto: On the last episode, we discussed the financial benefits of working with Red Dot, but today I want to discuss a topic that’s just as important. When a hospital partners with Red Dot, what is the impact on the patient? You and I have talked about this several times, and you’ve said to me more than once, “You can make money while doing the right thing.” Tell me how.

Bumann: Thank you. That’s a great question and obviously a very important part of our platform and something we’ve worked very hard to put together. And what we’ve done is, we’ve really looked at it from the patient’s perspective. These are patients that have been victimized by being injured in a car accident. Someone else has run into them, and especially for the self-pay patient, the financial impact and the overall impact of their life is immense. And what they realize, or what we’ve realized, is when that patient is sent through the account resolution process in-house, then often outsourced and often ending up in debt collection, is that patient feels re-victimized by that entire process. And so when we were putting our solution together, we kept a very clear and keen eye on how best to solve that problem with them. What we came up with is to simply avoid the debt collection process altogether. And so, with our platform, we deal simply with the liability carriers. We deal with all the attorneys that represent the parties involved. And we work through that process so the patient avoids the negative churn of debt collection. We’re able to do the right thing for our clients, which are the hospitals, and then also do the right thing for their patients by helping them navigate through that process without ending up in debt collection.

Grotto: Red Dot is the best technology-enabled acquisition solution for hospital self-pay motor vehicle accident accounts. Hospitals can now leverage Red Dot’s solution to improve their bottom-line revenue while dramatically improving their patient relationships by avoiding debt collection activities. Red Dot: Good for hospitals, good for patients. To learn more, visit reddotmgmt.com.

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Grotto: Right now, I am excited to welcome back to the podcast Todd Nelson. He is a health policy director at HFMA and in charge of partner relationships. Hey, Todd.

Todd Nelson: Hey, Erika. It’s great to be back.

Grotto: So, we were talking just before we started recording, and you were telling me that this is your favorite season. What season is that, Todd?

Nelson: Oh, it’s true. You know, some people like summer. Some like fall, spring and winter. I like awards season. Awards season is definitely my favorite season.

Grotto: And so are you, like, a Grammys guy, or are you into, like, the Academy Awards, the Golden Globes? What’s your favorite award?

Nelson: That’s a great question. There are many awards and awards shows that are important, but I think there’s none more important, and frankly my favorite, which is the MAP Award for high performance in revenue cycle. That is definitely my favorite award and therefore, that is why, it is my favorite award season.

Grotto: Definitely an exciting one. And we’re joking a little bit, but this actually is a really exciting time for healthcare organizations that have been making strides in their revenue cycle. So tell me what is new, because there’s been a little shift this year with some of the dates, so let’s start with talking about that.

Nelson: Absolutely. So we just made a change to the dates, giving more time to be able to submit a MAP Award for high performance. Round 1 is now going to close on March 31, 2022, and Round 2 will open up April 1 and close on May 6. And what that does is, it allows folks to learn more about the MAP Award and have a little bit more time to finalize and submit it after our Revenue Cycle Conference being held the middle of March in New Orleans.

Grotto: So, Todd, 2021 was another really difficult year in healthcare, and I’d like to hear from your perspective, what were some of the high points? What were some of the wins in rev cycle from some of the applications we’ve seen over the last couple of years?

Nelson: You know, you would think about the challenges of the last few years both from a financial perspective but a clinical perspective, and organizations in revenue cycle that were successful from a high performance perspective, winning that award really did a number of things. But one of them was being able to pivot quickly to managing a remote workforce and thinking through the technology and people and culture needs related to that allowed them to focus on revenue cycle performance. Also, those that were able to pivot their business focus in the revenue cycle specifically with, in many cases, lower volumes, they were able to tackle some of those more difficult areas like denials management, outstanding aged accounts receivable and really think about changing their process because they had the ability to spend the focused time on that due to lower volumes. Certainly, focusing on patient-friendly or consumer-friendly initiatives was another focus for those high-performance organizations, and then partnering and collaborating with health plans and community networks really was another focus for those that were the most successful and ended up ultimately winning the MAP Award for high performance.

Grotto: It’s always nice to hear about wins in these trying times. Anyone who is interested in learning more about the MAP Awards can find information on hfma.org on the Tools menu. We will also post a link in the show notes for easy clicking. So Todd Nelson, thank you once again for joining me today.

Nelson: Thank you, Erika. Always a pleasure.

Grotto: Voices in Healthcare Finance is produced by the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is our director of content strategy. Our president and CEO is Joe Fifer. Thanks again to our sponsor for this week, Red Dot. If you liked this episode and you’d like to hear more from us, subscribe to our podcast on whatever app you choose. And if you’d like to get in touch with our team, send us an email. You can reach us at [email protected].

Nelson: I think we done good.