Charity care and community benefit at the Cleveland Clinic jumped to $652 million in 2013, up 7% from $610 million in 2012, according to numbers released by health system. The number includes financial help or free care, and money spent on community outreach programs, physician training and research.

Free or charity care alone increased by 9.7% to $169 million in 2013, while Medicaid shortfalls, the unreimbursed amount spent to provide care for patients enrolled in the federal government's health insurance program for the poor, increased at twice the rate, or 18%, to $124 million.

The health system's total community benefit, which includes the value of externally-sponsored funding such as research grants, increased by 5% to $794 million.

Bad debt continues to increase and is expected to become a larger problem for the Cleveland Clinic as people pick up health insurance via the Affordable Care Act exchange with high co-pay and high deductibles, according to Steven Glass, the health system's chief financial officer.

Bad debt currently isn't tallied in a health system's uncompensated care total and there is debate about where it should fall in an organization's accounting. Traditionally, with hospital systems nationwide, it is a delicate matter regarding when it's called "bad debt" instead of "charity care".

Also in Cleveland, at University Hospitals, spending to cover Medicaid shortfalls fell 24% to $68 million in 2013 from $90 million in 2012. The drop was partly a result of a change in the Affordable Care Act that increased reimbursement rates for primary care physicians offering care to Medicaid patients at Medicare fee levels.

University Hospitals reported total spending on charity care, research, education and training remained steady last year at a total of $273 million.

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