Pinched by managed care and loss of autonomy, physicians continue to tend to the growing numbers of medically indigent
Pinched by managed care and loss of autonomy, physicianscontinue to tend to the growing numbers of medically indigent.
"Doctors have two key motivations for their work," says cardiothoracicsurgeon Paul N. Uhlig, director of cardiac care at Concord (NH) Hospital."They want to take something home to their families, and they wantto do the right thing for a patient in need."
Physicians' sense of compassion and caring, says Uhlig, is "thelargest resource in health care."
Historically, that resource has been large indeed. Expressed in termsof uncompensated care for uninsured and indigent patients, it totaled anestimated $11 billion in 1994, according to a study published by the AMA.
But physicians' charitable hearts are being strained these days. Whilethe number of uninsured patients continues to grow, the spread of managedcare has reined in reimbursements. That has affected cost-shiftingtheRobin Hood-like tradition of using reimbursement from paying patients tooffset the cost of treating those who can't pay. A study of nearly 11,000physicians nationwide, published in JAMA in March, found that although thevast majority of physicians spend more than 10 hours a week on charity care,"physicians involved with managed care plans and those who practicein areas with high managed care penetration tend to provide less charitycare."
The study also pointed to another factor influencing charity care: physicians'loss of autonomy and control as they move from ownership of their own practicesto being employees of groups. More charity care occurred in solo and two-physicianpractices than in any other practice size, the JAMA study found.
In a country that has failed to formulate a national health policy, anyindication that doctors are treating fewer uninsured patients has seriousimplications. But in view of the obstacles, the surprising story may beless about the doctors who are declining uninsured patients than about theones who are redoubling their effortsboth individually and collectivelytoredress society's indifference toward the uninsured.
While the conventional wisdom is that the uninsured go to hospital emergencyrooms for treatment, that's not always the case. "A lot of care isgiven by individual physicians in their offices," says FP Nancy Dickey,former president of the AMA, who has been traveling around the country tohighlight the problems of the uninsured. "The care isn't given throughany system. A doc will simply accept that 3 or 8 percent of his patientswon't be able to pay full price. If a patient builds up a good-sized bill,the doctor talks to him about it. And if the patient just can't afford topay more, the doctor takes care of him anyway. That's probably the singlegreatest source of uncompensated carestill."
One such physician is Louisiana ENT Wallace Rubin, a solo practitionersince 1951. When he first entered practice, Rubin recalls, all the physicianson staff at the local hospital would be assigned weekly shifts to see clinicpatients when necessary. "People were taken care of without any remunerationto the doctor, med school, or hospital, or any costs to the patient,"he says. Rubin laments that under the Johnson administration, the federalgovernment began reimbursing medical schools and hospitals for charity care."We need to go back to the original game plan," he says, "wherephysicians provide care on a voluntary basis without anybody being reimbursed,including the hospitals and medical schools."
Roughly 10 percent of Rubin's practice is uninsured, and he maintainsthat he'd find a way to continue providing that care no matter how squeezedhis reimbursements became. "If doctors flat out refuse to care forthe uninsured," he says, "they shouldn't have a license to practicemedicine."
As a solo practitioner, Rubin doesn't have to answer to anyone. But howdo group physicians deal with the medically indigent? When the Medical GroupManagement Association queried its members in 1996, 74 of the 190 respondentssaid they'd established a sliding fee scale for indigent patients. Somerespondents said they follow specific income criteria to qualify a patientfor reduced fees, and require the person to produce W-2 forms and tax returns.Others handle the issue case by case, sometimes leaving it to the individualdoctor's discretion.
That's the way it works at the Renaissance Family Practice, a group of25 FPs in Pittsburgh. Though the practice is about 50 percent managed care,Executive Director Daniel McCarthy says doctors don't shy away from treatingthe uninsured. "Frequently, the physician isn't aware of the patient'sinsurance status," he says. "The patient receives a bill, andthose who can't pay are dealt with case by case. Some bills are writtenoff." If the patient shows up again after that, McCarthy says, he'llstill receive treatment.
Although this unreimbursed care isn't yet a financial drain, McCarthyacknowledges that it could become one. "At some point," he says,"you have to evaluate what it's actually costing you to provide thiscaresupplies, staff, immunizations, and things like thatand you haveto say, 'If we continue at this pace, we won't stay in business. Then wewon't be able to provide medical care to any uninsured or indigentpatients.' "
Internist Richard G. Stefanacci's nine-doctor group has a different perspective.Based in Sicklerville, NJ, the practicewhich is more than 50 percent managedcarehas definitely felt HMOs' impact on reimbursements. Nevertheless,the doctors in the group go out of their way to provide charity care. Theyaccomplish this by announcing their policy of free or low-cost care throughlocal churches.
Do the doctors worry that their openness will cause them to be inundatedwith uninsured patients? Not at all, says Stefanacci. "So far, we'vemaintained a balance between our paying and nonpaying patients," hesays. (To date, roughly 8 percent of the group's 20,000 patients are uninsured.)"But if the balance shifted, we would attempt to subsidize this partof our practice so that we could continue to care for our uninsured patients.We'd use physician extenders to see uninsured patients before the physicianevaluation, or we'd try to increase our volume of fee for service, or we'ddecrease our take-home pay."
Caring for uninsured patients is what FP Joseph A. Babbitt and his associatesdo most of the time. The group of three FPs and one PA practice in DeerIsle, ME, a fishing community in which nearly 60 percent of the populationis uninsured. When the partners sold their practice to Blue Hill MemorialHospital four years ago, the financial pressures of treating the uninsuredlessened. "The hospital has a policy that we treat without regard toability to pay," says Babbitt. "So we have patients with $6,000bills paying $5 a month."
But a $3 million operating loss last year put pressure on the hospitalto step up the practice's workload. And now, as a rural health clinic withCritical Access Hospital certification, the hospital requires the doctorsto see a larger number of patients. "So although we don't pay attentionto our payer mix, we're acutely aware of how we're scheduling our day, andhow much time we're allotting to patients," Babbitt says.
Many physiciansincluding a number who treat uninsured and indigentpatients in their officesvolunteer in free clinics. There are approximately500 such clinics in the US, according to Volunteers in Health Care, a RobertWood Johnson Foundation program that assists community efforts to providemedical treatment for the uninsured. Some clinics, like the Volunteers inMedicine Clinic in Hilton Head Island, SC, rely on retired physicians. Othersare staffed by practicing physicians. In either event, their formation wasoften sparked by a single doctor.
That was the case with the Hernando Doctors' Clinic in Brooksville, FL,spearheaded by cardiologist M.P. Ravindra Nathan. He had been thinking aboutopening a clinic for years. "Every time an indigent person got admittedto my service through the ER," Nathan says, "I worried how hewas going to get follow-up care after his hospital discharge."
When Nathan became president-elect of the Hernando County Medical Society,he suggested that the organization establish a free clinic. This arouseda "litany of concerns" from his colleagues, he recalls. At thetop of the list was the fear of getting sued.
In 1992, the Florida legislature passed a law protecting physicians whocontract with the state to provide uncompensated care to indigent patients.Because the clinic was to be set up under the auspices of the Hernando CountyHealth Department, the physician volunteers would be agents of the state.With that protection in place, 90 percent of the Hernando County MedicalSociety's 80 members voted Yes. The Hernando Doctors' Clinic opened in October1993.
The participating doctors' motivation combined pragmatism and altruism."They realized, 'If I don't take care of indigents early on in theproper outpatient setting, I'm going to get them on my service one of thesedays anyway,' " Nathan recalls. "But they also realized, 'If Idon't take care of the indigents in my community, who will?' "
Clinic doctors see between 25 and 30 patients each Wednesday eveningfrom 6 to 9:30, and the waiting list stretches for two months. The typicalpatient population, Nathan says, includes migrant workers, disabled people,students, the working poor, and single mothers with sick children.
Though that one night a week may not sound like much care, it has madea huge difference in some lives. As an example, Nathan points to the unemployedwoman who showed up complaining of constant weakness. Her diabetes was discoveredand treated, allowing her to resume work. Then there was the asthmatic studentwhose condition was stabilized. "She finished her education and gota job as a nurse," Nathan says. "And now she has insurance."
Internist Donald T. Erwin, director of the residency program at the 500-doctorOchsner Clinic in New Orleans, can describe similar experiences. Ochsnerhas formed a partnership with the St. Thomas Health Center, an outpatientclinic located in a low-income housing development five miles away. St.Thomas is open from 8 am to 5 pm, five days a week, treating nearly 500people a month. Residents at the Ochsner Foundation Hospital work thereas part of their curriculum. And so many physicians in the practice volunteerthat the time commitment for each is minimalperhaps one shift every threeor four weeks.
St. Thomas is an independent institution with a budget of about $1 milliona year in federal, state, and local funds. Although Ochsner doesn't officiallytrack the value of the physicians' free care, Erwin estimates it at $300,000.But Ochsner benefits from the arrangement in several ways, says Erwin: "Ourresidents get ambulatory experience, and it's probably cheaper to care forthe people at the clinic than to wait for them to get to our hospital'sER, with more-serious problems."
The patients at St. Thomas have offered a profound learning experienceto the physicians who treat them, Erwin says. "Access to treatmentisn't enoughpatients need access to people who respect them and care aboutthem, and who don't see them as society's problem. The old attitude, 'Rollover, Mama, we're gonna biopsy your kidney,' just doesn't do it."
Erwin knows that in Louisiana's current economic climate, some eyes arecarefully scrutinizing the dollars going to St. Thomas. "I know thatnot every Ochsner physician and administrator thinks our partnership withSt. Thomas is great," he says. "But the huge majority of our 500physicians are happy to give their servicesand they expect to do it."
There's no doubt where Erwin stands. As a board member of the OchsnerFoundation, he sees himself as an "interface between an institutionthat has pretty deep pockets and a community that has nothing. I feel it'smy job to help that institution understand its responsibilities and theways it can be effective in helping that community. That's one of the mainreasons I get out of bed in the morning."
Some physicians firmly believe that uninsured patients receive care comparableto that of insureds. "Costs are always a concern," says Florida'sNathan. "But I don't think anyone here would give substandard carenotonly from the altruistic angle, but also from the legal angle." Thestate's protection notwithstanding, "you have to give the standardof care," he says.
Nancy Dickey disagrees that treatment for the poor and uninsured is upto the standard of care: "Most of the docs who work with the indigentwill tell you it's not. I ran a low-income clinic for five years, and Ican tell you it's not. We'd have to say to someone who was wheelchair-bound,'If you had insurance, we could probably find someone to replace your knees,and you'd be able to walk again. Unfortunately, you don't have insurance.So I'll give you some anti-inflammatories and teach you how to do some physicaltherapy at home.'
"I would like to think that in that clinic, we tread a very fineline between what's truly important to a diagnosis or treatment, and whatwe do in private practice simply to confirm, substantiate, or make ourselvesfeel better. We couldn't do anything in the second category, but we'd turnheaven and earth to get things in the first category done."
In Deer Isle, ME, much of the medicine Joseph Babbitt practices involvesthe art of compromise. He describes caring for a 35-year-old fisherman whosesmall facial abscess had spread to periorbital cellulitis, which Babbittfeared might threaten the patient's eye. "Ideally, I was thinking,'ophthalmologist, inpatient treatment with IV antibiotic: Protect this man'seye at all costs, and screen him for possible diabetes.' But it was clearthose things were off the table. The diagnosis took 15 seconds. The restof the visit was spent with, 'Will you take antibiotics? Will you not gofishing tomorrow so that I can see youpleaseso if this starts to jeopardizeyour eye, I have another chance to get you into more-aggressive therapy?'Finally, we decided on oral antibiotics, and he agreed to leave late forwork so I could see him.
"I'm offering the same standard of care to all my patients, butwhat care are they actually receivingor choosing to receive? I can makeit the patient's responsibility instead of mine, but I know what uninsuredpatients choose and why. Those who have the ability to pay are making choicesfrom a different list."
Babbitt is aware that the compromises and uncertainty he deals with everyday would anger many doctors who resent patients for making less-than-perfectdecisions about their health care. But unless something stems the growthof the uninsured, he thinks others eventually will have to practice theway he does. "We've been working with the 50 to 60 percent of the communitythat's uninsured and 75 percent of those with insurance who are underinsured,so we know how to do it," he says. "Maybe doctors in other placeswill have to learn our way of thinking and practicing."
Internist Suzanne E. Landis of Asheville, NC, has felt the frustrationof treating uninsured patients, knowing that there are no follow-up services."Physicians have to know that if they provide free care, others inthe community will follow up," she says. "They'll provide supportserviceslabs, X-rays, medicinethat will enhance the physicians' efforts."
Four years ago, Landis and several of her colleagues in the BuncombeCounty Medical Society learned there were about 13,000 poor and uninsuredpeople in their community who weren't getting regular primary care and hadno access to specialty care. The doctors determined to remedy the problem."I realized that if we had a system in which a lot of physicians couldparticipate and feel that their colleagues were participating equally, therewould be a notion of equity and fairness," she says. The fact thatthe program would be physician-led was especially important, Landis adds.
Aided by a grant from the Robert Wood Johnson Foundation, Landis andothers formed the BCMS Project Access, a program that has brought togetherall the agencies needed to provide a continuum of care for uninsured peoplein their community.
"I've long been frustrated by federal and state governments' failureeven to try to achieve universal access," says Landis. "Finally,a number of us realized it could only happen locally. We don't have a lotof clout statewide or nationwide, but we do have clout within our community.And this is, after all, where our patients get care. "
Primary care physicians in the community are asked to take 10 uninsuredpeople into their practice each year; specialists are asked to see 20. Almost500 physiciansroughly 85 percent of the totalparticipate.
Since Project Access began in 1995, citizen groups have developed a seriesof community health centers and neighborhood sites to offer patients a varietyof options. The vast majority of the uninsuredroughly 9,000go to thehealth department for care. About 2,000 visit the Doctors' Medical Clinic;1,000 see physicians in their offices; and others visit an inner-city clinic,a center for people with HIV and AIDS, and a clinic located in a housingdevelopment. Patients can also go to Mission St. Joseph's Health Systemand Thoms Rehabilitation Hospital for outpatient primary and specialistcare and inpatient care, as well as labs and X-rays.
To track the care, doctors submit claims to a physician-owned, for-profitPPO called Mountain Health Care, which calculates the value of the careand evaluates the kinds of illnesses being treated. It, too, provides theseservices for free.
The value of physicians' services has been documented at an average of$3 million annually for the past three years. Hospital care, including labwork, comes to $1.8 million per year. Mission St. Joseph's Health System,which is now a partner in Project Access, felt the effort expended to recoupthis money would yield such negligible results that it would be better towrite off the bills. Doing so would also enhance goodwill. "I thinkit has," says Landis.
Government funding has helped. The county donates $350,000, which islargely used to pay for medications. Project Access organizers note thatthe program has "leveraged" the $350,000 county donation intonearly $5 million worth of health care services.
"By focusing on prevention and identifying and treating illnessearlier, we've reduced the cost of caring for each patient," says AlanT. McKenzie, executive director of Project Access. "And our studiesshow that our low-income uninsured population is as healthy as the nationalnorm. That, more than anything, is why physicians are so dedicated and thecommunity is so enthusiastic."
The enthusiasm has spread well beyond the community. BCMS Project Accesswas the 1998 winner of the Innovations in American Government Program ofthe Ford Foundation and Harvard University.
When cardiothoracic surgeon Paul Uhlig heard about Project Access, hebecame interested in establishing a similar program in his hometown of Wichita,KS. (The fourth-generation Kansas doctor hopes to return to Wichita aftercompleting his current work in New Hampshire.)
"Physicians just aren't happy with what they're paid," saysUhlig. "Medicare rates are insulting, and it gets worse from there,leading to a spiral of anger and frustration. Then along comes this wonderfulidea: We say, 'We won't pay you at all. We'll just make you a part of thiseffort to do the right thing. And you decide what care your patient needs;there's no need for you to get approval.' Suddenly, doctors say, 'Wow! Ican't wait.' "
While still working in Wichita, Uhlig visited Asheville with his colleaguesin the county medical society to view Project Access. They needed only threemonths to enroll 349 out of 900 local physicians, all the independent pharmacists,and most of the major pharmacy chains in Wichita. The first donation, $25,000,came from the medical society; additional funding comes from the city, county,and United Way. The first patients were seen in September.
Wichita has now applied for a Robert Wood Johnson Foundation grant toexpand the program to dental care, mental health services, childhood immunizations,and well-baby checks. "We believe the program may actually decreasethe resources required from the community," Uhlig says. "We intendto show scientifically that we have improved health and decreased costs.
"Right now, our country is dealing with a very fragmented healthsystem. Interestingly, many of the entities that would tell us how to carefor patients don't care about the uninsured. It's almost like we're givenan opportunity to come in the back door, put our house in order, and makehealth care work really well here. We feel we can put together a systemthat could be a model for care anywhere."
Project Access Wichita was, says Uhlig, the result of over 100 peopleworking together with a common vision. "It's been magical so far. Itreawakens within the physician that long-dormant commitment: 'I'm here becauseI want to make people better.' That's joyous."
"Medical liability insurance is a problem in treating the uninsured,"says FP Nancy Dickey, former AMA president. "There's still a perceptionin doctors' minds that the poor are more likely to sue them. Statisticsandmy experiencesay that's not true. But when I talk to doctors, I hear thisa lot." It's a particular concern for retired physicians, who don'twant to pay for malpractice insurance, she adds.
The issue is so important to physicians performing charity care thatVolunteers in Health Care, a national program funded by the Robert WoodJohnson Foundation, is assembling a manual of charitable immunity legislationacross the United States.
Knowing of physicians' wariness of liability, the Buncombe County (NC)Medical Society's Project Access speaks of "two belts and a suspender,"says executive director Alan T. McKenzie. First, North Carolina expandedits Good Samaritan legislation to include protection for doctors seeingpatients for free based on a county referral. Then the Medical Mutual Group,a physician-owned company, created a special liability policy that the freeclinics can buy for about $1,000 a year. Finally, doctors have their ownmalpractice insurance. "It's virtually impossible for a doctor to haveto pay out in a suit," says McKenzie.
BCMS Project Access, 304 Summit St., Asheville, NC 28803; tel:828-274-6989; fax: 828-274-2093; e-mail: firstname.lastname@example.org.This community effort, begun by the Buncombe County Medical Society, providesa continuum of care for the uninsured, which includes physician and hospitalservices, labs, X-rays, and medications.
National Free Clinic Foundation of America, tel: 540-344-8242;e-mail: email@example.com;Internet: www.freeclinic.net. Aclearinghouse for information about free clinics, the organization publishesthe National Free Clinic Directory and the manual How to Starta Free Clinic.
Volunteers in Health Care, 111 Brewster St., Pawtucket, RI 02860;tel: 877-844-8442 or 401-729-3284; fax: 401-729-2955; e-mail: firstname.lastname@example.org; Internet: www.volunteersinhealthcare.org.A national nonprofit program of the Robert Wood Johnson Foundation, VIHseeks to help physicians and other health professionals organize or expandefforts to assist the uninsured in their communities. It provides informationon program models, charitable immunity legislation, and issues that freeclinics face.
Another VIH offering is RxAssist, a free, online resource to help healthprofessionals use patient assistance programs operated by pharmaceuticalcompanies for eligible uninsured patients. Call the toll-free number above,or visit the program's Web site (www.rxassist.org).
. Caring for the uninsured: How Americas doctors are making a difference. Medical Economics 1999;24:118.