Care for the Uninsured in General Internists' Private Offices

General internists provide a valuable service to uninsured patients, but one that also has limitations, according to a new study. A survey of internists in the United States revealed that over two-thirds treat uninsured patients who are unable to pay the usual fee, charging them a reduced or no fee and/or creating a payment plan. However, the care these patients receive can be jeopardized because it is difficult for them to obtain (and pay for) laboratory tests, diagnostic procedures, and prescription drugs. Moreover, many of the internists surveyed reported they are less able to provide quality care and continuity of care for their uninsured patients than for their insured patients.

The study, which was supported by The Commonwealth Fund and the American College of Physicians Foundation, also found that the type of uninsured patient whom internists were more likely to accommodate in their private offices was an existing patient who had lost insurance.

In "Care for the Uninsured in General Internists' Private Offices" (Health Affairs, Nov./ Dec. 2003), researchers Gerry Fair-brother, Heidi L. Park, and Roberta Scheinmann of the New York Academy of Medicine and Michael K. Gusmano of the International Longevity Center note that with high unemployment in the United States, the care provided to uninsured patients by internists is critically important. Community health centers and hospital outpatient departments, which traditionally provide medical care to those unable to pay, do not have the capacity to serve all of the uninsured.

Policies for the Uninsured

The authors found that the average charge for a routine office visit is $64, which may be difficult for an uninsured, unemployed person to pay. Among the internists surveyed, 65 percent reduce their fee or charge nothing for uninsured patients who have trouble paying, while 35 percent make no accommodation. Internists who are full or part owners of their practice are most likely to work out alternative financial arrangements for uninsured patients.

Most internists (75%) will accept partial or no payment at the time of the visit and bill for the rest later, if at all. Over two-thirds of internists will set up a payment plan for patients who cannot pay their bill. If the bill goes unpaid, 39 percent write off the charge, while 27 percent use a collection agency. The authors point out that patients who receive a bill from a collection agency may refrain from going back to the same physician and may be deterred from seeking health care in the future.

Type of Uninsured Patient Served
The uninsured whom internists serve in their private practices are more likely to be established patients who have become uninsured, according to the survey (Exhibit 1). "It appears that the uninsured patients served are not medically indigent, but rather patients who, because of job loss or other circumstance, have lost health insurance," the researchers conclude.

When taking on new patients, internists are more willing to accept those who are uninsured/self-pay than to begin seeing new Medicaid patients. This is an indication, the authors say, that the uninsured who are visiting internists' offices are not charity care patients; the free or reduced-cost care that internists are providing is helping to bridge a temporary gap in coverage.

Charity Care Provided by Internists
Sixty-eight percent of all internists provided at least some charity care each month. Approximately 60 percent of those who provided any charity care gave between a quarter-hour and five hours of their time per month, while another 15 percent gave six to 10 hours. Among internists who provided any free or reduced-cost care, the median was four hours per month. The study found that the greater the number of hours devoted to charity care, the greater the likelihood that at least some of these hours were provided outside the private office.

Limitations of Charity Care
While a majority of internists are willing to work out fee arrangements for those lacking health coverage, internists expressed concern that they are unable to provide uninsured patients the same quality and continuity of care that insured patients receive in their offices. Ninety-one percent of internists said they were "almost always" or "always" able to provide insured patients with the quality of care they would like to achieve, but only 49 percent said they were able to do the same for their uninsured patients. Even fewer (36%) said they could maintain continuity of care for their uninsured patients, while 92 percent said they could do so for insured patients.

Patients often require services outside the internist's office, such as laboratory tests, diagnostic procedures, consultation with specialists, and medications. Less than one-quarter of the internists surveyed said they are often able to secure reduced fees for their uninsured patients for medications (20%) or specialist referrals (23%), and one of 10 or fewer are often able to do so for lab tests (9%) and diagnostic procedures (5%) (Exhibit 2). Many uninsured patients fail to follow up with these services because of the costs.

An Essential Service
In spite of such constraints, the authors conclude that office-based internists in private practice are an important source of care for the uninsured. If this source of care were to erode, the traditional safety net providers could not absorb large numbers of uninsured. But certain market pressures may make it increasingly difficult for internists to continue providing this care.

As money becomes tighter, private practitioners are less able to afford caring for the uninsured, and managed care plans may decline to contract with physicians who serve too many uninsured patients. Also, physicians faced with financial pressures often consolidate or sell their private practices. This would result in fewer physicians who own their practice, and physician-owners were found to be most open to offering charity care to uninsured patients.

Finally, public reporting of how health care providers and institutions perform is essential for creating an accountable health care system.

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