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Safety Net

Limits To The Safety Net: Teaching Hospital Faculty Report On Their Patients’ Access To Care

Abstract

 
Many major teaching hospitals might not be able to offer adequate access to specialty care for uninsured patients. This study found that medical school faculty were more likely to have difficulty obtaining specialty services for uninsured than for privately insured patients. These gaps in access were similar in magnitude for public and private institutions. Initial treatment of uninsured patients at academic health centers (AHCs) does not guarantee access to specialty and other referral services, which suggests that there are limits to relying on a health care safety net for uninsured patients. AHCs and affiliated group practices should examine policies that limit access for uninsured patients.

A critical test of this approach to indigent health care policy is whether safety-net providers can provide adequate, comprehensive access to care.⁴ Recent research suggests that community health centers (CHCs), for example, are severely limited in their ability to provide comprehensive services, including diagnostic and specialty services and other important aspects of care that go beyond initial entry into the health care system.⁵ U.S. teaching hospitals, especially those closely affiliated with medical schools, might be expected to fulfill this function, since they have historically been associated with care of the poor.⁶ Teaching hospitals continue to play that role partly because many of them are publicly owned, and others are located in core urban areas where health care need is high. Teaching hospitals provide more uncompensated care than their nonteaching counterparts do, even after controlling for ownership status, and there is evidence to suggest that they play a prominent role as providers of specialty care to the poor.⁷ However, little is known about whether teaching hospitals are meeting the referral needs of uninsured patients or whether barriers exist that limit the amount of care provided. This topic is especially relevant to ongoing discussions around Medicare and Medicaid policy about whether and how to subsidize hospitals that serve a safety-net function.⁸

Study Methods

Top Study Methods Study Findings Discussion And Policy... Editor's Notes NOTES

 
We surveyed physician faculty at the 121 academic health centers (AHCs) located in the United States (excluding Puerto Rico) to assess their perception of access to care for their patients and limits placed on their ability to provide that care. AHCs, defined as medical schools and their closely affiliated clinical facilities, constitute just 2 percent of U.S. hospitals but accounted for 22 percent of hospital uncompensated care in 1994 and 44 percent of charity care in their local communities in 1996.⁹ Because they bear a particularly heavy burden of indigent care, publicly owned AHC hospitals are an important element of the safety net in their communities.¹⁰

Although individual AHC hospitals certainly influence the amount of care provided in their facilities, physician faculty play a major role. AHC physicians are often organized into group practice plans, through which they provide inpatient and outpatient services. This charity care is not usually captured by hospital statistics on uncompensated care, although a recent analysis of medical school finances shows that faculty practice plans provide a sizable and growing amount of care to indigent patients.¹¹

Study sample. We sampled medical school faculty from the Association of American Medical Colleges (AAMC) Faculty Roster System, which contains detailed information on faculty members in member institutions located in the United States (excluding Puerto Rico). This database included 90,358 faculty members at 121 U.S. medical schools. We excluded 3,535 faculty members who did not perform direct patient care or research; 1,406 with a rank other than instructor, assistant professor, associate professor, or full professor; 506 with primary affiliations in ineligible departments (administration, operations, library, and atypical medical school departments such as humanities and the arts); and 674 with missing age data, leaving an eligible population of 84,237 faculty members. This sample was constructed from a larger study intended to investigate the effects of the health care environment on academic activities, and so we oversampled young faculty and researchers. We initially drew a sample of 5,084. Upon administering the survey, we found that five members had died and 385 were found to have been otherwise ineligible (for example, left the medical school, retired, or were on leave). Of the 4,694 eligible faculty, 2,989 responded, yielding a response rate of 66.5 percent. This study is limited to the 2,295 respondents who provided direct patient care in the year preceding the survey.

Survey development and administration. The survey instrument was a modified version of one used in earlier work.¹² For this study we added several items seeking information on the care of underserved populations, and we performed cognitive testing. The survey was administered by mail between October 2000 and March 2001 by the Center for Survey Research at the University of Massachusetts.

Variables. Dependent variables. To assess providers’ reported ability to obtain needed care for their uninsured patients, we asked, "In the last year, were you unable to admit a patient or did you have to limit a patient’s care at your primary teaching hospital because the patient was uninsured?" In addition, we adapted a series of questions from the Center for Studying Health System Change (HSC) Physician Survey: We asked, "How often are you able to obtain: referrals to specialists of high quality; nonemergency hospital admissions; high-tech services like transplants or cardiac stents; high-quality outpatient mental health services; high-quality substance abuse services?" (Always, often, sometimes, rarely, or never).¹³ Responses were collapsed into rarely/never versus all others, to represent difficulty obtaining specialty services. Unlike HSC, we asked this series of questions twice—once with respect to privately insured and once with respect to uninsured patients.

To understand barriers to providing indigent care, we asked whether the faculty group practice had "formal policies limiting the number of uninsured patients or the amount of care provided to uninsured patients." We also assessed whether faculty perceived certain barriers (not necessarily formal policies) that limited the number of uninsured patients they could see in their practice.

Independent variables. We identified the ownership status of the parent medical school (public or private) and the ownership of the flagship or primary teaching hospital, if there was one (public versus all others). However, access barriers also could differ by individual providers’ level of involvement in indigent care. Clinicians whose caseload includes only a few indigent patients might not perceive access problems to the same extent as those who see many. Therefore, we classified respondents into high and low "safety-net status," by asking, "Thinking of all the patients you cared for during the last month, about what percentage were uninsured and unable to pay for their care?" High-safety-net faculty were the top quartile of respondents in terms of the reported proportion of their caseload that was uninsured. Because averaging the crude percentages could bias the results toward faculty with low clinical loads, we repeated the analysis after weighting the percentage of patients seen by the number of patient-care hours reported. Since this failed to change any of our results in a major way, we report only the crude data.

We experimented with various definitions of safety-net status, such as whether a physician practiced in a clinic or health center for the underserved, or the number of direct patient-care hours devoted to charity, or using a broader definition of underserved patients that included Medicaid and minorities. Our results did not change appreciably with these other definitions, so we include here only findings using the first definition.

Other characteristics of the faculty included sex, race/ethnicity, status as an international medical graduate (IMG), academic rank, and hours per week in direct patient care. We classified faculty into the following groupings of academic departments: primary care (internal medicine, family practice, pediatrics, and obstetrics/gynecology); psychiatry, other medical, and other surgical.

Data analysis. All responses were weighted to provide national estimates of AHC faculty who were physicians engaged in patient care. All reported p-values and confidence intervals were estimated using SUDAAN, to account for complex survey designs.¹⁴ For dichotomous response variables such as reported barriers or difficulty obtaining specialty services, we used logistic regression to control simultaneously for faculty and AHC characteristics. Results are presented as regression-adjusted percentages, with control for faculty characteristics and facility ownership.

Study Findings

Top Study Methods Study Findings Discussion And Policy... Editor's Notes NOTES

 
Nearly 70 percent of the respondents to our survey were male, and 44 percent were full or associate professors (Exhibit 1). More than half worked in a primary care department, 9 percent were in psychiatry, 17 percent were in other medical departments (for example, cardiology), and 19 percent were in surgery other than obstetrics. More than three-quarters spent twenty hours or more per week in direct patient care. About half were from public medical schools and a third from medical schools where the primary teaching hospital was publicly owned.

Access problems. Nearly one-quarter of faculty felt that in the past year they were unable to admit patients or had to limit their care because they were uninsured, and these responses did not vary by type of institution, after adjusting for faculty characteristics (Exhibit 2).

Formal policies limiting care to uninsured patients were reported by 13 percent of AHC faculty (Exhibit 3). There were no significant differences by ownership of school or hospital or by physician safety-net status (latter not shown).

Discussion And Policy Implications

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In their paper on the challenges of transforming insurance coverage into high-quality health care, John Eisenberg and Elaine Power argued that being insured, having initial access to medical services, or even having a consistent source of primary care do not constitute sufficient evidence of high-quality care. Access to referral services also is a necessary component.¹⁵ In this survey of more than 2,000 medical school faculty involved in direct patient care, we found large gaps in perceived access to referral services to specialists, high-tech care, outpatient mental health and substance abuse treatment, and even routine inpatient care. Although previous studies have identified disparities in care for uninsured patients, this study extends this knowledge by focusing on referral to specialty services after initial access had already been gained. Notably, this study demonstrates that disparities in access between uninsured and privately insured patients cross institutional boundaries, since they were commonly reported even among physician faculty at public teaching institutions.

"Despite what is taught in classes, the hidden curriculum could be saying that limiting services for uninsured patients is acceptable."

Personal barriers. There are a variety of explanations for this. For example, some physicians might feel uncomfortable referring nonpaying patients to their colleagues, or specialists might be less willing than primary care physicians to take on uninsured patients with whom they do not have established relationships, regardless of facility type. Another possible explanation is that respondents at public and private AHCs share certain other relevant characteristics, since faculty at nearly all teaching institutions pursue multiple activities in addition to patient care, including medical education and research. Thus, serving indigent patients, at least for certain specialties, might not always be the highest priority.

Lack of resources. Another factor could be the presence or absence of necessary hospital resources. Safety-net institutions are chronically underfinanced and might not have the most modern facilities.¹⁶ For example, in a study of cardiac revascularization in New York City, the strongest predictor of underuse was not insurance status but, rather, receiving initial treatment in hospitals that did not perform the procedures on site.¹⁷ Three of the four municipal hospitals in the study did not perform revascularization, while only one of nine private hospitals did not.

Insurance company restrictions. Finally, it is worth noting that for some services, such as outpatient mental health care and substance abuse treatment, respondents reported frequent access problems even for their insured patients. In such instances, restrictions placed by insurance companies could establish barriers that make the referral process difficult to navigate even for insured patients.

Institutional barriers. Our study also sought to shed light on the institutional barriers that might prevent faculty from providing indigent care. Nearly one in five clinical faculty felt that they were discouraged by their group practice or hospital from seeing too many indigent patients, and more than one in ten reported that their group practice placed formal limits on the number of patients or the amount of care they could provide. These phenomena were not limited to faculty from a few isolated schools. At least one (but not all) faculty respondent at nearly all of the schools surveyed reported barriers to treating uninsured patients. Still, the majority of faculty did not report being constrained by their institutions. Future research should determine whether these experiences are limited to a few departments, or perhaps whether some providers misunderstand the signals sent by their administrations.

Inadequate reimbursement. The factor most often cited as a barrier to treating more indigent patients was lack of referrals, but inadequate reimbursement also was prominent. It might be useful to place these barriers in a wider context. For example, one study found that fewer specialists were accepting new Medicare patients, and patients were reporting longer waiting times to schedule appointments.¹⁸ The authors suggested that these problems might be traced to changes in Medicare reimbursement that make payments to specialists less favorable. If this is true, one could envision that lower levels of payments from uninsured patients might result in even greater obstacles.

Federal policy. Current federal efforts addressing the safety net tend to focus on assuring primary care, perhaps via expansion of the community health center network. Less attention has been directed at supporting specialty services. At teaching hospitals, faculty practices must finance their charity care through revenues from paying patients, but they do so without the subsidies from Medicare and Medicaid that are available to hospitals serving a disproportionate number of poor and uninsured patients.¹⁹ One possible policy response might be to expand the subsidy programs of Medicare or Medicaid to include such payments to physicians. As an alternative, some states such as Massachusetts have long maintained an uncompensated care pool to spread the costs among hospitals. Lately they have been experimenting with using funds from the pool to pay for specialty care.

Medical education. Our findings also have implications for medical education. Medical schools and their affiliated hospitals have a centuries-old tradition of caring for the poor and training the next generation of physicians to undertake this vital social task.²⁰ Students might be taught to treat all patients equitably, but they are likely also to be influenced by a "hidden curriculum."²¹ Because medical school faculty function as role models, their behavior is constantly monitored by students and residents. Despite what is taught in classes, the hidden curriculum could be sending the message that limiting services for uninsured patients is acceptable.

Limitations on interpretation. This study had certain characteristics that might limit the interpretation of our findings. First, our measures of access to care relied on the perceptions of practitioners. Actual access by their patients may differ, and faculty physicians may not always know the insurance status of the patients they treat. Furthermore, we did not determine whether respondents were reporting on difficulties with referrals at their own or another institution, although it seems likely that most referrals for specialty care would occur at the parent facility. Third, our estimates could be conservative, since people tend to underreport socially less desirable activities such as limiting care to uninsured patients. Another limitation is that because of confidentiality concerns, we did not ask the respondents to identify the primary facility at which they saw patients, and this might have affected some of our comparisons between public and private institutions. Finally, we were unable to link the level of indigent care to the financial risk of the individual practitioner or to other characteristics of the institution.

The united states continues to hold the distinction of being the only developed country in the world with large numbers of uninsured citizens. There is wide concern that these numbers could increase further because of higher unemployment, strained state budgets, and rapidly rising insurance premiums.²² Numerous state and federal attempts at incremental reform have met with mixed success.²³ The phenomena reported in this paper illustrate the limits of charity care in our health care system. Because barriers to service and gaps in access occur at both public and private institutions, we conclude that there are limits to relying on a safety-net system for poor, uninsured patients. In the absence of universal coverage, we must understand and address barriers to high-quality care for uninsured patients in places where they routinely seek care. The capacity of safety-net institutions, including AHCs, to provide equitable care to all patients needs to be reexamined.

Editor's Notes

Top Study Methods Study Findings Discussion And Policy... Editor's Notes NOTES

 
This work was supported by a grant from the Commonwealth Fund as part of the activities of the Commonwealth Fund Task Force on Academic Health Centers, the Pew Charitable Trusts, Burroughs Wellcome, and the Doris Duke Foundation. The authors are grateful to Brian Clarridge and the staff at the Center for Survey Research, University of Massachusetts, for their expertise in administering the survey.

Joel Weissman is an associate professor, Eric Campbell is an assistant professor, Recai Yucel and Nancyanne Causino are instructors, and David Blumenthal is a professor in the Department of Medicine at Harvard Medical School and the Institute for Health Policy at Massachusetts General Hospital. Manjusha Gokhale is a senior programmer/analyst at the institute. Ernest Moy is a senior research scientist at the Agency for Healthcare Research and Quality (AHRQ)in Rockville, Maryland.

NOTES

Top Study Methods Study Findings Discussion And Policy... Editor's Notes NOTES

 

1. See, for example, J.S.Weissman and A.M. Epstein, "The Insurance Gap: Does It Make a Difference?" Annual Review of Public Health 14 (1993): 243–270; [CrossRef][Web of Science][Medline]S.H.Altman, U.E. Reinhardt, and A.E. Shields, The Future U.S. Healthcare System: Who Will Care for the Poor and Uninsured?(Chicago: Health Administration Press, 1998); and J.Hadley, Sicker and Poorer: The Consequences of Being Uninsured: A Review of the Research on the Relationship between Health Insurance, Health, Work, Income, and Education (Washington: Kaiser Commission on Medicaid and the Uninsured, 2002).
2. J.S.Weissman and A.M. Epstein, Falling through the Safety Net: Insurance Status and Access to Health Care, vol. 1 (Baltimore: Johns Hopkins University Press, 1994).
3. Some private charity care is funded implicitly with public funds, such as the Medicare/Medicaid disproportionate-share hospital (DSH) program or, in some states, uncompensated care pools.
4. Institute of Medicine, America’s Health Care Safety Net: Intact but Endangered (Washington: National Academies Press, 2000).
5. M.K.Gusmano, G. Fairbrother, and H. Park, "Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured," Health Affairs (Nov/Dec 2002): 188–194; and S.Felt-Lisk, M. McHugh, and E. Howell, "Monitoring Local Safety-Net Providers: Do They Have Adequate Capacity?" Health Affairs (Sep/Oct 2002): 277–283.
6. K.M.Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (New York: Oxford University Press, 1999).
7. J.S.Weissman, D.J. Gaskin, and J. Reuter, "Hospitals’ Care of Uninsured Patients during the 1990s: The Relation of Teaching Status and Managed Care to Changes in Market Share and Market Concentration," Inquiry 40, no. 1 (2003): 84–93; [Web of Science][Medline]Commonwealth Fund, A Shared Responsibility: Academic Health Centers and the Provision of Care to the Poor and Uninsured (New York: Commonwealth Fund, April 2001); and Commonwealth Fund, Health Care at the Cutting Edge: The Role of Academic Health Centers in the Provision of Specialty Care (New York: Commonwealth Fund, July 2000).
8. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, 2001).
9. E.Moy et al., "Academic Medical Centers and the Care of Underserved Populations," Academic Medicine 71, no. 12 (1996): 1370–1377[Web of Science][Medline]; and Commonwealth Fund, A Shared Responsibility.
10. J.S.Weissman, "Uncompensated Care: Will It Be There When We Need It?" Journal of the American Medical Association 276, no. 10 (1996): 823–828[Abstract/Free Full Text]; and Commonwealth Fund, A Shared Responsibility.
11. Commonwealth Fund, A Shared Responsibility.
12. E.G.Campbell, J.S. Weissman, and D. Blumenthal, "The Relationships between Market Competition and the Activities and Attitudes of Medical School Faculty," Journal of the American Medical Association 378, no. 3 (1997): 222–226; J.S.Weissman et al., "Market Forces and Unsponsored Research in Academic Health Centers," Journal of the American Medical Association 281, no. 12 (1999): 1093–1098[Abstract/Free Full Text]; and D.Blumenthal et al., "The Relationship of Market Forces to the Satisfaction of Faculty at Academic Health Centers," American Journal of Medicine 111, no. 4 (2001): 333–340.[CrossRef][Web of Science][Medline]
13. P.J.Cunningham et al., "Managed Care and Physicians’ Provision of Charity Care," Journal of the American Medical Association 281, no. 12 (1999): 1087–1092[Abstract/Free Full Text]; and Center for Studying Health System Change, Community Tracking Study Physician Survey Instrument (Washington: HSC, 1997).
14. B.V.Shah, B.G. Barnwell, and G.S. Bieler, SUDAAN User’s Manual, Release 7.0 (Research Triangle Park, N.C.: Research Triangle Institute, 1996).
15. J.M.Eisenberg and E.J. Power, "Transforming Insurance Coverage into Quality Health Care: Voltage Drops from Potential to Delivered Quality," Journal of the American Medical Association 284, no. 16 (2000): 2100–2107.[Abstract/Free Full Text]
16. IOM, America’s Health Care Safety Net.
17. L.L.Leape et al., "Underuse of Cardiac Procedures: Do Women, Minorities, and the Uninsured Fail to Receive Needed Revascularization?" Annals of Internal Medicine 130, no. 3 (1999): 183–192.[Abstract/Free Full Text]
18. S.Trude and P.B. Ginsburg, Growing Physician Access Problems Complicate Medicare Payment Debate, Issue Brief no. 55 (Washington: HSC, September 2002).
19. Commonwealth Fund, A Shared Responsibility.
20. Ludmerer, Time to Heal.
21. F.W.Hafferty and R. Franks, "The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education," Academic Medicine 69, no. 11 (1994): 861–871; [Web of Science][Medline]F.W.Hafferty, "Beyond Curriculum Reform: Confronting Medicine’s Hidden Curriculum," Academic Medicine 73, no. 4 (1998): 403–407[Web of Science][Medline]; and S.Turbes, E. Krebs, and S. Axtell, "The Hidden Curriculum in Multicultural Medical Education: The Role of Case Examples," Academic Medicine 77, no. 3 (2002): 209–216.[Web of Science][Medline]
22. W.S.Custer and P. Ketsche, The Changing Sources of Health Insurance, (Washington: Health Insurance Association of America, 2000); and J.E.Miller, A Perfect Storm: The Confluence of Forces Affecting Health Care Coverage (Washington: National Coalition on Health Care, November 2001).
23. S.A.Glied, "Challenges and Options for Increasing the Number of Americans with Health Insurance," Inquiry 38, no. 2 (2001): 90–105.[Web of Science][Medline]

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