Health Affairs, 22, no. 6 (2003): 217-224 doi: 10.1377/hlthaff.22.6.217 © 2003 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Care For The Uninsured In General Internists’ Private Offices

Abstract

 
This paper examines the care of uninsured patients in general internists’ private practices. More than two-thirds of internists provide at least some charity care, usually to their existing patients who have become uninsured. They appear to be filling a need for people who are moving between coverage, by helping bridge coverage intervals. Approximately two-thirds of all internists accommodate uninsured patients by reducing the charge or creating a payment plan, with internists who are practice owners much more likely to do so. This care to the uninsured is important, especially with growing unemployment rates, because the safety net would not be able to absorb these patients.

Despite this fact, most studies of the uninsured have focused on care in safety-net facilities, including our own work exploring the limits of care for the uninsured in CHCs.² However, because private practitioners are responsible for such a large share of the care to uninsured patients, understanding the nature of their care is important. In this paper we extend our earlier work by examining the level of care given to uninsured patients by one important group of private primary care physicians: internists.

Together with office-based family practitioners, internists account for approximately 83 percent of all primary care visits to office-based practices, with internists responsible for almost 40 percent of this.³ Despite their important role in the system, there have been few studies of internists’ practices with respect to the uninsured. One of the few studies found that almost all internists would see uninsured patients, although fewer reduced charges or otherwise adjusted policies to make the visit affordable.⁴ The study raised troubling issues, but it was limited because it surveyed internists in one location only and did not provide details about the level of care or the characteristics of the uninsured patients they treat. In this study we surveyed internists nationwide to determine the level of charity care they provide, the office policies they adopt to accommodate their uninsured patients, the characteristics of those patients, and their views on their ability to provide adequate care to their uninsured patients.

Data And Methods

Top Data And Methods Study Results Study Limitations Discussion And Policy... Editor's Notes NOTES

 
We conducted a mail survey (with four follow-up contacts) of primary care internists in private practice between July and October 2002.⁵ Internists in our sample were drawn randomly proportionate to four regions from a universe of 29,413 internists included in the master list of members maintained by the American College of Physicians/American Society of Internal Medicine (ACP-ASIM) that excluded internists who are hospital-based, at medical schools, at government-owned facilities, or in non–patient care settings or who indicated that they primarily practice a subspecialty. We received 607 completed surveys, for a response rate of 41 percent. This rate is consistent with that obtained for mail surveys of physicians.⁶ There were no statistically significant differences between responders and nonresponders in age, sex, practice type, or geographical region.

The survey asked internists whether they provided charity care and, if so, how many hours per month they provided and where they provided those hours. To define charity care in the survey, we used the definition in the Community Tracking Study: "Charity care is defined as charging no fee or a reduced fee to patients with financial need. Charity care does not include services you provided expecting to be paid but were not."⁷ We also asked about policies for self-pay/uninsured patients and their ability to secure additional services needed at reduced or no cost. We used the term "self-pay/uninsured" rather than "charity care" because we wanted to understand policies for patients who could pay for a primary care visit but not for any subsequent care.

We weighted our data to correct for response differences between regions, and we present descriptive information from weighted results. Chi-square tests were used to determine statistical significance of differences in proportions.

Characteristics of the practices in our sample. Almost three-quarters of the internists in our sample were practice owners, either full (42 percent) or in part (31 percent), while the remaining 27 percent were employees. Half of the practices consisted of three or fewer physicians, and the remaining half were evenly divided between practices of four to eight physicians (24 percent) and nine or more physicians (25 percent). Internists’ patients generally had private insurance (46 percent) or Medicare (44 percent), but 8 percent had Medicaid. Most of the revenue was from fee-for-service payments (69 percent), capitated managed care payments (21 percent), or other third-party sources (3 percent). However, 7 percent of the average practice revenue was from uninsured, self-pay patients.

Study Results

Top Data And Methods Study Results Study Limitations Discussion And Policy... Editor's Notes NOTES

 
Office policies regarding the uninsured. The average charge for a routine office visit is $64, with 75 percent of internists charging between $45 and $85 (data not shown). Uninsured patients might have trouble affording a visit if they are facing financial difficulties.⁸ In fact, most internists have charging and collection policies that accommodate uninsured patients (Exhibit 1). In almost all offices the insurance status of the patient is determined before the medical service is delivered, either at the time of the scheduling telephone call or upon arrival at the office.

Most internists also have collection policies to assist uninsured patients in making their payments. More than two-thirds of internists will create a payment plan, but approximately one-quarter will continue to bill. Ultimately, if the bill is not paid, more than a third of internists will write off the charge. However, 27 percent will use a collection agency. Thus, it is not surprising that in surveys approximately half of uninsured adults report problems paying for medical expenses and one-third report being contacted by a collection agency in the past year.⁹ Often, a bill from a collection agency, and the serious financial consequences of bankruptcy and devastated credit reports, can deter them from making another visit to the same provider or seeking care in the future.¹⁰ As might be expected, the internists who have charging policies that accommodate uninsured patients also have accommodating collection policies. Specifically, internists who reduce fees or charge nothing are less likely to use a collection agency than internists who do not modify their customary charge (22 and 35 percent, respectively; p < 01, data not shown).

"Internists have doubts about their ability to provide the quality of care that they would like to provide to uninsured patients."

Internists who are full or part owners are more likely to have policies that accommodate patients who have trouble paying than internists who are employees or in another category. Specifically, internists who are owners are more likely than nonowners to charge a reduced fee and are more likely to create a payment plan (Exhibit 1). This result is consistent with previous studies that found that physicians who own their practice are also more likely to provide charity care.¹¹ Owners have the discretion to set office policies, whereas employees do not; it appears that internist-owners accommodate the needs of their patients who are uninsured and need help paying for a visit.

Who are these uninsured patients? Most internists report that their uninsured patients are mostly established patients who lost their insurance (52 percent of internists reported serving mostly this type of patient; data not shown) or a mixture of new and established patients (10 percent). Another two percent of internists report seeing primarily uninsured patients referred by colleagues or uninsured relatives of existing patients. Only 33 percent of the internists reported that their patient population consisted mostly of new patients. Three percent reported seeing no uninsured patients. Providing care to uninsured patients who are not medically indigent but rather, because of job loss or other circumstance, have lost their health insurance is an important service, especially with rising unemployment rates. However, it is not the usual image of the uninsured or charity-care patient. Reinforcing the notion that it is not the medically indigent receiving care in private offices is the finding that internists would be more likely to take on a new self-pay/uninsured patient than to accept a Medicaid patient and almost as likely to accept a new self-pay/uninsured patient as to accept a new patient with private insurance (Exhibit 1). These surprising findings suggest that the self-pay/uninsured patients our physicians have in mind are not charity-care patients but rather patients who are temporarily uninsured or have the ability to pay. It could be sound business practice to see these patients, who might become insured again in the future.

Charity care given by internists. More than two-thirds (68 percent) of all internists provided at least some charity care each month. The amount varied considerably, but approximately 60 percent of the internists who provided any charity care provided between a quarter of an hour and five hours per month, while another 15 percent provided six to ten hours monthly (median, four hours per month). A few internists provided considerably more hours, bringing the mean number of hours per month to eleven.

However, as hours of charity care increased, it was increasingly likely that at least some of these hours were provided outside the private office (Exhibit 2). Internists who provided more than ten hours of charity care per month provided 34 percent of these hours in clinics, hospital settings, or other locations. We do not know whether internists volunteer time in safety-net sites or whether they are possibly salaried by sites that might or might not be safety-net institutions. Our findings on the percentage of physicians providing charity care and mean number of hours provided are consistent with other studies.¹² However, the fact that some of the hours might be provided in sites other than the private practice has not previously been reported.

View larger version (20K): [in this window] [in a new window]   EXHIBIT 2 Proportion Of Charity-Care Hours Provided In Internists’ Private Offices And Other Settings, By Amount Of Charity Care Provided, 2002 SOURCE: Authors’ analysis of survey of general internists, 2002.

View larger version (23K): [in this window] [in a new window]   EXHIBIT 3 Internists’ Ability To Care For Insured Versus Uninsured Patients, 2002 SOURCE: Authors’ analysis of survey of general internists, 2002. NOTE: Percentage of internists who responded that they are "almost always" or "always" able to do each of the activities noted.

View larger version (18K): [in this window] [in a new window]   EXHIBIT 4 Internists’ Ability To Get Additional Services For Their Uninsured Patients, 2002 SOURCE: Authors’ analysis of survey of general internists, 2002.

Top Data And Methods Study Results Study Limitations Discussion And Policy... Editor's Notes NOTES

Another limitation is that we relied on physicians’ self-reports. This limitation could lead to overreporting hours of charity care provided for those physicians who reported at least some charity care. Other questions about office policies and what patients they would see are more factual and less subject to reporting biases.

The third limitation is that we surveyed only general internists and not other primary care physicians; thus, our results generalize only to general internists. However, our study does capture an important group of primary care providers who provide about 40 percent of primary care visits nationwide.¹⁴ We plan to follow this study with one examining the same issues for family practitioners and other primary care providers.

Discussion And Policy Implications

Top Data And Methods Study Results Study Limitations Discussion And Policy... Editor's Notes NOTES

 
Although internists collectively provide many charity-care hours for uninsured patients every year, by their own reckoning they are not able to provide the same quality and continuity of care for uninsured patients that they provide for their insured patients, within their own offices. They are even less able to secure external services, such as medications, laboratory tests, or specialist consultations, if these are needed. Furthermore, a substantial proportion of internists’ charity care goes to their existing, formerly insured patients who become uninsured. These internists are providing a service to an important segment of the population, especially given growing unemployment rates. They are filling a need for people who are probably moving between coverage and no coverage. However, they apparently are not reaching deeply into the medically indigent population.

"If market forces cause private practitioners to reduce their care for uninsured patients, there will be nowhere for them to go."

Still, the care provided by office-based internists in private practice, as well as other private practitioners, is substantial and important. Based on our data, we estimate that the 29,413 internists of the ACP-ASIM membership in private office-based practice provide approximately 2.6 million hours of care—or 10.2 million visits—to uninsured patients per year, using 15.6 minutes as the average time for an office visit.¹⁵ It would be disastrous for the health care system if this source of care were to erode. There is simply not enough capacity in safety-net institutions to absorb large numbers of these patients.¹⁶

However, current forces at play—market pressures from insurance companies, managed care plans, employers, and government payers—are likely to reduce physicians’ willingness to see uninsured patients in at least three ways.¹⁷ First, as money becomes tighter, private practitioners are less able to fund care for uninsured patients from existing revenues. Furthermore, managed care plans are less likely to contract with physicians with high percentages of uninsured patients.¹⁸ Second, these market pressures have made it financially advantageous for physicians to consolidate or sell their private practices, which in turn results in fewer physicians who are owners of their practices.¹⁹ Our findings show that practice owners are far more likely than physician-employees are to adopt charging and collection policies that accommodate their uninsured patients. Practice mergers and consolidations take the decisions about charging and collection out of the hands of physicians, who may be responding to a sense of social responsibility to care for uninsured patients, and put them in the hands of managers, who are likely to have the financial health of the practice as their top priority. Third, practice managers, or physicians themselves, are more likely use aggressive tactics to collect payment as money becomes tighter. More than a quarter of physicians surveyed report that a collection agency is used in their practice setting if a patient does not pay.

These trends are cause for alarm, because if market forces and policy consequences cause internists and other private practitioners to reduce their care for uninsured patients, there will be nowhere for them to go. Private practitioners provide five times as many visits for the uninsured as safety-net institutions provide.²⁰ The safety net is simply not large enough to absorb the uninsured now being seen by internists and other private practitioners.

Editor's Notes

Top Data And Methods Study Results Study Limitations Discussion And Policy... Editor's Notes NOTES

 
The authors gratefully acknowledge the Commonwealth Fund and the American College of Physicians (ACP) Foundation for their financial support. They also thank Gerald Arnold, Wayne Bylsma, and Betty Nelson at the ACP Research Center, for assistance with sampling and instrument design; Jack Ginsburg and the ACP Health and Public Policy Committee, for assistance in selecting policy themes; and Al Ronca and his colleagues at Schulman, Ronca, Bucuvalas Inc. for data collection. Finally, they thank the internists who responded to this survey. The views expressed are solely those of the authors, and no official endorsement by the sponsors is intended or should be inferred.

Gerry Fairbrother is a senior scientist in the Division of Health and Science Policy, New York Academy of Medicine, in New York City, and an associate professor of epidemiology and population health at the Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx. Michael Gusmano is associate director of the World Cities Project at the International Longevity Center–USA in New York. Heidi Park and Roberta Scheinmann are research associates at the New York Academy of Medicine.

NOTES

Top Data And Methods Study Results Study Limitations Discussion And Policy... Editor's Notes NOTES

 

1. C.B.Forrest and E.M. Whelan, "Primary Care Safety-Net Delivery Sites in the United States: A Comparison of Community Health Centers, Hospital Outpatient Departments, and Physicians’ Offices," Journal of the American Medical Association 284, no. 16 (2000): 2077–2083.[Abstract/Free Full Text]
2. M.Gusmano, G. Fairbrother, and H.L. Park, "Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured," Health Affairs (Nov/Dec 2002): 188–194.
3. D.K.Cherry and D.A. Woodwell, "National Ambulatory Medical Care Survey: 2000 Summary," Advance Data from Vital and Health Statistics no. 328 (Hyattsville, Md.: National Center for Health Statistics, 2002); office visits for primary care were selected from NAMCS data as visits made to general or family physicians, general internists, and obstetricians/gynecologists.
4. T.O’Toole, P.M. Simms, and B.W. Dixon, "Primary Care Office Policies regarding Care of Uninsured Adult Patients," Journal of General Internal Medicine 16, no. 10 (2001): 693–696.[Medline]
5. Protocol included three full survey mailings with two reminders.
6. A.Robinson et al., "Physician and Public Opinions on Quality of Health Care and the Problem of Medical Errors," Archives of Internal Medicine 162, no. 19 (2002): 2186–2190[Abstract/Free Full Text]; and M.Davis et al., "A National Survey of Physician Practices regarding Influenza Vaccine," Journal of General Internal Medicine 17, no. 9 (2002): 670–676.[CrossRef][ISI][Medline]
7. 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]
8. Institute of Medicine, Coverage Matters: Insurance and Health Care (Washington: National Academies Press, 2001).
9. L.Duchon et al., Security Matters: How Instability in Health Insurance Puts U.S. Workers at Risk (New York: Commonwealth Fund, 2001).
10. H.F.T.Daly et al., "Into the Red to Stay in the Pink: The Hidden Cost of Being Uninsured," Health Matrix 12, no. 1 (2002): 7–62.[Medline]
11. Cunningham et al., "Managed Care and Physicians’ Provision of Charity Care."
12. Ibid.; and P.J.Cunningham, Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997–2001, Tracking Report no. 6 (Washington: Center for Studying Health System Change, December 2002).
13. Cunningham et al., "Managed Care and Physicians’ Provision of Charity Care."
14. Cherry and Woodwell, "National Ambulatory Medical Care Survey: 2000 Summary."
15. Forrest and Whelan, "Primary Care Safety-Net Delivery Sites."
16. Gusmano et al., "Exploring the Limits of the Safety Net"; and Institute of Medicine, America’s Health Care Safety Net: Intact but Endangered (Washington: National Academies Press, 2000).
17. Cunningham et al., "Managed Care and Physicians’ Provision of Charity Care."
18. A.B.Bindman et al., "Selection and Exclusion of Primary Care Physicians by Managed Care Organizations," Journal of the American Medical Association 279, no. 9 (1998): 675–679.[Abstract/Free Full Text]
19. D.Dranove, C.J. Simon, and W.D. White, "Is Managed Care Leading to Consolidation in Health Care Markets?" Health Services Research 37, no. 3 (2002): 573–594; [CrossRef][ISI][Medline]R.A.Dudley and H.S. Luft, "Managed Care in Transition," New England Journal of Medicine 344, no. 14 (2001): 1087–1092[Free Full Text]; and P.Kletke, D.W. Emmons, and K. Gillis, "Current Trends in Physicians’ Practice Arrangements: From Owners to Employees," Journal of the American Medical Association 276, no. 7 (1996): 555–560.[Abstract]
20. Forrest and Whelan, "Primary Care Safety-Net Delivery Sites."

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