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Report: Most Internists Provide Charity Care to the Uninsured

(Washington, DC): About 68 percent of internists in general practice provide charity care to the uninsured, usually to their existing patients who have lost health insurance coverage, according to a new report released in today's edition of Health Affairs. Researchers at the New York Academy of Medicine developed the report in conjunction with the American College of Physicians (ACP) Foundation and the CommonWealth Foundation.

Approximately two-thirds of all general internists accommodate uninsured patients by reducing the charge and/or creating a payment plan.

"Private practitioners provide five times as many visits for the uninsured as do health safety-net institutions, which would not be able to absorb this number of patients," said American College of Physicians President Munsey Wheby, MD, FACP.

The study, "Care for the Uninsured in General Internists' Private Offices," by Gerry Fairbrother, Michael K. Gusmano, Heidi L. Park and Roberta Scheinmann, surveyed ACP members nationwide to determine the level of charity care they provide, the office policies they adopt to accommodate their uninsured patients, the characteristics of the uninsured patients they treat, and their views on their ability to provide adequate care to their uninsured patients.

The study points out that in 1994, over 27 million of the 33 million primary care visits for the uninsured occurred in physicians' offices (82 percent), in contrast to 3.3 million (10 percent) in community health centers (CHCs) and 2.6 million (8 percent) in hospital outpatient departments.

If the patient is uninsured and has trouble paying for the visit, 65 percent of internists reduce the customary fee or charge nothing. Most internists will accept partial payment at the time of the visit or bill later.

Most internists also have collection policies to assist uninsured patients in making payments, if they cannot pay their bill. Over two-thirds of internists (68 percent) will create a payment plan, but approximately one quarter (28 percent) will continue to bill. If the bill is not paid, 39 percent of the internists will write off the charge, while 27 percent may employ a collection agency.

Internists who are full or part owners of their practices are more likely to have policies that accommodate patients who have trouble paying.

Over half of the internists report that their uninsured patients are mostly established patients who lost their insurance. Only one-third of the internists reported that their uninsured patient population consisted of mostly new patients. 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.

Internists report that they are generally able to spend adequate time during the office visit for both insured (83 percent) and uninsured patients (74 percent). Fewer physicians are able to provide the quality of care they would like to achieve for their uninsured as compared to their insured patients (49 vs. 91 percent). Likewise, physicians were better able to maintain continuity of care for their insured patients (92 vs. 36 percent), and to solve their insured patients medical problems using the resources at hand in their offices (79 vs. 43 percent).

However, less than one quarter of the internists reported that they could provide medications to their uninsured patients or refer them to specialists "most of the time or often." Almost half of the internists reported that their uninsured patients failed to follow advice about receiving these services because of cost "most of the time or often" (47 percent).

The study estimates that the 29,413 internists of the ACP membership in private office-based practice provide approximately 2.6 million hours of care — or 10.2 million visits — to uninsured patients per year.

Current forces at play — market pressures from insurance companies, managed care plans, employers, and government payors — are likely to reduce the willingness of physicians to see uninsured patients, according to the report.

"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," said Dr. Wheby. "The safety net is simply not large enough to absorb the uninsured now being seen by internists and other private practitioners."

The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include more than 115,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection and treatment of illnesses in adults.

Jack Pope, 202-261-4556, jpope@acponline.org

Page posted: 11/12/2003

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