Uninsured Patients Receive Unpredictable, Rationed Access to Health Care
[Writer] This is research news from U-I-C – the University of Illinois at Chicago.
Today, Dr. Saul Weiner, associate professor of pediatrics and internal medicine, talks about a case study of three health care institutions with different ownership models that found self-pay patients must navigate a system that provides no guarantees that medical centers will follow their own policies for providing uncompensated care.
Here’s professor Weiner:
[Weiner] As most people now know in the United States, the uninsured have become a major issue for people in politics, in government. We have somewhere in the range of 44-46 million Americans now who don’t have any health insurance. And as the political cycle heats up, there’s a lot of interest in what we’re going to do about these people and one of my research interests has been what is actually happening to them.
There’s already excellent data (showing) that being uninsured is a bad thing – that people uninsured basically end up getting less care. We know that they have poor outcomes on a number of measures and we know they are less likely to seek care when they need it. But my own particular interest was in looking at what happens when people who don’t have health insurance actually try to get it, and more specifically, what institutions do with these folks. So the study that I had completed recently is titled “Managing the Unmanaged: A Case Study of Intra-institutional Determinants of Uncompensated Care at Health Care Institutions with Differing Ownership Models.” So there are a couple of key (phrases) here: one is “managing the unmanaged.” That phrase really alludes to the idea that everybody else who seeks health insurance pretty much knows, at least in the broadest terms, what to expect. They know they’re covered for this and not covered for that, and the folks who take care of them pretty much know that they’re going to get paid and they’re not going to get paid for that, but when people don’t have health insurance, there’s obviously a big question about whether they’ll be seen, whether they’ll be turned away, if they get care what they’re going to have to pay, what’s going to happen if they don’t pay. So it’s a very stressful situation for people.
We were interested in actually seeing what their experiences are and also what the institutions’ experiences are. So when we set up this study, we realized we had to really delve deeply into three institutions – a for-profit, a not-for-profit and a public – and we had to do it from several different perspectives. We had to interview uninsured patients seeking care. We had to look at the policies and practices of the institutions as they’re written. We had to see what they were really doing by talking to personnel. And then we had to look at their financial data for a whole year and see what they were actually providing in the way of free care and what they’re getting paid.
I think a few themes emerged from this that I think may be useful to people, and are just generally interesting.
One is that there were some similarities across these three types of institutions. At all of them, we basically found that they had policies, but no one really followed them too closely. There might be policies specifying that somebody should pay $60 if they don’t have insurance just to see a doctor, and we found that a clerk might make them pay it, or a clerk might waive them in anyway. And similarly, they might have been told that if
they didn’t pay a bill it would go to collection – we found that it might or might not happen. Often tt happened to do with the willingness of the patient to negotiate, the willingness of the billing person to negotiate. So there was an enormous amount of variation. That was really common to all (three) sites.
The major differences were also very interesting and significant. We found that the public institution was the most open to seeing patients in a variety of settings. By contrast, the for-profit institution would really only see patients in the emergency department. This was very concrete. When you look at the financial data and when you look at where patients are registered at these three sites, you find that at the for-profit, very few were seen outside of the emergency room setting – only about two percent of their patients were actually uninsured. Whereas at the public institution, it was more like 12-13 percent. At the not-for-profit, it was closer to the for-profit actually, but just a little bit higher. So that was one thing that was really important.
The other thing that was important was that the public institution, although it saw patients in a variety of diverse settings, worked really hard to get some money from these patients and actually was much more successful at collecting a percentage of charges than was the for-profit. One got the sense that the for-profit just basically took its losses and said “We’ll just see these folks in the E.D. (emergency department), we won’t wok too hard to get money from them, and so be it.” And, not surprisingly, the not-for-profit sort of fell in-between. On the hand they were willing to see patients, not as diverse as the public institution – in fact, much less diverse. But also that they were going to try a little bit harder to try to collect money than the for-profit did.
That was really the pattern. And it’s hard to really generalize across other sites in the United States. We were just looking at three, of course. But the pattern sort of makes sense — it makes sense that the public institution would see patients in a diversity of settings and then do its best to collect something from these folks. By the way, the amount they collected did not make up for the greater volume. They actually ended up having greater net losses in caring for the uninsured than the for-profit or the not-for- profit. But they did a better job at getting some money. And, on the other side I said, the for-profit institution really was focused on just providing minimal care.
In terms of take home messages, I think what we have to recognize is that in this country the law states that you can’t turn people away from an emergency department if you want to get Medicare dollars, which virtually all hospitals do. But other than that, there are really no expectations. We see, as a result, an enormous amount of variation – across and within institutions, and we see a complete lack of clarity about how these patients are going to get care, who’s going to care for them and what care they’re going to receive. For the uninsured, it’s a pretty capricious system. And actually, even for the health care providers, it’s a tough payer group because you don’t know that magnitude of losses that you’re going to accrue, particularly for institutions which have very narrow margins where they often times may be just one percentage point in the black or one percentage point in the red, to have to deal with this population where they would rather not be taking care of them, but due either because of a mission or a legal obligation, there’s an equal lack of comfort about how to handle the uninsured. And I think that as we move forward in the political process we have to recognize that this is essentially an unmanaged group – a group of people who don’t know what they’re going to get, who are getting care from a set of institutions that are uncomfortable and unsure about what it is they want to provide.
[Writer] Dr. Saul Weiner is an associate professor in pediatrics and internal medicine.
For more information about this research, go to www-dot-news-dot- uic-dot-edu … click on “news releases” … and look for the release dated August 25, 2008.
This has been research news from U-I-C – the University of Illinois at Chicago.