Treating the Uninsured

Twenty years ago physicians routinely provided free or reduced-fee care to uninsured patients because reimbursements for insured patients were so high physicians could afford to cover the costs of other patients.

That's rarely the case these days. Instead, the number of uninsured is going

up (47 million U.S. residents currently have no insurance), while both insurance reimbursements and government subsidies for indigent health care are going down. And that means physicians are having a harder and harder time making ends meet while providing charity care.

That doesn't sit well with many health professionals. According to the Institute of Medicine's 2003 report "A Shared Destiny: Community Effects of Uninsurance," providing consistent care to the uninsured helps patients stay healthy and live longer, keeps the community healthier and more prosperous, and allows doctors to improve the profession’s image.

But what's a doctor to do with so many patients who can't pay? How can you provide consistent care to patients who may have lost their insurance only temporarily? Across the country, a number of family physicians are finding ways to treat the uninsured while maintaining their practice's solvency. Here's how to do it:

1. Make a formal plan. If you dole out free or reduced services on an ad hoc basis, you can get in all sorts of trouble. If you don't provide discounts to everyone who claims a need, for instance, you can be accused of being discriminatory. But if you give discounts to too many people, both insurance carriers and the government can get antsy. If the Medicare folks see that you often charge patients, say, $30 for an office visit, they'll decide that’s your standard fee and lower their volume discounts accordingly. Similarly, if you waive copay for certain patients, insurance companies may protest because they prefer you discount the entire fee (so their cost is reduced, too).

The way to avoid this loss is to create a formal policy that clearly states to whom you're providing charity care (e.g., what makes them eligible); what your discount is; and what services this covers (i.e., just sick visits, or wellness visits, too? Just the cost of the exam, or also diagnostics?) Have a health care attorney review and finalize the policy for you, then keep it in a safe place. You can use it as a guideline for your staff, and pull it out if you're ever questioned on your approach.

2. Join or create a partnership. One of the most creative and economically viable ways of treating the uninsured is to create a group or network of health specialists who are willing to care for this population. Ideally, such a network would include primary care physicians, pharmacists, hospitals (which can provide some of the screening and major procedures), and specialists (who generally won't treat the uninsured unless they can pay out of pocket). Several such networks currently exist across the country, including the American Project Access Network.

These kinds of partnerships allow a group of doctors to share the burden of poor clients in their community so that no one doctor gets overwhelmed (or goes broke). They also give the primary care physician a ready-made network of other doctors who will see charity cases, which can alleviate the time and effort it sometimes takes to find a colleague who will help a certain patient.

3. Ask for cash upfront. Even if the fee is reduced, ask the patient to pay at the time of service. That will help your practice's cash flow. It also helps retain patients since sometimes people who haven' paid their bills are too embarrassed to return for follow-up visits.

4. Offer flexible payment plans. Granted not all your uninsured patients will be able to pay even your discounted fee at the time of service. For those patients, having some kind of payment plan available, whether it's sending a monthly invoice or allowing them to use a credit card, will help. A report by the New York Academy of Medicine in conjunction with the American College of Physicians Foundation and the Commonwealth Foundation found that more than two-thirds of the internists who treat the uninsured come up with some kind of payment plan for their patients. (If the patient still doesn't pay, the researchers found, 39 percent of the internists write off the charge, while 27 percent use a collection agency.)

5. Get involved. If you're frustrated about the difficulties of treating the uninsured, start researching the causes of the problem and current theories on how to change it. Getting involved with the larger political and social issue can help you feel that you're part of the solution, not a victim of the problem.