A case study of three health care institutions -- public, for-profit and not-for-profit -- within one metropolitan area found that self-pay patients must navigate a system that provides no guarantees medical centers will follow their own policies for providing uncompensated care.
"We know from previous research that the uninsured have poor outcomes on a number of measures and they are less likely to seek care when they need it," said Dr. Saul Weiner, University of Illinois at Chicago associate professor of pediatrics and internal medicine, and lead author of the study. "But we know less about what actually happens when the uninsured try to obtain health care in various settings, and more specifically, how institutions deal with these patients."
There are about 47 million Americans who do not have any health insurance and must pay for care out-of-pocket, according to Weiner.
The study analyzed how three medical centers with different ownership models rationed uncompensated care to patients without insurance. Data were obtained from hospital financial reports, a survey of 292 self-pay patients, and from the self-pay policies and practices of front-line staff.
The researchers found that all three institutions had policies for accepting self-pay patients, but that many times their practices did not match the policies. Prepayment was often left to the discretion of front line staff, who also determined whether a patient might be turned away from care.
The researchers found the differences among the three institutions were significant. The institutions and the city in which they are located were not identified.
"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," said Weiner.
Federal regulations mandate emergency care in order for a hospital to obtain Medicare and Medicaid funding.
Nearly 13 percent of patients were uninsured at the public hospital, compared to four percent and six percent at the not-for-profit and for-profit the researchers reported.
Although the public institution saw patients in a variety of diverse settings -- such as specialty clinics and surgery -- it worked really hard to obtain some payment from these patients and actually was much more successful at collecting a percentage of charges than was the for-profit, said Weiner.
The public hospital collected 67 percent of charges to self-pay patients, whereas the private hospital collected only 13 percent.
However, the public hospital actually had greater net losses in caring for the uninsured than the for-profit or the not-for-profit.
"The for-profit basically took its losses and seemed to say, 'We'll just see these folks in the emergency department, we won't work too hard to get money from them, and so be it,'" said Weiner. "And, not surprisingly, the not-for-profit fell in between."
Self-pay patients accounted for only 20 percent of bad debt at the for-profit hospital, compared with 52 percent and 76 percent of bad debt at the not-for-profit and public hospitals.
"For the uninsured, it's a pretty capricious system," said Weiner.
"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. They are getting care from a set of institutions that are uncomfortable and unsure about what it is they want to provide."
The study is published in the August issue of the journal Medical Care.
The study was funded by the Robert Wood Johnson Foundation and the Veterans Administration.
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