No, say Jonathan Gruber and David Rodriguez:
We measure uncompensated care as the net amount that physicians lose by
lower payments from the uninsured than from the insured. Our best
estimate is that physicians provide negative uncompensated care to the
uninsured, earning more on uninsured patients than on insured patients
with comparable treatments. Even our most conservative estimates
suggest that uncompensated care amounts to only 0.8% of revenues, or at
most $3.2 billion nationally.
Can any of you find an ungated copy of this paper?
Wow, this certainly shakes up some deeply held beliefs of mine.
I had always thought the exact opposite. Unfortunately, deeper comment will require reading the full paper.
Robin, would you write (if you haven’t already) about the economics of why academics accept the terrible deal they get from the publishers of academic journals? Why they publish in places that make it extremely difficult for the public-at-large to view their work?
Their data seems to include only office visits, which wouldn’t take into account uncompensated care provided during hospital admissions or ER visits. I would suspect these are two major sources of uncompensated care.
Doctors don’t have to see uninsured patients in their offices. I’ve even heard of private docs calling 911 to transport an uninsured patient to the ER– from the doctor’s own waiting room– instead of risking non-payment.
I’d suspect the results here are perhaps a lower bound for the amount of uncompensated care.
If the paper only looks at office visits, I’d say that would be a very skewed set of data.
Anecdotally, I would say that I’ve observed that the insured make more office visits compared to ER visits, and the uninsured tend the other way. I think there is a perception (true or not) among the uninsured that it’s either not possible, or is a difficult or time-consuming process, to become a new customer of a general practitioner.
Thus many treat the ER as a kind of substitute. They don’t do regular office visits or checkups, and will not bother to get set up with one in order to see them over what they perceive to be more minor health complaints. Often they will later end up in the ER if what starts off as a minor pain or illness gets worse because it goes untreated. Oddly enough, uninsured persons also seem to go to ERs for more minor things than the insured, such as when a child has a nasty cold/flu, something that an insured person would be more likely to schedule an office visit with their general practitioner for. The ER is seen as the convenient, if not the only, alternative available to the uninsured.
Gotta see the paper, this really bothers me.
Background: accounting, budgeting and financial analysis for physician
groups for 30 years.
I have never in 30 years found a medical practice ( 1 to 100
doctors) in which this would be true (excepting cash only service
providers, and odd practices, e.g. dermatology).
Since the majority of practices either don’t track this well or track it
inconsistently, how would an economist gather the data?
For many docs the ER is a place where uncompensated care is
routine and extensive (the orthopaedist on trauma call, for example).
How could this be? Well, many uninsured patients do pay some or all
of their bills. Some services (breast implants) are a strictly cash
business. Some wealthier people simply pay cash. Add all of that up
and it still doesn’t work for me.
My girlfriend is a nurse case manager at a major teaching hospital in Boston. She had this same debate a couple years ago with some left-leaning (Gee, in Boston? Go figure) colleagues, so she decided to track the insurance status of her cases. Her purview is Neurology only. In 18 months:
Mass Health (Medicaid)-33%
Medicare-27%
Private insurance-21%
Uninsured-19%
We see that almost 80% of her clients’ care was paid at well below “market” rates (Medicare/Medicaid) or vastly below (uninsured) from the infamous “Free Care Pool” set up by the commissars her in the People’s Republic of Massachusetts.
How long is this sustainable?
My girlfriend is a nurse case manager at a major teaching hospital in Boston. She had this same debate a couple years ago with some left-leaning (Gee, in Boston? Go figure) colleagues, so she decided to track the insurance status of her cases. Her purview is Neurology only. In 18 months:
Mass Health (Medicaid)-33%
Medicare-27%
Private insurance-21%
Uninsured-19%
We see that almost 80% of her clients’ care was paid at well below “market” rates (Medicare/Medicaid) or vastly below (uninsured) from the infamous “Free Care Pool” set up by the commissars her in the People’s Republic of Massachusetts.
How long is this sustainable?
I don’t have the cite anymore, but some time ago I read that gunshot injuries are among the worst things from a hospital’s financial point of view because something like two-thirds of them involve uninsured (and usually low-income) people. They also can be extremely expensive to treat.
“I’ve even heard of private docs calling 911 to transport an uninsured patient to the ER– from the doctor’s own waiting room– instead of risking non-payment. ”
Doctors offices call 911 because a medical situation has developed that requires emergent care,
and the office is not equipped to provide such care. Insurance status is not relevant.
Standard protocol is for the doctor to provide triage care will waiting on EMTs. EMTs are equipped and trained to transport.
If the office transfers a non-emergent patient, that is not proper.
This is the key sentence in the paper, describing their assumptions / methodology:
“For example, if an uninsured patient receives a procedure with a list price of $200, but insurance companies would only pay that doctor $90 on average, we say that patient received $90 worth of care. If the patient paid nothing, we
call that $90 of uncompensated care.”
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treat erectile dysfunction (ED). Consistent with the effects of PDE5 inhibition, administration of Levitra with nitrates and nitric oxide donors is
contraindicated. Caution is advised when PDE5 inhibitors, including Levitra, are used
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