Thursday, May 7, 2009
Your Thoughts Exactly: Handling patients who can't afford to pay
With the economy uncertain and unemployment rising, ACP Internist readers reported they are facing patients in their offices who are ill, but unable to pay for health care. The situation has left many physicians with the unexpected dilemma of how to treat such patients while also trying to manage a practice. Or worse, patients may not seek health care at all, an option suspected by virtually all respondents in our latest poll, Your Thoughts Exactly: Caring for unemployed/uninsured patients.
Results were collected anonymously throughout April. The results are not scientific and do not reflect any ACP policy, and are reported for their news value only.
When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
Options (respondents could choose more than one; n=73)
- I've offered free care or reduced payments. 66.7%
- I've offered free samples for prescriptions. 61.1%
- I've referred them to community clinics. 34.7%
- I've reduced or eliminated co-pays. 18.1%
- I've deferred billing. 16.7%
- I've had to refuse care to delinquent patients. 6.9%
- I've let the front desk handle it. 6.9%
Among those who offered other options, hospitalists who responded are generally able to refer to their own facilities. One reported, "As a hospitalist I try to take care of them as I do the others ... but I have the devil's own time getting consultants to see them, and arranging outpatient follow-up is often difficult or impossible."
Another respondent said, "I have the luxury of practicing in an academic setting where most of these decisions are made for me. I would hate to be faced with the situation of not providing care due to inability to pay. I can say that since our institution has implemented a co-pay policy, attendance at our resident teaching clinics has fallen off dramatically. I see a future where residents graduate with even less ambulatory care experience than they're already getting."
Office-based practitioners are setting up payment plans, steering patients toward low-cost or no-cost generic options through their local chain pharmacy or grocery. A few have some sort of sliding scale for payments; others suggested downcoding services, even comprehensive exams, so the overall cost would be less.
"I provide them information on how to shop for their prescriptions, explain the excessive cost of needless over-the-counter products, attempt to keep the costs of tests and other health care to a minimum, refer to the physicians who will provide the same level of care and concern that I have whenever possible; I also refer to the state."
Many are referring to local support groups or working at free clinics--in one case the doctor opened a free clinic. Many physicians are doing more chronic care management by phone, which as one person said, "I have done it in previous recessions."
Nearly all (72 of 73 doctors, or 98.6%) said that they know or suspect their patients are skipping needed care, while the other respondent replied he or she wasn't sure. Among the patients suspected of skipping care, they were thought to be rationing medications or not coming back for follow-ups. "I suspect this is a much bigger problem than any physician actually knows about," one physician added.
One doctor suggested a way to prevent losing patients to follow-up: "Be sensitive to proud patients who do not want to admit they are having financial troubles."
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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One of the most popular anonymous blogs written by an emergency room physician.