The always excellent Manoj Jain writes a piece on the uninsured in the Washington Post. It seems doctors, consciously or not, treat those without health insurance differently.
Sometimes it can be in helpful ways, like giving generic medications instead of expensive brand names.
Most of the time however, being uninsured is a stigma when seeking care:
A 2006 study of 25 primary care private practices in the Washington area showed that in nearly one in four encounters, physicians reported adjusting their clinical management based on a patient’s insurance status; nearly 90 percent of physicians admitted to making such adjustments. For patients with no insurance, alterations occurred 43 percent of the time; and for the privately insured, just 19 percent.
Some behavior is downright disturbing:
A heart surgeon told me he operates on uninsured patients but schedules them for the end of the day; if other cases take longer than expected, the uninsured get bumped. Some gastroenterologists are quick to perform endoscopies or colonoscopies on insured patients; not so for the uninsured.
With some states considering cutting already low Medicaid payment rates, those with this insurance are rapidly joining the uninsured by being treated with preferentially poor care.
Some doctors don’t look at a patient’s insurance status prior to an office visit, although it can be difficult with that information often prominently displayed on the chart.
Most simply choose to practice in affluent areas with a favorable (i.e. a low proportion of uninsured or Medicaid) payer mix, as Dr. Jain admits to doing:
I do not discriminate at an individual level, but many doctors, including myself, discriminate more broadly by moving our clinics to wealthier parts of the city, for example. To compensate for the cost of treating uninsured patients (about 10 percent of my practice), I inflate my charges for all patients, thus increasing my income from commercial insurance.
{ 4 comments… read them below or add one }
This is especially funny as uninsured can also mean self-paying patients, which will pay the entire amount in cash… a better sum than the insurance pays. The doctor’s dream patient these days!
This happened to me when I brought my father from out of country to the doctor. My PCP doctor that did not look at the insurance, treated us in the same rushed way as any other patient even though he was paid much better. The staff treated us like second-hand people. Finally the cardiologist asked about the insurance and treated us accordingly: advised against any expensive testing, explained why this is not necessary, and waived his fee. We still had to pay the administration/hospital fee and we waited forever for the doctor to see my father, but it ended up well.
If insurance status will change between 20-40% of treatment/test decisions I have to wonder whether that same proportion of treatments/tests are un-necessary.
For this discussion, it would be more useful to separate the uninsured patients who have the means to pay and expect to do so from those who believe the status of not having insurance is an entitlement to have charges deferred indefinitely or waived.
The former are welcomed. The latter present a threat and a burden to a private practice which does not have the privilege of not paying its bills or meeting its payroll.
I can completely understand the reluctance to take on a patient who shows indications of being unable to meet their payment obligations. “Need” notwithstanding, no one should think themselves entitled to charity or lenient terms, but too many do. I had one patient who ran up a big bill in my practice come back for more services and when asked for payment of her arrearage become angry because she expected that because her payment was so far behind she expected us to have written he charges off by that point. As if just not paying for a long enough time was somehow a way to make her obligations go away. As if the accounting treatment of unpaid charges somehow equated with some change in obligation to pay. Incredible.
It has been a very long time since most patients routinely were expected to pay all of their charges at time of service, and few really understand that credit from their doctor is not an automatic entitlement.
I find that the various types of cash patients make better use of my clinical skills. They aren’t simply looking for referrals to a specialist for each body part or every lab or x-ray test their friends told them about. We try hard to get their procedures done at outpatient facilities that charge them less than the local hospital.