MEDICAL MARKETS

Charity care: Picking up the tab

The pressures of managed care may end up cutting down on charity care, but efforts are under way to make it easier for physicians to consider working on more free cases.

By Leigh Page, AMNews staff. April 17, 2000. Additional information

A patient needs the fibroids in her uterus removed, but she cannot afford the operation's $4,500 cost, and as a noncitizen she doesn't qualify for Medi-Cal or other government programs.

So Dr. Johnson will do the surgery free this month at Cedars-Sinai Medical Center.

He said he performs free surgery very seldom because reimbursements for California surgeons have fallen, and "no one can afford to be this involved more than once or twice a year."

As well as not generating income, the operation takes a big bite out of his time.

For this free operation, Dr. Johnson has spent eight to 10 hours arranging operating room time, securing the free services of a surgery team and making sure the hospital doesn't charge his patient.

He said these arrangements were actually quicker for him than they would be for other surgeons, because he has connections at Cedars-Sinai as its former chief of staff.

Dr. Johnson isn't a rare case. Pressures on doctors in managed care markets to see more patients and to preserve their income are threatening the age-old practice of giving free care to patients who need it.

A study published in the March 24/31, 1999, issue of the Journal of the American Medical Association found that physicians with a high percentage of managed care revenue were considerably less likely to provide charity care.

Studying physician survey data from the national Community Tracking Study in 1996 and 1997, the authors found that physicians deriving at least 85% of their revenue from managed care provided half as much charity care -- about five hours a month on average -- than those with much less managed care revenue.

A reduction in physicians' ability to provide charity care has grave implications for the health care system, the authors of the study said. Doctors provide an estimated $11 billion in charity care each year, and the physician's office is the sole source of care for one-third of uninsured persons, the authors said.

Losing doctors' free care comes at a time when the uninsured have grown to 44 million nationwide and other sources of charity care -- hospitals, academic medical centers and community health centers -- are undergoing cutbacks in federal funding.

Pressures on free care

Although JAMA's survey information may seem dated, the forces it portrays are still true today.

Doctors are still committed to charity care, typically logging about 10 hours of care a month nationwide, according to the JAMA study, said Robert F. St. Peter, MD, a co-author of the study and president of Kansas Health Institute in Topeka.

But Dr. St. Peter added, "Physicians are not immune from the financial motivation. You have to think about making the revenue to keep the practice open."

Surgeons who do charity care on their own face particularly high hurdles, said Ed Whitman, MD, part of a three-member surgery group in Hayward, Calif., near San Francisco, who participates in Operation Access, a Robert Wood Johnson Foundation-funded charity care project.

Surgeons have to make more arrangements than a primary care physician, and sometimes hospitals refuse to cooperate, citing crowded schedules, potential liability or simply a preference for their own indigent care programs, he said.

Dr. Whitman also reported that many doctors in the Bay Area have little interest in charity care. Indeed, the JAMA study found that doctors in the same geographic area tend to agree on the appropriate level of charity care, and that level is lower in areas with more managed care.

Neither of Dr. Whitman's partners does charity work. He said one of them could afford to do so, but told him: "At this stage in my career, I just don't have the time to do things for gratis."

The JAMA study also found that physicians in large groups -- very common in managed care markets like California -- are less likely to provide free care. This is likely because they have less discretion over the facilities or their work time, said Glennah Trochet, MD, who helped organize a charity care program in Sacramento, where she is the county health officer.

Although a medical group's leaders usually agree to allow charity work when approached, colleagues may get upset when a volunteer doctor is using company time and thus forces them to treat more paying patients, she said.

"Everyone is overworked, and there are so many patients to see," Dr. Trochet added.

Physicians interested in charity work also are discouraged by the clinical paperwork they must fill out even for free care, with yet more forms needed to qualify for government or private programs to help pay for the care, Dr. Trochet said.

Twenty years ago, "a doctor would see a patient deserving charity care and say, 'Yeah, I can do that,' just like that," she said. "Now there's a lot more bureaucracy."

Rekindling doctors' interest

Stripping away the paperwork has been the key to successful efforts to rekindle doctors' interest in charity care.

For example, many physicians are renewing their commitment to charity care through a host of programs nationwide that do all of the organizing, leaving physicians to do just the medicine. Many of these programs got their start with $12 million in grants distributed by Robert Wood Johnson Foundation's Reach Out program from 1993 to 1999.

During three years of its operation, the grants helped fund charity care for 200,000 patients by 11,200 volunteer physicians.

The success of such an approach proves that "doctors are willing to volunteer if you make it easy for them," Dr. Trochet said.

Dr. Trochet said she began to understand the effect of red tape in 1994, when her understaffed county clinics in Sacramento tried to attract volunteer doctors.

To lure orthopedic surgeons to mend broken bones at the clinic, she promised that her staff would handle all the arrangements and even write up their medical charts. She received a call back from the head of one of the biggest orthopedic groups in town who could scarcely believe it: "Do you mean there is no paperwork?"

Yes, she said. And the orthopedic surgeons arrived to help. The program now operates as a communitywide venture called Spirit.

Hundreds of physician volunteer programs nationwide follow Spirit's basic format, said H. Denman Scott, MD, director of Volunteers in Health Care in Pawtucket, R.I., which is continuing the Robert Wood Johnson grant program on a much smaller budget.

Experience from the grant program shows that charity care organizations must have one or more full-time staffers to be effective, he said. The staff raises funds, recruits volunteers, arranges schedules, and works with hospitals and specialists. It also collects applications for free care, which are reviewed by doctor advisers.

Dr. Scott said an organization helps shield doctors from more requests. "If you did this on your own, you can be overwhelmed with requests because you're known as the good guy," he said.

Douglas Grey, MD, a thoracic surgeon at Kaiser Permanente, said he has no trouble getting staff to volunteer for charity surgery for Operation Access, where he is medical director and a participating surgeon.

A sign-up sheet in the doctors' lounge is filled within two days. The organization relies on 130 medical volunteers, 20 to 25 of whom are surgeons. They've done 450 relatively simple operations so far, such as breast biopsies and hernia repairs, for uninsured people who earn too much to qualify for Medi-Cal.

Worried about liability, hospitals have refused to allow the group to perform more complicated surgery, but Dr. Grey said none of the operations had had any complications.

He said the volunteers usually do their work on Saturdays on their off time, when the OR is less crowded. Sometimes surgery teams doing paid work come at the same time, and "they look morose and sad," Dr. Grey said. "It's like they're saying, 'Why am I here on Saturday?' "

He said it actually takes the paid team longer to do the same amount of work as the volunteers.

In contrast, the volunteers' mood is "like a party," Dr. Grey said. They eat brunch together, and the high point is sharing flan baked by one of the surgery nurses.

Dr. Trochet reported the same happy spirits among volunteer physicians who work in the Sacramento clinic on their vacation days.

"Our volunteers have told me they like having no time pressures so that they can spend as long as they want to, and patients are so grateful."

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Physicians' charity care is:

• Typically 10 hours a month
• Valued at $11 billion a year
• The only source of health care for one-third of the uninsured

Source: Journal of the American Medical Association, March 24/31, 1999

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Box: Charity in practice