Practice pressures diminish charity care

If you're feeling like you have less time or income to provide charity care to patients, you're not alone.

About three in four doctors provided free care to patients at offices, hospitals and clinics in 1996-97. But that number dipped to two in three doctors in 2004-05, according to a national study by the Center for Studying Health System Change, a nonpartisan policy research organization based in Washington, D.C.

The decline means a shrinking safety net for a rising number of uninsured, which climbed from 39.6 million Americans in 2000 to 45.5 million in 2004.

Physician leaders said the study's findings are a wake-up call that something needs to be done to provide insurance to those without it. They also said the study correctly highlights how increasing time demands and financial burdens make it more difficult for physicians to provide free care.

"Charity care is not the solution to the problem of the uninsured in this country," said American Medical Association President J. Edward Hill, MD. "We've got to address the uninsured problem to stop the escalation of people going on the uninsured rolls."

Researchers examined data from surveys of 12,000 physicians in 1996-97, 1998-99 and 2000-01 and of 6,600 physicians in 2004-05. They found that 68% of doctors provided free or reduced-cost care in 2004-05, down from 76% of physicians in 1996-97. Despite the percentage point drop, the actual number of physicians providing charity care remained stable, because the pool of practicing physicians expanded. But the number of charity care hours per 100 uninsured patients declined from 7.7 hours in 1996-97 to 6.3 hours in 2004-05, an 18% decrease.

"If there are more uninsured and less charity care, clearly some of the uninsured are going to suffer," said Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change.

Other study findings:

• Among specialists, surgeons are most likely to provide charity care, probably because they are on call at hospitals and have less choice about treating uninsured patients. Pediatricians are least likely to do charity care, perhaps reflecting that fewer children are uninsured because of more generous public coverage eligibility.
• Charity care is highest in solo or small group practices, likely because they have more control over the types of patients they treat and there are fewer organizational barriers to see the uninsured. But a decreasing number of physicians are in solo practice.
• Physicians with the highest incomes did the most charity care, with 76% of doctors with practice incomes more than $250,000 providing care compared with 66% of doctors earning less than $120,000.

A changing practice environment

The study concluded that financial and time pressures, along with changes in the medical marketplace, might account for the decline in charity care. For example, lower reimbursements have hurt physician incomes, and shrinking incomes make it more difficult for doctors to subsidize charity care, according to the study.

"It's a combination of financial pressures as well as other pressures. Physicians are feeling pretty financially squeezed," said study co-author Peter J. Cunningham, PhD, senior researcher for the Center for Studying Health System Change.

Dr. Hill said young doctors might be discouraged, because they have amassed an average $119,000 in debt from medical school.

"You might not think about doing that much charity care when you've got that kind of debt," he said.

A 2001 AMA survey found 65% of physicians provided charity care, spending an average of 7.5 hours a week doing so. The average value of care provided was $54,468.

"We certainly encourage charity care where it's necessary and people don't have the financial means to be taken care of," Dr. Hill said.

C. Anderson Hedberg, MD, immediate past president of the American College of Physicians, agreed that the decline reflects trends in medicine. Physician salaries are shrinking, and doctors are having to see more patients. "It leaves less slots open for them to do charity care," said Dr. Hedberg, of Chicago.

Charles Willson, MD, president of the North Carolina Medical Society, said, "In order to make ends meet, physicians are having to see more patients each day. I'm surprised physicians continue to do as much charity care as they do, but it's part of our professionalism."

Internist David Gregory, MD, makes it a point to volunteer, despite increasing time and financial pressures. He provides charity care each Monday evening at a faith-based primary care clinic in Tennessee, often treating uninsured patients. "We're seeing a generous giving by volunteers," said Dr. Gregory, assistant professor of medicine in infectious disease in the department of medicine at Vanderbilt University School of Medicine in Nashville.

As a volunteer with the Judeo Christian Health Clinic, Tampa, Fla. general surgeon Sylvia Campbell, MD, also provides care to patients who don't have insurance.

"People who go into health care go into it to help people who are hurt and who are suffering. That is what the heart of being a physician is," said Dr. Campbell, who was awarded a Pride in the Profession Award this year by the AMA Foundation.