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Charging Peter to examine Paul
POLICY
WATCH
men of becoming infected with HIV from a heterosexual partner. In fact, several studies of couples with one infected partner suggest that the relative efficiency of sexual transmission of HIV from male to female may be greater than that from female to male. The continued use and refinement of mortality statistics, AIDS case surveillance, and HIV seroprevalence surveys will be crucial to the documentation and analysis of the increasing impact of HIV on the health of women in the U.S. Although public education efforts have improved, they continue to be inadequate; policymakers must allocate and target more resources to campaigns that educate women in general, and high-risk women in particular, with regard to how they can adopt protective behaviors to stem the progression of this epidemic.-WBA
Charging Peter to Examine Paul [Blumenthal D, Rizzo JA. Who cares for uninsured persons? Med Care 1991; 29: 502-20.1 [Hollernan MC, Loe HD, Selwyn BJ, Kapadia A. Uncompensated outpatient medical care by physicians. Med Care 1991; 29: f&54-9,]
n
timulated by institutional missions and Internal Revenue Service requirements for nonprofit status, American
3
IV
March
1992
The American
Journal
hospitals document the annual amount of uncompensated care they give. According to the American Hospital Association, $17.8 billion of uncompensated care was provided by hospitals in 1990. While physicians claim they too provide large amounts of charity care, there is a frustrating lack of documentation about the magnitude of this care either in the hospital or in the office. The articles by Blumenthal and Rizzo and by Holleman et al give some insight into the quantity of charity care provided by physicians. Blumenthal and Rizzo used a 1987 American Medical Association survey that asked a representative sample of physicians about their caseload of uninsured patients. On average, 11.4% of a doctor’s practice consists of uninsured patients. Self-employed physicians tend to see fewer uninsured patients (10.1%) than their employed colleagues (16.4%). The percent of uninsured patients in a practice varies across specialties, from a high of 17.4% in psychiatry to a low of 6.6% in the medical subspecialties. Female physicians have fewer uninsured patients than do male physicians, which may reflect a greater tendency to provide more care to Medicaid patients. Not unexpectedly, self-employed physicians practicing in areas of high poverty and unemployment have a higher proportion of uninsured patients. This analysis of physician responses to a questionnaire indicates first, that physicians “exercise considerable discretion” over who they will see, and second,
of Medicine
Volume
92
that employed physicians may be relatively protected from the disincentives to care for the uninsured. Third, there are more uninsured people in the population (15.5%) than uninsured patients (11.4%), and fourth, the uninsured have more difficulty seeing a physician than do Medicaid recipients. HolIernan and colleagues report on a survey of 549 physicians practicing in a community with a poverty rate of 30%. Almost 80% of the physicians report providing free or reduced-fee care, and there were no differences across specialty areas. Uncompensated care represents 7% of outpatient visits, and care to these patients constituted. 8% of a physician’s total monthly billings. On average, each physician was denied one patient hospitalization per month because of lack of insurance. Taken together, these reports provide a sobering picture of what’s happening out there in practiceland. Most doctors are providing some free or reducedfee care, perhaps as much as their practices can afford. Remaining are a large number of persons without insurance who simply don’t have an entree into the system. We all know these peoplethey overload the emergency rooms and outpatient clinics with the tragic consequences of untreated medical problems. In the face of this information, even the proposal “Fifty Hours for the Poor” (JAMA 1987; 258: 3157) would hardly put a dent in the amount of unmet medical care needs for the uninsured. -MM
WATCH
men of becoming infected with HIV from a heterosexual partner. In fact, several studies of couples with one infected partner suggest that the relative efficiency of sexual transmission of HIV from male to female may be greater than that from female to male. The continued use and refinement of mortality statistics, AIDS case surveillance, and HIV seroprevalence surveys will be crucial to the documentation and analysis of the increasing impact of HIV on the health of women in the U.S. Although public education efforts have improved, they continue to be inadequate; policymakers must allocate and target more resources to campaigns that educate women in general, and high-risk women in particular, with regard to how they can adopt protective behaviors to stem the progression of this epidemic.-WBA
Charging Peter to Examine Paul [Blumenthal D, Rizzo JA. Who cares for uninsured persons? Med Care 1991; 29: 502-20.1 [Hollernan MC, Loe HD, Selwyn BJ, Kapadia A. Uncompensated outpatient medical care by physicians. Med Care 1991; 29: f&54-9,]
n
timulated by institutional missions and Internal Revenue Service requirements for nonprofit status, American
3
IV
March
1992
The American
Journal
hospitals document the annual amount of uncompensated care they give. According to the American Hospital Association, $17.8 billion of uncompensated care was provided by hospitals in 1990. While physicians claim they too provide large amounts of charity care, there is a frustrating lack of documentation about the magnitude of this care either in the hospital or in the office. The articles by Blumenthal and Rizzo and by Holleman et al give some insight into the quantity of charity care provided by physicians. Blumenthal and Rizzo used a 1987 American Medical Association survey that asked a representative sample of physicians about their caseload of uninsured patients. On average, 11.4% of a doctor’s practice consists of uninsured patients. Self-employed physicians tend to see fewer uninsured patients (10.1%) than their employed colleagues (16.4%). The percent of uninsured patients in a practice varies across specialties, from a high of 17.4% in psychiatry to a low of 6.6% in the medical subspecialties. Female physicians have fewer uninsured patients than do male physicians, which may reflect a greater tendency to provide more care to Medicaid patients. Not unexpectedly, self-employed physicians practicing in areas of high poverty and unemployment have a higher proportion of uninsured patients. This analysis of physician responses to a questionnaire indicates first, that physicians “exercise considerable discretion” over who they will see, and second,
of Medicine
Volume
92
that employed physicians may be relatively protected from the disincentives to care for the uninsured. Third, there are more uninsured people in the population (15.5%) than uninsured patients (11.4%), and fourth, the uninsured have more difficulty seeing a physician than do Medicaid recipients. HolIernan and colleagues report on a survey of 549 physicians practicing in a community with a poverty rate of 30%. Almost 80% of the physicians report providing free or reduced-fee care, and there were no differences across specialty areas. Uncompensated care represents 7% of outpatient visits, and care to these patients constituted. 8% of a physician’s total monthly billings. On average, each physician was denied one patient hospitalization per month because of lack of insurance. Taken together, these reports provide a sobering picture of what’s happening out there in practiceland. Most doctors are providing some free or reducedfee care, perhaps as much as their practices can afford. Remaining are a large number of persons without insurance who simply don’t have an entree into the system. We all know these peoplethey overload the emergency rooms and outpatient clinics with the tragic consequences of untreated medical problems. In the face of this information, even the proposal “Fifty Hours for the Poor” (JAMA 1987; 258: 3157) would hardly put a dent in the amount of unmet medical care needs for the uninsured. -MM