Charity care by doctors falling off, says survey

WASHINGTON -- The portion of doctors providing charity care is falling, a sign of tight times that makes it harder for the uninsured to get health care.

Most doctors do some charity care but in most cases it represents a small fraction of their work. The portion spending more than 5 percent of their time with these patients is falling, however.

"Physicians are under a lot of growing financial pressures," said Peter Cunningham, who wrote the report for the Center for Studying Health System Change, a health policy think tank that conducts the ongoing survey of doctors. "This may be making it more difficult to serve uninsured patients."

Its survey found that in 2001, 71.5 percent of doctors provided free care. That's down from 76.3 percent in 1997.

The results are similar to those found by the American Medical Association, which also saw a drop in charity care between 1994 and 1999 in a survey it conducted of doctors.

The result is less care for people who can't afford it.

A companion survey by the Center for Studying Health System Change found that between 1997 and 2001, the portion of uninsured people who had seen a doctor or who had a usual source of medical care dropped.

Specifically, in 1997, 51.5 percent of the uninsured had seen a doctor in the last year. That fell to 46.6 percent by 2001. Over the same period, the portion of patients with Medicaid and with private insurance who had seen a physician stayed even or rose.

The report suggested that doctors are facing the financial squeeze from several quarters, leading them to do less for free. Payments for Medicare, which serves the elderly, and Medicaid, which serves the poor, aren't keeping pace with the rising cost of health care, and health insurance companies have kept a tight rein on reimbursements through managed care.

Doctors also complain about the rising cost of malpractice insurance.

Worse for Medicaid

The situation for Medicaid may get even worse in coming months as states facing budget shortfalls look to Medicaid, which generally makes up one-third of state budgets.

The survey of doctors found that the portion seeing Medicaid patients dipped between 1997 and 2001, from 87.1 percent to 85.4 percent. But it also found an increase in the number of practices that derived more than 20 percent of their income from Medicaid, suggesting the Medicaid patients are concentrating among fewer doctors.

Not so for those providing charity care. In this case, the portion of high-volume providers fell as the portion of low-volume providers rose. That means that doctors who do provide charity care were providing less of it -- and fewer total doctors were providing any at all.

The survey also found that doctors who are heavily involved with managed care -- receiving more than 75 percent of their income from health maintenance organizations and other plans that cap payments -- are more likely to have closed their practices to new Medicaid and Medicare patients. These same practices were still taking new privately insured patients.