This survey of primary care sites represents a novel approach to understanding issues and obstacles associated with accessing care if uninsured. Findings from this survey are notable for the conflicting policies that exist in many sites that potentially exclude patients from primary care. While the vast majority of sites surveyed reported they were accepting patients without health insurance, they also reported billing practices that are likely prohibitive, particularly for lower-income individuals. Over 70% of sites required full payment at the time of service, with professional fees between $51 and $100 dollars at almost 40% of all sites. At the same time, 36% of sites reported offering discounted-fee care, 39% provided free care, and 77.6% provided payment plans for medical bills. It is unclear from our survey how well advertised or consistently applied these policies are, particularly given the overlap in sites reporting both full payment at the time of service and the availability of payment plans. Findings from an earlier consumer survey indicated that most patients were not aware of the payment options of their providers (TPO, unpublished data, 1999). There were also significant limitations on the type of care made available to uninsured patients. Almost one in three sites limited care to only acute problems and a similar proportion to only chronic conditions. This is consistent with findings by Woolhandler et al. that fewer preventive services are available to uninsured persons.15
Site characteristics associated with different policies regarding care of uninsured patients are notable given the current market trends toward more consolidation, mergers, and purchases of smaller practices. Sites with more physicians on staff and those located in urban areas were less likely to accept uninsured patients. This may represent a confounding association of more large sites being located in urban settings. Alternately, the association between larger practices and uninsured care policies may reflect more restrictive business plans at these sites that preclude uninsured care. Practices in urban areas, where there is a greater concentration of uninsured and Medicaid populations, may have either reached a capacity for uninsured patients or be operating at a lower profit margin that precludes this care. Alternately, in urban settings where there are more community health centers for referrals, sites may feel less civic obligation to provide care to uninsured patients. Additional research is needed to clarify these findings.
Compared with physician-owned practices, hospital/health system–owned and larger group practice–owned sites were less likely to offer discounted-fee care, free care, or payment plans. These findings are consistent with a previous study13
and may reflect centralized billing and policy making along with a greater reliance on contracted billing services by health systems and large group practices. At physician-owned sites, where there is greater autonomy and on-site control in policy decisions, a greater proportion accepted patients without insurance and provided discounted-fee or free care and payment plans. That physician-owned practices more commonly require payment at the time of service may reflect smaller operating margins and more strained revenue streams. Since all of the hospitals and health systems in Allegheny County are not-for-profit, this designation does not seem to define practice behavior.
These findings have several policy implications. First, the data suggest that a willingness to accept patients without insurance does not always equal access to affordable care, and office policies have the potential to be a substantial obstacle to accessing primary care. As researchers assess community health access, it is important to take a more in-depth approach that accurately describes true health services availability. Second, uninsured adults need greater availability of free care and discounted-fee care. It is unclear how well-informed patients are regarding office policies. The current trends in health care consolidation make it unlikely that the practice of free and discounted care will expand without an external stimulus. Further work is needed to determine whether this care needs subsidization from a pooled “charity fund” or other incentives for more sites to participate. Finally, the issue of disproportionate share of uninsured care and the need to better coordinate available services among primary care sites is inferred by the urban/suburban distinction in uninsured care policies.
This survey has several limitations. First, it is a survey of only those sites listed in the telephone directory available to the general public and may not be entirely representative of primary care sites in the region. We purposely excluded those care sites specifically chartered to care for uninsured patients, to center our evaluation on the willingness and availability of the broader medical community to care for those without health insurance. The data presented here are self-reported, typically by office staff, to a public health agency–sponsored survey and may not necessarily reflect what actually takes place at that site. We did not confirm our findings with documented office policy or actual patient experience. Finally, the data represent findings from only one region and may not be representative of other parts of the country. However, Pittsburgh, like many metropolitan areas, has recently undergone a period of practice buy-outs and consolidations and has very high penetration of managed care, so we suspect that this environment is not unique.
In summary, barring a public policy breakthrough that expands the availability of affordable insurance to the 43 million Americans currently uninsured, we need to look to our existing systems of care to make it easier for uninsured persons to get primary and preventive care. This responsibility should be collectively shared.