"Charity Care"

[docB]

Here's the article (it's short, c'mon read it):
http://www.foxnews.com/story/0,2933,189075,00.html

So fewer docs are giving out free care and it will drive more patients into the ER. No surprise there. It's going to get worse? No surprise there either.

This quote really bugs me though: "The highest rate of free care, 78.8 percent, comes from surgeons, perhaps because many of these doctors treat uninsured patients in emergency rooms."

It just goes to show how little people understand about EM and EPs. I can sometimes get a surgeon to take an acute appy or other truly emergent pt to the OR but other than that they never set foot down here. They are sure not hanging around in the ED giving out free care and hugs and foot massages to the indigent like the article makes it sound.

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[Telemachus]

Here's the article (it's short, c'mon read it):
http://www.foxnews.com/story/0,2933,189075,00.html

So fewer docs are giving out free care and it will drive more patients into the ER. No surprise there. It's going to get worse? No surprise there either.

This quote really bugs me though: "The highest rate of free care, 78.8 percent, comes from surgeons, perhaps because many of these doctors treat uninsured patients in emergency rooms."

It just goes to show how little people understand about EM and EPs. I can sometimes get a surgeon to take an acute appy or other truly emergent pt to the OR but other than that they never set foot down here. They are sure not hanging around in the ED giving out free care and hugs and foot massages to the indigent like the article makes it sound.

Let's not forget that when they say surgeons provide free care, they probably just mean that the surgeon waived their fee. The patient probably still gets a bill from the gas man, the hospital, etc. that they can't/won't pay anyway.

 

[ERMudPhud]

I read the article yesterday and thought it was interesting that it said surgeons had the highest rate of charity care. The rate was defined I think as seeing at least some charity cases in the last year. Which to me meant we have the highest rate. I can't imagine an EM doc who hasn't seen at least some "Self-Pay" patients in the last year.

 

[GeneralVeers]

Part of the issue is liability. The charity cases tend to have higher liability, due to poor social/financial standing, lack of follow-up, and co-morbidities.

Why would I want to see the non-paying patient and risk getting sued?

Patients should waive the right to sue if they want free medical care, otherwise they should should seek another provider who's willing to be sued.

 

[bulgethetwine]

Part of the issue is liability. The charity cases tend to have higher liability, due to poor social/financial standing, lack of follow-up, and co-morbidities.

Why would I want to see the non-paying patient and risk getting sued?

Patients should waive the right to sue if they want free medical care, otherwise they should should seek another provider who's willing to be sued.

I call "A comment wholly without basis" on that one....


While I won't argue with you about them having poor social/financial standing, lack of follow-up, and co-morbidities, I don't think this translates into higher liability. For one, there is no proof that they are any more/less litigious. Second, even if they were, it is unlikely -- for the same reasons -- that they would pursue it through the judicial system.

 

[a_ditchdoc]

"For one, there is no proof that they are any more/less litigious. Second, even if they were, it is unlikely -- for the same reasons -- that they would pursue it through the judicial system"


I am afraid I have to disagree with you. Although I cannot speak from statistics, in my experiences in the medical community, both the observed and threatened lawsuits were largely from the lower socioeconomic class. If an upper middle class family got rear ended at a low speed, no problem "We're all ok". The same scenario with a poor family, noone could walk to the ambulance...all boarded. If two poor families were in an accident, the ones not at fault would go to the emergency department, the driver at fault was invariably ok.

I know this sounds biased, and I certainly don't mean for it to be, but this has been my experience and probably the experience of many others. While you quote poverty as being a reason someone is less likely to sue, keep in mind that poor people are also generally less educated and will therefore not understand mistakes, have more of an incentive to pursue money, and are often enticed by personal injury lawyers to sue without cost, only a percentage of the award.

I am all for Charity care. But, I also agree that when provided, the liability of the physician should also be reduced or eliminated. Otherwise, why assume risk without the potential for benefit?

 

[CS_22]

"For one, there is no proof that they are any more/less litigious. Second, even if they were, it is unlikely -- for the same reasons -- that they would pursue it through the judicial system"


I am afraid I have to disagree with you. Although I cannot speak from statistics, in my experiences in the medical community, both the observed and threatened lawsuits were largely from the lower socioeconomic class. If an upper middle class family got rear ended at a low speed, no problem "We're all ok". The same scenario with a poor family, noone could walk to the ambulance...all boarded. If two poor families were in an accident, the ones not at fault would go to the emergency department, the driver at fault was invariably ok.

I know this sounds biased, and I certainly don't mean for it to be, but this has been my experience and probably the experience of many others. While you quote poverty as being a reason someone is less likely to sue, keep in mind that poor people are also generally less educated and will therefore not understand mistakes, have more of an incentive to pursue money, and are often enticed by personal injury lawyers to sue without cost, only a percentage of the award.

I am all for Charity care. But, I also agree that when provided, the liability of the physician should also be reduced or eliminated. Otherwise, why assume risk without the potential for benefit?

In Kansas there is a tort fund that is set aside by the government to protect and pay out for any lawsuit brought by someone receiving charity care. The only stipulation, is that the medical provider has to be registered as a charity care provider.

Its nice to know that you don't have to look over your shoulder when you're providing free care, and that the state is more than willing to help in the event of a mistake.

Don't know that this applies anywhere else though...

 

[f_w]

Some people here seeem to confuse 'Charity care' with 'unpaid bills written off as uncollectable after 90 days'.

Charity care is if you waive your fee up front for a patient who has problems to get medical care due to financial constraints. Typically these are established patients who loose their insurance coverage or relatives of established patients. And yes, surgeons and surgical specialists will relatively often do this (at least around here). Most non-profit hospitals have policies that allow the hospital to waive or discount their fees if a case is admitted/posted as charity care. (patients have to provide information regarding their financial status in order to get this waiver). The problem is often to get other physicians (anesthesia, pathology) involved in these cases to waive their fees as well, they might not have the same motivation as the surgeon to provide care to a particular patient for free.

It's only charity if you intend it to be for free. If someone you treated in the ED turns out to be a deadbeat who evades the calls of your business office, it's not charity.

The numbers on how often various specialties provide true charity care are naturally skewed. An ED doc (or other hospital based specialty) rarely has the option to decide up front whether he will see a particular patient as charity care, they just roll through your door and you have to figure out the financials later.

Some states have programs where the state indemnifies you for anything but 'gross neglect' for care provided at registered free clinics (usually outside of your primary practice).

I don't have numbers to support this, but due to the wonderful system of contingency fee lawyers, the socioeconomic status of patients has no negative influence on their ability to bring bogus suits. Every downtown hospital has a cluster of store-front ambulance chaser law-offices offering free consultations to the wronged masses.

And yes, I think the ability to sue should be restricted to patients who paid their bill (and I mean within the typical time frame, not 2 days before the suit is filed).

 

[ERMudPhud]

Some people here seeem to confuse 'Charity care' with 'unpaid bills written off as uncollectable after 90 days'.

The methodology for the study was a telephone interview of physicians asking, "Did you provide any charity care within the last month" The definition of charity care was left up to the respondent.

I would define charity care as providing excellent care even when you know darn well there isn't a chance in a hell you are going to get paid. Based on that definition when I suture a complex lac on somebody whose chart says insurance=self-pay and address=none I would call that charity care. After all even if you wanted to bill them you couldn't. Based on that definition I still say EM docs would answer yes to the charity care question even more than the surgeons did. I'm not complaining because one of the things I like about EM is that we treat everyone without regard to their ability to pay but I think the survey must not have included us.

 

[f_w]

The methodology for the study was a telephone interview of physicians asking, "Did you provide any charity care within the last month" The definition of charity care was left up to the respondent.

I am not defending the methodology of the study.

I think the widely reported conclusion of the study that 'surgeons provide freee care in ERs' is nonsense. But the fact remains that surgeons often provide charity care for semi-elective procedures while other specialties will see the same patient more often in a 'bad debt' scenario.

when I suture a complex lac on somebody whose chart says insurance=self-pay and address=none I would call that charity care.

That is one way of looking at it. In addition, you are fulfilling a legal mandate.

 

[bartleby]

Your mileage may vary. The upper crusters from the 'burbs are the first ones to drop names, think they've got it all coming and mention that, oh, by the way, their relative/good friend X is the senior partner of the local ambulance chaser law firm who will "sue you if you screw up". I'm always that people think that threatening their healthcare provider in advance of any bad outcome (to ward off the bad spirits?) in some way guarantees quality medical care.

There are plenty of people who take advantage of the system in every social strata. But in my experience, the rare person who actually says "thank you" is the one who realizes that they didn't have a whole lot of other treatment options other than my ED.

I am afraid I have to disagree with you. Although I cannot speak from statistics, in my experiences in the medical community, both the observed and threatened lawsuits were largely from the lower socioeconomic class.

 

[mikecwru]

That is one way of looking at it. In addition, you are fulfilling a legal mandate.

We are legally mandated to treat life threatening conditions and people in active labor, which the majority of work in the ED is not. The majority of people I see are uninsured and I still treat them anyway. I order their tests, provide their care, etc, the same as I would for someone with insurance, which is more than I can say for other specialties. As ErMudPhud said, I would call this charity care if I did this with full knowledge that I would never see a dime. It's not like we're surprised everytime someone doesn't pay a bill.

The EDs are the backbone of the healthcare system, especially for the under/uninsured.

mike

 

[f_w]

We are legally mandated to treat life threatening conditions and people in active labor, which the majority of work in the ED is not.

So you think you provided the standard of care if you do your 'screening exam', decide that a complex lac is not life threatening and send the patient back out into the world with a couple of 4x4s and a paper tape slapped on the injury ?

The EDs are the backbone of the healthcare system, especially for the under/uninsured

Nobody disputes that. When it comes to primary care EDs are the safety net providers in many areas of the country. But you are certainly not the only ones treating patients for free.

 

[ERMudPhud]

So you think you provided the standard of care if you do your 'screening exam', decide that a complex lac is not life threatening and send the patient back out into the world with a couple of 4x4s and a paper tape slapped on the injury ?

No, but we would have fulfilled the legal mandate you mentioned. Everything beyond that is precisely charity care. We all do it every day and most of us gladly but to say that surgeons (at 78% participation) provide the most charity care is I think a product of ED docs not being surveyed. That or the surveyed ED docs aren't aware when they are providing free care. I know that I never bother to look at the patient demographic sheet unless I am trying to arrange followup. If see the dreaded selfpay/no address I know followup is going to be impossible so I will often have them come back to the ED (more charity care) for their wound care etc...

A more meaningful measure than this phone survey would be the total dollar value of free/charity/uncompensated care provided nationwide broken down by specialty. I suspect the surgeons would come out on top here since the value of the free care we provide is quite low compared to the cost of say a multisystem trauma with a 1 month SICU stay.