U.S. teaching hospitals, many of which are located in inner-city areas, are often considered key providers of health services to uninsured and underinsured patients. However, a recent survey of teaching hospital faculty finds that such physicians may have difficulty accessing specialty care for their uninsured patients. The study from the Institute for Health Policy at Massachusetts General Hospital (MGH) appears in the November/December issue of Health Affairs.
"Our research suggests that the so-called safety net has more holes than previously thought," says Joel S. Weissman, PhD, the report's lead author. "Even patients who get initial access to care in our nation's teaching hospitals may have significant problems getting referred for specialty care and high-tech services or getting admitted for a non-emergency condition. What is notable is that these problems obtaining services occurred in both private and public institutions."
The research team surveyed more than 2,000 physicians at U.S. academic health centers who had provided direct patient care during the preceding year. Among the questions asked were whether the physicians were unable to admit uninsured patients or had to limit such patients' hospital care; how often they could obtain specialty referrals or advanced services - such as organ transplants or cardiac stents - for either insured or uninsured patients, and whether their physician group practices had policies limiting their ability to care for uninsured patients.
Among study respondents, about 25 percent reported problems with admitting an uninsured patient or having to limit that patient's care. Respondents were nine times as likely to report difficulty obtaining specialty care for their uninsured patients as they were for privately insured patients, with particular problems accessing non-emergency hospital admissions, high-tech services, and outpatient mental health and substance abuse services. For both admissions and specialty care, similar problems were reported for private and public institutions.
Formal practice policies limiting care to uninsured patients were reported by 13 percent of responding faculty. Factors cited as barriers to care of the uninsured included the fact that few such patients were referred, inadequate reimbursement for services, and a sense that - even in the absence of formal policies - providing such care was discouraged by their practice or hospital.
The authors note that efforts to provide services for the uninsured must go beyond primary care, which is the usual focus of existing safety net programs. They also note that several currently available sources of reimbursement for care of the poor or uninsured - including Medicare and Medicaid subsidies and state uncompensated care pools - have traditionally been available only to hospitals and not to physician practice groups. Broadening the availability of such funds is a possible way to increase the availability of specialty services, they suggest.
"One also might ask what message it sends to residents in our teaching hospitals, when on the one hand they are being taught that care is provided regardless of the patient's financial condition and on the other hand they see the problems their teachers have obtaining needed services for their uninsured patients," adds Weissman.
Weissman's co-authors are David Blumenthal, MD, MPP, director of the MGH Institute for Health Policy; Eric Campbell, PhD, Manjusha Gokhale, Recai Yucel, PhD, and Nancyanne Causino, EdD, all of the MGH Institute for Health Policy; and Ernest Moy, MD, of the Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety. The research was supported by The Commonweath Fund, The Pew Charitable Trusts, Burroughs Wellcome and the Doris Duke Charitable Foundation.
Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $350 million and major research centers in AIDS, cardiovascular research, cancer, cutaneous biology, medical imaging, neurodegenerative disorders, transplantation biology and photomedicine. In 1994, MGH and Brigham and Women's Hospital joined to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups, and nonacute and home health services.