Researchers: Managed care may cut doctors' charity work

The Associated Press

WASHINGTON -- Doctors who earn most of their income from managed care insurance devote less time to charity than other physicians, according to a study in the Journal of the American Medical Association.

A separate study in the same journal raised the possibility that co-cutting by managed care systems is also reducing some of the money available for research. "The number of uninsured is increasing, and I think we face serious questions about whether the health-care safety net can remain viable," said lead researcher Peter J. Cunningham, of the Center for Studying Health System Change, based in Washington. A Topeka researcher, Robert St. Peter, M.D., co-authored the study. St. Peter is the president of the Kansas Health Institute. Traditionally, doctors and hospitals have charged insured patients enough to subsidize free or low-cost care for some people without insurance. But health maintenance organizations and other managed care groups in recent years have imposed price limits to reduce the cost of health care. "As a result, many physicians may reduce or altogether eliminate charity care to the medically indigent," the study says. But that conclusion was challenged by Karen Ignagni, president of the American Association of Health Plans, who said the study established no cause-and-effect between managed care and charity work. "It is market forces that have brought us to this point," Ignagni said, concluding that paid medical care can no longer subsidize the uninsured. In the last decade, cost-cutting by managed care systems has brought three million to five million Americans into health insurance systems who otherwise wouldn't have had coverage because of its high cost, she said. Both new studies compared communities where managed care is more common with areas where it is less in use. However, neither included comparable figures for earlier years and Cunningham acknowledged that, without such data, "we cannot conclude with certainty that access to care has eroded over time with the increase in managed care." The use of managed care has grown sharply in recent years in reaction to the rising costs of health care in America. Managed care includes private systems such as HMOs, preferred provider organizations and point of service plans, including Medicare and Medicaid. Such plans impose various limits on which doctor a patient can choose, set cost limits for treatments and sometimes require pre- approval for certain treatments to keep costs down. In their sample of 9,871 physicians across the country, the researchers found that those who received no income from managed care systems donated an average of 10 hours to free or reduced-cost medical care in the month before they were surveyed. By contrast, physicians who earned more than 85 percent of their income from managed care had donated just 5.2 hours. The researchers also found charity care was less available in communities where managed care is more common than in places where it is less common. And, doctors in private practice more often provided charity care than those in larger groups or those working for HMOs. There are an estimated 43 million uninsured Americans, and such care has been a major source of assistance for them. Cunningham said possible solutions could include providing direct public subsidies for the indigent, expanding insurance coverage or adjusting insurance payment rates to doctors. "We need to confront, as a society, straight-up now, how we're going to fund the uninsured," said Ignagni.

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