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Health Care Costs and Financing

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Many major teaching hospitals might not be able to offer adequate access to specialty care for uninsured patients

Initial treatment of poor and uninsured patients at major private and public U.S. teaching hospitals, which often serve as a health care safety net for these individuals, does not guarantee them access to specialty or other referral services, according to a new study. The capacity of safety-net institutions, including academic health centers (AHCs), to provide equitable care to all patients needs to be reexamined, according to Ernest Moy, M.D., M.P.H., of the Agency for Healthcare Research and Quality, and his colleagues from Harvard Medical School and the Institute for Health Policy at Massachusetts General Hospital.

In their survey of more than 2,000 medical school faculty involved in direct patient care, they found large gaps between nonpaying and paying patients in referrals to specialists, high-tech care, outpatient mental health and substance abuse treatment, and even routine inpatient care. Relative rates (uninsured versus privately insured) ranged from 2.1 for problems obtaining substance abuse services to 8.9 for referral to a specialist. Nearly one-fourth of clinical faculty reported that they were rarely or never able to obtain nonemergency hospital admissions for uninsured patients.

Nearly one in five clinical faculty felt that they were discouraged by their group practice or hospital from seeing too many indigent patients, and more than one in ten reported that their group practice placed formal limits on the number of patients or the amount of care they could provide. At teaching hospitals, faculty practices must finance their charity care through revenues from paying patients. However, they do so without the subsidies from Medicare and Medicaid that are available to hospitals serving a disproportionate number of poor and uninsured patients. The second most common reason given for limiting care to the uninsured was inadequate reimbursement.

See "Limits to the safety net: Teaching hospital faculty report on their patients' access to care," by Joel S. Weissman, Ph.D., Dr. Moy, Eric G. Campbell, Ph.D., and others, in the November 2003 Health Affairs 22(6), pp. 156-166.

Reprints (AHRQ Publication No. 04-R028) are available from the AHRQ Publications Clearinghouse.

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