Another way docs can transform lives

The American Hospital Association (AHA) has reported that uncompensated care—“bad debt” (unrecoverable reimbursement for care provided) plus “charity care” (care for patients never expected to pay)—eclipsed $41 billion in 2011, a 13% increase from 2008. At two not-for-profit hospitals in Tennessee where I practice, the rise in uncompensated care has roughly doubled in four years.

Half the states have opted not to expand Medicaid. So, reimbursement to hospitals for much of the indigent uninsured and underinsured care will not materialize in the short run. Charity care rising faster than net income threatens institutions' long-term viability. Fiscal realities and the Patient Protection and Affordable Care Act have motivated public and private sectors to scramble to find ways to mitigate and reverse this debt trend.

Coincidentally, America has seen a tripling of hospitalists in the past 10 years. In parallel, fewer nonhospitalist physicians are seeing patients in the hospital. In the past, doctors who saw inpatients had to accept and care for patients regardless of their personal politics, charitable inclination or patients' economic status. Those doctors often continued care after discharge. Charity care was, therefore, “imposed” by the hospital and determined by random assignment of patients seen in the ER or hospital. Today, at discharge, patients are typically referred to indigent clinics or community health centers. Nonhospitalist physicians are not required or asked by hospitals or clinics to share in the outpatient care of the poor.

A survey of doctors at our hospitals found that 74% of primary-care providers and 29% of specialists do not see inpatients. Some 78% of physicians reported that less than 5% of their patients were self-pay (not all indigent). In contrast, ERs reported 18% of patients were self-pay. Thus, in our community, there's a trend mirrored nationwide—clinicians who could significantly contribute to the well-being of the least fortunate are no longer required or asked to do so.

Within our grasp is a retrievable resource and an opportunity for system symbiosis. Tapping into the altruism of many physicians, who might alter the trajectory and well-being of the sickest patients, is difficult given the stressors of EHRs, falling reimbursement and increasing overhead. Fortunately, most can be encouraged to provide more charity care, for reasons they went into medicine, to help others, especially the less fortunate. Their involvement could transform the lives of the sickest and costliest and most complex patients—the 5% who account for 50% of all healthcare costs.

Hospitals and government healthcare systems, beneficiaries of such a focused care model, could become fiscally healthier and more sustainable. In turn, those stakeholders could reinvest and financially incentivize providers who choose to help coordinate and manage care of the sickest and costliest.