Coleman, David L. MD
Many challenges and opportunities facing academic medical centers (AMCs) and medical schools reflect these institutions’ critical roles in advancing health care, as well as the impact of social, political, and economic factors on our health care system. Academic medicine’s ability to conduct optimal research, education, and clinical care is particularly challenged by the problems of health care financing in the United States. Faculty in clinical departments typically face very high practice costs and are reimbursed for clinical services by insurers whose rates have not kept pace with inflation in the cost of health care. Accordingly, the margins of clinical practice in medical schools and AMCs are increasingly unable to cross-subsidize the care of uninsured patients from the care of insured patients. Consequently, individual faculty and clinical departments are under increasing pressure to limit care of uninsured patients.
However, AMCs and medical schools have traditionally played a critical role in the care of the uninsured.1 The Association of American Medical Colleges (AAMC) has affirmed this role in its mission statement: “Caring for those who remain uninsured during a transition period to universal coverage or for those who may never be adequately incorporated into the health system.”2 In addition, the AAMC established the following goal for education of medical students in 1998: “A commitment to provide care to patients who are unable to pay and to advocate for access to health care for members of traditionally underserved populations.”3 Restricting AMCs and medical schools’ ability to care for the uninsured population would have significant adverse effects on the health of the uninsured, since the alternative “safety net” providers in nonacademic institutions do not have sufficient capacity to care for this growing population.4 In addition, limiting care of the uninsured would be contrary to the ethical foundations of medicine in general and academic medicine in particular. Therefore, a proactive strategy to resist this pressure and to mitigate the effects of a lack of health insurance on patients is particularly compelling.
According to the U.S. Census Bureau, 45.8 million Americans (15.7% of the population) did not have health insurance coverage in 2004.5 Relative to people with health insurance, uninsured individuals have substantially worse general health, longevity, and outcomes for both chronic diseases and hospitalizations for acute illnesses, making a lack of health insurance especially distressing.4,6–10 Moreover, racial and ethnic disparities in health care are exaggerated by a lack of health insurance.8 Uninsured children are at greater risk for developmental delays that adversely affect educational achievement, and both uninsured families and individuals experience substantial economic and psychological stress from the health risks and financial uncertainty caused by the lack of health insurance.7–10
Institutions and communities also bear a substantial burden from caring for the uninsured. Care of the uninsured reduces the financial stability of health care institutions and limits public funds available for broader public health initiatives.4 As a consequence, communities with high local rates of uninsurance have fewer hospital-based and emergency care services, less advanced trauma care, and diminished population-based disease surveillance and health monitoring.4,10
A high rate of uninsurance also adversely affects health care providers.4 Primary care physicians who provide care for the underserved find it difficult to make ends meet and to obtain specialty care for their uninsured patients.4,7 In areas with Medicaid managed care contracts, the care of patients covered by Medicaid may be directed away from traditional safety net providers. The resultant increase in the proportion of uninsured patients who turn to these providers for care further compromises the financial stability of safety net providers.4
The lack of health insurance also has a troubling and insidious effect on professionalism. The core values of medical professionalism—beneficence, equity, and justice—are compromised when physicians choose not to care for the uninsured.11 Medical students and residents who observe faculty providing different standards of care for insured and uninsured patients may be more inclined to adopt this behavior in the future. In addition, delivery of a lower standard of care to uninsured patients may degrade the perception of physicians by the public and policy makers.
Although medical schools and AMCs have played an important role in improving the health care of the underserved, the widespread consequences of uninsurance and the responsibility of academic medicine for the health of the citizenry require that leaders, educators, and clinicians be particularly vigilant in addressing the consequences of the lack of health insurance for all patients, communities, institutions, and health care providers. As it has done with other health crises such as the influenza pandemic of 1918, HIV-AIDS, bioterrorism, and avian influenza, academic medicine should mobilize to counter the threat to public health represented by the lack of adequate health insurance. However, the political, social, and economic causes of uninsurance are numerous and certainly cannot be fully addressed by medical schools and AMCs alone.12 Indeed, all clinicians in the public and private sector share the obligation to care for the uninsured. Nonetheless, specific measures in the traditional domains of academic medicine—clinical care, research, and education—should be undertaken to address this crisis.
Sharing the responsibility of care
The financial relationships and governance among medical schools and AMCs vary throughout the country. Nevertheless, a joint strategy employing best business practices is needed to proactively address care of the uninsured in the inpatient and outpatient settings. AMCs and medical schools should identify care of the uninsured as a shared responsibility; the financial consequences of caring for the uninsured should be transparent; and an equitable strategy for cross-subsidy between AMCs and affiliated medical schools of the costs of caring for the uninsured should be developed. In the absence of a shared approach, the financial dynamics between individual AMCs and the affiliated medical schools will be adversely affected by the strain of providing care to the uninsured, thereby further jeopardizing these institutions’ capacities to care for uninsured patients.
Rewarding physician work instead of collections
Faculty who provide care to uninsured or underinsured patients may be financially disadvantaged by compensation plans based on clinical income. Consequently, as some faculty seek paying patients, the “payer mix” within individual faculty members’ practices may vary substantially within and among clinical departments. As a result, faculty may earn varying amounts of money for equivalent work, depending upon the type of insurance their patients have, or indeed, whether their patients have insurance at all. Therefore, academic departments should implement faculty incentive programs that compensate faculty directly for clinical work, independent of the insurance status of individual patients. Where possible, the metric of clinical work should be work Relative Value Units (wRVUs), rather than clinical collections.13,14 In order to implement a wRVU-based plan, clinical collections should be pooled and redistributed in proportion to each faculty member’s wRVUs.
The obvious concern about wRVU-based compensation systems is that they may have the unintended effect of lowering total collections. However, incentive programs that use wRVUs can improve physician productivity and clinical collections by encouraging faculty to develop consistent approaches to scheduling and documentation of care without regard for the patient’s insurance status.14 Indeed, incentive systems using wRVUs have been shown to increase clinical collections in academic practice.14 Basing compensation on work instead of clinical collections has two other important advantages: achievement of greater equity among faculty by directly aligning effort and compensation, and monitoring of clinical productivity in real time without having to wait for bills to be processed and paid. Faculty working in a wRVU-based compensation system have no disincentive to care for uninsured or underinsured patients, and are more likely to develop consistent documentation practices and to render one standard of care to all patients.
Recognizing care of the uninsured in the promotion process
Academic institutions must consistently align the structure of faculty rewards with their missions and values to ensure that their complex goals are fulfilled. Since a core mission of most medical schools and AMCs is to promote the health of the local community, full-time and voluntary faculty who provide care to the uninsured should receive credit for this activity in the appointment and promotion process.15 Indeed, when considering a faculty member for a promotion, many medical schools consider service to the institution in addition to the traditional metrics of academic and clinical accomplishment. Caring for the uninsured should not be sufficient in and of itself to warrant appointment or promotion. However, faculty should be recognized for this form of community service, since it provides a compelling example for students and trainees, meets an important health care need in the local community, creates good will, and helps the AMC and medical school fulfill their responsibilities to the community.
Determining billing rates for the uninsured
Faculty practice plans have some discretion in establishing the billing rates for uninsured (“self-pay”) patients. Although some of these patients have sufficient resources to pay their medical bills, many self-pay patients cannot afford to pay the full cost of professional and technical services. As a consequence, medical bills may cause considerable financial hardship for some uninsured patients. Indeed, the cost of health care is the most common source of personal bankruptcy in the United States.16 In view of the potential hardship derived from the costs of medical care, strategies to mitigate these costs should be considered, including discounting the charges for professional and technical services for those uninsured patients who are unable to pay the full cost of care.
Ensuring one standard of care
In many AMCs, care of indigent or uninsured patients often occurs in residents’ clinics. These clinics typically have a lower ratio of faculty to trainees and a lower level of faculty involvement in patient care than other sites of faculty practice. In addition to risking noncompliance with standards of the Joint Council on Accreditation of Healthcare Organizations by potentially providing different levels of care depending upon health insurance status, academic departments may inadvertently contribute to disparities in health outcomes by diverting care of the uninsured to residents’ clinics. Furthermore, faculty may be violating ethical standards by conveying a subtle message to trainees that it is permissible to treat patients differently based upon their ability to pay. Finally, the credibility of medical schools and AMCs in the public debate on health care financing will be diminished if an unequal level of care is provided for patients with different abilities to pay for care.
Investigating the impact of uninsurance
The basis for the profoundly negative effect of uninsurance on access to preventive care, medications, and primary care is obvious.7 However, it is less clear why uninsured trauma victims are less likely to be admitted, receive fewer services, and are more likely to die in the hospital.7 We need to understand why uninsured inpatients receive fewer hospital-based services and substandard care, and are more likely to die in the hospital.7 Similarly, we should characterize the reasons why uninsured patients with acute cardiovascular disease are less likely to be admitted to a full-service hospital, less likely to receive angiography or revascularization procedures, and have a higher short-term mortality rate.7 The influence of insurance status on the diagnostic and therapeutic decisions of health care providers should be investigated with the goal of identifying correctable sources of poor care. Moreover, the relative role of uninsurance compared to other sources of disparities in health care should be better characterized.
Assessing intervention strategies
Services available to individuals without health insurance include forms of public assistance, such as Medicaid and government-supported outpatient clinics.8 The impact of existing services and innovative interdisciplinary team-based strategies on increasing effective use of health care services by vulnerable populations is a vital area of study. Schools and graduate programs in public health and public policy have been the traditional academic home of research on the impact of strategies to improve the health of the uninsured. Clinical faculty in schools of medicine have a critically important perspective and ability to evaluate existing and new approaches to the care of the uninsured. Therefore, clinical faculty should build on existing partnerships with faculty in schools and graduate programs in public health or public policy to rigorously evaluate the impact and sustainability of services for the uninsured.
Taking a leadership role in measuring quality
Providing a single standard of health care and eliminating disparities in care that arise from insurance status or racial and ethnic factors are critically important professional goals.2,4,6–11 Although all providers of health care should help attain these goals, AMCs and medical schools are uniquely positioned to design new strategies to measure, monitor, and improve the quality of health care.11 To ensure that health care delivery is continually enhanced, medical schools will need to create new training opportunities for trainees and faculty in the emerging discipline of health care quality, and also recognize faculty members’ scholarship and achievement in improving quality of care. In so doing, institutions will equip and encourage faculty to make enduring contributions to improving the quality of care that is available to all patients.
Calling attention to the prevalence and impact of uninsurance
The curricula for medical students and residents should include a description of the broad array of factors that contribute to poor health access and outcomes. In addition to factors such as race, culture, gender, and socioeconomic status, the effects of the lack of health insurance should be included in these curricula with the following specific goals: to provide a broad understanding of health care financing and its impact on access to care; to understand how disparities in health care arise and the relative role of the lack of health insurance in contributing to inequities in health care; to describe the services available to the uninsured and the roles of each member of the health care team in addressing the patients’ needs; and to better understand how bias among health care providers or institutions may lead to poor health outcomes.
Physicians can bring an essential perspective to efforts to reform health care financing by actively participating in the political process. Therefore, in addition to educating trainees, faculty should also participate in the debate on health care financing by providing more information to the public and governmental institutions regarding the impact of uninsurance on health care institutions, on public health services, and on all citizens regardless of their insurance status.
Creating educational materials and training opportunities for health care providers
Academic medicine faculty can be particularly helpful to health care providers working in underserved areas by designing continuing medical education curricula that address the specific health care needs of the populations these health care providers serve. For example, clinicians in government-supported clinics in urban areas may see a disproportionate number of patients with HIV infection, substance abuse, or diabetes mellitus. AMCs and medical schools should assist these clinicians by providing focused instruction on cost-effective management strategies for the clinical problems prevalent in underserved areas.
Learning from the health care providers of the underserved
For AMCs and medical schools to provide exemplary training in the care of underserved patient populations, the considerable expertise and experience of providers who care for the underserved should be incorporated into medical student and resident teaching programs. These providers can make critical contributions to didactic curricula on the health care needs of the underserved. Exposing trainees to community-based clinics that provide care for the underserved will provide important experience in addressing the health care needs of this patient population and will expose trainees to inspirational role models. Finally, greater integration of the clinical, educational, and research activities of AMCs and medical schools with safety net health care providers may improve health care in underserved communities by facilitating the recruitment and retention of these providers.
The financial challenges for AMCs and medical schools in caring for the uninsured are formidable. The aforementioned strategies should not obscure the need for innovative approaches to health care financing or minimize the financial challenge of caring for the uninsured. Indeed, the problem of uninsurance will ultimately be solved by a thoughtful social, economic, and political approach.12,17,18 Additional financial resources will be required to improve the care of vulnerable populations by providing direct clinical services, to support more research on the evaluation and refinement of new and existing approaches, and to support educational initiatives. Until a comprehensive solution to health care financing is implemented in the United States, AMCs and medical schools are uniquely positioned to design and implement a broad range of academic, clinical, and financial strategies to meet the health needs of the uninsured. Faculty in academic clinical departments have a vital role in advocating a more equitable model of health care financing, modeling outstanding clinical care, creating positive solutions through education and research, and improving the care of all citizens. As the financial pressures on AMCs and medical schools intensify, the difficulties in caring for the uninsured are likely to increase. Consequently, a joint preemptive strategy is needed to address this problem.
The author wishes to express his gratitude to Drs. Asghar Rastegar, Jill Lacy, Jerome Kassirer, David Leffell, and Michael Bennick for their thoughtful comments and suggestions.
1 Legnini MWW, Emily K. Academic Medical Centers and the Culture of Local Markets. Washington DC: Economic and Social Research Institute, 1999.
3 AAMC Medical Schools Objectives Project. Report I. Learning Objectives for Medical Student Education. Guidelines for Medical Schools (http://www.aamc.org/meded/msop/msop1.pdf
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13 Coleman DL, Moran E, Serfilippi D, et al. Measuring physician productivity in a Veterans Affairs Medical Center. Acad Med. 2003;78:682–89.
14 Wilson MS, Joiner KA, Inzucchi SE, et al. Improving clinical productivity in the academic setting: a novel incentive plan based on Utility Theory. Acad Med. 2006;81:306–16.
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17 Quadangno J. One Nation Uninsured. Why the U.S. Has No National Health Insurance. New York: Oxford University Press, 2005.
18 AAMC Executive Council. Principles for the Evaluation of Proposals for the Uninsured (http://www.aamc.org/uninsured/principles.htm
). Accessed 26 April 2006. Association of American Medical Colleges, Washington, DC, February 9, 2001.