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Proportion of Doctors Giving Charity Care Declines
Busy Schedules, Lower Reimbursements and High Medical-School Debt Cited as Factors

By Ceci Connolly
Washington Post Staff Writer
Thursday, March 23, 2006

The proportion of U.S. physicians providing charity care has steadily declined over the past decade, even as the number of Americans without health insurance has risen significantly, a new study finds, suggesting that government health programs and clinics will face increased demand.

In 2004-2005, 68 percent of doctors said they delivered some free or discounted care to low-income patients, down from the 76 percent recorded 10 years earlier, according to a national survey being released today by the Center for Studying Health System Change. The center, a nonpartisan research group funded primarily by the Robert Wood Johnson Foundation, noted that the number of uninsured people climbed to 45.5 million in 2004.

"One of the striking things about this is that the decrease is pretty much across the board," said lead author Peter J. Cunningham. Charity care declined regardless "of specialty, type of practice, size of practice or part of the country."

Overall, higher-paid specialists or doctors working in small private practices were more likely to provide charity care than internists, pediatricians or those employed by large managed-care companies, the survey found.

Nearly 80 percent of surgeons reported providing free care, largely because they spend more time in hospitals, which are required by law to treat indigent patients. Pediatricians, on the other hand, probably saw less demand for charity care because higher percentages of children receive care through government programs. Although the number of physicians providing charity care has remained stable, the proportion has fallen because there are many more doctors practicing medicine.

Less charity care in the doctor's office means more demands on hospital emergency rooms and more patients who simply go without care, said Cunningham, who oversaw the survey of 6,600 physicians. In a related study, the center found that a declining number of uninsured Americans received routine medical care. In 2003, 46 percent of people without health insurance had a regular doctor, down from 52 percent in 1996.

Busy schedules, reduced reimbursement rates and high medical-school debt appear to be contributing to the problem.

"Physicians are still committed to charity care," said J. Edward Hill, president of the American Medical Association. "Time pressures for physicians have increased enormously, and there have been income drops."

At a time when insurers are clamping down on reimbursements, most young doctors carry an average medical-school debt of $119,000, he said. And although charity care has dipped, Hill, a family physician from Mississippi, stressed that "nearly 70 percent" of doctors still offer some.

Until recently, the nonprofit Family and Child Services Inc. of Washington relied on a network of volunteer doctors to provide free checkups to needy children heading to summer camp. But now, "that service just isn't available," said Charlotte L. McConnell, the group's executive director.

Time pressures and fear of lawsuits are the two most common reasons doctors give McConnell. "My sense is they have to do a certain volume to cover their expanding costs, especially in D.C. to cover [malpractice] insurance," she said.

In Texas, President Bush's home state, "volunteer charity care is nonexistent," said Sherry L. Hill, chief executive of the Community Health Centers of South Central Texas Inc. "It is the rare physician that will donate a day or an afternoon or morning."

Last year, 7,000 patients made 25,000 visits to the centers' clinics, more than triple the number served in 1999, she said. The clients, 70 percent of whom are uninsured, all work -- as farmers, ranchers, domestic help or gas station attendants.

At a dinner meeting with local doctors, Hill, who is not related to the AMA president, asked if anyone would volunteer to be a substitute when the center's staff physicians went on vacation. "I didn't get a taker in the group," she said.

The real problem, said the AMA's Hill, is the steadily rising number of people with little or no health insurance.

"The solution is fair coverage for all," he said. "We've got to wake up in this country and decide we're going to solve that problem."

Since taking office, Bush has added or expanded 865 federally funded community health centers, serving about 14.6 million patients this year, said Bill Hall, a spokesman for the Department of Health and Human Services.

"They've been expanding, but they are not universally available across the country," and most of the community health centers offer limited services, Cunningham said.

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