Managing the Unmanaged

A Case Study of Intra-Institutional Determinants of Uncompensated Care at Healthcare Institutions with Differing Ownership Models

This study presents a case analysis of how three urban medical centers with differing ownership models within one metropolitan area, ration access to uncompensated care to uninsured patients. Data were triangulated from three sources: hospital financial reports by service line for a fiscal year; a survey of 292 self-pay patients; and the self-pay policies and practices of clerical personnel described in a previous publication.

Although the public, for-profit and not-for-profit institutions used different strategies for managing self-pays, there were also commonalities in the experiences indigent patients reported. The public institution provided the broadest access to the largest percentage of self-pay patients, but offset the burden with the most successful prepayment and collection practices. The for-profit site obeyed federal regulations mandating emergency care, but severely curtailed other services, and the not-for-profit limited assess (but not to the extent of the for-profit) and pursued collection (but not to the extent of the public).

At all sites, actual practices by clerical staff often diverged from institutions' written self-pay policies. The probability of being turned away because of inability to pay ranged from zero percent to 40 percent with front-line personnel exercising considerable discretion on a case-by-case basis.

Large institutional providers balance their particular social and legal obligations with strategies to limit access and optimize prepayment and collection. Stated policies generally do not reflect the practices of personnel. Uninsured patients are forced to navigate a capricious system that manages them as a liability rather than as a legitimate client.