Managed care and charity care - are they incompatible or are they one and the same? While the cost of dealing with managed care goes up, (increased paperwork, increased staff time waiting on hold with the insurance company, increased time making appeals on behalf of patients, increased time and effort to secure long overdue payments, and of course increased cost of H2 blocker prescriptions for the physicians and office staff), at the same time reimbursement rates are decreasing. Around the country many physicians are going out of business or choosing to retire early because it has gotten to the point where expenses exceed revenue. In this difficult professional and economic environment can we still afford to provide charity care for the growing number of uninsured patients? What would happen to our profession if we stopped providing charity care? Perhaps the more important question to ask ourselves is - can we afford not to provide charity care? 

Alarming trends
A recent national survey of 11,000 physicians showed an inverse correlation between the amount of charity care provided and the percentage of revenues derived from managed care. Locally the Doctors' Care program, which over the past ten years has provided over 25 million dollars of unreimbursed medical services to indigent patients in Arapahoe and Douglas counties, is struggling from a lack of primary care physicians. At one point Doctors' Care had over 120 primary care physicians enrolled in the program - now there are only 17. This dramatic drop is compromising the ability of Doctors' Care to provide a much needed service. In some cases employed physicians are being forced to not provide charity care because it doesn't contribute to the bottom-line of their employer. 

How should we respond?
Physicians are increasingly frustrated by the financial constraints and clinical challenges of providing quality care to patients in the managed care setting. We try to compensate by working harder, working smarter, and cutting expenses. We join groups and pay experts to attend to the increasingly complex business of medicine so that we can focus on clinical practice. Unfortunately even the experts aren't doing very well at managing the business of medicine in the current environment. Sometimes we feel like we are put into an adversarial position with our patients and forced to practice medicine with our hands tied while our pockets are being picked. As a result the joy of practicing medicine is gone for many physicians. Professional burn out is on the increase as are disability claims and disability insurance premiums for physicians. 

Organized medicine and physicians, both locally and nationally, are coming up with innovative strategies to better represent physicians, and the patients they serve, in today's hostile regulatory and insurance climate. These strategies, while crucial from a business perspective, do little to address the medical needs of the uninsured or the heart needs of physicians. If the practice of medicine becomes nothing more than a business we have lost the battle and the heart and soul of medicine is stone cold dead. 

Why we NEED charity care 
Charity care is the CPR (Caring Principle Resuscitation) needed for the heart and soul of medicine to be revived. The caring principle is what made many of us choose medicine as a profession in the first place and without it we are doomed to simply go through the clinical motions that superficially resemble the practice of medicine. The satisfaction of doing the right thing for a person in need, regardless of their ability to pay, brings life and joy back to the practice of medicine. 

Are managed care and charity care incompatible? If anything charity care is more necessary for our professional health as managed care threatens our hearts even more than our balance sheets. If seeing uninsured patients in the office is not possible due to employer restrictions or other constraints then we should consider volunteering time at one of the many indigent clinics that are continually in need of physicians. 

Are managed care and charity care one and the same? At times managed care reimbursement may make it seem like we are providing charity care. The difference is that the former is coerced out of us and often engenders resentment and cynicism while the latter is voluntary and invigorating.

Giving our heart away is the best insurance against having it taken away by the pressures of managed care. More than ever there are patients in need of charity care. More than ever we need to give it.