She was a lovely, yet panicked, 56-year-old female presenting to my clinic. She was a single mom, uninsured, with a lump on her breast and unexplained weight loss. She told me that after 3 months of feeling a mass on her left breast, she decided to see a doctor.
She knew that medical care was expensive and was fearful of not only her health outcome but the financial burdens she might face.
The financial burden of medical care
After my physical exam, it was clear that my patient needed an ultrasound, most likely followed by fine needle aspiration. Her first question wasn’t related to her health; instead, she asked me, “How much is this going to cost?”
I knew I couldn’t give her an answer, as we would have to refer to a specialist for the procedure. Although my clinic at the time accepted patients with no insurance, we expected them to pay with cash at the time of service.
Often, we would set them up with a payment plan. Very few specialists in the area operated this way, and I knew many required that patients have insurance.
"It was heartbreaking to watch this mother contemplate whether or not she would follow up with a specialist to formally diagnose her with breast cancer."
— Kristen Fuller, MD
My practice ended up working together with a breast cancer specialist, who agreed to see my patient and work with her financial concerns. She ended up being diagnosed with stage 3 invasive ductal carcinoma. She endured a long road of treatment, thankfully with a medical team that agreed to take her on as a cash-paying patient, as she did not qualify for any state insurance programs.
A matter of ethics
As physicians, we often see patients complaining about medical costs (rightfully so) or who cannot pay their medical bills. Medical insurance is expensive and often tied to employment—running a medical practice is costly, and so is medical care in general, so when patients lack sufficient insurance coverage, financial matters become intertwined with physicians’ clinical decision-making. Unfortunately, medicine in this country is a business, and physicians need to be able to support themselves financially.
Still, we as physicians are also in the humanitarian business of healing. As a result, we face an ethical dilemma when our patient cannot afford their medical care.
Do we continue to treat them? Do we refer out? Do we have access to community resources we can dispense? Do we know how to reduce patient costs in our practice? Can we differentiate between medically indigent patients and patients who are unwilling to pay? Do we have a policy in place for self-pay patients? These are all questions good physicians should be able to answer.
First, confirm that your patient is uninsured
Nearly 8% of Americans of all ages did not have health insurance in 2022, so it is not unusual to see patients in your office who are uninsured. Many practices only accept patients with insurance coverage to alleviate any stress associated with self-pay patients. However, physicians at these practices must still deal with patients who cannot pay their deductibles or who do not have adequate funds for out-of-pocket expenses.
If your practice accepts uninsured patients, it is important to have some sort of requirement for uninsured patients to go through the eligibility and qualification process at their local Medicaid office. Many uninsured patients assume they don’t meet the requirements for Medicaid, and therefore have never tried.
Many patients don’t qualify for Medicaid because they have not provided (or aren’t able to provide) the right documentation, such as a pay stub or birth certificate. Other uninsured patients may qualify for programs they are unaware of, such as veterans benefits, worker’s compensation, or state disability insurance. Hopefully, your office has a step-by-step manual in both English and Spanish with instructions for how to apply for federal and state medical insurance.
Advocating for your indigent patient
Patients who are unable to pay their medical bills due to extreme financial distress are known as “medically indigent.” An indigent patient is different from a patient who is unwilling to pay their medical bills.Related: Managing self-pay patients: What if they stop paying their medical bills?
An indigent person may be uninsured, or they may be insured but cannot pay their out-of-pocket expenses. Your hospital or medical practice should have a way to determine a patient’s ability to pay for services, along with an indigent policy.
Suppose your patient is proven to be indigent according to your office’s policy. In that case, you can waive or reduce medical charges as long as it doesn't interfere with business payable by Medicare, Medicaid, or any other federal health program. If your patient is self-pay, the federal anti-kickback statute does not apply, but if they have some insurance, it is important to be legally sound when offering discounts to your indigent patients.
If you choose not to offer discounts or waive fees for underinsured patients, you can provide payment plans, resources to free or low-cost clinics and hospitals, and pharmacy assistance programs. You should always have plenty of low-cost or free healthcare community resources for patients, regardless of insurance or financial status.
Sometimes, hiring a patient advocate in your practice and hospital helps streamline this process. They may also help your uninsured or underinsured patients obtain federal healthcare coverage and advise them on payment plans. This not only helps generate revenue that you may have lost, but it can also help patients obtain affordable medical care and increase their overall satisfaction.
Tips and tricks for reducing medical costs
Here are some ways you can advocate for your indigent patients and keep healthcare costs affordable:
Talk openly with patients about the cost of your services and their ability to pay
Prescribe generic medications when possible
Take advantage of low-cost pharmacies in the area (maybe you can even maintain an ongoing list)
Shop around for low-cost lab and radiology services
Run simple tests in-house
Be aware of available social services in your community, and keep a list of community specialists who are willing to take on uninsured/underinsured patients
We as physicians are working in an almost impossible reality: We want to treat our patients to the best of our ability, we want to make a living, and we want our patients to be able to afford medical care. As a result, we have to put on our social services hat to provide affordable medical care. We should not only care about our patients’ mental and physical health, but we should also be advocates for affordable medical care for all.
Each week in our "Real Talk" series, mental health advocate Kristen Fuller, MD, shares straight talk about situations that affect the mental and emotional health of today's healthcare providers. Each column offers key insights to help you navigate these challenging experiences. We invite you to submit a topic you'd like to see covered.