How to advocate for your indigent patients

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. 

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.

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. 

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. 

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. 

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. 

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

• Reduce polypharmacy

• 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.