WASHINGTON -- The efforts of managed-care organizations to cut Americans' health costs may be having unplanned effects on care for the poor and on medical research, according to a study by an independent medical research foundation.
Traditionally, doctors and hospitals have charged insured patients enough to subsidize free or low-cost care for some people without insurance.But this is being threatened by cost-cutting imposed in recent years under managed care, according to the study, which appears in Wednesday's edition of the Journal of the American Medical Association. The study was undertaken by the Washington-based Center for Studying Health System Change.
"As a result, many physicians may reduce or altogether eliminate charity care to the medically indigent," the study says.
That conclusion was challenged by Karen Ignagni, president of the American Association of Health Plans, who said the study established no cause-and-effect between managed care and lower levels of charity work.
"It is market forces that have brought us to this point," Ignagni said, concluding that paid medical care can no longer cross-subsidize the uninsured.
In the last decade, cost-cutting by managed care systems has brought 3 million to 5 million Americans into health insurance systems who otherwise would not have had coverage because of its high cost, she said.
The study on charity work found that doctors who earn most of their income from managed care insurance systems devote less time to charity than other physicians.
"The number of uninsured is increasing, and I think we face serious questions about whether the health-care safety net can remain viable," said the study's lead researcher, Peter J. Cunningham.
A separate report in the same journal raised the possibility that cost-cutting by managed care systems is also reducing some of the money available for medical research.
Both reports compared communities where managed care is more common with areas where it is less in use.
But neither included comparable figures for earlier years, and Cunningham acknowledged that, without such data, "we cannot conclude with certainty that access to care has eroded over time with the increase in managed care."
The use of managed care has grown sharply in recent years in reaction to the rising costs of health care in America. Managed care includes private systems such as HMOs, preferred provider organizations, independent practice associations and point of service plans, including Medicare and Medicaid.
Such plans impose various limits on which doctor a patient can choose, set cost limits for various treatments and sometimes require pre-approval for certain treatments to keep costs down.
In their sample of 9,871 physicians across the country, the researchers found that those who received no income from managed care systems donated an average of 10 hours to free or reduced-cost medical care in the month before they were surveyed. By contrast, physicians who earned more than 85 percent of their income from managed care had donated just 5.2 hours.
The researchers also found that charity care was less available in communities where managed care is more common than in places where it is less used. And, the report added, doctors in private practice more often provided charity care than those in larger groups or working for HMOs.
Cunningham said possible solutions could include providing direct public subsidies for the indigent, expanding health-care insurance coverage or adjusting insurance payment rates to doctors.
Dr. Thomas J. Reardon, president-elect of the American Medical Association, which has had run-ins with the managed care industry, said the nation should consider expanded coverage for children, tax deductibility for health insurance costs, tax credits and public vouchers for low-income people.