When patients can't pay: Some innovative solutions

How do you decide whether (or how much) to charge when a patient can't afford your care? Physicians share their answers.

By Katherine Vogt, AMNews staff. July 21, 2003.

The woman had a disabling mental illness and a mounting tab for psychiatric treatment. Her insurance and other benefits were exhausted. Still, Michael Denson, MD, her psychiatrist in Chicago, wanted to keep treating her. "She had the experience of being dumped by doctors in the past, and I didn't want to do that," he said.

So the doctor and the patient -- an amateur artist -- got creative.

"One way we thought of her being able to pay her bill was to sell me some of her paintings," said Dr. Denson, who knocked about $1,300 off the woman's bill, or roughly half her tab, in exchange for three brightly colored paintings of potted plants. "It helped her out financially, and I got some art that I really like."

The goods-for-services trade is one way doctors have dealt with the often-difficult decision of what to do with patients who can't pay. More commonly, physicians opt to discount their usual fees or simply provide free care.

But these choices aren't made easily. Without a set policy from a hospital affiliate or managed care organization, the private physician must decide on a case-by-case basis which patient deserves a break, and how much. Charitable care programs and advice from consultants can help, but most physicians have to make decisions based on what their guts tell them.

Federal estimates say there are 41 million uninsured Americans, many of whom make too little to buy private insurance but too much to qualify for public plans. And the demand for free and discounted care can be especially difficult for physicians struggling to keep practices afloat amid dropping reimbursements.