Non-medical staff play key role in healthcare access for uninsured patients
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《英国医生杂志》
Non-medical staff play a major role in decisions affecting access to care for uninsured patients in clinics in the United States and in the admissions areas of three large urban medical centres, a new study shows (Medical Care 2004;42:306-12). But they are also ambivalent about dealing with a system that discourages care for people without insurance, it adds.
Dr Saul Weiner, of the department of medicine at the University of Illinois, Chicago, and colleagues write that each year many of the more than 40 million Americans without health care insurance seek routine (non-emergency) services they cannot afford, but most providers are not required to take care of them.
"Front-line bureaucrats—clerical staff who have direct contact with patients, including registration clerks, insurance verifiers, and patient representatives—are charged not only with facilitating their employer抯 mission of caring for patients with need, but also with securing payment to cover the costs of that care," their article says.
The researchers interviewed 55 frontline non-medical staff in 13 clinics and three admissions areas. They discussed their findings with managers and administrators who, though anxious to reduce the number of people paying for their health care themselves, were also concerned about the legal and political implications of denying services, about public relations with their communities, and about the cost of employing additional staff to implement complex policies.
"Seventy-one percent (39 of the 55) staff interviewed reported that they did not independently turn patients away," says the article. "Although we found no written policies stating that patients are never to be turned away (not counting emergency room policies), a number of clerks believed otherwise."
The researchers found that staff members who were closest to the point of delivery of health care were the least likely to report turning patients away and the most likely to be sympathetic.
"The data suggest that decisions about access are the product of a network of unwritten rules and understandings and the preferences of staff as they interface with a group of individuals who are attempting to become or remain clients of a reluctant bureaucracy. If this approach is widespread, then concerns arise about whether patients who are getting care are, in fact, those with the highest need, or, rather, those best able to negotiate within such a system. If the latter, then greater emphasis on standardisation of processes, including means testing and triage by medical personnel, could bring greater predictability and equity to access," the study concludes.
In an accompanying editorial Dr Nicholas Walter and Dr Dean Schillinger, of the University of California San Francisco General Hospital, call this conclusion "characteristic of our indecisive communal response to the moral questions posed by the US healthcare system."
"Care for the poor and uninsured will remain inadequate until we, as a nation, choose to systematically include this sector of our society as being worthy of care. Try as we might, as individual health care workers we cannot provide care to the uninsured when the system operates against us," the editorial says.(Quebec David Spurgeon)
Dr Saul Weiner, of the department of medicine at the University of Illinois, Chicago, and colleagues write that each year many of the more than 40 million Americans without health care insurance seek routine (non-emergency) services they cannot afford, but most providers are not required to take care of them.
"Front-line bureaucrats—clerical staff who have direct contact with patients, including registration clerks, insurance verifiers, and patient representatives—are charged not only with facilitating their employer抯 mission of caring for patients with need, but also with securing payment to cover the costs of that care," their article says.
The researchers interviewed 55 frontline non-medical staff in 13 clinics and three admissions areas. They discussed their findings with managers and administrators who, though anxious to reduce the number of people paying for their health care themselves, were also concerned about the legal and political implications of denying services, about public relations with their communities, and about the cost of employing additional staff to implement complex policies.
"Seventy-one percent (39 of the 55) staff interviewed reported that they did not independently turn patients away," says the article. "Although we found no written policies stating that patients are never to be turned away (not counting emergency room policies), a number of clerks believed otherwise."
The researchers found that staff members who were closest to the point of delivery of health care were the least likely to report turning patients away and the most likely to be sympathetic.
"The data suggest that decisions about access are the product of a network of unwritten rules and understandings and the preferences of staff as they interface with a group of individuals who are attempting to become or remain clients of a reluctant bureaucracy. If this approach is widespread, then concerns arise about whether patients who are getting care are, in fact, those with the highest need, or, rather, those best able to negotiate within such a system. If the latter, then greater emphasis on standardisation of processes, including means testing and triage by medical personnel, could bring greater predictability and equity to access," the study concludes.
In an accompanying editorial Dr Nicholas Walter and Dr Dean Schillinger, of the University of California San Francisco General Hospital, call this conclusion "characteristic of our indecisive communal response to the moral questions posed by the US healthcare system."
"Care for the poor and uninsured will remain inadequate until we, as a nation, choose to systematically include this sector of our society as being worthy of care. Try as we might, as individual health care workers we cannot provide care to the uninsured when the system operates against us," the editorial says.(Quebec David Spurgeon)