Rationing access to care to the medically uninsured - The role of bureaucratic front-line discretion at large healthcare institutions

Background: Medically uninsured patients seeking nonemergency care are not guaranteed access to services at most healthcare institutions. They must first register with a clerk who could require a deposit and/or payment on an outstanding debt. Objectives: This study examines the factors that influence whether nonmedical bureaucratic staff sign in or turn away uninsured patients who cannot meet prepayment requirements. Research Design: The study was conducted at a for-profit, a not-for-prolit, and a public healthcare institution in a metropolitan area. The authors explored the relevant policy environment through interviews with senior administrators and a review of documents pertaining to the management of self-pay patients. Then they examined how policies affecting access were implemented through in-depth, semistructured, audiotaped interviews with 55 front-line clerical personnel. Results: At all 3 institutions, policies were ambiguous about what to do when uninsured patients cannot afford required prepayments. Seventy-one percent of staff reported they do not turn patients away; the remainder stated that on occasion they do. A variety of rationales were provided for how decisions are made. Those with the lowest-level positions were significantly more likely to be sympathetic to indigent patients and less likely to report turning patients away. Conclusions: Consistent with other studies of front-line bureaucracies indicating that low-level personnel who interface with clients make discretionary decisions, particularly when organizations pursue potentially conflicting priorities, this preliminary investigation found that nonmedical personnel play a significant role in decisions affecting access to care for medically indigent patients.