title: Rationing access to care to the medically uninsured: the role of bureaucratic front-line discretion at large healthcare institutions.
abstract: 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.
  
  
  OBJECTIVE
  This study examines the factors that influence whether nonmedical bureaucratic staff sign in or turn away uninsured patients who cannot meet prepayment requirements.
  
  
  METHODS
  The study was conducted at a for-profit, a not-for-profit, 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.
authors.affiliation: Department of Medicine, University of Illinois at Chicago, 60612, USA. sweiner@uic.edu
authors.forename: Saul J
authors.initials: SJ
authors.lastname: Weiner
authors.forename: Margaret
authors.initials: M
authors.lastname: Laporte
authors.forename: Richard I
authors.initials: RI
authors.lastname: Abrams
authors.forename: Arthur
authors.initials: A
authors.lastname: Moswin
authors.forename: Richard
authors.initials: R
authors.lastname: Warnecke
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003659:Decision Making, Organizational; D005260:Female; D015276:Health Care Rationing / Q000458:organization & administration*; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000458:organization & administration*; D006302:Health Services Research; D006779:Hospitals, Public / Q000458:organization & administration; D006786:Hospitals, Urban / Q000458:organization & administration; D006788:Hospitals, Voluntary / Q000458:organization & administration; D006801:Humans; D008297:Male; D008489:Medical Indigency; D008502:Medical Secretaries / Q000193:education / Q000458:organization & administration / Q000523:psychology; D017057:Medically Uninsured; D008875:Middle Aged; D016134:Organizational Policy; D010067:Ownership; D010343:Patient Admission; D012017:Referral and Consultation; D011795:Surveys and Questionnaires