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Some observers are concerned that hospitals with high percentages of unpaid, indigent and Medicaid patients, especially those in inner-city and rural areas, might be excluded from the new networks. Yet some networks are scrambling to seek out and include hospitals with both high and low percentages of uncompensated care because one of a network's most crucial tasks is to secure the facilities and patient populations needed to offer health care over a wide geographic area.
Networks are also seeking a wide spectrum of hospitals because universal access, under the Clinton administration's reform plan, is expected to secure or boost reimbursement for much of what is now uncompensated care. This means that those formerly financially burdensome patients will become a significant revenue source for hospitals.
But universal access is still a long way off, and some providers are concerned the old ways of curbing poor patients' access to health care will continue in some of the new networks.
"Some hospitals are in a financially distressed position because they treat larger numbers of uninsured and Medicaid patients, and it may be difficult for them and other providers to muster the resources needed to develop their own community care networks. These financial disadvantages may also limit these providers' attractiveness in becoming a partner in a network," says Carmela Dyer, senior associate director for policy development at the American Hospital Association. "The answer to this is ensuring that we have fair payment and financing mechanisms as part of the nation's new health care system."
CONCERNS ABOUT EXCLUSION
"My great fear is that capitation means physicians won't want to see sick patients. If you're an inner-city doctor or primary care practice treating many AIDS patients, for instance, then you might be considered too expensive to be part of a network," says Thomas Delbanco, M.D., of Health Care Associates at Beth Israel Hospital, Boston.
"I don't think the Clinton administration has figured out that care-givers still have disincentives to provide care. Inner-city providers are responsible for a disproportionate share of the nation's health care, so it's likely the expanded alliances won't know how to pay them enough," Delbanco says. "I'm already seeing a quiet pressure among some providers to seek healthy people and stay away from the sick, especially when...