"I can't afford that!" Dilemmas in the care of the uninsured and underinsured

When patients lack sufficient health care insurance, financial matters beco me integrally intertwined with biomedical considerations in the process of clinical decision making. With a growing medically indigent population, cli nicians may be compelled to bend billing or reimbursement rules, lower stan dards, or turn patients away when they cannot afford the costs of care. Thi s article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (1) whether to refer the individua l to a safety net provider, such as a public clinic; (2) whether to forgo i ndicated tests and therapies because of cost; and (3) whether to reduce fee s by fee waivers or other adjustments in billing. Clinicians' responses to these dilemmas impact on quality of care, continuity, safety net providers, and the liability risk of committing billing violations or offering nonsta ndard care. Caring for the underinsured in the current health care climate requires an understanding of billing regulations, a commitment to informed consent, and a beneficent approach to finding individualized solutions to e ach patient care/financial dilemma. To effect change, however, physicians m ust address issues of social justice outside of the office through politica l and social activism.