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Those kinds of ambiguities left decisions on healthcare access to the front-desk staff.

These staff were often advocates for indigent patients, going out of their way to argue that a patient should be admitted or classifying the case as "insurance pending" rather than "self-pay." In fact, Weiner found, none of the clerical staff at the lowest level of the pay scale reported ever having turned a patient away. These individuals also tended to be those who were sympathetic with the patients' plight -- some of them having previously been uninsured themselves.

By contrast, 39 percent of the more senior admitting staff (supervisors who are responsible for controlling costs and ensuring payment and who have less patient contact) said they had at times denied access to care, doing so for pragmatic reasons and with regret.

"The data suggest that decisions about access to healthcare are the product of a network of unwritten rules and understandings and the preferences of staff as they interface with individuals who are attempting to become or remain clients of a reluctant bureaucracy," Weiner wrote in his study.

"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."

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Contact: Sharon Butler
sbutler@uic.edu
312-355-2522
University of Illinois at Chicago
10-May-2004