Hospitals' Care of Uninsured Patients during the 1990s: The Relation of Teaching Status and Managed Care to Changes in Market Share and Market Concentration

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Abstract
Competitive forces in health care make it difficult for hospitals to shift the costs of caring for poor and uninsured patients onto paying patients. The care of uninsured patients in teaching hospitals may have been especially affected by increased levels of managed care during the 1990s. We found that the market share of uninsured patients during the 1990s grew at academic health center hospitals relative to other hospitals in their service areas, and these increases occurred primarily in areas with high levels of managed care. More generally, in urban areas, the care of uninsured patients was twice as concentrated as that of all patients, and the ratio of concentration (uninsured patients vs. all patients) was greater in areas with high managed care levels than in areas with low managed care levels (p < .01). These results have implications for the design of payment policies for indigent care.