Doctors, hospitals feel the pinch of ongoing financial constraints.

Insurance coverage changes, rising medical costs and higher unemployment have caused Los Angeles health care providers' bank accounts to shrink.

Patients are seeing doctors less frequently. People who don't have insurance or credit go to emergency rooms for care and don't pay the bill. Health insurance companies are cutting back on coverage.

As a result, hospitals are owed more money than any other business category surveyed by the Minneapolis, Minn.-based American Collectors Association Inc. Individual physicians rank seventh and miscellaneous health care firms rate ninth.

The American Medical Association reported hospitals nationwide provided $12.1 billion in care in 1990 at no cost to patients. The total included charity cases and uncollectable debt. The 1991 figures still haven't been finalized and the AMA doesn't have separate data for Los Angeles County, said Jon Ross, spokesman for the Chicago-based organization.

Locally, the Hospital Council of Southern California reports patients were unwilling to pay Los Angeles hospitals a total of $401 million for the fiscal year ending in June 1991. Coupled with the value of treatment administered to people who couldn't pay, the Los Angeles hospitals provided $882.42 million in care for which they received no payment.

For the same period, the value of accounts that patients were unwilling to pay totaled $633 million for Southern California (Los Angeles, Orange, Santa Barbara, San Bernardino, Riverside, Santa Barbara and Ventura counties). Added to the total of hospital bills patients couldn't pay, the hospitals in the seven counties were out a total of $1.39 billion.

"The total amount of bad debt charged off by hospitals in Los Angeles County has been rising 10 percent for each of the last three years," said David Langness, vice president of communications for the Hospital Council of Southern California.

Because of the increasing percentage of nonpayment, few doctors or clinics will treat patients who can't prove their ability to pay, said the American Medical Association's Ross. As a result, they get treated at hospital emergency rooms. The practice is one of the main factors driving hospitals' uncompensated totals higher, Ross said.

The average total for emergency room visits per Los Angeles hospital rose 33.1 percent from 15,984 visits in 1980 to 21,277 in 1990, according to data supplied by the American Hospital Association. The number of hospitals rose from 42 to 51 during the same period. That means the total number of emergency room visits in Los Angeles rose from 671,228 in 1980 to 1,105,127 million in 1990.

"Many of the patients who visit emergency rooms are uninsured or underinsured. The problem may get worse before the recession is over," Ross said.

Of the hospital accounts turned over for collection only 22 percent pay up. The rest are written off as losses by the health care providers, said Nick Di Giovanni, public relations director of the American Collectors Association.

Of all physicians accounts turned over for collection, only 25 percent get paid. Of health care providers that are categorized as neither doctors nor hospitals, only 27.8 percent of the accounts turned over for collection pay their bills, according to American Collections Association data.

As a result, agencies that collect for the medical profession have seen the total dollars owed per average account rise even though the percentage of delinquent accounts hasn't grown, Di Giovanni said.

Classified by the value of uncollected fees, physicians rank seventh on a national basis. That's down from fifth place in 1989 and fourth place in 1988.

San Pedro-based pediatrician Dr. Gary Skrieger has one explanation. "Unless I'm up front about the payment schedule, I get lots of delinquencies. That may sound mean but if I don't get payment up front, I'll never see my money in most cases," he said.

Collectively, doctors are feeling the pinch almost as much as hospitals. Los Angeles County Medical Association President Dr. Richard Wigod said doctors' gross income is declining while their costs are rising. He said average income figures for Los Angeles doctors were not available.

"Doctors are dealing with the drop in income by working longer hours and making themselves more available. But even though their patient load may go down, their expenses won't," Dr. Wigod said.

Individually, doctors are having problems making rental payments on their offices. Most doctors in private practice have watched their incomes shrink 20 to 30 percent in the past five years, said Sherman Oaks-based dermatologist Dr. Jack McClary. "We have agreed to accept payments from Medicare, MediCal and the preferred provider organizations. Where we used to collect 95 percent of what we billed, we now collect about 75 percent of what we bill," he said.

Along with the insurance problems, McClary said, patients are coming in less often. "Patients with acne and skin cancer are waiting longer to come in for treatment. As a result, they need more complex procedures when they do come in," he said.

Doctors are taking various measures to cut costs and boost income. They are combining practices to lower administrative and office expense. They are spending more time in the office and less on the golf course or on their sail boats.

Even so, Rich Namerow, a senior manager in the Los Angeles office of Ernst & Young, a certified public accounting and consulting firm, said most doctors will find a way to get their incomes back to normal.

"Doctors will guard their income. They will ask patients to come in for more visits after an operation. There isn't a jury in the country that would convict them in a malpractice suit for that," Namerow said.

To make up for the slow pays and no pays, surgeons are operating three days a week instead of one or two days a week, Namerow said.