Healthcare markets are complex and confusing places. But one fact is simple and straightforward: all else equal, hospitals and emergency departments are a lot more expensive than outpatient clinics. Which makes it all the more bewildering that so many low income patients prefer hospitals over primary care clinics.
Bewildering until now. Shreya Kangovi and colleagues at the University of Pennsylvania interviewed low income patients and discovered some fascinating reasons why they aren’t attracted to primary care clinics.
It starts with affordability. When patients lack health insurance, it is hard to make appointments at primary care clinics which, like most healthcare practitioners, initiate their evaluation of patients with a procedure sarcastically referred to as a “wallet biopsy.” If you want an appointment to see a primary care physician for an earache, the appointment clerk is going to ask you about your insurance. If you don’t have coverage, the clerk is usually going to remind you that you will have to pay the doctor’s fee out-of-pocket, before receiving care. By contrast, if you show up in an emergency room with that same earache, the clinicians there will be obligated to evaluate you and make sure you don’t have an emergent condition. In other words, you’re going to be seen.
The problem continues with accessibility. Schedule that primary care appointment, and you might also need to schedule affordable transportation, perhaps a local van service that will take you to that appointment. As one patient in Kangovi’s study explained: “Transportation is hard. Every time I use the van service, [it] will get me there late, maybe twenty minutes late, and I’m marked as a no-show.” This no-show problem, by the way, is another reason many physicians limit the number of Medicaid patients they see in their practice, an issue I wrote about recently. This accessibility problem is yet another reason many patients find it easier to go directly to a hospital.
To compound these access issues, there is also a set of patients who simply believe they will get better care in the hospital then in outpatient clinics. Haul your way over to a primary care clinic, and you might spend 15 minutes with a clinician who tries to adjust your blood pressure medicines and address your pain problems. Go to a hospital and, if you get admitted, you will probably experience intensive efforts to manage many of your problems. That’s at least how patients in this study expressed their perceptions.
Does that mean we should simply accept the fact that many low income patients will, and perhaps should, continue to seek care at hospitals rather than outpatient clinics? I don’t know anyone who thinks the answer to that question is “yes.” Instead, we need to figure out how to make outpatient care more attractive to these populations. We need:
1. More flexible hours and appointment schedules
2. Better ways to transport patients to and from clinics, especially since two taxi rides is still cheaper than an emergency department visit
3. And a healthcare system that provides incentives for clinicians to care for such patients more efficiently, thereby letting the creativity of the marketplace solve this problem rather than relying on top-down regulations.
We should not blame low income patients for seeking care from hospitals, when our system is set up in such a way as to give them little incentive to go to primary care clinics. Instead, we should find ways to make outpatient care more attractive for them.
Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel. He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes.
