Don’t blame low income patients for seeking care from hospitals

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.

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  • Mengles

    ” 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.”
    Right and bc they know they will never pay that bill that comes from the care they received from the ER.

    • Noni

      Every time I take care of an uninsured patient I look and see their ER visit history. Without exception there are at least 20 visits in a 12 month period for “emergencies” such as earache, sore throat, leg pain, severe menstrual cramps, bladder infection, abdominal pain with diarrhea, headache, etc. It doesn’t matter if the patient is 25 or 85 (though interestingly I find the younger patients hit the ER even more for non emergent visits). It’s frustrating to see.

      • Suzi Q 38

        Such a waste of money, time, and resources.
        There are more efficient ways, and the hospitals aren’t making an effort.
        Why would they want their hospital to shut down due to having to serve so many of the patients that you have described?
        I think the government should not pay for this unless it is a true emergency.
        This way, all of these minor illness will be sent away, and the ER can be there for those truly in need.

        • Noni

          And there is the problem in a nutshell. There are too many parties making tons of money off our dysfunctional system. So where is the incentive to change it?

          • Suzi Q 38

            There is no incentive. In fact the hospitals have become dependent on the government payback gravy-train. Just like illegals going to our public schools. The Teacher’s Union loves it. Why? more students means more teachers and administrators. They became dependent on the ADA, and then the free lunch reimbursements.

  • azmd

    So, to recap, we need clinics which could provide free healthcare, 24 hours a day, seven days a week, preferably within walking distance for the patient.

    I don’t disagree, but what exactly is the incentive for the market to provide such a wonderful resource?

    • Suzi Q 38

      Hopefully, someone will “wake up” and realize where our tax money is going.

  • EE Smith

    As others have pointed out, there’s no incentive whatsoever for low-income patients to go to proper primary care practices/clinics rather than the hospital, with one of the main advantages to fronting up at the hospital being that it’s free. So for all of the disadvantages of going to a regular practice or clinic rather than the ED, they actually have to PAY for those disadvantages to boot. That’s just not logical.

    Restaurant A: You have to book two months in advance, if you don’t have Comprehensive Restaurant Insurance they make you pay $60-$90 ahead of time before they’ll even take your booking, it takes two hours or more on public transport to get there, if you’re 10 minutes late they give away your reservation PLUS charge you a penalty, and once you’ve been at your table for 12 minutes they boot you out whether you’re done or not.

    Restaurant B: You just show up whenever you feel peckish, it’s probably right on all the main public transport lines or even within walking distance – but if it’s not, call for a free Restaurant Taxi and it’ll show up immediately and get you there quick-smart, with lights flashing and sirens blaring (and unlike a regular taxi, you don’t pay a dime). You might have to wait a little while for a table, but once you get one you can be assured that you’ll get all of your needs seen to, and best of all, unless you have any significant wages or assets for debt collectors to attach, it’s all completely “free”.

    Poor people are poor, they’re not stupid. Of course they go to Restaurant B. I would too, in their position. Dr. Ubel’s suggestion is that “we should find ways to make outpatient care more attractive for them”. I would suggest that there’s no way to make outpatient care as attractive as hospital care as it stands today. Even if you make outpatient care “free” like ED care, and include “free transport” like they can get if they’re going to a hospital, and make the clinics offer “more flexible hours”, that still won’t compare favorably with ED care. Look at England, where they do have free PCPs (GPs) with extended hours who have to offer a certain number of same-day appointments: their EDs (A&Es) are just as clogged full of people with non-emergent issues as ours are.

    So in addition to “we should find ways to make outpatient care more attractive for them”, I would add “we should find ways to make hospital care less attractive for them”. We need to, as the Indonesians say, “take the sugar off the table”. How we do that, I do not know.

    • Margalit Gur-Arie

      those who sell sugar will never take the sugar off the table.

      If we put a 24×7 primary care clinic next to the ED and have triage nurses direct traffic at the door, chances are that the ED will remain mostly empty.

      Now, why won’t hospitals do that (and not just for the poor)? Something to do with the price of sugar I presume?

      • EE Smith

        An excellent point.

      • T H

        My hospital actually did that in an attempt to aid ED overload: the clinic was open 6a to midnight. They had to close it after several months because patients preferred the ER. If a person insisted on being checked in to the ED, per state law (California) they could not be turned away, even after a triage exam. Two main reasons when people were asked: the clinic did not offer IM injections of opiates and lab testing results were not available until the next day.

        • Margalit Gur-Arie

          This is disturbing information, to say the least. Does this mean that a large portion of ED visits is for narcotics? And why would lab results be such a priority after a person has been triaged NOT to have an emergency?
          Maybe the law needs to be changed, because treatment next door to the ED does not constitute turning people away, in my opinion.

    • guest

      the interesting thing is that it is unlikely that an ER doc will be able to resolve the issue. Depends on the problem but I am assumig if it is a chronic problem it is unlikely even going to be addressed at the free clinic ER.

      • EE Smith

        With the example that the author uses, an earache, it’s equally unlikely that the patient is going to get the issue resolved at a doctor’s office. The difference being, the doctor’s office will have all of the disadvantages listed above, and then send the patient away with no prescription for antibiotics (hopefully), saying to give it a few days, and the patient will think “I jumped through all those hoops and paid $75 and didn’t even get fixed, and didn’t even get any pills, what a rip-off!”

        Even for actual chronic problems which need medical treatment, it’s uncertain how likely the type of patient who now uses EDs as their de facto “primary care physician” would be to go to a PCP in the first place and then make the ongoing commitment to attend regularly and do whatever is necessary on their own, to see that problem resolved. Definitely, without bringing the price of the PCP down to the same price as the ED (i.e., free); or conversely bringing the price of the ED up to the same price as the PCP (i.e. $75 or $80 or whatever), it’s not going to happen.

        • guest

          well put. Basically if anyone bothered to study this I think there would discover morbidity and mortality.

          • EE Smith

            It’s really a shame, because so many of the people who would most benefit from having a relationship with a good PCP, instead of ad hoc care at an ED, just aren’t receiving it. But I don’t know how we change this.

          • guest

            I agree. I have learned so much from reading about these problems here and have appreciate your thoughts. I think I even have a better understanding now in general about how healthcare went south. Unfortuantely you and I my friend EE aren’t the policy makers here. But maybe we should be.

    • Kristy Sokoloski

      One of my friends who lives in the UK said that when she goes to see her PCP for an appointment she gets 5 minutes although if it goes over they aren’t going to throw her out because it did. Also, not everyone in the UK has the NHS. There are people that pay for private care. Also, I read an article a little while back about that some Emergency Departments (in New York I think it was but don’t remember for sure) were considering having those that came in for non-emergent care pay for using the Emergency Department. I am not sure what came of doing it that way as far as whether it was implemented. And yes, you are definitely right about the A&Es there having the same kinds of problems that are being had here in the U.S.

  • Anthony D

    You can’t go to a body shop and make them repair your car if you don’t
    have money to pay.. But you can go to a hospital, get care and not pay..
    Well YOU might not pay but anyone with insurance has been paying with
    higher premiums. It’s really that simple.

  • Suzi Q 38

    The hospitals should have a portable desk outside or just inside the front door of the lobby.
    If you have insurance and it is not a true “emergency,” You go to Urgent Care.
    If you have no money and it is not a serious emergency you go to urgent care.
    The ER, will cost you a minimum of $2000.00.
    The urgent care will cost considerably less if you have insurance, and nothing if you don’t have insurance.

    I think too that the hospitals like the fact that they have to treat all, medically necessary or not, indigent or not.

    This way, they have more patients to treat and the government pays (our taxes) regardless. Job security.

    • EE Smith

      “The urgent care will cost considerably less if you have insurance, and nothing if you don’t have insurance.”

      Penalizing people for having insurance is probably not a great precedent to set if we want to work towards requiring that everyone have insurance.

      • Suzi Q 38

        But it is not going to happen for people who do not own property or have money.
        There is incentive for me to buy insurance because I don’t want to lose my life savings or my house with any kind of lien.
        for people who don’t have insurance or money of any kind, they just are going to our ERs without a thought to the huge price that they do not pay anyway.
        I am just saying…send them to a room with a PCP or dare I say it…NP and the cost will be considerably less.
        Putting our heads in the sand and allowing this to continue for minor illnesses is not the answer.

        • EE Smith

          Obama, Congress, and the Supreme Court have decreed that it is “the law of the land” that every American MUST have health insurance as of January 1, 2014. A hospital that gives lawbreakers an advantage over those who are obeying the law is not doing the right thing, in my opinion.

          • Suzi Q 38

            They haven’t been doing the right thing, anyway, so what is going to make them change with the new year in 2014? They will just pay the fine, it is cheaper.

  • EE Smith

    Speaking of price controls and shortages, I recently read an article detailing an example:
    “Price Controls Make Venezuela the Only Country in the World where Used Cars Cost More than New”.
    Who’s going to bother to manufacture and sell new cars if the government won’t let you make any money off them? Well, no one, apparently. But they haven’t capped the prices of *used* cars, and *new* cars may be artificially “cheap” but they’re almost impossible to get, so….

  • Suzi Q 38

    It makes sense to me. The urgent care could save lots of money.

  • Margalit Gur-Arie

    Question about staffing: couldn’t a (large) hospital staff something like this with residents mostly? They do staff EDs, so why not an adjacent little urgent care?
    It occurs to me that most of these larger hospitals advertise on TV and billboards for their ED services. Chances are that poor people see those ads too, and chances are that the hospital did the math and accounted for patient mix.

    • buzzkillerjsmith

      Maybe to some extent, but remember that residency programs exist to train docs to do serious stuff and urgent care is mostly brainrot. That said, taking a few urgent care shifts during a emergency medical rotation wouldn’t kill anybody. Best to keep the med students away, however, lest they learn the horror.

      • Margalit Gur-Arie

        Makes sense… :-)

  • Suzi Q 38

    I can tell you that even in the 60′s and 70′s this stuff was not happening as much.
    People knew not to go to the ER unless it was a true emergency, and most either had insurance or knew they owed the money for the services at some point.

    Right now, it is virtually free to those that have no money.
    My daughter said that the homeless come in and claim that they are ill, get all of these services, when all they want is a shower, clean clothes, and a bed for the night.

    • EmilyAnon

      Suzi, we’re both in So. Calif. so you might remember when one hospital here got in trouble for delivering a discharged patient to his “home” which was a homeless encampment. Somehow the TV news people were informed ahead of time and were already there set up to film the “dumping” of the patient to the sidewalk. The reluctant patient didn’t want to leave the van as the driver struggled to pull him out. Visually, it looked terrible. There was a hue and cry from the public, with the resolution that he was taken back to the hospital.

      The follow-up news was that he got some amount of money to voluntarily leave.

      • Suzi Q 38

        Hi Emily,
        Yes, I remember that.
        It did look bad.
        I also read about certain cities buying the homeless one-way tickets out of their cities.

    • querywoman

      You forgot to mention the free meal for the homeless! That’s what they really want, after they sold their food stamps. Many people don’t sell their food stamps, though, and use the ER more appropriately.
      In the old days, the truly poor waited for hours, often more than 24 hours, at public hospital ER’s for care.
      Then came Medicaid.
      Family doctors used to make house calls. Then they didn’t want to do that anymore, and the ER began to really change.
      Then came minor emergency/urgent care centers. Most insurance companies will let you go there for evening/weekend care.
      Twice I think I appropriately got ER only care. With my skin disease, I have had some major flaking/bleeding problems in one of my armpits. I went to the ER twice with that. Once I got a a shot and pills to combat the infection. The second time I got an IV, over a few hours, and some pills.
      Becuase I once had a very bad abcess in the other armpit, this probably needed to be checked and monitored in the ER.

  • SarahJ89

    You would NOT believe what a hassle it is to use one of those medical/handicapped van services. Nor would you believe how routinely they screw up the pick up times. I have a friend who has a regular appointment and her life is a continuing nightmare of “no shows” and financial penalties, all thanks to the van service she has to depend upon. She is an extremely organized person but gets to pay the price and look back to her medical providers, thanks to the ineptitude of others.

  • medicontheedge

    In my area, hospital ED’s are directly marketing to everyone via all media, about “wait times”, call ahead “reservations”, how all their bells & whistles are better than others, etc. There is money to be made from non-emergency patients, and hospitals are eager to tap that market. Whether the “customer” has private insurance or the insurance WE pay for with taxes, (welfare), they want that business. Add to the latter the fact that customers on state assistance have no skin in the game in the way of throttles or co-pays, and there ya go. Our ED is full of complaints that absolutely should be dealt with in clinics or PCP offices, but we want our healthcare like our fast food: quick, cheap to US, and without any effort on our part. As someone who has been in emergency services for almost 30 years, I have decided to cope with the “abuse” of the ED services in this way: I view our ED as a walk-in clinic that is capable of handling emergencies.

    • querywoman

      They do that where I live, too. It just now hit me that it’s a marketing tool.
      Thank you.

    • Suzi Q 38

      You are so right.
      They want the money, regardless of how wasteful it is.

  • bill10526

    Every so often the Defense Department’s $700 hammer comes up. The problem was that huge development costs for a major project were spread over items in an accounting manner. A similar accounting technique says that emergency room visits are very expensive. From what I observed, lots of patients were lined up and fed through a rather efficient heath care machine. If I am right, then the savings from the ACA on this item will be illusory. For people, such as myself, doctors were a once in a decade or less need. Having an ER catch makes sense for us.

  • T H

    Throwing out facts and anecdotes like this gives me a smidgen of hope. As does the Medicaid recipients (and in my case, SSI) who drive late model, expensive cars while my car is from 1992 and has >280k miles on it.

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