When low-income patients compare hospital care to primary care, they find the former to be more affordable, convenient and trustworthy than the latter.
And that, according to a new study from the University of Pennsylvania, is why those patients tend to use emergency rooms and hospitals more heavily than primary care.
Low-income patients are the norm in South Los Angeles, particularly at community health centers like UMMA Community Clinic. Dr. Tipu Khan is a family physician and the lead obstetrics provider there. He says the patient mentality described in the study is certainly a reality, but "changing a little bit."
"I think it really varies," said Khan. "That's what it used to be prior to the advent of patient-centered medical homes."
Khan said before community health centers started "really boosting up" their presence in South L.A., most safety-net care was provided by county clinics, which he described as "overrun, overburdened and overstaffed." He would know, because he used to work in the county system. Now, though, UMMA is doing better at keeping patients away from unnecessary visits to the E.R. or the hospital, in part through educating patients on why primary and preventive care make for better health outcomes in the long-run.
"The community feels UMMA is closer to their culture and their society because we do a lot of outreach," Khan said.
The researchers on the UPenn study suggested that improving hospital care to reduce readmissions – a big tenet of health care reform – could "backfire," in that doing so would make hospital care "even more attractive" to low-income patients.
"To generate system-wide savings, it's important to make outpatient services [care that doesn't require a hospital stay, like primary care] more appealing to [low-socioeconomic status] patients by addressing their concerns around cost, quality and accessibility," said Dr. Shreya Kangovi, the study's lead author, in a statement.
Meaning that in addition to improving hospital care, health providers also need to work on making primary care the better option for patients. If they don't, noted the study's authors, poorer patients will continue forgoing preventive care and using urgent care, a pattern of behavior that costs the U.S. nearly $31 billion annually and still results in poor health.
Dr. Tipu Khan says that he still has to send patients to the E.R., particularly when wait times at the very busy UMMA Clinic are long and the health center just won't be able to get to someone.
"But it is frustrating, because I know there's nothing that they're going to do [at the E.R.] that we couldn't do here," he said. "Unfortunately, it is definitely a big burden [on the health care system] and a waste of resources, but it's all we have at this point."
Here are some more findings from the UPenn study:
- Patients who were surveyed said they trusted the quality of hospital care more than outpatient care, and viewed hospitals as more able to handle complex conditions.
- Patients said outpatient care was more likely to have longer wait times and be less accessible via transportation. Emergency care, on the other hand, could be accessed by ambulance and was described as a "one-stop shop" for services.
- For uninsured patients, who couldn't afford the fees to see a doctor or specialist, hospital charity care became the only option. For patients on Medicaid, the overall cost of outpatient care was higher due to the additional time and testing that was required.
One important finding from the study: It "debunks" the notion that low-income folks "abuse the emergency room," according to senior author Dr. David Grand.
"To the contrary, these patients eloquently explained to us how we have built a health care system that incentivizes them to wait and get sick in order to get care that is more costly to society," said Grand in the news release accompanying the study.
The research appeared in the journal Health Affairs.