Dollars Continue to Drive Access to Care in US

BY Megan Rauscher

NEW YORK (Reuters Health) - After being treated in a emergency room for an urgent condition, Americans with private health insurance are much more likely to secure a timely follow-up appointment with a community doctor than those with Medicaid or no health insurance, a study shows.

"The bottom line is that if you're not a card carrying member of our healthcare system you're going to have a very difficult time getting access to care, " Dr. Brent R. Asplin from Regions Hospital and HealthPartners Research Foundation in St. Paul, Minnesota, told Reuters Health.

Americans will make roughly 114 million visits to hospital ERs this year alone, and more than 80 percent will be treated and discharged with a recommendation to seek follow-up care. That, however, may be easier said than done, according to Asplin and colleagues who examined access to follow-up appointments according to insurance status in nine US cities.

As they report in the Journal of the American Medical Association this week, eight research assistants called 499 ambulatory clinics and identified themselves as in need of follow-up care for pneumonia, high blood pressure or possible ectopic pregnancy -- early pregnancy implanted outside the uterus, such as in the Fallopian tube.

The same research assistant called each clinic twice using the same scenario but reporting different insurance status - no insurance, private insurance, or Medicaid -- the federal/state program for the poor.

"In our study, the callers who were trying to get appointments had potentially very serious conditions," Asplin emphasized. "These were not people trying to get an appointment for a sore throat or a cold. But despite the severity of there conditions, callers still had problems getting appointments when they didn't have the right insurance card."

"This study, I think, speaks to a really important myth that is out there," Asplin said. "That is that a lot of Americans think that, sure we have 45.8 million uninsured people, but when they really need care they get it -- and in our study the uninsured callers really needed care and they weren't able to get it."

Specifically, 63 percent of callers claiming to have private insurance secured timely follow-up appointments compared with just 34 percent of those who said they had Medicaid.

Callers claiming they had private insurance were also much more likely to secure appointments than were callers claiming to have no insurance but who offered to pay $20.00 and arrange payment for the balance due, typically about $80.00.

There was no difference in rates of secured appointments between callers claiming private insurance and those who were uninsured but willing to pay the entire $100 fee for the visit. Clearly, the ability to pay matters, Asplin said.

It's also noteworthy, he said, that 98 percent of clinics screened callers for a source of payment but only 28 percent attempted to determine the severity of the callers medical condition. This shows that "financial screening trumps medical triage in our care system," Asplin said.

This study, Asplin pointed out, also shows that people who have private health insurance "shouldn't think they will immediately get care as over one third of callers claiming to have private insurance could not get a follow up appointment within a week." This finding raises the question whether there is adequate capacity in our ambulatory care system, he said.

Although the ultimate consequences of these access barriers are not known, they may cause patients to delay seeking needed follow-up care, risking poor outcomes or additional emergency care or hospitalization. "Someone needs to tell me how this saves us money," Asplin said.

SOURCE: Journal of the American Medical Association, September 14, 2005.