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Researchers Look At Why Poor Patients Prefer Hospital Care

By Ankita Rao

July 8th, 2013, 5:30 PM

Long wait times, jammed schedules, confusing insurance plans – there’s no shortage of obstacles between a patient and her doctor. That is, if she has a doctor.

But a Health Affairs study published Monday says the barriers for poor people looking to get care are even higher, and it’s leading them away from preventive doctor visits and toward emergency rooms and costly, hospital-based care.

“This was like holding up a magnifying lens to the problems of our health care system,” said Dr. Shreya Kangovi, lead author and a physician at the Philadelphia Veterans Affairs Medical Center.

Researchers interviewed 40 patients of low socioeconomic status in the qualitative study to document how and where they receive health care. The patients fell into two groups: socially dysfunctional or disabled patients who sought hospital care five or more times a month, and those who were socially stable but found it hard to access ambulatory care. The researchers identified the study subjects by their zip codes and hospital usage.

The study found that common themes driving the group to hospitals included how they perceived their ability to pay for care, location of facilities and availability of treatment based on their schedules.

“Transportation is hard,” said one respondent.

Another woman said she and her husband were treated for years at “a wellness center” but their high blood pressure was not treated aggressively or brought under control. “I went to the hospital, and they had it under control in four days,” she told researchers.

Kangovi said the study was meant to inform the efforts to create a more efficient health care system.

Measuring readmissions, for example, is one way that the government currently gauges hospital efficiency by tracking when patients need to return to the hospital within 30 days. But the study, Kangovi said, could shed light on other factors keeping hospital beds full, like patient preference and perceptions of quality care.

Some programs are tackling the problems of low-income patients and primary care directly.

“An ER is not preventive. It’s not a good system for continuous care,” said Vincent Keane, CEO of Unity Health Care Inc., which includes about 30 community health clinics across the D.C. metropolitan area.

As part of Unity’s goal of serving marginalized communities, the health system started a program supported by Blue Cross Blue Shield to divert frequent emergency users to a clinical setting. They employ social workers, regular wellness visits and testing in an effort to provide long-term care.

For patients like those interviewed in the study, and the health care reformers looking to rein in hospital costs, these new models could be the answer for patients getting lost in the health care system.

“It’s not that patients have the wrong perception – they are the ones educating us that these are the results our system is producing,” Kangovi said.

29 Responses to “Researchers Look At Why Poor Patients Prefer Hospital Care”

  1. Cecil says:

    Why do poor patients prefer hospital care? What an idiotic question! Isn’t it obvious? Isn’t it as plain as the nose on your stupid face? Poor patients prefer hospital care because they have no other choice. Republican Governors like Tom Corbett and Rick Perry are shutting off all other options for poor people! If Republican governors want poor people to try to find less expensive health care, then they should do everything possible to encourage poor people to buy private health insurance or, as a last resort, allow them to be eligible for Medicaid with the Medicaid Expansion contained in the Affordable Care Act. Pulling all that data together, researchers found that the average charge for a single emergency room trip is $1,233. Is that cheaper than Medicaid? Apparently Republicans think so! You would think even the dumbest Republican would try to understand that it’s less expensive for a poor person to be on Medicaid than it is for them to get their healthcare at the hospital emergency room but apparently Republicans still don’t understand that. Do Republicans really think that poor people are paying when they visit the emergency room? Huh? Republicans! Really dumb! Really stupid!

  2. Carol says:

    Even in countries with fully socialized medicine, it’s actually the well-to-do who cost more, because they go to specialists more often. Unfortunately you didn’t give any details about whether these “poor people” were Medicare/Medicaid or simply uninsured – there’s a difference. A study not long ago which showed that “Although uninsured people rely on EDs to a greater extent than insured people do because of a lack of access to other outpatient care, their actual use of hospital EDs is no greater than that of the privately insured, probably because fear of incurring the entire cost of an ED visit acts as a constraint on how frequently they visit EDs.” Medicare and Medicaid beneficiaries had the highest levels of health care use overall, including EDs.

    http://content.healthaffairs.org/content/25/5/w324.abstract

  3. Cecil says:

    Firstly, the well-to-do need not worry about healthcare coverage regardless of their country of origin, right? They can afford to pay. If other countries would model their healthcare system to be more like Medicare/Medicaid, they would phase out socialized medicine as incomes increased. You need to get your facts straight and stop believing Republican lies. With few exceptions, Medicare/Medicaid was basically designed for senior citizens and for people that are economically disadvantaged. I don’t know what an ED is but, with regard to ER’s, the people that don’t pay for their ER care are the people without any healthcare coverage whatsoever. If they had Medicare/Medicaid, they would not be categorized as uninsured. With Medicare/Medicaid, hospitals see them as payer customers. Uninsured people do not hesitate going to an ER for their care because of cost. Why? Because they don’t pay anyway. The cost of paying for the uninsured ER visits is shared between private insurance companies, taxpayers and the hospitals. We all pay a hidden premium for the uninsured! Yes, Medicare/Medicaid beneficiaries may have the highest levels of healthcare use overall, but hospitals love seeing them because, unlike the uninsured, Medicare/Medicaid patients have the coverage needed to pay their bills. Not true with the insured. Obviously, only Republicans think the ER is a smart way to deliver routine healthcare. Otherwise, they would be trying their best to find a less expensive way. Republican governors would be quick to expand Medicaid so that the uninsured have a way to see a private doctor for their routine care at one tenth the cost of an ER. Talk about nitwits!

  4. Carrie says:

    The reason that people use the ER is because they don’t bother you about past bills AND if you grew up using the ER then you will continue the pattern for your family. I have been to the emergency room and have witnessed patients declaring the triage nurse their primary care physician. You do what you know. It’s not rocket science. Why would you go to a PCP and/or Urgent care when you have a 24/7 no need to pay, go on a whim option? Since I have insurance through my employer, I get slammed if I go to the ER AND I care about my credit score, therefore I am very careful not to go there.

  5. We have been led to believe small numbers of Americans are falling through the cracks. Sadly the truth is that we know very little about the bottom half of Americans – because they have been left behind in education, health, and other designs. No one is saying “we don’t know” but this does not stop the non-stop opinions, innovations, and reorganizations.

    About 40,000 zip codes with 200 million people have only 25% of physicians in local or adjacent zip codes. Physicians are packed by our designs 45% into 1% of the land area inside of 1100 zip codes. ERs, retail clinics, urgent cares, and other quick fixes are also packed into zip codes that already have higher to highest health care workforce – because they follow the money also. If primary care received 30% more revenue over the cost of delivering care, primary care continuity offices would be open weekends and evenings, but such is not the case in a design that so favors non-primary care over primary care.

    Using county level data about 100 counties have 450 physicians per 100,000 or above for top concentrations, 150 counties have 300 – 450 for higher than average, 300 will soon be the average, while 2900 counties with 200 million people have less than average or below in physician concentration levels. Social determinants and designs that shape social determinants insure that more are left behind while fewer benefit. By the way, the counties with lower to lowest health workforce are growing faster in total population, elderly, and in those in need of health care coverage.

    About 80 million people reside in counties with lowest health workforce concentrations – losing out on access, services, local leadership from health care workforce, and the economic impact of health care. Designs divide the US into locations where 10% of the population receives multiple times greater health spending (especially parts of 7 states) with most of the nation found in locations where health spending is multiple times less per person. Health spending, education spending, and Social Security spending are more important for these areas with most Americans – the dark side of austerity measures.

    There is only one source of clinicians that is specific to multiple times greater practice locations where 200 million Americans are found. Sites in need of workforce offer family practice positions and the MD, DO, NP, and PA graduates willing to accept are the ones who can make a difference. Our design prevents family practice. Despite major increases in MD and DO graduates, there are still just 3000 annual FM graduates 33 years after first reaching 3000. The doublings of NP and PA annual grads have largely failed because family practice position result has declined from over 50% to less than 25%. More declines are on the way as our design attracts more to higher salary, greater support, and more benefits in more different non-primary care specialties with more added to each specialty. Teaching hospitals took 30,000 to replace resident workforce lost due to resident work hours limitations – a movement of NP and PA to highest concentration locations by design, or lack thereof.

  6. This is an interesting study that needs to be extended. With all the hospital consolidations and closures because of budget cuts, why not create ambulatory care centers and medical homes housed in these once vibrant hospitals? The costs associated with spread out medical practices could be mitigated with share services (and distance to travel can be afforded with free transportation / transit fares for attending patients using primary care).

    The larger question that this study did not broach is why poor patients overwhelmingly prefer hospital care. Our country’s privately-run and administered healthcare system is the most expensive in the world with amongst the worst outcomes. Patients poor or not would be more likely go to more appropriate healthcare settings if we were afforded care without the threat of crippling financial debt that the current private insurance-based system mandates. It would be excellent to consider a similar study in countries like Canada and France that have comprehensive and universal single-payer healthcare systems.

  7. Janet says:

    My comment is addressed to “Cecil”. I don’t know what state you live in, but as a person with 26+ years in healthcare in rural Oklahoma I can tell you that our hospital no longer views Medicare/Medicaid as “payer customers” nor does it “love seeing them”. These days, thanks to continuous, seemingly endless cuts in reimbursement rates, our hospital comes out in the red on the majority of such patients who come through the door. It’s considered extremely fortunate to just break even on the cost of their care.

  8. larry says:

    So tell us Janet, would rural hospitals in Oklahoma rather treat Medicare and Medicaid (CMS) patients or would your hospitals trade those CMS insured people for the truly uninsured non-payers that regularly visit urban hospitals? My guess is, you probably rarely see totally uninsured people that never pay for their care so, to you, CMS insured people are considered deadbeats. Believe me, if rural hospitals were faced with the massive problems that urban hospitals regularly deal with, they would kiss and hug each CMS patient that walks through the front door.

  9. Janet says:

    Larry, you couldn’t be more wrong about our hospital rarely seeing totally uninsured patients that never pay for their care. In FY 2011 our hospital wrote off $8M in charity/bad debts care; in FY 2012 it was $7.3. And I personally resent your use of the word “deadbeats” when referring to CMS patients; definitely your word, not mine. I don’t blame the patients. Most of them have absolutely no idea how little their healthcare providers are actually being reimbursed for their care. In fact I think a great number of them, particularly Medicare patients, would be truly shocked and mortified. I would also point out that urban hospitals are reimbursed at a higher rate for Medicare patients than rural hospitals; a fact that may have contributed to your skewed point of view. I don’t know of any business that could lose money on almost every customer who walked through their doors and still continue to keep their doors open.

  10. Steven Watkins says:

    Message to Beanie (Larry) and Cecil: Janet is correct. As a hospital CEO, I can tell you that filling an ER with ungrateful, manipulative Medicaid customers who are sponsored by somebody else’s hard-earned dollars since they are “entitled” at a rate of about 40% of the actual cost is not a sustainable business model. Smart hospitals with good reputations like the Mayo Clinic dropped Medicare & Medicaid participation years ago because of this. Most Caid patients use the ER because they know it’s a federal EMTALA violation if they are turned away. Period.

  11. Joan says:

    I recently accompanied my unemployed, uninsured, college-educated, past upper-income earning and seriously-ill brother to the ER/ED at the Contra Costa County Regional Medical Center in Martinez. It was the best example of one-stop-shopping I’ve experienced. Their team reviewed all his systems, prescribed medications, ran tests no one in the outpatient care sites even discussed, and encouraged him to stay in-house until his diagnosis was properly confirmed and treated to the point of stability. One RN confided to me that most patients in his situation would not be able to comply with the recommended frequent outpatient treatments because of delays in scheduling follow-up appointments, constant tranportation challenges (20-30 miles ea way), inability to drive, prolonged IV therapy, costly medications not covered in the outpatient setting, etc. I clearly see why so many patients like him “end up” in the ER/ED and hospital settings. Much of the treatment he was able to receive in-house was not available in the outpatient setting due to regulatory limits set by outpatient medical programs in the county and state.

    If you expect lower utilization in the ER/ED/hospital settings, then we must provide the same level of service in the outpatient models.

  12. larry says:

    Steven Watkins CEO,

    Jeanie and Cecil, huh?

    I’m sure you’ll agree, it’s amazing what you can find on the Internet…

    Would you mind sharing the name of the hospital that you are associated with so myself and other readers can research your financials with regard to CMS reimbursements?

    For that matter, maybe Janet could offer the name of her rural Oklahoma hospital so we can research the financials there too?

  13. paula says:

    If things are as bad as you say. If hospitals are in such financial trouble. If Medicaid and Medicare reimbursements are not sufficient to pay the actual cost of hospital services. Then why are hospitals all across America pleading for governors to participate in Medicaid Expansion?

  14. Isabelle says:

    Good point Paula… With hospitals begging and lobbying their governors and their state legislators to expand Medicaid as soon as humanly possibly, it shoots holes in theories of those people here who are whining and crying about CMS not paying a fair reimbursement. If you ask me, it sounds a bit hypocritical. With greedy providers and greedy executives in healthcare delivery, they have milked the cow for so long now that, regardless of what Medicaid and Medicrae pays, it will never be enough. These providers and executives hate seeing the end of a lucrative fee-for-service model and are fighting it tooth and nail.

  15. Cecil says:

    Hey Larry, the silence is deafening!

  16. cat says:

    the bottom line is — those without medicare, medicaid or insurance have no options but to go to an ER — if the stupid politicians had to use medicare, medicaid instead of their very good insurance (along with autos and chauffers) they would realize that the USA has to have free or low cost health care). So let’s make the politicians use the ER rooms for their health care — and I’m still ‘irrigated’ that Cheney got a heart which should have gone to a young father/mother with children to support!!! Let him go buy a heart from some prisoner in a foreign country.

  17. Kate says:

    I was researching public hospitals many years ago when there was a pusht to establish primary care centers in communities as an alternative for those who often sought care in the EDs. Even though these centers were closer for many to reach than the EDs were and offered the potential of continuity of care the EDs could not, patients frequently circumvented them and traveled to the EDs instead. Why? we asked. The answer many gave was the EDs were where the better doctors, technology and resources were. The primary care centers were perceived to be a low cost–and lower quality–way to prevent low income people from seeking the care those with better insurance could automatically get. And, Joan’s experience with her seriously ill brother suggests that the quality differential is often more than a perception.

  18. Cecil says:

    “Message to Beanie (Larry) and Cecil: Janet is correct. As a hospital CEO, I can tell you that filling an ER with ungrateful, manipulative Medicaid customers who are sponsored by somebody else’s hard-earned dollars since they are “entitled” at a rate of about 40% of the actual cost is not a sustainable business model. Smart hospitals with good reputations like the Mayo Clinic dropped Medicare & Medicaid participation years ago because of this. Most Caid patients use the ER because they know it’s a federal EMTALA violation if they are turned away. Period.”

    If your hospital is in such financial trouble, as the CEO, what was your bonus last year?

  19. DS says:

    I have extended family with an older grandparent on Medicaid and Medicare. She has some health issues and is living in an assisted living facility. When she had a few health problems a few months ago, instead of going to her PCP (I asked, she does have a PCP through the county), she kept going in to the ER – probably at least 6 times in 8 weeks. During this time she was admitted to the hospital twice, but again after being released, when things came up again she went back to the ER. I don’t know if it’s that the family didn’t know how to get her to her PCP, didn’t trust her PCP, didn’t feel like issues were being resolved by her PCP, or the assisted living facility just calls an ambulance and sends their patients to the ER for liability reasons, but I kept thinking what a broken way of doing things this was and how costly it was.

  20. Steven Watkins says:

    Isbella and Cat,
    Excellent question. The reason for so many state hospital associations asking for the Medicaid expansion is that many of them believe that “something is better than nothing”. The folly in this is that most hospital CFOs incorrectly believe they can continue to cost shift to commercial payers. This is fatal thinking because soooo many large employers are now self-insured and are loudly demanding skinny networks which exclude the most expensive facilites. Sooo, many hospitals supporting this exansion are going to wake one day soon and find themselves Medicaid havens….with no place to shift costs….hence will either close or be enslavened to the White House. And THAT is what the objective is here.

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