In the US, un- and under-insured patients use the emergency department (ED) and inpatient services disproportionately. In part, this occurs because these facilities provide care for all who seek it, regardless of ability to pay. However, even in countries with universal health coverage, low socioeconomic status patients seek care with the same patterns.
Reigning in health expenses in the US includes efforts to shift non-emergency care from the ED and the inpatient ward to the outpatient setting. In the 1990's, many states experimented with Medicaid HMO's, assigning the poor to primary care clinics as part of the effort. Success was limited at best, and we now find those least able to pay seeking care in the most expensive venues.
A recent study from the University of Pennsylvania explores reasons that those with low socioeconomic status (SES) use more acute care and less primary care than patients with high SES. They invited 64 adult inpatients of low SES based on Zip Codes to participate in structured qualitative interviews; 40 agreed to the study. Of these patients, 12 (Profile A) had 5 or more acute care episodes in the prior 6 months. The remaining 28 individuals (Profile B) had 4 or fewer hospital encounters over the same period. Patients of the two profiles had similar income, sex distribution, and ethnicity. The major difference between the two groups seemed to be the presence of a social support network for subjects in Profile B.
The figure shows themes that differed between the two profiles. All patients identified ease of access and quality of care as reasons for choosing hospital-based services. Profile A patients reported more chaotic lives than those with fewer encounters; they experienced more trauma, dysfunction, substance abuse, survival insecurity, and problems with activities of daily living. Profile B patients also experienced barriers, including the need to be caregivers; however, their social networks also provided support as well as this burden. Finally, Profile B patients saw their health issues as concrete problems to be solved, rather than an intangible challenge.
The study provides an important first step in improving care for low SES patients by identifying themes that influence their care choices. Like all qualitative studies, it gives no results with a p value but provides data to generate new hypotheses and policies. The study population was also limited to urban, primarily African American patients; the rural poor we see in Oklahoma may identify different barriers. Further study is clearly needed.
The study is available here; this is the citation: