Patients prefer care in a hospital setting as a better way of meeting their needs.
Low-income patients say they prefer care in hospital emergency departments (ED) over a doctor's office because of greater accessibility, perceived higher quality, and lower out-of-pocket costs, a series of in-depth interviews found.
The findings shed further light on the tension between patients and health-system providers that can be addressed through ongoing health reform movements, Shreya Kangovi, MD, of the Philadelphia Veterans Affairs Medical Center in Pennsylvania, and colleagues said in the July issue of Health Affairs.
While providers want care offered in the most cost-effective setting possible, patients prefer care in a hospital setting as a better way of meeting their needs. For example, some patients said the primary care provider may send them to two or three specialists — each requiring a copay — while the ED offers what they need in one visit, making it less expensive and more efficient.
Researchers queried fourty patients thought to be of low socioeconomic status who were admitted to one of two academic medical centers in Philadelphia.
"For patients covered by Medicaid, the direct financial cost of an ED visit and physician office visit were similar," the authors stated. "However, the overall cost of ambulatory care was higher because of the additional time and expense required for specialty visits or additional testing recommended by the primary care provider."
Most participants stated two main benefits of hospital care when compared with a doctor's office: better overall access and higher levels of trust in the quality of providers and services, the researchers found.
Patients were between eighteen and sixty-four, uninsured or covered by Medicaid, and residing in a 5-ZIP-code region of Philadelphia that has more than thirty percent of its residents living below the poverty line. They were purposely selected to have had a range of ED visits in the last 6 months to compare those with higher and lower patterns of care.
Physician office scheduling was viewed as unaccommodating while hospitals offered after-hours care. Hospitals were also more convenient to public transportation.
The patients also expressed a greater faith in hospital quality of care.
The healthcare community can conduct better public outreach to educate patients on handling their health needs — not with visits to the hospitals and immediate medications or interventions — but with less dramatic lifestyle changes primary care providers are more likely to give, Daniel Ehlke, PhD, of State University of New York Downstate Medical Center School of Public Health in Brooklyn, N.Y., said.
"It's not satisfying for most individuals to simply be given perhaps a list of subtle lifestyle changes that could lead to better health," Ehlke told MedPage Today in a video interview. "That's exactly where effective outreach could make a big difference, really de-emphasizing the idea of dramatic intervention in healthcare [and] emphasizing the importance of developing a healthy lifestyle."
Similarly health reform efforts such as accountable care organizations (ACOs) can make themselves more responsive to low-income patients, Kangovi and colleagues said.
Physician office scheduling was viewed as unaccommodating while hospitals offered after-hours care. Hospitals were also more convenient to public transportation.
"Accountable care organizations may instead focus on making ambulatory care more of a convenient, 'one-stop shop' experience for patients by physically co-locating services and coordinating access (for instance, scheduling or arranging transportation) whenever possible," they said.
There were several limitations of the study. For starters, ninety percent of participants were black, so results may not be generalizable outside of an urban, poor, mostly black patient population.
ACOs and providers should also avoid measures that discourage the use of ambulatory care, including complicated referral systems. "These measures may backfire by fragmenting care and driving patients to the higher-cost hospital setting," the authors said.
Results are based on patient perspective rather than objective, longitudinal data. Also, there was no comparison with high socioeconomic status patients to see if the views of low-income patients are unique.
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