Why poorer patients prefer hospital care

A new Health Affairs study examines why low-income patients prefer hospitals to doctor's offices and use more hospital care and less primary care than patients with high socioeconomic (SES) status. The study authors point out how this low-value pattern of care is both costly to the healthcare system and harmful to the health of the patients using it.

With the advent of accountable care organizations comes a need for understanding what drives low-value healthcare use. Researchers from the Perelman School of Medicine at the University of Pennsylvania interviewed 40 urban low-SES patients to explore the preference for hospital care.

In the interviews, participants said they view hospital care as less expensive, more accessible and higher quality than ambulatory care. This brings in the paradox that improving hospital care to reduce readmissions could actually increase hospital use.

"When I go to my primary, I don't have a copay. I don't have a copay in the ER either. But my primary may send me to two or three specialists, and sometimes there is a copay for them," one respondent reported in the study. "Plus time off from work to go see them. It's cheaper to just go to the ER."

Another respondent said primary care doctors can't help them with particularly diagnostically challenging issues--"[My primary] didn't help me. I had to go to the emergency room just to get rid of this. She couldn't do it."

In the study, the authors found two different types of people who prefer hospitals--Profile A patients reported social dysfunction and disability, and Profile B reported social stability but thought access to ambulatory care was difficult. When health policymakers brainstorm interventions, they must keep in mind these differences.

"To generate system-wide savings, it's important to make outpatient services more appealing to low-SES patients by addressing their concerns around cost, quality and accessibility," Sherya Kangovi, M.D., lead study author, said today in an announcement from Penn Medicine. "For instance, health systems might reduce barriers such as complicated referral systems that are often required for seeing specialists. These barriers may actually drive patients to the higher-cost, one-stop-shop hospital setting."

To learn more:
- read the study in Health Affairs (.pdf)
- read the announcement from Penn Medicine

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