Disparities in Access to Outpatient Care

A recent paper questions the availability of timely and affordable outpatient follow-up to emergency department visits in Washington, D.C.  Under DC Alliance, a managed care prototype program for low income residents, Washington D.C. provides care to individuals with incomes less than 200% of the federal poverty limit and who are not eligible for Medicaid.  As a result, Washington D.C. has fewer uninsured adults than the national average.  The authors hypothesized that regardless of the unique coverage for the city’s low income patients, people without insurance or with Medicaid had greater barriers to receiving outpatient care after discharge from the city’s emergency departments.

The authors randomly selected 163 individual health care providers and clinics. Researchers called to evaluate appointment availability for hypothetical patients with hypertensive urgency who differed only by insurance status: private insurance, Medicare, Medicaid managed care, Medicaid fee-for-service, and uninsured.  The rate of appointment success among the DC Alliance (57%), Medicare (49%), and Medicaid managed care (58%) scenarios were comparable to private insurance (53%).  The Medicaid fee-for-service (27%) and uninsured (range 11%-27%) scenarios were significantly different, and they also faced out-of-pocket costs and time limitations that were prohibitive for appropriate outpatient follow-up.

Commentary:

The results of this proxy patient survey suggest that even when medically indicated after an emergency department discharge, the uninsured as well as those patients with Medicaid fee-for-service have decreased access to care.  The study is limited in its general applicability by the local resources of Washington D.C. (namely, the number of primary care clinics and physicians available). The unique insurance environment (i.e. the presence of D.C. Alliance) leaves room to predict an even more alarming disparity based on insurance status in cities or areas without such a coverage environment.  The study also sheds light on the difficulty of access for the average patient based on the sheer lack of contact information for appropriate clinics and physicians.  32.5% of clinics and providers called had wrong numbers listed, did not serve the population of interest, or did not answer the phone after five attempts.  Though access to care is most certainly affected by socioeconomic barriers, the logistical negotiation of the health care system can also be deemed an unacceptable limitation that should be addressed more comprehensively.

Journal of Health Care for the Poor and Underserved 19 (2008): 687–696.

by

Kameron Leigh Matthews, MD, Esq