A small but very interesting study conducted by S. Kangovi, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar, and colleagues (2013) found "that current approaches to getting patients from low-socioeconomic groups to seek preventive and primary care in physicians’ offices or accountable care organizations instead of hospitals are often ineffective," (RWJF, 2013). The Patient Protection and Affordable Care Act signed by President Obama in 2010 assumes that when patients have health insurance they will access primary care early and as needed for health care and prevention. In actuality, even with Medicaid coverage, patients often seek care in the emergency department (ED). Kangovi and colleagues’ (2013) study involved interviews of 40 Medicaid patients in an urban setting who used the ED instead of primary care sites. Interviews were done by community health workers who were known and trusted by these patients.
Themes that emerged in the patient interviews fell into 3 categories: cost, convenience, and quality. It appears from patient quotes that they have done an excellent job of identifying the barriers and doing what works best for them. In terms of cost, the co-pay for primary and specialty care visits is a barrier and they must take time off from work for one or more visits. In addition, they cannot qualify for Medicaid transportation, which requires a 72-hour notification when seeking same-day access in primary care. In addition, there is a convenience factor when they go to the ED they see a doctor; this is not always the case in same-day access primary care and, if admitted to the hospital, their problems are treated quickly and aggressively. "The [primary care doctor] never treated me or my husband aggressively to get blood pressure under control. I went to the hospital and they had it under control in four days. The [physician] had three years," (Kangovi et al., 2013, p. 1198). This statement also conveys the belief that quality of care is better in the ED and hospital.
To better understand patient perceptions of barriers to using ambulatory care, Kangovi and colleagues (2013) divided patients into two groups. First were patients who experienced a traumatic health problem that not only affected their health status but this "event set off a cycle of social dysfunction, mental illness, and disability that drove their repeated hospital visits," (RWFJ, 2013). The second grouping was "most often highly functional caregivers for social networks strained by poverty and illness. These people often put off caring for themselves," (RWJF, 2013) and when confronted with illness, chose the ED.
So where do we go from here? This study clearly indicates the need to hear the voices of patients so that health care settings and systems are designed to meet patient needs for convenience, cost, and quality. Certainly this study needs to be replicated in other geographical areas and also with patients who obtain health insurance through state insurance exchanges. The Institute for Healthcare Improvement (IHI, 2009) has recognized the impact that socioeconomic factors, along with comorbidities, can have on patients’ choices and management of their health care needs. ED departments have begun to delve into the group of patients they see as "frequent flyers" and often the reasons are socioeconomic. The issue of perceived quality needs to be addressed in ambulatory care settings where evidence-based guidelines should be used; population health management data and teams should be available so that patients can see most, if not all, practitioners in one visit; and patients should have individualized care plans that move electronically to whoever is caring for the patient. Patients should also have a voice in design of these care plans so that they accurately reflect patient values, preferences, and goals.
This study also indicates that there are issues that require national policy changes such as the Medicaid regulations regarding transportation to and from health care settings. The Centers for Medicare & Medicaid Services (CMS) is considering bundling payment for health care, but health care settings (especially ambulatory settings) need to move away from the fee-for-service mentality that values multiple visits to specialists and for testing each with a separate cost, and move toward aligning/bundling testing and provider visits so that patients are not forced to take time off of work for multiple visits and testing. Ambulatory care organizations need to look at alternative arrangements such as hours of care, including early morning and late evening/night. For the low income poor where parents often work two or more jobs, the most common time for ED visits is 2 a.m., when one or both parents and child are home and able to get to the ED.
Dr. Kangovi evolved this study from her assessments of issues in practice. Ambulatory care nurses need to consider issues such as those raised in this study (Kangovi et al., 2013) and replicate their qualitative research design that offers the opportunity to get the patient’s perspective. There is a new funding mechanism that highly values the patient perspective: Patient Centered Outcomes Research Institute (PCORI), which may be a vehicle for funding for such qualitative research.
Institute for Healthcare Improvement (IHI). (2009). Improvement map: From here to excellence — Reliable routes to exceptional hospital care. Retrieved from http://app.ihi.org/imap/tool/
Kangovi, S., Barg, F.K., Carter, T., Long, J.A., Shannon, R., & Grande, D. (2013). Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Affairs, 32(7), 1196-1203.
Patient Centered Outcomes Research Institute (PCORI). (2013). The PCORI Challenge initiative. Retrieved from http://www.pcori.org/funding-opportunities/challenge/
Robert Wood Johnson Foundation (RWJF). (2013). Low-income patients say ER is better than primary care. Retrieved from http://www.rwjf.org/en/about-rwjf/newsroom/newsroomcontent/2013/07/low-i...
Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at firstname.lastname@example.org