Reform Update: Low-income patients prefer hospitals for primary care

Federal healthcare reform efforts have focused on keeping people out of the hospital and getting them into primary-care offices for preventive care and health management. Projects to achieve this include the Federally Qualified Health Center Advanced Practice Primary Care Demonstration and the Comprehensive Primary Care Initiative.

But some low-income patients strongly prefer going to the hospital for primary care, and they give some good reasons for this. That's reason to think reformers may be pushing a rock uphill to try to change patient behavior.

A recent Health Affairs article, based on interviews with 40 hospitalized low-income patients between January 2011 and June 2011, found that low-income patients have more trust in healthcare delivered in the hospital setting and find primary care outside the hospital inaccessible and unaffordable.

The article, by researchers at the University of Pennsylvania's Perelman School of Medicine in Philadelphia and other Pennsylvania institutions, included a comment from one patient who called the provider at a wellness center a “quack” who did not do enough to manage either her or her husband's hypertension. “He never treated my husband or me aggressively to get the blood pressure under control,” the patient said. “I went to the hospital, and they had it under control in four days.”

Other patients in the study cited the convenient “one-stop shop” nature of the hospital and its emergency department. In contrast, ambulatory care required traveling to multiple locations. Many of the interviewees said that they did not own a car and that subsidized van services were unreliable and caused them to miss appointments.

“The patients in our study articulated clear, logical reasons for preferring hospital to ambulatory care,” the authors wrote. “The reasons provided cannot be attributed to a cultural tendency or ignorance remediable by education on the appropriate use of the ED.”

Still, the article cited a study that found avoiding hospitalizations for conditions that could be treated in ambulatory-care settings could save the U.S. healthcare system $30.8 billion annually.

Full implementation of the patient-centered medical home practice model resulted in higher quality scores and lower costs, according to a study in the Health Services Research journal.

In the study, funded by the Agency for Healthcare Research and Quality, researchers with Blue Cross and Blue Shield of Michigan and University of Michigan's School of Public Health in Ann Arbor compared self-reported medical home implementation and administrative claims data for 2,432 Michigan primary-care practices in June 2009 and June 2010. They found a 3.5% increase in quality scores, a 5.1% higher score for delivering preventive services and $26.37 lower per member a month medical costs. The Michigan Blues plans estimated that this resulted in $155 million in savings between July 2008 and June 2011.

The savings did not materialize for pediatric practices, however.

The American College of Physicians issued a statement calling on Congress to follow the recommendations that the National Commission on Physician Payment Reform released this year. These included ending the Medicare sustainable growth-rate payment formula, increasing reimbursement for evaluation and management services and a phasing out fee-for-service as stand-alone payment method over a five-year period. (Under the recommendations, fee-for-service would remain as part of a “blended” payment system, but would be recalibrated to “encourage behavior that improves quality and cost-effectiveness.”)

“The debate over reforming Medicare physician payments is now at a critical juncture with both the House and Senate working on bipartisan bills to repeal the SGR and transition to new approaches to paying for and delivering care, like patient-centered medical homes,” Dr. Steven Weinberger, ACP executive vice president and CEO, said in a news release. “The commission's report offers a well-considered, evidence-based and consensus approach to reform that should be considered by Congress as it moves forward on such legislation.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks