Patients with low socioeconomic status use emergency and hospital care more often than primary care because they believe hospital care is more affordable and convenient, and of better quality than care provided by primary care physicians, according to the results of a new study from researchers at the Perelman School of Medicine at the University of Pennsylvania. The results of the study, appearing in the July issue of Health Affairs (and featured on its cover), have significant implications for policy initiatives such as the Affordable Care Act that seek to lower health care costs by reducing avoidable hospitalizations, readmissions, and emergency department visits.

"Our findings suggest that efforts to reduce hospital readmissions solely by improving the quality of hospital care could backfire by making hospitals even more attractive for low-SES patients," said lead author Shreya Kangovi, MD, director of the Penn Center for Community Health Workers and a Robert Wood Johnson Foundation Clinical Scholar in the Department of Medicine at the Philadelphia Veterans Affairs Medical Center. "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. 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."

Data consistently show that low-SES patients receive health care differently than high-SES patients; low-SES patients use less preventive care and are more likely to become acutely ill and require urgent hospital care. This is not just explained by lack of insurance. This pattern of health care use, which costs $30.8 billion annually and leads to poor health outcomes, is a lose-lose for patients and payers.

To better understand the reasons for this persistent discrepancy, Penn researchers worked with trained community health workers to conduct detailed interviews with 40 low-SES Philadelphia patients (low-income, and uninsured or on Medicaid) on why they choose to visit the hospital/emergency department over a primary care physician. Community health workers have been shown to engender trust and form close relationships with low-income patients.

Quality: Many participants described a greater sense of trust in the quality of hospital care than in ambulatory care. Participants described hospitals as better able to correctly diagnose and control problems, particularly for conditions they view as complex. "[My primary care physician] didn't help me. I had to go to the emergency room just to get rid of this. She couldn't do it," one participant said.

Convenience: Outpatient care was commonly described by low-SES patients as less available due to long wait times, and less accessible via transportation than hospital care. Emergency care, the participants said, can be accessed via ambulance for urgent complaints and provides a "one stop-shop" for services; outpatient care required a great deal of transportation coordination for participants, most of whom did not have their own car.

Cost: Uninsured participants often could not afford fees for regular visits to see a doctor or specialist, leaving them no choice but to rely on hospital charity care when they became ill. For patients covered by Medicaid, the direct financial cost of an emergency department visit and physician office visit were similar; however, the overall cost of outpatient care was higher because of the additional time and expense required for specialty visits or additional testing recommended by the primary care provider.

The study also uncovered what appeared to be two very different groups of low-SES patients: super-utilizers whose hospital use was driven by trauma and social dysfunction, and lower-utilizers who reported postponing ambulatory care because of caregiver burden and job pressures.

"This study debunks the perception that low-SES individuals abuse the emergency room and need to be educated on its proper use," said David Grande, MD, MPA, assistant professor of Medicine at Penn Medicine and senior author on the study. "To the contrary, these patients eloquently explained to us how we have built a health care system that incentivizes them to wait and get sick in order to get care that is more costly to society."