Barriers to seeing PCPs send patients to EDs

According to new research, what patients perceive as barriers to office-based primary care may be more important than health insurance coverage in determining whether they go to emergency departments (EDs) for nonacute care. The bigger problem, however, may be shortages of primary care physicians (PCPs), the authors suggested.

In a research letter published in the August 8 issue of Archives of Internal Medicine, patients were found to be more likely to visit the ED if they have one or more barriers of care, defined as limited physician office hours, wait times for appointments, difficulty in getting in touch with a PCP’s office to make an appointment, and transportation issues.

Researchers also noted that those barriers have doubled over the past decade, with 6.3% of adults reporting at least one barrier to primary care in 1999 compared with 12.5% in 2009. The study was based on analysis of the National Health Interview Survey data of approximately 317,000 adults across the United States from 1999 to 2009.

“In addition to expanding health insurance coverage, policy makers may need to address the shortage and availability of primary care physicians. Without adequate primary care access, many people will continue to require emergency services and emergency departments will only continue to get busier and more crowded,” said Adit Ginde, MD, MPH, senior author of the research letter, assistant professor of emergency medicine at the University of Colorado School of Medicine and ED physician at University of Colorado Hospital in Denver.

A study (“Safety-net providers after healthcare reform: Lessons from Massachusetts”) in the same issue of Archives of Internal Medicine looked at the effect of 2006 Massachusetts legislation, similar to the federal Patient Protection and Affordable Care Act, which raised the rate of citizens with health insurance to more than 90%.

It found that the number of patients served by community health centers (CHCs) in Massachusetts increased by 31%, even though many of them had gained health insurance. During that time period, the number of those patients without insurance in the CHC caseload decreased from 35.5% to 19.9%.

Use of EDs for primary care was more common for lower-income, safety-net patients, 33.3% of whom said they had sought care for a nonemergency condition at an ED, compared with 14.7% of all adults. They said safety-net facilities such as EDs and CHCs were convenient and affordable; one-quarter said they had trouble getting care elsewhere.

"Despite the significant reduction in uninsurance levels in Massachusetts that occurred with healthcare reform, the demand for care at safety-net facilities continues to rise," the authors wrote. "Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after healthcare reform programs are established."

In an editorial in the same issue, Mitchell H. Katz, MD, from the Los Angeles County Department of Health Services, said that the answer to increasing capacity for patients newly insured under federal health reform may not be just training more PCPs but to do more to develop teams of healthcare providers.

"Ironically, safety-net providers have more experience working in teams than most commercial providers because low reimbursement rates have forced them to learn to be more cost-efficient," Katz argued. "The challenge will be proving that they can also be a system of choice for their patients, not just in Massachusetts, but across the country."

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