Primary care practices discriminating on socioeconomic status

By Christopher Walsh, medwireNews Reporter

An audit of family physician and general practitioner offices in Canada reveals that patients with lower incomes are subject to discrimination when trying to access primary care.

Individuals calling a physician's office as new patients are 50% more likely to be given an appointment if they are of high socioeconomic status compared with those of low socioeconomic status.

In Canada, there are little or no financial incentives driving physicians to preferentially accept individuals on the basis of their ability to pay, because physicians are reimbursed equally for any patient, regardless of their socioeconomic status. As such, the results clearly indicate that other factors are at play.

"Because we see this finding in a single-payer universal health insurance system, it provides evidence of discrimination by physicians' offices on the basis of socioeconomic status," say Stephen Hwang (University of Toronto, Canada) and co-authors in the Canadian Medical Association Journal.

Following a standardized script and playing the role of someone requesting an appointment as a new primary-care patient, the researchers made unannounced telephone calls to a random sample of 375 practices in Toronto from March to July 2011.

The scripts were designed to present the patients as being of high or low socioeconomic status - either a bank employee who had recently transferred to the city or a welfare recipient, respectively. In addition, the patients presented with either chronic health conditions (diabetes and back pain) or no chronic health conditions.

Individuals of high economic status were significantly more likely to gain an appointment than those of low socioeconomic status (22.6 vs 14.3%), or an offer of an appointment, screening visit, or a place on the waiting list (37.1 vs 23.8%).

Reassuringly, individuals with chronic health conditions were significantly more likely to get an appointment than were those with no chronic health conditions (23.5 vs 12.8%).

Although the study was not designed to explain why individuals of low economic status might be less likely to gain access to primary care, the authors suggest that negative attitudes of staff or directives from the physicians themselves may be to blame.

Hwang told medwireNews: "I believe that the most likely explanation is that the office staff who answer the phone have unconscious biases against people who are low income or disadvantaged (and especially people on welfare), and it inclines them to turn down the caller.

"It is also possible that the physicians for whom they work have specifically instructed them to only accept people who will be 'good' patients, and they are implementing these directions by turning away patients on welfare."

He concluded: "Our findings clearly demonstrate that discrimination against low-income patients is not due to an assumption that they are medically sicker and therefore more difficult to care for."

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