Primary Care Accessible, But Costly for Uninsured Patients

In a study, only 6% of would-be patients were told they were refused an appointment because they were not covered by a health plan. But fewer than 20% of physicians were willing to see an uninsured patient unless they were paid in full up front.

People with no health insurance have few problems making appointments at a primary care physicians' offices, but they likely will have difficulty paying for it, research shows.

Researchers at Johns Hopkins University Bloomberg School of Public Health conducted a telephone survey of 1,613 primary care physicians' offices in 10 states in late 2012 and early 2013, before Medicaid expansion under the Affordable Care Act.

The callers, posing as uninsured patients seeking routine care, found that nearly 80% of the primary care physicians were willing to schedule an appointment. Office visit fees ranged from a low of $128 in Pennsylvania, to a high of $188 in Oregon, and a 10-state average price of $160 for a basic checkup or hypertension evaluation. The callers did not request prices quotes for blood work, imaging, or lab tests.

Only 6% of callers were told they were refused an appointment because they had no insurance. However, fewer than 20% of the physicians were willing to see the uninsured patients unless they paid the full cost up front. The study was published Monday in Health Affairs.

"The message here is that the uninured can get appointments at some price. They don't experience more difficulties with private insurance, but it costs a lot of money," says Brendan Saloner, the study's lead author and an assistant professor of Health Policy and Management. "The kinds of prices that callers in our study were being quoted would represent a real financial burden for the typically uninsured person."

Even with the advent of the Patient Protection and Affordable Care Act, Saloner says the study's findings remain relevant because 22 states have declined to expand their Medicaid roles.

"In states where Medicaid expansion has not taken off because the state made the decision not to expand the program the reality of 2012–2013 is pretty much representative of what life is like today," Saloner says.

"The big unknown is how things are evolving on the provider side, their capacity to see different kinds of patients, and whether the prices they are charging in this evolving market are going up or going down. Either of those would be possible, but we don't know for right now."

Saloner says there was no sense in the study that physicians were jacking up prices to discourage uninsured patients.

"I don't think they're in the business of frightening people away," he says. "While there are some prices that were quoted that were so high that it wouldn't be realistic for a typical patient, more typically they were offering similar prices. The prices they were quoting were what that office felt like they should be trying to get as a standard rate from a self-paying client."

"Based on what we learned in the study and comparing rates with private insurance markets, the uninsured are probably quoted prices that are similar with what the doctor has negotiated with private insurance companies."

Saloner says the study is not a critique of primary care physicians. "They are under a lot of financial pressures," he says. "What we need to understand is how this fits into the broader context of where the uninsured are getting their care. For a lot of uninsured people a primary care physician's office may not be the best option. They may be better served going to a federally qualified health center."

'What States Can Do is Expand their Medicaid Programs'
The researchers found that the average price for the same basic primary care services at a federally qualified health center was $109. A $100 office visit represents about 10% of monthly income for a person living at poverty level.

"The primary care market is not going to just fix itself for the uninsured, and we shouldn't look to the broad network of primary care physicians to solve this problem by providing more charity care," Saloner says.

"If I had a message it would be more around what states can do, and what states can do is expand their Medicaid programs. That is something that is going to provide a lot of relief to people below the poverty line who are uninsured, and that is where a lot of the room for increasing the insured rate is going to be in the immediate future."

"There are states that have been sitting on the sidelines trying to figure out what to do and our study really speaks to the impact of taking a complacent stance and not moving forward with the Medicaid expansion."

The study found that office visit fees were lower in Zip Code areas where the populations were poorer, and higher in areas where there were more primary care physicians, which Saloner calls counterintuitive.

"I don't know that that is necessarily a causal relationship. I doubt that putting more primary care physicians in a market with low supply is going to drive up the cost of primary care. That runs counter to economic theory," he says.

"What it more reflects is something that our study can't exactly measure that would be true of those areas. Physicians are setting prices based on a number of factors, including the ability to schedule lucrative patients with good insurance. If you are in a market where there are a lot of people with good insurance that is going to attract more providers to the area and that, in turn, could be where the higher price is coming from."