Patient's Insurance Status Affects Choices Doctors Make

Uninsured miss out on drugs and key tests because of cost, study finds

TUESDAY, Sept. 26, 2006 (HealthDay News) -- Doctors treat patients who lack health insurance differently than patients who are insured, a major new study finds.

For example, the uninsured are much more likely to get two generic medications instead of one easier-to-take brand-name drug. Or, they might be prescribed a cheaper generic drug that must be taken longer than a pricier brand-name version.

Both of these prescribing decisions make it harder for uninsured patients to stick to their medications as needed, experts warned.

"This paper underscores the tragedy that America doesn't have a single-payer health care system," said Dr. Michael Mendoza, a clinical assistant professor of family medicine at the University of Chicago.

He was not involved in the study, which was published in the September/October issue of the Annals of Family Medicine.

According to the U.S. Census Bureau, 46.6 million Americans went without heath insurance in 2005, up from 45.3 million in 2004. Overall, the number of Americans without health insurance has risen by 7 million since 2000.

The new study finds that doctors often make health-care decisions that are based, at least in part, on whether a patient is insured.

In the study, researchers led by Dr. David Meyers, of Georgetown University Medical Center, surveyed 25 doctors from a primary care, practice-based research network in Washington, DC.

The doctors completed brief surveys immediately after seeing each patient during two half-day office sessions.

According to the survey, 88 percent of the doctors made at least one change in their patients' clinical management due to his or her insurance status. Overall, physicians changed management strategies for 99 of 409 patients. Nearly two-thirds (62.6 percent) of the time, doctors discussed insurance issues with patients and made changes based on insurance status.

Common changes in practice included prescribing two separate generic medicines instead of one brand-name combination pill, or using a less expensive but longer course of medication. Both strategies make it more likely that a patient will not keep up with the prescribed regimen, the researchers noted.

Doctors also said lack of insurance often caused them to forego treatments that might boost patient health. For example, they might not prescribe smoking-cessation aids, or fail to refer patients with a family history of colon cancer to life-saving (but expensive) colonoscopy.

Primary care doctors face the problem of the uninsured all the time, experts say.

"We know that the two biggest factors that impact access to care are insurance and a usual [regular] source of care," said Dr. Patrick T. Dowling, professor and chair of the Department of Family Medicine at UCLA's David Geffen School of Medicine.

Dowling said prescribing generic drugs is generally a good idea, since people without insurance are less likely to buy higher-priced brand-name drugs. "We should always use generic drugs whenever we can," he said.

However, it is worrisome that many uninsured patients don't get recommended screening tests, Dowling said. "We see uninsured people all the time. We say, 'this is what is recommended, but this is going to be the cost, and this is how we could proceed as an alternative.' We try to discuss it upfront," he said.

However, health care could be compromised if patients don't get tests that can detect diseases such as cancer, heart disease or HIV, Dowling said.

Mendoza, who works in a Chicago community health clinic, said he also prescribes generic medications first. And, he said, "I really go out of my way to find [specialist] doctors who will accept patients without insurance."

That's important, because uninsured patients often have trouble getting timely appointments with specialists, Mendoza said. In those cases, "I continue to take care of them even though I want them to see a specialist," he said. "I do the best I can -- as a primary care physician -- to take care of their specialty needs. That can definitely compromise care."

Many specialists require insurance or payment upfront, Mendoza noted. "I can't send people to universities [medical centers], because they won't be able to afford the bill they are going to get. They are not even going to let you in the door unless you can demonstrate insurance or independent wealth," he said.

In a related study in the Sept. 25 issue of the Archives of Internal Medicine, researchers find that when prescribing new medications, doctors often don't tell patients important details, such as side effects, how long or how often to take the drug, or the specific name of the medication.

According to the report, doctors used the specific drug name 74 percent of the time for new prescriptions, explained the purpose of the drug 87 percent of the time and discussed adverse effects 35 percent of the time, and gave instructions on how long to take the drugs 34 percent of the time.

"This study demonstrates spotty physician counseling about new medication prescriptions," wrote a team from the University of California, Los Angeles. "Although physicians educated patients more about psychiatric and analgesic medications, the overall quality of communication was poor even for these medication types and could contribute to patient misunderstandings about how and why to take their new medications," they concluded.

More information

There's more on the plight of the uninsured at the Center on Budget and Policy Priorities.

SOURCES: Patrick T. Dowling, M.D. M.P.H., professor and chair, Department of Family Medicine David Geffen School of Medicine at UCLA; Michael Mendoza, M.D., clinical assistant professor of family medicine, University of Chicago; September/October 2006, Annals of Family Medicine, Sept. 25, 2006, Archives of Internal Medicine
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