It is hard for anyone to find a doctor these days, but studies by Portland State researchers suggest that some people have more difficulty than others.
Rajiv Sharma and Sarah Tinkler, professors of economics at PSU, are experts in studying healthcare disparities. Since 2013, Sharma has led the Longitudinal Access to Physicians Study (LAPS), which examines how factors like race, ethnicity, gender and insurance status can influence how easy—or difficult—it is to make a doctor’s appointment.
The study works like this: student research assistants call randomly selected doctors offices across the United States to request appointment information on behalf of a purported uncle or aunt who has specific demographic characteristics, including a type of insurance (private, Medicare, Medicaid or no insurance) and a name that suggests that they belong to a particular ethnicity or race. The research assistants record whether a particular doctor offered an appointment and, if so, how long the “aunt” or “uncle” would have to wait for that appointment.
Rajiv Sharma, PhD, professor of economics (photo courtesy of Sharma)While the LAPS data collection is ongoing, Sharma and Tinkler have already published several crucial findings, including:
Medicaid patients had a tougher time getting appointments
Prior to the implementation of the Affordable Care Act (ACA), Sharma and colleagues found that Medicaid patients were 27 percent less likely to be offered an appointment than privately insured patients, and non-white women were the least likely to secure appointments. Patients on Medicaid also had to wait the longest for their appointments—37 days longer than those on other insurance—and Black women on Medicaid had to wait the longest (80 days).
An inequity paradox
A follow-up LAPS study by Sharma, Tinkler and colleagues found that in states that paid providers the same amount for Medicaid patients and Medicare patients, Medicaid patients were only 6% less likely to be able to secure an appointment, suggesting that poor Medicaid reimbursement rates may underlie some of the discrimination faced by Medicaid patients.
However, raising Medicaid reimbursement wasn’t enough to ensure equity across the board. Non-insured people who lived in states with higher Medicaid reimbursement rates were less likely to be offered an appointment and had longer wait times than non-insured people who lived in states with lower Medicaid reimbursement. These uninsured patients are more likely to be low-income, Black, Hispanic or undocumented immigrants, showing how, paradoxically, reducing inequities for some can lead to new inequities.
Who hears "We're not taking new patients"
A 2021 study by Sharma, Tinkler and colleagues used LAPS data to look at whether the stated reasons for being denied an appointment varied between groups, and found additional evidence of racial and ethnic inequality. Hispanic patients were most likely to be told that the physician did not take their insurance while white women were the most likely to be told their insurance was accepted. White women were also the least likely to hear that the provider was “not taking new patients” whereas Black and Hispanic women were the most likely to be turned away.
Medicaid expansion and equity
While the LAPS has seen an overall decrease in racial and ethnic disparities in access to primary care since the ACA was implemented—perhaps because schedulers are less likely to use race or ethnicity as a proxy for ability to pay—the failure to expand Medicaid by some states has created its own set of inequities.
Tinkler, Sharma and colleagues recently completed a study that looked at racial, ethnic and gender discrepancies in access to primary care in states that chose to expand Medicaid and states that did not.
“There remain significant disparities in the states that did not take the Affordable Care Act up on its offer to expand Medicaid to larger groups,” says Tinkler. The results of this study are expected to be published later this year.
"Nudging" toward equity
Sarah Tinkler, PhD, professor of economics (photo courtesy of Tinkler)The LAPS team, which also includes researchers from Tulane and Oakland Universities, is currently looking at ways to improve access and equity in scheduling primary care appointments by “nudging” providers with different behavioral interventions.
These interventions include flattery (such as by telling schedulers that their office is known for taking great care of all kinds of people), asking whether another provider in the practice has availability and sending a letter to the provider reminding them of the importance of equity and access in healthcare before attempting to schedule an appointment.
The team is still collecting and analyzing data, but preliminary results suggest that the efficacy of some of these nudges may depend on the race or ethnicity of the patient, providing yet another potential source of disparity in access to care.
Other forms of inequity
Tinkler and Sharma have also looked at other sources of disparities in access to primary care. In one study they found that people who report being overweight are offered more appointments than those who describe themselves as smokers, which suggests that smoking is more stigmatized than being overweight. Currently, the pair are studying gay and lesbian patients to see if they have more difficulty accessing primary care appointments.
A healthcare barometer
Sharma says that the ongoing LAPS work is a way to keep tabs on changes in the healthcare system over time. “It provides a barometer of what’s going on with the healthcare system, just as the inflation rate provides the barometer of what’s going on with the economy more broadly,” he says.
Along these lines, Sharma and Tinkler are currently studying how the pandemic affected physician availability and whether older physicians who withdrew from offering appointments in greater numbers than young physicians during the pandemic have subsequently returned to their practices.
Tinkler cautions that there are some limitations to the methods used in the LAPS that should be kept in mind. “These are all standalone doctors. A lot of people get care through channels such as Kaiser Permanente or other health maintenance organizations,” she says. She also notes that the increased use of online scheduling may change disparities in access to primary care down the road—perhaps lessening discrimination for some groups and cementing it for others (such as those with a certain types of insurance).
Keep calling
While Sharma and Tinkler continue to chip away at the various ways in which discrimination hampers access to primary care—and what can be done about it—they note that one takeaway from their work is that it is difficult for everyone to find a new doctor these days because there is a shortage of primary care physicians.
“Most people have to make several phone calls before they can get in with a physician, and you mustn't be discouraged if this happens to you. You need to just keep calling,” says Tinkler. “You might have to make more phone calls if you fit into a group that is getting either overtly discriminated against—where the the physician might say ‘Oh, we don't take Medicaid'—or there might be some subtle discrimination going on, but you're going to have to be persistent because there are physicians out there who will see you.”