March 7, 2013 / 7:00 PM / 5 years ago

Even in Canada, wealth influences treatment: study

NEW YORK (Reuters Health) - Poorer people have a harder time getting a doctor’s appointment in Canada, a new study suggests - even though the country’s universal health insurance pays doctors the same amount regardless of the type of patient they see.

Researchers who called primary care practices pretending to be a bank employee or on welfare were 80 percent more likely to be offered an appointment when taking on the wealthier persona.

“We expected that we would find the result that we did, which was that there would be preferential treatment,” said Dr. Stephen Hwang, who worked on the study at St. Michael’s Hospital and the University of Toronto.

“As a physician who provides care for people who are marginalized or disadvantaged, they not infrequently tell me that they feel like they’ve been treated poorly by healthcare providers in the past simply because they’re poor,” he told Reuters Health.

Hwang expects the disparity to be due more to doctors’ and receptionists’ unconscious biases than an explicit policy to cherry pick wealthier patients.

Members of his team called 375 family physicians and general practitioners in Toronto pretending to be looking for a primary care doctor. Half of the time the caller pretended to be a bank employee recently transferred to the city; for the other half of calls, the caller took on the role of a welfare recipient.

Researchers impersonating a bank employee were offered an appointment almost 23 percent of the time. In the other cases, a receptionist put the caller on a waitlist or said the doctor wasn’t taking new patients.

In comparison, callers pretending to be on welfare were offered an appointment at just 14 percent of offices, the researchers found.

Receptionists were more likely to offer an appointment to a caller posing as someone with diabetes or low back pain than one without a chronic condition. That, at least, suggests patients who need care the most “are being appropriately prioritized,” Hwang and his colleagues wrote in the Canadian Medical Association Journal.

Past studies suggest patient discrimination based on income is an even bigger problem in the United States, where doctors tend to be reimbursed more for treating a person with private insurance than one on Medicare or Medicaid.

“When people have no health insurance or if they have health insurance that pays less than more general coverage does, they’re much more likely to get turned away by physicians. But that’s hardly surprising,” Hwang said. “It simply pays more to look out for those patients.”


“The fact that they found the results they did in a universal health insurance population is particularly interesting,” said Dr. Karin Rhodes, who has studied access to care at the Perelman School of Medicine, University of Pennsylvania in Philadelphia but wasn’t involved in the new research.

“Everything I’ve seen has been economically driven,” she told Reuters Health, meaning doctors’ reimbursements would be affected by which patients they saw - unlike in Canada.

“The next step is (the authors) really need to follow it up with some qualitative research to identify the potential reasons behind their findings,” Rhodes added.

Hwang said it may be human nature to have an unconscious bias toward the well-off, but healthcare workers especially need to recognize and fight against that urge.

“Physicians and particularly office assistants/receptionists who play a very important role in our healthcare experience have to be aware of the risk of treating people either preferentially or negatively simply because of their background, and we have to guard against that tendency,” Hwang said.

“In the realm of healthcare, I feel strongly that we should be providing care on the basis of people’s need and not their wallet.”

SOURCE: Canadian Medical Association Journal, online February 25, 2013.

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