A person calling a physician’s office and asking to be seen as a new primary care patient was more than 50% more likely to be given an appointment if he or she presented as being of high socioeconomic status. 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. The effect of socioeconomic status was independent of the presence or absence of chronic health conditions.
Although our study was not designed to identify why individuals of low socioeconomic status were less likely to receive appointments for primary care than their higher status counterparts, staff at physicians’ offices may hold negative attitudes toward this group, especially toward people receiving social assistance. Physicians have been shown to perceive patients with low socioeconomic status more negatively in terms of their personalities, abilities, behavioural tendencies and role demands.8
Most previous studies of discrimination in health care have examined the effects of patient race or ethnic background on treatment decisions.9,10
These studies have typically presented physicians with clinical vignettes11,12
or used observational databases and adjusted for confounding factors.13
Far fewer studies have focused on discrimination on the basis of patient socioeconomic status.8,14
Audit studies, a well-established method of testing for discrimination in labour and housing markets,15–17
have been used in the United States to show that Medicaid recipients and patients who are uninsured encounter substantial barriers to care.18–21
However, these effects may be due to the economic incentive of differing levels of reimbursement, rather than discrimination on the basis of socioeconomic status itself.
Financial barriers to accessing primary care are greatly reduced within Canada’s system of universal health insurance.22
However, 15% of Canadians report that they do not have a regular medical doctor. Among those patients who have looked for a doctor unsuccessfully, the most common reason given for not having a doctor is that local physicians are not accepting new patients.23
During the past decade, the province of Ontario has encouraged primary care providers to shift from a fee-for-service model to a capitated system in which payments are adjusted for age and sex but not patient comorbidities.24,25
This situation creates a possible financial incentive to preferentially enrol patients with few or no chronic health conditions. We found no evidence of such selection; on the contrary, a strong trend in the opposite direction was found, with physicians’ offices giving preferential access to patients with chronic health problems. This finding suggests that patients with greater medical needs are being appropriately prioritized.
We examined the behaviour of staff at physicians’ offices, which does not necessarily reflect the attitudes or directives of the physicians; nonetheless, any discriminatory behaviour by office staff can clearly have an adverse effect on patients’ access to physicians.
Referring to having a welfare worker was chosen as one of the few plausible and effective ways for the caller to rapidly convey low socioeconomic status. As a result, our study cannot distinguish between discrimination on the basis of low socioeconomic status and discrimination directed specifically against recipients of social assistance. Furthermore, we could not account for further patient selection that may take place at an initial screening visit or when patients are chosen from a waiting list. In addition, we did not have access to information on the reimbursement model (fee-for-service, capitation or blended) under which the physicians were practising.
We chose not to use a study design in which each physician’s office received paired calls from callers of high and low socioeconomic status. Although such a design would have had greater power to detect discrimination, the calls would have to have been separated in time to reduce the risk of detection. Our results might then have been influenced by the intermittent opening and closing of physicians’ practices to new patients, a phenomenon that is common in the geographic area in which we conducted this study.
Finally, our results may not be generalizable to jurisdictions in which there is a plentiful supply of primary care physicians who are accepting new patients.
This study provides evidence that discrimination against patients of low socioeconomic status can occur within a universal health insurance system and have an adverse effect on access to primary health care. Although it is reassuring that patients with chronic health conditions received prioritized access to primary care, our results suggest a need for greater efforts to ensure that physicians and their office staff do not discriminate against people of low socioeconomic status. Further research is needed to determine whether discrimination on the basis of socioeconomic status has an effect on other aspects of health care, such as quality of care and patient–physician communication.