Financially better-off individuals seeking a family doctor appear more likely to get an appointment than those who are poor, even though Canada's universal health system offers no monetary incentive for cherry-picking patients, a study suggests.
The study found that individuals who called a physician's office asking to be seen as a new patient were more than 50 per cent more likely to get an appointment if they presented themselves as having a well-paying job.
'It is not appropriate for physicians to screen potential patients because it can compromise public trust in the profession.' - College of Family Physicians of Canada
"Our study provides very strong evidence of discrimination, but it does not identify specific offices that are discriminating," said principal researcher Dr. Stephen Hwang, a specialist in inner-city health at St. Michael's Hospital in Toronto.
"It simply shows that you are more likely to get an appointment if you are of high socioeconomic status," he said. "We think this indicates pretty clearly that there is preferential access to primary care."
To conduct the study, published Monday in the Canadian Medical Association Journal, researchers phoned 375 family physician and general practitioner offices in Toronto, posing as a bank employee or a welfare recipient, either with chronic health conditions or needing only routine care.
"So every physician's office got a call from one person and there were four possible scenarios that they could be randomly assigned to," said Hwang, noting that the doctors' offices were chosen at random and most responses were from receptionists or other administrative staff.
The proportion of calls resulting in an appointment offer was greater for those posing as bank employees — 23 per cent — than for those presenting themselves as welfare recipients — 14 per cent.
When including those who were offered a screening visit or a spot on a waiting list, 37 per cent of so-called better-off callers got a positive response compared to 24 per cent for those of more limited income.
"Typically, the caller who was turned down would be told: 'I'm sorry, but Dr. X is not accepting patients currently' or 'The practice is not open to new patients,"' Hwang said.
"That's what they would be told, but what we observed is that you're more likely to be told that if you're of low socioeconomic status than if you're of high socioeconomic status."
Hwang stressed he was not trying to single out family physicians or suggest they discriminate more than other physicians or professions.
Health problems got priority
"We don't know if this is a subconscious bias on the part of the receptionist or if they're carrying out instructions that are given to them or if it's conscious bias. We don't know."
Dr. Marie-Dominique Beaulieu, president of the College of Family Physicians of Canada, said her organization promotes patient equality and would frown on any of its 28,000 members across the country choosing patients based on their social or financial profile.
"Socioeconomic status or any other [patient] characteristic shouldn't be considered" when a physician is in a position to accept new patients, Beaulieu said from Montreal, where she practises family medicine.
The study has some limitations, including the fact that doctors' offices were called only once with a single scenario, not twice by two different researchers posing as patients on relatively opposite sides of the socioeconomic coin.
Hwang conceded that two calls would have been ideal — providing a "smoking gun" if each caller got a different response — but there were logistical pitfalls, including time constraints and concern about detection if the calls were made too close together.
"I think we have to take this study for what it is," said Beaulieu, "which is a small study that maybe adds to a body of knowledge, but certainly cannot be considered as conclusive at demonstrating bias."
Unexpectedly, researchers who said they had chronic health conditions — in this case, diabetes and low back pain — were more likely to receive appointment offers than those seeking routine care, such as a check-up (24 per cent versus 13 per cent).
"We were very surprised by that," said Hwang, who had hypothesized that patients without complex health problems would be more likely to be accepted as patients.
"We thought because patients with chronic health conditions take more time and more effort that physicians might be preferentially seeking to enrol healthy patients in their practices.
"But we were pleased to see the opposite, that physician offices were appropriately giving priority to people with health problems over those who did not have immediate health problems."
College does not support cherry-picking
Beaulieu said the fact that patients with complex health-care needs were more likely to be offered an appointment is reassuring.
"So this would not support the idea of cherry-picking," she said.
The study found no evidence that the length of time a doctor had been practising nor the socioeconomic status of the neighbourhood where offices were located had any bearing on whether a patient was accepted.
Hwang said the College of Physicians and Surgeons of Ontario, for one, recommends against doctors cherry-picking patients based on their health status, socioeconomic profile or other factors.
"They say 'it is not appropriate for physicians to screen potential patients because it can compromise public trust in the profession, especially at a time when access to care is a concern."'
The College of Physicians and Surgeons has a clear policy that new patients should be taken on a first-come, first-served basis, but the policy does not appear to be enforced, he said.
"I think the first thing is we need to recognize is …[that we're] all prone to treating people differently and discriminating," Hwang said.
"Socially, within the realm of health care, we feel that that's inappropriate."
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