Even in cases where doctors have no financial incentive, a study has found that patients with high socioeconomic status are more likely to get an appointment than their lower-status counterparts.
That's the finding of research published in the Canadian Medical Association Journal Monday, based on a study of family doctors' practices in Toronto.
In the study, led by Stephen Hwang of the Centre for Research on Inner City Health at St. Michael's Hospital, researchers role-played the parts of patients seeking an appointment.
In their calls to a random sampling of 375 doctors' offices across the city, the researchers followed a script that suggested their socioeconomic status was either high or low -- by posing as a banker transferred to the city, for example, or as a recipient of social assistance.
They also pretended to either have one of a variety of chronic health conditions, or no pre-existing condition at all.
The researchers then recorded the frequency with which their callers were able to secure an appointment, put on a waiting list or outright refused.
Overall, 69 of the calls resulted in appointments, 33 in offers for a screening visit and 12 went onto waiting lists.
According to the results of the survey, potential patients who presented a high socioeconomic status were able to make appointments in approximately 23 per cent of their calls, while the lower-status callers did the same in just 14 per cent of their calls.
And when it came to being offered a screening date or waiting list slot, the difference was also pronounced: at 37 per cent of higher-status callers versus 24 per cent of those purportedly of lower means.
Callers who presented chronic health problems were also nearly twice as likely to secure appointments than those who did not, but the researchers say the data shows the two factors had independent effects.
In the published results of their study, the researchers say their findings point to an underlying discrimination, even within a universal health insurance system where doctors receive the same payment for every patient, regardless of income or occupation.
The practice ultimately impairs access to primary care, the study’s authors say.
Dr. Hwang notes that the apparent discrimination is occurring despite Ontario College of Physicians and Surgeons explicit policy against patient screening.
“They should not be having patients auditions where the patients comes in and then the doctor decides whether they’re going to accept them or not,” he said in an interview on Canada AM Tuesday.
Under the College rules, family doctors are expected to take new patients on a first-come, first-served basis.
“I think we should just be enforcing this policy,” Hwang said.
The results are significant, its authors write, in light of the 15 per cent of Canadians who say they do not have a regular doctor and the trend away from fee-for-service models of payment.
Hwang said he was surprised to see that they found no evidence of preferential enrolment for patients with few or no chronic health conditions.
Instead, the research points to "a strong trend" in the opposite direction, suggesting that patients with greater medical needs are being appropriately prioritized.
“So if the person said they had health problems -- that they needed looking after rather than just wanting a regular check-up, they were more likely to get an appointment, and that’s a good thing,” Hwang said.
The study also highlights the fact that most of the researchers' calls were fielded by administrative staff who do not necessarily reflect the views of the doctors for who they work.
Hwang said it’s unclear exactly what is causing the bias, but said it’s likely due to an “unconscious bias” that society has regarding socioeconomic status.
“We treat people differently depending on their status,” he said.
Hwang said he suspects his Toronto findings are indicative of a wider trend across Canada.
“I think it’s probably going to happen anywhere where there is a shortage of primary care providers and a lot of patients looking for family doctors.”
