Health Policy$ense

Priced out of primary care?

Although the ACA has cut the level of uninsurance dramatically, roughly 30 million adults remain uninsured, many of them in states that did not expand Medicaid. Can these self-pay patients get an appointment with a primary care provider, and if so, at what price?

In the latest analysis from a “secret shopper” study conducted in 2012-2013, Brendan Saloner and colleagues report on the prices quoted for new patient primary care visits and whether patients could pay less than the quoted price at the time of the visit. In the parent study, trained research assistants called a representative sample of providers in 10 states posing as patients requesting a new patient visit. The callers were randomized to say they had different insurance types (private, Medicaid, or self-pay).

Nearly 80% of self-pay patients were offered an appointment, at an average price of $160. This varied from a low of $128 in Pennsylvania to a high of $188 in Oregon.  The price quoted at federally-qualified health centers (FQHCs) was lower ($109) and actual patients might have qualified for even lower prices, since FQHCs operate on a sliding scale basis. Prices were lower for family practitioners than general internists, for providers participating in Medicaid managed care, and for offices in zip codes with higher poverty rates.

Overall, only 18% of offices told uninsured callers that they could bring less than the full amount to the appointment and make an arrangement to pay the rest later. On average, patients able to bring less than the full amount were told that they needed to pay 61% of the total quoted price at the time of the appointment.

Saloner and colleagues (Dan Polsky, Genevieve Kenney, Katherine Hempstead, and Karin Rhodes) note that these fees could be a barrier to care for the uninsured.  They write:

The prices quoted to uninsured patients in our study would represent a substantial expense for a typical uninsured adult and may be a deterrent to seeking care. Before the 2014 coverage expansions of the ACA, 27 percent of the uninsured lived in households with incomes below poverty, and an additional 30 percent lived in households with incomes of 100–199 percent of poverty.  A medical bill of $100 would represent about one-tenth of the monthly income of a single adult living at the poverty level.

The callers did not request any tests or imaging, and so these fees do not likely account for any further diagnostic or treatment costs. But many poor patients will not get that far; although the door to primary care offices is open, the price of admission may be too high.