Access to Care

Socioeconomically disadvantaged patients with lupus have less access to and use of health care

Patients with lupus (systemic lupus erythematosis), a chronic inflammatory disease that can affect the skin, joints, heart, kidneys, and other organs, suffer a variety of symptoms that may come and go over time. The most common symptoms include painful or swollen joints, unexplained fever, and extreme fatigue. Despite better survival for patients with lupus, the burden of the disease remains high, especially among persons of low socioeconomic status. Yet this group has less access to and use of care than other groups, according to three studies supported by the Agency for Healthcare Research and Quality (HS13893).

The studies, part of the Lupus Outcomes Study, were led by Edward Yelin, Ph.D., of the University of California, San Francisco. They are briefly discussed here.

Yazdany, J., Gillis, J.Z., Trupin, L., and others (2007, May). "Association of socioeconomic and demographic factors with utilization of rheumatology subspecialty care in systemic lupus erythematosis." Arthritis & Rheumatism 57(4), pp. 593-600.

Although elderly and impoverished groups traditionally have access to health care through Medicare and Medicaid programs, having health insurance alone did not ensure equal use of care for lupus patients in this study. Patients who were older than 50 or in the lowest income category were twice as likely to report no rheumatology visits in the past year, even after taking insurance, disease severity, and other factors into account. This suggests that additional barriers to accessing rheumatology specialty care may exist in these patient populations, note the researchers. They examined Lupus Outcomes Study survey data between 2002 and early 2004 on 982 people with lupus to identify predictors of use of rheumatology and other specialty care for lupus in the previous year.

Medicare insurance, male sex, and less severe disease were also associated with lack of rheumatology care. Race/ethnicity and educational attainment were not significantly related to seeing a rheumatologist. Yet blacks were twice as likely to report severe disease and three times more likely to have markers of kidney disease such as undergoing a renal biopsy, and thus, were twice as likely to see a rheumatologist.

Although three-fourths (77 percent) of lupus patients identified a rheumatologist as the physician primarily responsible for their lupus care, older and lower-income patients were least likely to identify a specialist as primarily responsible for their lupus care.

However, most patients who lacked rheumatologic care had seen a primary care provider (80 percent) or other physician such as a pulmonologist, nephrologist, dermatologist, or obstetrician/ gynecologist (62 percent). Many patients reported care by multiple providers, such as a rheumatologist and a primary care provider, nephrologist, or pulmonologist.

Gillis, J.Z., Yazdany, J., Trupin, L., and others (2007, May). "Medicaid and access to care among persons with systemic lupus erythematosus." Arthritis & Rheumatism 57(4), pp. 601-607.

A limited number of rheumatologists routinely accept Medicaid patients, according to the authors of this study. They found that Medicaid-insured patients with lupus may face more barriers than other lupus patients to obtaining comprehensive medical care near where they live. The researchers used an Internet mapping program to calculate the distance between the homes of 982 adults with lupus and their physicians. They then assessed the association between Medicaid status and distance traveled to the primary lupus provider, as well as the number of visits to lupus specialists and other physicians.

About 6 percent of patients were insured only by Medicaid, 9 percent by Medicare plus Medicaid, and 85 percent by other types of insurance. Medicaid patients traveled 11.5 more miles than those with other insurance to see any lupus care provider and 19.8 more miles to see a rheumatologist, after adjusting for other factors such as lupus severity, age, ethnicity, urban status, and education. Medicaid-insured individuals were equally as likely to have seen a rheumatologist and to have visited the rheumatologist a similar number of times in the past year as those with other types of insurance. They also did not differ from those with other types of insurance in their use of other types of physicians.

However, Medicaid patients were 2.6 times more likely to see a general practitioner for lupus-related symptoms and reported a mean of about five more visits to the general practitioner within the past year for lupus-related issues. Similarly, Medicaid patients were more likely to have visited the emergency room (ER) for lupus one or more times in the past year. These differences in use patterns remained significant, even after accounting for other factors affecting care use.

Yelin, E., Trupin, L., Katz, P., and others (2007, April). "Impact of health maintenance organizations and fee-for-service on health care utilization among people with systemic lupus erythematosis." Arthritis & Rheumatism 57(3), pp. 508-515.

This study compared health care use among persons with lupus in health maintenance organizations (HMOs) and fee-for-service (FFS) health insurance plans. It found lower use of outpatient physician visits and less use of diagnostic testing, along with fewer outpatient surgeries and hospital admissions among people with lupus in HMOs than in FFS health plans. These effects were not completely explained by socioeconomic, demographic, and health characteristics.

However, the largest differences in care use between HMO and FFS members were among lupus patients with Medicare and Medicaid insurance. This suggests that reduced use of health care resources by HMO lupus patients is concentrated among the aged, disabled, and impoverished patients insured by these government programs.

The largely middle-class employed population may be able to negotiate the rules of HMOs in a way that minimizes the effects of HMO coverage, note the researchers. They examined Lupus Outcomes Study survey data to compare health use of 982 patients with lupus in HMO and FFS plans between 2002 and early 2005.

After adjusting for socioeconomic, demographic, and health factors, lupus patients in HMOs had 2.3 fewer physician visits, 4.4 percent fewer outpatient surgery visits, and 4 percent fewer hospital admissions than those in FFS plans. Health, sociodemographic characteristics, and insurance type accounted for some of the difference in physician visits between those in HMO and FFS plans. Health characteristics and source of insurance, but not sociodemographic characteristics, accounted for some of the differences in hospital admissions. Nevertheless, all variables combined reduced the difference in hospital admission rates between those in HMOs and FFS plans from 5.5 to 1.7 percent.

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