The Content of a Low-Income, Uninsured Primary Care Population
Background: Poor and uninsured people have increased risk of medical and psychiatric illness, but they might be more reluctant to seek care than those with higher incomes. Little information exists about the biopsychosocial problems and concerns of this population in primary care.
Methods: We surveyed 500 consecutive patients (aged 18 to 64 years) in a primary care clinic serving only uninsured, low-income patients. We used self-report questions about why patients were coming to the clinic, a chronic illness questionnaire, the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, and items from the Childhood Trauma Questionnaire. Providers completed a questionnaire naming problems elicited from patients.
Results: Patients reported their most common chronic medical problems to be headaches, chronic back problems, and arthritis. The most common concerns patients wanted to discuss with providers and that providers elicited from patients were problems with mood. Compared with patients without current major mental illness, patients with a current major mental illness reported significantly (P < .001) more concerns, chronic illnesses, stressors, forms of maltreatment and physical symptoms.
Conclusion: The illness content of this uninsured, low-income population is dominated by emotional distress and physical pain. These needs place a serious burden on providers and can complicate management of chronic medical illnesses. Recommendations for specialized interview training and integrating mental health services are discussed.
People without health insurance often have different health-careseeking behaviors than people who are insured. The uninsured are less likely to pursue care for acute illnesses, chronic illnesses, preventive care, or for serious or morbid symptoms Their hesitance to seek health care becomes apparent after short periods without health insurance and is more pronounced after extended uninsured periods. In midlife, those who are uninsured experience a greater decline in overall health status than those who are insured. The most vulnerable sectors of the uninsured population are those persons living in poverty. In 2000, 41% of the population living below federal poverty guidelines, aged 18 and 64 years, lacked health insurance.
The relation between poverty and poor health is well established. Compared with middle- and upper-income populations, indigent populations have more medical illness and mental illness, diminished psychological, social, and physical functioning, and greater mortality rates. Those living in poverty, even when covered by health insurance, are more reluctant to seek health care than persons with higher incomes.
These features of low-income and uninsured populations suggest that the characteristics of indigent, uninsured primary care populations might be different from general primary care populations. There is growing evidence to support this hypothesis. We could find only limited documentation, however, of the full content of medical or psychiatric problems, common co-occurring illnesses, or the reasons why patients in low-income uninsured, primary care populations seek care.
The present study builds on data from two earlier studies of an uninsured, low-income, primary care adult population. To better understand provider time use, we studied the frequency of diagnoses and of diagnostic combinations in all patient visits during a 1-year period between 1998 and 1999. The most common visit diagnoses recorded by providers were depression (23%), hypertension (12%), sinusitis (7.4%), tobacco abuse (6.7%) and anxiety (6.0%). In one half of the visits, providers recorded two or more problems. Fifty percent of these multiple problem visits included depression, anxiety, or alcohol abuse. In a second study we surveyed 500 consecutive patients (only one visit per patient was included) to assess the prevalence of mental disorders and compared findings with results from a parallel study of 3,000 patients from a representative primary care sample. Twice as many low-income, uninsured primary care patients had mental disorders compared with the general primary care sample (34% vs. 15%). Within the low-income sample, those with mental disorders had significantly more medical problems, lower functional status and greater disability than patients without mental disorders. Because our visit data included multiple visits by the same patients and our prevalence study only assessed mental disorders, we did not have a measure of the relative prevalence of all health care problems or of problem combinations.
In the current study, we sought to describe the biopsychosocial content of this population. Because middle- and high-income, insured people have different health-careseeking behaviors than low-income and uninsured people, we wanted to learn what concerns prompted them to seek care. Because mental disorders are so prominent in this population and because they often complicate overall health care efforts, we studied which problems were most associated with mental disorders. We believed this information would be helpful in designing health care efforts to respond to the unique needs of poor, uninsured working-age patients seeking primary health care.
Background: Poor and uninsured people have increased risk of medical and psychiatric illness, but they might be more reluctant to seek care than those with higher incomes. Little information exists about the biopsychosocial problems and concerns of this population in primary care.
Methods: We surveyed 500 consecutive patients (aged 18 to 64 years) in a primary care clinic serving only uninsured, low-income patients. We used self-report questions about why patients were coming to the clinic, a chronic illness questionnaire, the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, and items from the Childhood Trauma Questionnaire. Providers completed a questionnaire naming problems elicited from patients.
Results: Patients reported their most common chronic medical problems to be headaches, chronic back problems, and arthritis. The most common concerns patients wanted to discuss with providers and that providers elicited from patients were problems with mood. Compared with patients without current major mental illness, patients with a current major mental illness reported significantly (P < .001) more concerns, chronic illnesses, stressors, forms of maltreatment and physical symptoms.
Conclusion: The illness content of this uninsured, low-income population is dominated by emotional distress and physical pain. These needs place a serious burden on providers and can complicate management of chronic medical illnesses. Recommendations for specialized interview training and integrating mental health services are discussed.
People without health insurance often have different health-careseeking behaviors than people who are insured. The uninsured are less likely to pursue care for acute illnesses, chronic illnesses, preventive care, or for serious or morbid symptoms Their hesitance to seek health care becomes apparent after short periods without health insurance and is more pronounced after extended uninsured periods. In midlife, those who are uninsured experience a greater decline in overall health status than those who are insured. The most vulnerable sectors of the uninsured population are those persons living in poverty. In 2000, 41% of the population living below federal poverty guidelines, aged 18 and 64 years, lacked health insurance.
The relation between poverty and poor health is well established. Compared with middle- and upper-income populations, indigent populations have more medical illness and mental illness, diminished psychological, social, and physical functioning, and greater mortality rates. Those living in poverty, even when covered by health insurance, are more reluctant to seek health care than persons with higher incomes.
These features of low-income and uninsured populations suggest that the characteristics of indigent, uninsured primary care populations might be different from general primary care populations. There is growing evidence to support this hypothesis. We could find only limited documentation, however, of the full content of medical or psychiatric problems, common co-occurring illnesses, or the reasons why patients in low-income uninsured, primary care populations seek care.
The present study builds on data from two earlier studies of an uninsured, low-income, primary care adult population. To better understand provider time use, we studied the frequency of diagnoses and of diagnostic combinations in all patient visits during a 1-year period between 1998 and 1999. The most common visit diagnoses recorded by providers were depression (23%), hypertension (12%), sinusitis (7.4%), tobacco abuse (6.7%) and anxiety (6.0%). In one half of the visits, providers recorded two or more problems. Fifty percent of these multiple problem visits included depression, anxiety, or alcohol abuse. In a second study we surveyed 500 consecutive patients (only one visit per patient was included) to assess the prevalence of mental disorders and compared findings with results from a parallel study of 3,000 patients from a representative primary care sample. Twice as many low-income, uninsured primary care patients had mental disorders compared with the general primary care sample (34% vs. 15%). Within the low-income sample, those with mental disorders had significantly more medical problems, lower functional status and greater disability than patients without mental disorders. Because our visit data included multiple visits by the same patients and our prevalence study only assessed mental disorders, we did not have a measure of the relative prevalence of all health care problems or of problem combinations.
In the current study, we sought to describe the biopsychosocial content of this population. Because middle- and high-income, insured people have different health-careseeking behaviors than low-income and uninsured people, we wanted to learn what concerns prompted them to seek care. Because mental disorders are so prominent in this population and because they often complicate overall health care efforts, we studied which problems were most associated with mental disorders. We believed this information would be helpful in designing health care efforts to respond to the unique needs of poor, uninsured working-age patients seeking primary health care.
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