The Impact of Health Insurance Coverage and Socioeconomic Status in Access to Care in Patients with Inflammatory Bowel Disease

Abstract

Purpose: A study of prevalence of IBD in Puerto Rico showed a significant difference between patients with commercial insurance (CI) versus those insured through a government sponsored (GS) capitated managed care system (61.5 vs. 14.6 per 100,000).To determine if the type of health insurance, CI or GS, influenced the time to referral to a specialist, and overall patient satisfaction in patients attending the clinics of the UPR Center for IBD. Methods: 155 patients with a diagnosis of IBD from the UPR Center for IBD participated in the study. Three patients with Medicare insurance were excluded from the analysis. The data was collected through a questionnaire distributed at the clinics. Demographic, socioeconomic and health care utilization data was collected. STATA v10 was used for descriptive statistics and Pearson chi-square was used to calculate differences between proportions. A logistic regression analysis was conducted to assess several dependent variables simultaneously. The study was approved by the MSC IRB. Results: 97/152 (64.0%) were covered by commercial insurance and 55 (36.0%) were covered by the government sponsored health plan. CI patients reported higher levels of education (p=0.0003) and income (p=0.0001) as compared to GS patients. Both groups reported similar satisfaction with their medical insurance (91.8% and 89.1% respectively, p=0.58). Of the 113 patients referred to a gastroenterologist by their primary physician, 68 (60.0%) were CI and 45 (40.0%) were GS (p=0.05). Median delay before referral to a gastroenterologist was 1 month for CI and 6 months for GS. Ten patients were never referred to a gastroenterologist, 1 (10%) was CI and 9 (90%) were GS (p=0.0004). All 29 patients who directly visited a gastroenterologist were CI. Of the 36 patients referred to a gastroenterologist within one month of diagnosis, 30 (83.3%) were CI and only 6 (16.7%) were GS (p=0.0006). This difference was sustained after adjusting by gender, education and income. Conclusion: Our study shows that commercially insured patients with IBD attending the UPR IBD clinic are more timely referred to a gastroenterologist as compared to patients with a government sponsored plan. Delay in referral to subspecialty care could be a factor in the difference in prevalence between the CI and the GS individuals with IBD in Puerto Rico. A study of all patients participating in GS coverage is necessary to validate this finding, as we studied only patients who were receiving subspecialty care. If confirmed, this highlights the importance of appropriate educational intervention at the primary care level. Supported by the UPR SoM Endowed Health Services Research Center, Grants 5S21MD000242 and 5S21MD000138, NCMHD-NIH.