Ninety-eight percent of clinics contacted screened callers for a source of payment, but only 28 percent attempted to determine the severity of the caller's condition.

To reach that conclusion, research assistants posing as new patients in urgent need of care called clinics in nine cities. The callers were much more likely to get an appointment within a week when they claimed to have private insurance than if they said they had Medicaid.

Having private insurance also got people in the door more often than those without insurance who offered to pay a nominal amount at the time of their appointment.

"Health insurance matters -- and that's the basic message from this study," noted lead researcher Dr. Brent R. Asplin, head of the emergency medicine department at Regions Hospital in St. Paul, Minn.

"If you are not a card-carrying member of our healthcare system," he added, "you have a very difficult time getting access to care."

The research is reported in the Sept. 14 issue of the Journal of the American Medical Association.

'Financial Screening Trumped Medical Triage'

Dr. Mark Murray, a consultant and authority on patient access to care, said the new findings are not surprising. "Despite our views to the contrary, in the current US healthcare system, we make decisions like this every day," he said.

Visits to hospital emergency departments reached a record high of 114 million in 2003, according to a US Centers for Disease Control and Prevention report earlier this year. And, the study authors added, of those who end up in the ER, 80 percent are treated and released with a recommendation for follow-up care.

"What we were interested in understanding was how big of a role health insurance plays in patients' ability to get access to care after they leave us," Asplin said. The researchers particularly wanted to know whether insurance status matters when people with urgent or potentially dangerous health conditions try to book an appointment.

So the study team devised an experiment involving eight graduate students posing as patients. Each assistant called 499 randomly selected ambulatory "clinics," including community clinics and private doctors' offices, in nine US cities from May 2002 to February 2003.

Callers read from one of three clinical scenarios requiring follow-up care: pneumonia, high blood pressure or possible ectopic pregnancy. Women using the latter vignette called only obstetrics and gynecology and family medicine clinics. Each caller contacted each clinic twice using the same clinical scenario but reporting a different type of insurance.

Overall, 47 percent of all callers were offered appointments within a week, compared with 64 percent of privately insured callers.

And while clinics rigorously screened callers for insurance status, the medical screening process left much to be desired. Ninety-eight percent of clinics contacted screened callers for a source of payment, but only 28 percent attempted to determine the severity of the caller's condition.

"In some respects, financial screening trumped medical triage," Asplin said.

'Don't Get Sick'

A caller claiming to have private insurance was almost twice as likely as someone with Medicaid to land a timely appointment, with success rates of 63 percent vs. 32 percent, respectively.

Privately insured callers also had much greater success booking appointments than those who said they were uninsured but could pay $20 at the time of their visit. However, if a caller claimed to be uninsured but could pay for the visit in cash, there was no difference in rates of securing timely appointments.

Still, even having private insurance did not guarantee timely follow-up care, the researchers found.

"Over a third of the callers who claimed to have private insurance coverage could not get a follow-up appointment within one week in our study," Asplin said. "And that finding really begs the question of whether there is adequate capacity in our ambulatory care system to see people who most need to be seen."

So what can Medicaid recipients and the more than 45 million uninsured Americans do to boost the odds of getting seen promptly?

"Lie," said Murray, the patient access expert.

Most health systems are backlogged with work, making it difficult for many Americans to get timely appointments, not just those who lack private insurance or have no insurance at all, he said.

"So I suppose, don't get sick or lie is the best approach," he added.

More information: Visit The Commonwealth Fund for more on healthcare coverage and access.