Uninsured patient opinions about a reduced-fee retainer program at Academic Health Center Clinics

Background: Access Assured, an experimental program to deliver primary care to uninsured patients using a monthly retainer payment system, has been shown to provide a financially viable method of delivering primary care services to people without health insurance. This qualitative study was designed to assess patient attitudes and concerns about this program and to identify ways to improve it. Methods: We conducted telephone interviews with 40 purposefully selected Access Assured members between May and June of 2009. This population was stratified to include a sample of 20 patients from those who had elected to renew enrollment in the program after their first 6-month enrollment period. The other 20 patients were selected from those enrollees who had not re-enrolled in the program after this initial period. The semistructured interviews were based on an original list of 19 standardized questions, which were asked of each participant. All interviews were audio taped. The interview tapes were transcribed verbatim and content analysis was conducted using immersion-crystallization methods. Results: Content analysis identified 9 themes related to patient attitudes and concerns about this program. (1) Patients could not understand why they needed to remain enrolled if they were healthy. (2) Patients had variable levels of personal agency or responsibility for their own care. (3) Patients reported they had no choice and needed to enroll in the program to have access to care. (4) Patients liked that the program allowed them to choose their provider and see that provider with continuity from visit to visit. (5) Patients felt they were respected and treated the same as other patients. (6) Patients expressed appreciation for the program. (7) Patients had a range of comments about the quality of care and service they received. (8) Patients reported confusion about the rules of the program and often did not understand its terms and benefits. (9) Patients were under personal and family economic stress. Twenty of the subjects in our study had re-enrolled in Access Assured and 11 of the 20 patients who had not re-enrolled expressed an intention to do so. Conclusions: Our study population expressed gratitude and other positive opinions about the retainer-based program for uninsured patients in 2 academic family medicine clinics. Conversely, some were concerned about the perceived lack of choice related to enrollment. Significant gaps in patient understanding about the program were identified. Based on these results, we have made improvements to the program and plan to continue to offer this care model to uninsured patients in our practices.