Wong and colleagues observe two interesting and unfortunate findings in their study.1 Individuals at higher risk of poor outcomes, including those with more comorbidities, are less likely to receive follow-up care, and those who visited a physician in the preceding year were more likely to receive follow-up care. This important work shows that medical need does not determine who receives follow-up care in a Canadian setting. Sicker patients may be less likely to see a physician for follow-up because of their “underlying conditions and the resulting restrictions in activity.” Those who had not seen a physician in the previous year represent a “vulnerable population.”
There may be a more fundamental cause that could explain, in part, both primary findings. In 1971, Julian Tudor Hart, a Welsh general practitioner, proposed the “inverse care law,” which states, “the availability of good medical care tends to vary inversely with the need for it in the population served.”2 The social determinants of health (when poverty and marginalization make people sicker) are largely the same as the social determinants of health care (when the same factors make good care harder to access). As a result, individuals who need care the most are least likely to get it, even in a publicly funded system.3–7
We appreciate the authors’ conclusions, which advocate identifying and proactively retaining patients most likely to be lost to follow-up. We encourage readers to consider these findings at the level of our society and health care system.
If we want a system that effectively prioritizes and responds to medical need, it might be necessary to engage the underlying social, political and economic factors that determine who gets sick and who gets good care. In doing so, an effective health care system would also be a fair one, and a force for social equity.