access to health services ty borders, ph.d. assistant professor health services research &...
TRANSCRIPT
Access to Health Services
Ty Borders, Ph.D.
Assistant Professor
Health Services Research & Management
Texas Tech School of Medicine
Objectives for today
• Define access
• Discuss the organization and types of health services organizations
• Describe trends in access in the U.S.
• Describe major conceptual models of access
• Describe the possible determinants of service use and health outcomes
Andersen’s definition
• “Actual use of personal health services and everything that facilitates or impedes the use of personal health services”
– Visiting a physician / volume of visits– Hospitalization / no. of nights hospitalized– Visiting an ER
Donabedian’s definition of access
• Socioorganizational fit (whether organizational attributes match societal needs)– Whether providers speak Spanish– Whether office hours are convenient
• Geographic fit (geographic distribution of facilities, providers, and services)
Why should we care about access?
• To predict utilization at the population level (forecast demand)
• To explain and understand why persons access services (market research)
• To encourage the appropriate use of services to improve health
Andersen’s dimensions of access
• Potential
• Realized
• Equitable
• Inequitable
• Effective
• Efficient
Potential access
• Structural characteristics of health system– Capacity (physician/pop. ratio, hospital
bed/pop. ratio) – Organization (% of population in managed care)
• Enabling characteristics– Personal resources (income, insurance)– Community resources (rural/urban residence)
Realized access
• Actual use of health services– number of visits, number of days in
hospital, whether visited a physician, whether visited a psychologist
• Characterized in terms of….– Type (e.g. ambulatory, inpatient, dental)– Site (e.g. physician office, hospital)– Purpose (e.g. primary, secondary,
tertiary)
Equitable / inequitable access
• Equitable - use determined by need for care– No differences in service use according to
need
• Inequitable - use influenced by social and enabling factors – Differences in service use according to race,
ethnicity, occupation, insurance coverage
Effective and efficient access• Effective - Use improves health
outcomes, including health status and satisfaction with care
• Efficient - Health services use improves health outcomes at minimum cost
Utilization statistics for Texas
Inpatient 1997 1995 1993
beds 55,759 57,178 58,157
admissions 2,126,610 2,029,050 1,963,869
days 11,355,612 11,366,956 11,811,104
alos 5.3 5.6 6.0
from AHA Guide, 1999. Includes nursing home units.
Andersen & Aday’s Behavioral Model
Health care
system
External environment
Predisposing Enabling Need
Environment
Personal health
practices
Use of health
services
Perceived health status
Evaluated health status
Consumer satisfaction
Population Characteristics Behavior Outcomes
Environmental factors
• Hypothesized to have the most indirect influence on access to care
• Health system factors – availability of physicians– availability of hospitals
• External environment – level of community’s economic development– pollution control
Predisposing factors
• Fairly immutable
• Examples– Demographics (gender, marital status, race)– Social structure (education, ethnicity, social
integration)– Beliefs (e.g. beliefs about the effectiveness of
medial care)
Enabling factors
• More mutable
• Examples– Income– Health insurance status (whether have insurance)– Type of insurance coverage (Medicare or
Medicaid)– Transportation (whether have a car)
Need factors
• Perceived need – Subjective health status (Health-related quality of
life)– Symptoms– Discomfort
• Evaluated need – Health care professional’s judgement about your
health status– Diagnosis
Health behavior / service use
• Personal health practices– Exercise– Wear a seat belt when driving in car
• Use of health services– Visit a physician– Stay over night in a hospital– Visit a psychologist
Types of outcomes
• Perceived health status– Health-related quality of life
• Evaluated health status– Health professional’s judgment
• Consumer satisfaction– Satisfaction with technical and interpersonal aspects of
care
Health Belief Model (Rosenstock)
• A social-psychological theory – Focuses on evaluative, cognitive variables
that motivate an individual to practice preventive health behavior (Rosenstock, 1974)
Health Belief Model (Rosenstock)
• 4 factors influence health behavior decisions– Perceived susceptibility to diseases
– Perceived severity of disease, including emotional concern about potential harm
– Relative benefits and costs associated with a treatment
(Rosenstock, 1974; Maiman and Becker, 1974;
Janz and Becker, 1984)
Modifying factors
Demographics
Sociopsychologocical
Structural variables (knowledge about
disease)
Cues to action
Likelihood of action
Perceived benefits
minus
Perceived barriers
Likelihood of taking
recommended action
Perceived threat of disease
Perceived susceptibility to disease X
Perceived seriousness
Individual perceptions
Health Belief Model
Hispanic Ethnicity, Rural Residence,
and Satisfaction with Access to Care
Results from the Texas Tech 5000
Overview• TT5000
– Sample of 5,000 elders residing in west Texas
– Survey of health status, demographics, health care accessibility and quality
• Including satisfaction with access to prescription drugs and specialists
– Relatively large % of Hispanics and rural residents
– Key personnel
• James E. Rohrer, P.I.
• Ty Borders, Barbara Rohland, Tom Xu, co-investigators
Access measures in TT5000
• Numerous items derived from CAHPS
• Satisfaction with ability to get prescription drugs when needed
• Satisfaction with access to specialty physician services
TT5000 Methodology
• 65,000 household telephone listings– 10 replications of 6,500 numbers
• Household screened for elderly person– If more than 1, most recent birthday chosen
• Informed consent obtained
• MMSE administered to screen for dementia
TT5000 Methodology, continued
• Participation rates:
– Excluding eligible respondents who failed cognitive screener: 72%
– Accounting for 361 telephones not answered: 75%
• Potential biases
– Hispanics and other races potentially slightly under-represented
– Females probably slightly over-represented
Independent Variables
• Predisposing
– Gender
– No. persons in household (proxy of social support)
• 1 other person
• 2 other person
– Age category – Educational status– Marital status– Ethnicity/race
• Hispanic, non-Hispanic white, other
Independent Variables (cont.)
• Enabling
– Household income category
– Employment status
– Health insurance coverage
• Medicare only
• Medicare plus private or other gov’t
• Medicaid only or Medicaid plus other, private only or gov’t only
• Private only
– Urban / Rural residence
• (rural defined as county with fewer than 50,000 persons)
Independent Variables (cont.)
• Need
– SF-12 PCS and MCS
– Self-reported diseases and conditions (hypterension, coronary heart disease, myocardial infarction, stroke, arthritis, asthma/emph/chronic bronchitis, and diabetes)
– Need help with ADLs
– Need help wit IADLs
Dependent Variables
• Derived from Consumer Assessment of Health Plans Study (CAHPS)
– How often did you see a specialist when you needed one?
• Never, sometimes, usually, always, didn’t need to
– How much of a problem, if any, have you had getting prescription medications?
• Big problem, small problem, no problem, have not had any
Profile of ethnicity by county of residence (%)
90.4
80.0
84.5
2.8
4.8
3.9
6.9
11.6
15.2
Ruralresidents
Urbanresidents
Overall Non-HispanicWhitesHispanics
OtherRaces
Education level of respondents (%)
Other Races Hispanics Non-HispanicWhites
Urban residents Rural residents Overall
8th grade or less Some HS HS graduate/GED 1-3 yrs college Bachelor's or more
% of respondents with any insurance who have private coverage
52.1
27.5
75.4
68.3
69.3
68.7
Other Races
Hispanics
Non-Hispanic Whites
Urban residents
Rural residents
Overall
% of respondents who did not visit a doctor
19.9
29.0
20.6
19.0
24.9
21.6
Other Races
Hispanics
Non-Hispanic Whites
Urban residents
Rural residents
Overall
% of respondents hospitalized
12.4
13.9
11.9
12.2
12.1
12.2
Other Races
Hispanics
Non-Hispanic Whites
Urban residents
Rural residents
Overall
% of respondents who had no problem getting prescription medications
81.4
82.1
86.3
85.2
86.1
85.6
Other Races
Hispanics
Non-Hispanic Whites
Urban residents
Rural residents
Overall
% of patients who always or usually saw a specialist when they needed one
70.9
56.0
70.8
71.0
66.9
69.2
Other Races
Hispanics
Non-Hispanic Whites
Urban residents
Rural residents
Overall
Multivariate logistic results: Predisposing factors (p<0.10)
Prescript. DrugsPrescript. Drugs Specialists Specialists
Variable (comparison group) OR 95% C.I. OR 95% C.I. Ethnicity
Hispanic (white) n.s. 1.33 1.01, 1.75
Other race (white) n.s. n.s.
Urban (rural) n.s. 0.81 0.70, 0.95
Gender n.s. n.s.
Number persons in household
1 other n.s. 0.75 0.58, 0.97
2 or more other n.s. 0.70 0.55, 0.90
Age category
age 71 to 75 (65 to 70) 0.84 0.68, 1.04 0.77 0.63, 0.93
age 76 to 80 0.64 0.51, 0.82 n.s.
age 81+ 0.48 0.36, 0.64 n.s.
Enabling factors (controlling for predisposing)
Prescript. DrugsPrescript. Drugs Specialists Specialists
Variable (comparison group) OR 95% C.I. OR 95% C.I. Educational status
High school grad (less HS) 0.88 0.70, 1.12 0.82 0.66, 1.01
Some college 0.83 0.64, 1.08 n.s.
College grad 1.09 0.81, 1.47 0.53 0.41, 0.70
Religiousness not included 0.84 0.72, 0.98
Income
Income > $30,000 (<$30,000) 0.56 0.44, 0.72 0.85 0.69, 1.04
Income missing 0.65 0.52, 0.80 0.86 0.71, 1.05
Insurance coverage
Medicare only (none) n.s. n.s.
Medicaid n.s. 0.83 0.61, 1.01
Private only n.s. n.s.
Medicare plus n.s. 0.79 0.61, 1.01
Need (controlling for predisposing and enabling)
Prescript. DrugsPrescript. Drugs Specialists Specialists
Variable (comparison group) OR 95% C.I. OR 95% C.I. Hypertension n.s. n.s.
Coronary heart disease 1.43 1.38, 1.79 0.59 0.48, 0.74
MI n.s. n.s.
Stroke n.s. n.s.
Arthritis n.s. n.s.
Respiratory disease n.s. n.s.
Diabetes n.s. n.s.
Need help with ADLs n.s. n.s.
Need help with IADLs n.s. n.s.
SF-12 Physical Score 0.97 0.96, 0.98 1.02 1.01, 1.03
SF-12 Mental Score 0.97 0.96, 0.99 n.s.
Implications - Access to Medication
• Vast majority of persons who received prescriptions do not have problems getting them
– Insurance coverage not associated with problems
• Expanding insurance may not make a difference
• Even Medicaid (which typically has better benefits) was not associated with fewer problems getting medicine
• The bureaucracy of insurance plans may inhibit getting medicine (gov’t insurance in Texas known for this)
Implications - Access to Medication
• Hispanic ethnicity not associated with ease of access to prescription drugs
• Rural residence not associated with ease of access to prescription drugs
Implications - Access to Specialists• Approximately 30% of elders had a problem
seeing a specialist when they needed to
– Hispanics are less satisfied with ease of access to specialty doctors
• Perhaps Hispanics under-use primary care (they have fewer doctor visits overall)
• If so, they may need to be directed to primary care, rather than specialty care
• Perhaps the health system discriminates against Hispanics (this is supported by previous literature).
• Hispanics may not be as knowledgeable about how to navigate system
Implications - Access to Specialists
– Rural residents less satisfied with ease of access to specialists
• Issue of availability?
• Issue of distance?
– Number of persons in household associated with ease of access to specialists
• Issue of instrumental support? e.g. Transportation problems
Place / site of utilization
• Most persons go to doctor’s office
• Among the poor, a higher % go to hospital outpatient dept.
Place / site of utilization
• Most persons go to doctor’s office
• Among the poor, a higher % go to hospital outpatient dept.
Rise of ambulatory care
• Before WWII, most care provided in the home– medicine not technical– docs could carry most equipment
• After WWII, care moved to the physician’s office– incredible advances in technology– increased demand for medical care
Types of ambulatory care orgs.
• Physician office or clinic– Solo or group
• Community health centers
• Freestanding emergency rooms
• Freestanding amb. care center
• Clinical labs
Types of ambulatory care (cont.)
• Ambulance services
• Renal dialysis
• Trauma centers
• Ambulatory surgery centers
• Hospital-based
– Clinics– Freestanding outpatient hospitals
Types of hospitals• Government
– Local, state, government• UMC is a county owned hospital
• Private, not-for-profit – Owned by private non-government groups
• Religious affiliated hospitals, such as Covenant• University hospitals, such as Duke
• Private, not-for-profit• Hospital Corporation of American (HCA)
Rise of hospitals in the U.SSite of care in 1790s Type of patientAlmshouse (poorhouse) Non-paying, acute
Chronic
Mental disorders
Jail Mental Disorders
Pest houses Contagious disease
Billeting in private homes Merchant seamen,
military veterans
Rise of hospitals in the U.S.:the 18th and 19th centuries
• Medical care was secondary to housing
• First voluntary (community) hospitals in late 1700s, early 1800s
• European trained physicians led the way for voluntary hospitals
Rise of hospitals in the U.S.:the 19th and early 20th centuries
• Advances in medical science– Anesthesia (Ether used by Long in 1842)– Germ theory– Steam sterilization in 1886– Antibiotics in 1940’s– X-rays in 1896– Blood types in 1901– Nursing care
Rise of hospitals in the U.S.:the early twentieth century
• Role of the social elite
• Role of physicians– Promoted voluntary, community hospitals because feared
gov’t. regulation
• Fragmentation of hospital system– Religion– Race– Income
Rise of hospitals in the U.S.:the mid 20th century
• Hospital Survey & Construction Act– Referred to as Hill-Burton Act, 1946– Between 1947 and 1971, government paid
$3.7 billion to expand community and regional hospitals (Levey, 1996)
• Medicare and Medicaid, 1965– Increased demand for hospital care
Regulation
• Without gov’t. control, hospitals had to self-regulate– American College of Surgeons the 1st– American Hospital Association 2nd– Comprised to form JCAHO
• Self-regulation may have led to higher quality (Stevens)
Teaching & Academic Hospitals
• Teaching hospitals– Graduate medical education (residency
programs)
• Academic medical centers– Graduate medical education– Supports research
Organization of AMCs
• University owned– Duke University Hospital– University of Iowa Hospitals & Clinics
• University affiliated– Mass General and Brigham & Women’s /
Harvard University– UMC / Texas Tech University HSC
Organization of AMCs (cont.)
• University affiliated, for profit– Tulane University sold most of its hospital
to Columbia/ HCA– University of Minnesota sold it’s hospital
to Fairview Health System
Organization of AMCs (cont.)
• An alternative
• University owned, but not university governed– University of Kansas Med. Ctr.– University of Wisconsin Med. Ctr.– Governed by a state appointed board, not
the University nor the state itself
Critical Access Hospitals
• In response to BBA of 1997
• Limited to max. 15 beds, additional 10 swing beds
• Patient stay limited to 96 hours
• 24 hr. emergency care required
• Cost-based reimbursement
Reasons for rising hospital costs
• Aging population
• General inflation
• Technology
• Unnecessary surgery
• Unnecessary admissions
• Excess capacity– too many inpatient beds, services
Cost control mechanisms
• Government regulation – Certificate of need (CON)– Rate regulation– Peer review organizations (PROs)
• Competition– Business coalitions– Vertical integration– Horizontal integration