1. Department of Family & Community Medicine
STFM Health Care Forum
April 25, 2007
Kevin Grumbach, MD
Department of Family & Community Medicine
UCSF

2. Quality
Cost
Access

3. Dimensions of Access Financial Structural Geographic
What’s covered, to what degree, affordability
Structural
Available human and capital resources
Geographic
Language and culture
Others

4. Assessing Access Specific health services and sectors
1° - 2° - 3° care
Physicians, pharmaceuticals, nurses, long term care, etc
Specific services/populations (abortion, HIV care, etc)
Appropriateness of access (quality)
“Average” access vs equity of access

5. Data From International Comparions
UK: comprehensive public coverage with minimal out of pocket payments
Canada: universal public insurance for physicians and hospital care, more uncovered services and OOP payments
US:

6. Source: Commonwealth Fund 2001 International Survey

7. Source: Commonwealth Fund 2001 International Survey

8. Primary Care Access
Source: 2002 Joint Canada/US Survey of Health

9. Source: Commonwealth Fund 2001 International Survey

10. MRI Units and CT Scanners per Million Population,
2001
Source: OECD

11. Coronary Artery Bypass Graft Surgery Rates, 1989
Source: Anderson et al. JAMA 1993;269:1661

12. Regionalization of CABG in High Volume Hospitals
*at least 500 CABG operations annually
Source: Grumbach et al. JAMA 1996;274:1282

13. Persons on Dialysis per 100,000 Population, 2000
Source: OECD

14. Kidney Transplantation Among Patients With End Stage Renal Disease
Source: Hornberger et al. Med Care 1997;35:686

15. Access and Income Status: % of Adults Not Getting Medical Care Due to Cost

16. Access and Income Status: % Reporting Difficulty Seeing a Specialist

17. Access and Income Status: % Reporting Overall Medical Care as Excellent or Very Good

18. % With a Regular Doctor
Source: 2002 Joint Canada/US Survey of Health

19. Source: Blendon, HealthAffairs 2003 (22/3)

20. Physician Attitudes of Problems with Medical Practice
US Canada
Patients can’t afford necessary care 73% 25%
Limited supply of facilities 14% 50%
Hassles with billing 78% 24%

21. 1988
2001
Source: Blendon, HealthAffairs 2002 (21/3)

22. Getting More, Complaining More: Canadians With MI Attitudes and Experiences at 30 day F/U, By SES Group
Source: Alter DA et al. JAMA 2004;291:1100

23. Insured But Not Equal: Medicaid vs Private Insurance

24. Patients Hospitalized in NY With MI: Odds of Receiving Cardiac Procedures During Initial Hospitalization
Source: Philbin EF et al. Am J Public Health 2001;91:1082.

25. % of California Physicians in Urban Areas Accepting New Medicaid Patients
Source: UCSF California Physician Surveys

26. Medicare vs Private Insurance vs Uninsured

28. Summary Points Compared with US, UK & Canadian systems
Lessen overall financial access barriers
Reduce disparities in access (and quality) based on SES
Have less regressive financing of health care
Less reliance on rationing based on ability to pay means more reliance on other methods of rationing/cost control
Capacity, supply
Has effects on convenience and timeliness, not necessarily as apparent on quality and outcomes
Too much access can be bad for your health

29. Summary Points
Waiting times in public systems often serve as the political “access meter” in the access/quality vs cost control debate
Poor people appreciate equity more than rich people do
Maintaining social solidarity fundamental to successful universal programs
Not all coverage is equal in multipayer systems
Equal coverage vs “good enough” coverage
Americans rate Medicare as the “access leader”