1. Access to Health Services Ty Borders, Ph.D. Assistant Professor Health Services Research & Management Texas Tech School of Medicine

2. 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

3. 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

4. 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)

5. 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

6. Andersen’s dimensions of access Potential Realized Equitable Inequitable Effective Efficient

7. 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)

8. 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)

9. 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

10. 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

11. Utilization statistics for Texas Inpatient1997 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.

12. Andersen & Aday’s Behavioral Model Health care system External environment Predisposing EnablingNeed Environment Personal health practices Use of health services Perceived health status Evaluated health status Consumer satisfaction Population Characteristics BehaviorOutcomes

13. 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

14. 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)

15. Enabling factors More mutable Examples –Income –Health insurance status (whether have insurance) –Type of insurance coverage (Medicare or Medicaid) –Transportation (whether have a car)

16. 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

17. 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

18. 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

19. Health Belief Model (Rosenstock) A social-psychological theory –Focuses on evaluative, cognitive variables that motivate an individual to practice preventive health behavior (Rosenstock, 1974)

20. 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)

21. Health Belief Model (Rosenstock) Cue to action may also be necessary –media –advice from family

22. 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

23. Hispanic Ethnicity, Rural Residence, and Satisfaction with Access to Care Results from the Texas Tech 5000

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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)

30. 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

31. 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

39. Multivariate logistic results: Predisposing factors (p<0.10) Prescript. Drugs Specialists Variable (comparison group) OR 95% C.I. OR 95% C.I. Ethnicity Hispanic (white) n.s.1.331.01, 1.75 Other race (white) n.s.n.s. Urban (rural) n.s. 0.810.70, 0.95 Gendern.s.n.s. Number persons in household 1 othern.s.0.750.58, 0.97 2 or more othern.s.0.700.55, 0.90 Age category age 71 to 75 (65 to 70) 0.84 0.68, 1.040.770.63, 0.93 age 76 to 80 0.640.51, 0.82n.s. age 81+ 0.480.36, 0.64n.s.

40. Enabling factors (controlling for predisposing) Prescript. Drugs Specialists Variable (comparison group) OR 95% C.I. OR 95% C.I. Educational status High school grad (less HS)0.880.70, 1.120.820.66, 1.01 Some college 0.830.64, 1.08n.s. College grad1.090.81, 1.470.530.41, 0.70 Religiousness not included 0.840.72, 0.98 Income Income > $30,000 (<$30,000) 0.560.44, 0.720.850.69, 1.04 Income missing0.650.52, 0.800.860.71, 1.05 Insurance coverage Medicare only (none)n.s.n.s. Medicaid n.s.0.830.61, 1.01 Private onlyn.s.n.s. Medicare plusn.s.0.790.61, 1.01

41. Need (controlling for predisposing and enabling) Prescript. Drugs Specialists Prescript. Drugs Specialists Variable (comparison group) OR 95% C.I. OR 95% C.I. Hypertension n.s.n.s. Coronary heart disease 1.431.38, 1.790.590.48, 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 ADLsn.s.n.s. Need help with IADLsn.s.n.s. SF-12 Physical Score 0.97 0.96, 0.981.021.01, 1.03 SF-12 Mental Score 0.97 0.96, 0.99n.s.

42. 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)

43. 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

44. 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

45. 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

46. Place / site of utilization Most persons go to doctor’s office Among the poor, a higher % go to hospital outpatient dept.

47. Place / site of utilization Most persons go to doctor’s office Among the poor, a higher % go to hospital outpatient dept.

48. 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

49. Types of ambulatory care orgs. Physician office or clinic –Solo or group Community health centers Freestanding emergency rooms Freestanding amb. care center Clinical labs

50. Types of ambulatory care (cont.) Ambulance services Renal dialysis Trauma centers Ambulatory surgery centers Hospital-based –Clinics –Freestanding outpatient hospitals

51. 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)

52. Rise of hospitals in the U.S Site of care in 1790sType of patient Almshouse (poorhouse)Non-paying, acute Chronic Mental disorders JailMental Disorders Pest housesContagious disease Billeting in private homesMerchant seamen, military veterans

53. 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

54. 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

55. 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

56. 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

57. 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)

58. Teaching & Academic Hospitals Teaching hospitals –Graduate medical education (residency programs) Academic medical centers –Graduate medical education –Supports research

59. 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

60. 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

61. 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

62. 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

63. Reasons for rising hospital costs Aging population General inflation Technology Unnecessary surgery Unnecessary admissions Excess capacity – too many inpatient beds, services

64. Cost control mechanisms Government regulation –Certificate of need (CON) –Rate regulation –Peer review organizations (PROs) Competition –Business coalitions –Vertical integration –Horizontal integration

65. Health Systems Vertical integration –Expansion of organization into new fields e.g. Hospitals expanding into primary care, nursing home care, etc. Horizontal integration –Expansion of organization with own field e.g. A hospital merges with other hospitals