1. Today’s Topic: Health Services Access T EXAS T ECH U NIVERSITY Health Services Research & Management

2. Objectives for today Define access Describe trends in access in the U.S. Understand major models of access T EXAS T ECH U NIVERSITY Health Services Research & Management

3. Data from Celinda Lake & W.D. McInturff October 12, 1999

16. What is access? Donabedian’s definition of access Fit between need for services and services delivered Geographic and quantitative adequacy Socio-organizational T EXAS T ECH U NIVERSITY Health Services Research & Management

17. Donabedian’s dimensions 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) T EXAS T ECH U NIVERSITY Health Services Research & Management

18. Andersen’s definition “Actual use of personal health services and everything that facilitates or impedes the use of personal health services” T EXAS T ECH U NIVERSITY Health Services Research & Management

19. 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 promote efficiency To improve health outcomes T EXAS T ECH U NIVERSITY Health Services Research & Management

20. Andersen’s dimensions of access Potential Realized Equitable Inequitable Effective Efficient T EXAS T ECH U NIVERSITY Health Services Research & Management

21. 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) T EXAS T ECH U NIVERSITY Health Services Research & Management

22. Ex: Hospital supply in Iowa CountyNo. beds No./10,000 residents Adair 31 38.4 Johnson1,092106.3 Polk2,033 56.5 State 15,103 52.8 from Iowa Health Fact Book, 1999 T EXAS T ECH U NIVERSITY Health Services Research & Management

23. 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) T EXAS T ECH U NIVERSITY Health Services Research & Management

24. Ex: Inpatient hospital utilization, 1996 (per 1,000 population) Char.Discharges Days ALOS Total 82.4 469.9 5.7 Under 15 37.3 212.3 5.7 45-64 yrs 113.7 621.4 5.5 65 + 268.7 1,818.0 7.0 from National Health Interview Survey, NCHS, CDC T EXAS T ECH U NIVERSITY Health Services Research & Management

25. 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 T EXAS T ECH U NIVERSITY Health Services Research & Management

26. Ex: Vaccinations of children age 19-35 months (1996) White, Black, Amer. All non-Hisp non-Hisp Hisp Indian 69% 72% 67% 62% 82% from National Center for Health Statistics and National Immunization Program, National Immunization Survey, CDC T EXAS T ECH U NIVERSITY Health Services Research & Management

27. 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 T EXAS T ECH U NIVERSITY Health Services Research & Management

28. Understanding and measuring access - the Behavioral Model Behavioral model was developed by Ronald Andersen Sociological, but includes health system and health status characteristics Most widely-used model of access, especially for studies of utilization T EXAS T ECH U NIVERSITY Health Services Research & Management

29. Andersen’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

30. Environmental factors T EXAS T ECH U NIVERSITY Health Services Research & Management 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

31. Predisposing factors T EXAS T ECH U NIVERSITY Health Services Research & Management Fairly immutable Examples Demographics (gender, marital status, race) Social structure (education, ethnicity, social integration) Beliefs (e.g. beliefs about the effectiveness of medial care)

32. Enabling factors T EXAS T ECH U NIVERSITY Health Services Research & Management More mutable Examples Income Health insurance status (whether have insurance) Type of insurance coverage (Medicare or Medicaid) Transportation (whether have a car)

33. Need factors T EXAS T ECH U NIVERSITY Health Services Research & Management Perceived need Subjective health status (Health-related quality of life) Symptoms Discomfort Evaluated need Health care professional’s judgement about your health status Diagnosis

34. Health behavior / service use T EXAS T ECH U NIVERSITY Health Services Research & Management 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

35. Types of outcomes T EXAS T ECH U NIVERSITY Health Services Research & Management 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

36. Social - Psychological Models of Access T EXAS T ECH U NIVERSITY Health Services Research & Management

37. Models of health and illness behavior Health behavior activity undertaken by a person to prevent illness or detect illness (Kasl and Cobb, 1966; Wyant, 1996) Illness behavior activity undertaken by a person who feels ill to define their health state or discover a remedy T EXAS T ECH U NIVERSITY Health Services Research & Management

38. The Sick Role (Parsons’ theory) Being sick is a role, not simply a condition Sick role behavior Activity undertaken by a person who believes they are ill for the purpose of getting well. T EXAS T ECH U NIVERSITY Health Services Research & Management

39. The Sick Role’s 4 institutionalized expectations Sick persons are exempt from some activities Sick persons must have a condition they can’t fix on their own The sick must want to get well Sick persons are obligated to seek technically competent help T EXAS T ECH U NIVERSITY Health Services Research & Management

40. Defining Sick (Mechanic) 4 dimensions of illness affect decision to seek medical care Frequency with which disease occurs in reference population Familiarity of symptoms to the average member of population Predictability of the outcome of the illness Threat from the illness T EXAS T ECH U NIVERSITY Health Services Research & Management

41. Health Belief Model (Rosenstock) A social-psychological theory Focuses on evaluative, cognitive variables that motivate an individual to practice preventive health behavior (Rosenstock, 1974) T EXAS T ECH U NIVERSITY Health Services Research & Management

42. 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) T EXAS T ECH U NIVERSITY Health Services Research & Management

43. Health Belief Model (Rosenstock) Cue to action may also be necessary media advice from family T EXAS T ECH U NIVERSITY Health Services Research & Management

44. 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

45. The Behavioral Model applied to a health management problem T EXAS T ECH U NIVERSITY Health Services Research & Management Borders, Rohrer, Hilsenrath, et al. 1999 To determine why rural residents who use medical care migrate or travel for physician care Service use variable of interest Whether the physician was located in the individual’s home county or another county

46. Why study migration? T EXAS T ECH U NIVERSITY Health Services Research & Management Migration could indicate a problem with local health services Migration undermines the viability of the local health delivery system Migration could impede coordination and continuity of care Migration is inefficient

47. Theoretical Guide (a variation of the Behavioral Model) Health system factors Predisposing factors Location of Enabling factors physician Perceived Need T EXAS T ECH U NIVERSITY Health Services Research & Management

48. Independent Variables Health system factors Perceived shortage of local family physicians note: dummy variables created for most independent variables Perceived shortage of local specialty physicians Rating of local delivery system (excellent/very good versus good/fair/poor) T EXAS T ECH U NIVERSITY Health Services Research & Management

49. Predisposing - Demographic/Social Structural variables Age categoryGender Education Employment status RaceAncestry ReligionLive in-town Live on farm High number of individuals in household Social support for health-related problems T EXAS T ECH U NIVERSITY Health Services Research & Management

50. Predisposing - Health belief variables Believe family physicians care beneficial Believe family physician care cost-beneficial Believe specialty physician care beneficial Believe specialty physician care cost- beneficial T EXAS T ECH U NIVERSITY Health Services Research & Management

51. Enabling variables Residence located in a fringe county Location of specialty physician Location of family physician Household income level Type of insurance coverage Prepaid or FFS financing Adequacy of insurance coverage Bureaucracy of insurance coverage Overall rating of health insurance coverage T EXAS T ECH U NIVERSITY Health Services Research & Management