1. "The Effects of Health Care Financing Arrangements on Consumer Utilization Decisions in Harris County." Presented at the Healthcare Safety Net Initiatives Conference: Policy and Performance on February 9, 2007 Pamela Behan, PhD., Assistant Professor of Sociology University of Houston-Downtown Patrice Williams, Graduate Research Assistant University of Texas School of Public Health

2. Project Description Telephone Survey with telephone numbers from a random-digit-dialed list from University of Houston Center for Public Policy. Inclusion criteria  Harris County resident  At least 18 yrs of age  Comprehensive knowledge of a time in the past year when someone in Harris County needed medical care Exclusion criteria  Business telephone numbers  Less than 18 years of age

3. The study budget  Houston Health Services Collaborative  University of Houston Center for Public Policy

4. Spanish Survey Experience Finding translators Translation of survey Delivery of the survey

5. What terms used  Healthcare changed to medical care issues  The introductory statement When to call  Mornings  Afternoons  Evenings  Weekends Where to conduct the survey  U of H survey lab  Home  Office How to conduct the surveys  Pen and paper surveys  Computer assisted  Internet Flexibility

6. Thank you for your time

7. The Effects of Health Care Financing Arrangements on Consumer Utilization Decisions in Harris County: Preliminary Results

8. OR Does our safety net (and system) work the way we think it does?

9. The Problem: A lack of timely care leads to: ▫preventable health care problems ▫pain, stress, grief, poverty ▫wasted human potential ▫the need for more expensive care ▫wasted safety net resources

10. Why do people not get timely care? One explanation: Lack of insurance or funds -> Refusal by providers Another explanation: Inadequate insurance or funds, or confusion about either -> Fear of costs or fear of refusal -> Delay or avoidance by consumers

11. Is it only the uninsured that don’t get timely care? One answer: Yes. Insurance takes care of access & costs. Another possibility: No. All insurance is not equal. Some requires cash to get care and covers very little, while other insurance requires no cash and covers a lot.

12. Also, insurance is changing: Increasing health care costs -> Decreasing coverage by employment-related and government insurance programs -> Increased likelihood of less timely care among the insured

13. Which answers are correct? How can we find out?

14. Ask consumers!

15. How? Our Research Format: Telephone Survey Random Sample of 500 Harris County residents Questions about: ▫a recent episode of need for medical care ▫the patient’s insurance coverage ▫the patient and decision-Maker (if different)

16. Preliminary Results based on: 403 cases 82% insured; 18% uninsured Patient ages: 1 to 99; average 51years old Patient race/ethnicity: 51% white, 27% African- American, 20% Hispanic, 2% Other Patient gender: 62% female; 38% male Household Incomes: 15% < $10,000 per year; 32% > $75,000 per year; average $35-50,000

17. First, we look at decisions which involved insurance or financial considerations: Total: 270 Positive only: 182 (67%) Negative only: 69 (26%) Mixed: 19 (7%)

18. Types of decisions affected by insurance or financial considerations: To seek care right away (98) To wait before seeking care (61) To not seek care (22) To have all recommended tests and treatments done right away (121) To wait on some or all tests & treatments (5) To not have all tests & treatments done (20)

19. Now, we look at decisions to delay or avoid care: Total (188) For non-financial reasons (91) For financial or insurance-related reasons (98)

20. Now let’s add in insurance status: Delayed or avoided care, tests or treatments: Insured (136 / 327) 42% Uninsured (52 / 73) 71% Considered insurance or finances in making that decision: Insured (47 / 327) 14% Uninsured (51 / 73) 70%

21. Other factors that appear to affect care avoidance or delay for financial or insurance-related reasons: Insurance source Race Income Age Whether the patient makes their own care decisions Whether the patient has a regular provider Whether the patient has ever been refused care Whether the patient has avoided care in the last year

22. Decisions are made differently when a situation is perceived as an emergency. Insurance and financial considerations are ignored (73) Care is sought “in spite of” financial or insurance concerns (40)

23. Possible Implications About the same number (not percent) of insured as uninsured citizens are discouraged by financial concerns from getting care in a timely manner. Any insurance is not necessarily better than no insurance in its consequences for timely care. Current arrangements ignore many user concerns and decision-making patterns, leading to less timely care. These concerns and patterns must be clarified and used in policy planning if resource waste is to be minimized and program results maximized.