1. HSC 6636: Access to Care 1 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Topics Overview The Uninsured The Under Insured Impacts of Economic Barriers Noneconomic Barriers Healthcare Reform “An insurance card alone does not eliminate barriers to access.” Text, p. 446

2. HSC 6636: Access to Care 2 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Overview As with Quality, the study of Access is the study of tradeoffs Almost everyone would like –Higher quality –Better (more) access –Lower cost Without an exogenous shock, improving one of these measures can only come at the expense of the others –Better knowledge –Improved infrastructure Both are improvements to the capital stock

3. HSC 6636: Access to Care 3 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Overview (cont.) What resources are needed for improvement? How do we measure… –…current status? –…progress? What are responsibilities of individual participants as elements of an entire healthcare system? What role might you play in this area? Who will pay? Who benefits? Slide copied from the Quality class

4. HSC 6636: Access to Care 4 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Overview (cont.) Access problems are not one-dimensional issues –Having or not having health insurance does not explain all HC access problems –Access problems include Structural problems in the HC system Other individual economic issues (beyond insurance) Institutional economic issues that affect individuals Non-economic individual barriers

5. HSC 6636: Access to Care 5 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest The Uninsured Rates of Uninsured Individuals 2009 Household Income and Insurance Data* By RaceTotal White NH†BlackAsianHispanic Avg. Income$49,777$54,460$32,584$65,469$38,039 % With No Health Insurance 16.7%12.0%21.0%17.2%32.0% By Income< $25k $25 ‒ $49k$50 ‒ $74k > $75 26.6%21.4%16.0%9.1% By Age< 18 18 ‒ 2425 ‒ 3435 ‒ 4445 ‒ 64 10.0%30.4%29.1%21.7%16.1% * Source: Income, Poverty, and Health Insurance Coverage in the United States, U.S. Bureau of the Census http://www.census.gov/prod/2010pubs/p60-238.pdf † “NH” = Non Hispanic Only 1.8% of 65+ Americans are uninsured 10% of uninsured Americans are uninsured by choice

6. HSC 6636: Access to Care 6 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest The Uninsured (cont.) Structural issues for the uninsured –Lack of employer-based insurance is a huge factor Younger workers Part-time or underemployed workers Transient workers Self-employed workers Employees of small companies –Most uninsured Americans work at least part time –Medicaid eligibility rules omit many young adults also facing employment challenges

7. HSC 6636: Access to Care 7 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest The Uninsured (cont.) Structural issues for the uninsured (cont.) –Many small companies cannot or do not offer any health insurance plan –Some workers cannot afford employee contributions to employer health plans

8. HSC 6636: Access to Care 8 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest The Underinsured Underinsurance is insurance that does not cover the recipient’s needs 61 million adult Americans were considered to be significantly underinsured in 2005 Underinsurance can consist of –Exclusion of services (e.g., mental health) –Restrictions on payment amounts –High co-payments and/or deductibles –Preexisting condition exclusions –Pharmaceutical coverage

9. HSC 6636: Access to Care 9 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest The Underinsured (cont.) Medicare has significant underinsurance potential –High deductible –Donut hole in prescription drug coverage –Substantial restrictions on long-term care –Estimated to pay only 50% of elderly HC costs

10. HSC 6636: Access to Care 10 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Impacts of Economic Barriers Impacts of Un-/Underinsurance go beyond the obvious restrictions on care –Much less likely to have a usual source of care Less longitudinal HC history Fewer physician visits for known conditions –Reduced preventive care –More likely to have hospital admission for preventable or avoidable conditions –Receive fewer diagnostic tests

11. HSC 6636: Access to Care 11 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Impacts of Economic Barriers (cont.) Impacts of Un-/Underinsurance (cont.) –Prenatal care starts later with fewer visits –Newborns have more adverse outcomes –Breast cancer diagnoses are made later –Higher overall mortality—25% higher risk of dying than insured counterparts even after all factors are considered

12. HSC 6636: Access to Care 12 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Impacts of Economic Barriers (cont.) Un-/Underinsured patients over utilize “must- provide” care sources –Stresses resources –Increases costs to paying patients through cost shifting But managed care encroaching on the ability to shift costs by forcing down reimbursement rates

13. HSC 6636: Access to Care 13 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Impacts of Economic Barriers (cont.) Rates of hospitalization higher for uninsured and underinsured –Massively higher admissions for Ambulatory Care Sensitive (ACS) conditions for (Figure 16.3) Income < $25,000 Blacks –Patients report important concerns with (Table 16.2) Fear or nervousness Appointment wait times No free time to get care

14. HSC 6636: Access to Care 14 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers Ethnicity –Minorities significantly underutilize healthcare services compared to whites –Ethnic background is highly correlated to economic status which is highly correlated to insurance availability –But significant differences in healthcare utilization have been found for minorities even after adjusting for insurance availability

15. HSC 6636: Access to Care 15 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers (cont.) Ethnicity (cont.) –Ethnic background is also highly correlated to educational attainment Is this correlated to job status? To organizational and administrative sophistication? –Interesting studies still show small but real bias in treatments recommended for some groups

16. HSC 6636: Access to Care 16 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers (cont.) Cultural Factors –Immigrants face unique barriers Language barriers Preferences for alternative HC sources Concern with immigration status of self or family members Perceptions of disrespect from providers –One study showed that better language skills resulted in more HC use

17. HSC 6636: Access to Care 17 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers (cont.) Gender Differences –Women have unique healthcare needs –Insurability of young women is more expensive –Many insurance programs do not cover family planning services, medications, or procedures Abortion services explicitly excluded from Medicaid coverage Many providers do not offer abortion services –Women have been systematically excluded from clinical trials for new medications

18. HSC 6636: Access to Care 18 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers (cont.) Gender issues (cont.) –Women have historically had “less attachment to the labor market” and therefore less anchoring to employer-sponsored health insurance More likely to work part time with no benefits More susceptible to losing benefits through divorce –Poorer women who may have been eligible for Aid To Families with Dependent Children saw this assistance decoupled from Medicaid

19. HSC 6636: Access to Care 19 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers (cont.) Educational Impact –Educational attainment is correlated with ethnic and economic characteristics –Lower educational levels are correlated with Lower levels of prenatal care Lower HC use by children –The modern HC system requires literacy for effective use –Lower levels of education affect follow-up with treatments Taking medications Following directions

20. HSC 6636: Access to Care 20 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Noneconomic Barriers (cont.) Resource Availability –Previous classes have discussed lower levels of provider availability in Rural areas Inner cities –Problems include Hospital and clinic availability Physician availability Specialist availability

21. HSC 6636: Access to Care 21 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest Barriers Revisited An individual or a family has characteristics associated with… –…their descriptive demographic characteristics –…their individual endowment of ability, intelligence, and motivation Groups with similar characteristics realize systematic differences in access to healthcare The challenge is to recognize the underlying causality of diminished healthcare access… …and to develop remedial programs

22. HSC 6636: Access to Care 22 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest HC Reform HC reform has been a controversial step whenever it has been tried –Social Security (not a HC program) –Midicare/Medicaid –Clinton HC efforts –HIPAA –PPACA (2010)

23. HSC 6636: Access to Care 23 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida http://systems.cohpa.ucf.edu/lwest HC Reform (cont.) Successful reform often marked by –Compromise initial program –Modifications after implementation The current environment is marked by special characteristics –Economic challenges –Government deficits –Reaction to increased government size and scope