today’s topic: health services access t exas t ech u niversity health services research &...

Today’s Topic:

Health Services Access

TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management

Objectives for today Define access Describe trends in access in

the U.S. Understand major models of

access


Data from Celinda Lake & W.D. McInturff

October 12, 1999

Now, over the next ten years, the federal government is projected to have a budget surplus, with more money coming in than being spent. If there were a budget surplus, which ONE of the following three

choices do you believe would be best? Would it be...

55%

23% 20%

Help Uninsured Families&Children Get Health Ins.

Cut FederalIncome Taxes

Pay Down TheNational Debt

56%

21% 20%

Preserve Social Securityand Medicare

Cut FederalIncome Taxes

Pay Down TheNational Debt

There is equal support for using the federal budget surplus to help uninsured families and children and to

protect Medicare & Social Security.

59%

16% 17%

Increased Decreased Stayed The Same

51%

18% 21%

Increase Decrease Stay The Same

A majority of Americans say the number of uninsured Americans has increased over the LAST ten years and

believe it will increase in the NEXT ten years.

Over The Last Ten Years Over The Next Ten Years

In the last ten years/next ten years, do you think the number of uninsured Americans has/will..?

Americans tell us on an open-end question the reasons they believe the number of uninsured Americans will increase over the NEXT ten years:

There are an increasing number of jobs that do not provide health care benefits to employees;The cost of health care is too expensive;There is not a sufficient government program to help cover the uninsured;With more single parent families and more of the population aging, access to affordable health care is becoming more difficult; andThere has been and will continue to be significant population growth, as well as large numbers of immigrants coming into the United States and having difficulty accessing affordable health care coverage.

76%

69%

60%

%True

Forty-three millionAmericans do not have health coverage.

More than 8 out of 10uninsured Americansare in working families.

Over 70 MILLION Americans have gone without health carecoverage for at least some period of time duringthe past three years.

"Uninsured Americans – that is,people with no health insurance at all."

Surprisingly, even when reminded of Medicare and

Medicaid coverage, Americans estimate 30% of Americans have no health

coverage.

People find statements about the large number of Americans affected by this issue

to be believable but over estimate the number of Americans effected.

Favor90%

Oppose6%

Don't Know/Refused4%

65% 69%

January 1992* October 1999

Now...to assure that all Americans had health insurance coverage, would you be willing to pay

as much as $50 per year in additional taxes?

Do you favor or oppose making sure all families and CHILDREN have access to affordable

health insurance coverage?

*Data is from Public Opinion Strategies & The Mellman Group.

There is almost unanimous support for making sure all families and children have health

insurance coverage and roughly seven out of ten Americans support paying additional taxes for

this coverage.

Support for paying higher taxes is fairly flat across all age groups.

To assure all Americans had health insurance coverage, would you be willing to pay as much as $50 per year in additional taxes?

69% 72%63%

75%

13th Generation(Ages 18-38)

(35%)

Baby Boomers(Ages 39-56)

(36%)

Silent Generation(Ages 57-74)

(20%)

GI Generation(Ages 75+)

(8%)

% Yes

Even a majority of Republicans support paying more in taxes to make sure all

Americans have health insurance coverage.To assure that all Americans had health insurance coverage, would you be willing to pay as

much as $50 per year in additional taxes?

55%

70%81%

Republican(33%)

Independent(23%)

Democrat(39%)

% Yes

Over half of respondents would be more likely to vote for a Presidential candidate who talks about expanding

access to health care.If a candidate for president talked about making sure all families & CHILDREN have access to

affordable health insurance coverage, would you be...more likely or less likely to vote for this candidate or would it make no difference in how you would vote?

Much MoreLikely25%

Somewhat MoreLikely29%

Somewhat LessLikely

2%Much Less

Likely3%

No Difference36%

Don't Know/Refused

6%

Total More Likely 54%Total Less Likely 5%

A lot of people's lives are touched by lack of health insurance coverage.

12%

17%

43%

% Uninsured Today Age 18-64

(10% for Total Population*)

% Insured Today, But Uninsured Sometime Over

the Last 3 Years*

% Insured For Three Straight Years, But Know

Someone Uninsured Sometime Over the Last 3

Years**All percentages are reflected as a percent of the total number of respondents.

Uninsured NowInsured Today, But Uninsured

Sometime Last 3 YearsService Workers 19% 24%

Single Women with Kids 17% 32%Women 18-34 17% 23%

Single Men with kids 15% 26%HH Income $20K-$40K 15% 26%

HH Income Under $20K 24%Men 18-34 21%

Self-Employed 19%Age 18-34 19%

Work in Company With 11 to 100 Employees

17%

Single/Divorced/Widow 15%

Work in Company With 10 or Less Employees

15%

Medicaid Recipients 32%Have Children Under Age 4 27%

Have Children Age 5-8 25%African Americans 24%

Married Women with Kids 23%Have Children 18 or Under 22%

Conservative Democrats 22%Blue Collar Workers 22%

Soft Democrats 21%Democratic Men 21%

HS or Less 21%Age 35-44 21%

It's clear who the "at risk" sub-groups are for being uninsured now or not having coverage sometime over

the last three years.

A majority of Americans misidentify and believe most uninsured are in households

where no one is working.

37%

58%

5%

Employed people and people from families in which someone is employed

Don't Know/Refused

Unemployed people and people from families in which no one is employed

I'd like your views on uninsured Americans - that is people with no health insurance at all. Would you say that more of them are...?

There are clear differences on people's health care related activities and their

insurance coverage.

Uninsured NowInsured Today, But

Uninsured Sometime in Last Three Years

Insured For Three Straight Years, But

Know Someone Uninsured

Sometime Over the Last 3 Years

Postponed Treatment Because of Lack of

Coverage48% 59% 15%

Take Prescription Drug Daily

25% 51% 49%

Spent One Night or More As Hospital Inpatient

27% 44% 34%

What is access?Donabedian’s definition of access

Fit between need for services and services delivered

Geographic and quantitative adequacy Socio-organizational


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)


Andersen’s definition

“Actual use of personal health services and everything that facilitates or impedes the use of personal health services”


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


Andersen’s dimensions of access

Potential Realized Equitable Inequitable Effective Efficient


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)


Ex: Hospital supply in Iowa

County No. beds No./10,000 residentsAdair 31 38.4Johnson 1,092 106.3Polk 2,033 56.5

State 15,103 52.8

from Iowa Health Fact Book, 1999


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)


Ex: Inpatient hospital utilization, 1996 (per 1,000 population)

Char. Discharges Days ALOSTotal 82.4 469.9 5.7Under 15 37.3 212.3 5.745-64 yrs 113.7 621.4 5.565 + 268.7 1,818.0 7.0

from National Health Interview Survey, NCHS, CDC


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


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


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


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


Andersen’s Behavioral Model

Health care

system

External environment

Predisposing Enabling Need

Environment

Personal health

practices

Use of health

services

Perceived health status

Evaluated health status

Consumer satisfaction

Population Characteristics Behavior Outcomes

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

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)

Enabling factors


More mutable

Examples Income Health insurance status (whether have

insurance) Type of insurance coverage (Medicare or

Medicaid) Transportation (whether have a car)

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

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

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

Social - Psychological Models of Access


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


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.


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


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


Health Belief Model (Rosenstock)

A social-psychological theory Focuses on evaluative, cognitive

variables that motivate an individual to practice preventive health behavior (Rosenstock, 1974)



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)



Cue to action may also be necessary media advice from family


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

The Behavioral Model applied to a health management problem


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

Why study migration?


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

Theoretical Guide(a variation of the Behavioral Model)

Health system factors

Predisposing factors Location of

Enabling factors physician

Perceived Need


Independent Variables Independent Variables Health system factorsHealth 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)


Predisposing - Predisposing - Demographic/Social Structural Demographic/Social Structural variablesvariables Age category Gender Education Employment status Race Ancestry Religion Live in-town Live on farm High number of individuals in household Social support for health-related problems


Predisposing - Predisposing - Health belief Health belief variablesvariables

Believe family physicians care beneficial Believe family physician care cost-

beneficial

Believe specialty physician care beneficial

Believe specialty physician care cost-beneficial


Enabling variablesEnabling 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


today’s topic: health services access t exas t ech u niversity health services research &...

Documents

iowa health fact book

inequitable use

service use

hospital purpose

inpatient hospital utilization

hospital supply

hospital bedpop

physician office