today’s topic: health services access t exas t ech u niversity health services research &...
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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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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)
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
Andersen’s definition
“Actual use of personal health services and everything that facilitates or impedes the use of personal health services”
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
Andersen’s dimensions of access
Potential Realized Equitable Inequitable Effective Efficient
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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)
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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)
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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
Predisposing factors
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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)
Enabling factors
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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)
Need factors
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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
Health behavior / service use
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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
Types of outcomes
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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
Social - Psychological Models of Access
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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.
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
Health Belief Model (Rosenstock)
A social-psychological theory Focuses on evaluative, cognitive
variables that motivate an individual to practice preventive health behavior (Rosenstock, 1974)
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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)
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
Health Belief Model (Rosenstock)
Cue to action may also be necessary media advice from family
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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
Why study migration?
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth 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
Theoretical Guide(a variation of the Behavioral Model)
Health system factors
Predisposing factors Location of
Enabling factors physician
Perceived Need
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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)
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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
TTEXAS EXAS TTECH ECH UUNIVERSITYNIVERSITYHealth Services Research & ManagementHealth Services Research & Management
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