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Today’s Topic: Health Services Access

T EXAS T ECH U NIVERSITY Health Services Research & Management. Today’s Topic: Health Services Access. T EXAS T ECH U NIVERSITY Health Services Research & Management. Objectives for today. Define access Describe trends in access in the U.S. Understand major models of access.

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Today’s Topic: Health Services Access

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  1. TEXAS TECH UNIVERSITY Health Services Research & Management Today’s Topic:Health Services Access

  2. TEXAS TECH UNIVERSITY Health Services Research & Management Objectives for today • Define access • Describe trends in access in the U.S. • Understand major models of access

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

  4. TEXAS TECH UNIVERSITY Health Services Research & Management What is access?Donabedian’s definition of access • Fit between need for services and services delivered • Geographic and quantitative adequacy • Socio-organizational

  5. TEXAS TECH UNIVERSITY Health 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)

  6. TEXAS TECH UNIVERSITY Health Services Research & Management Andersen’s definition • “Actual use of personal health services and everything that facilitates or impedes the use of personal health services”

  7. TEXAS TECH UNIVERSITY Health 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

  8. TEXAS TECH UNIVERSITY Health Services Research & Management Andersen’s dimensions of access • Potential • Realized • Equitable • Inequitable • Effective • Efficient

  9. TEXAS TECH UNIVERSITY Health 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)

  10. TEXAS TECH UNIVERSITY Health Services Research & Management Ex: Hospital supply in Iowa County No. beds No./10,000 residents Adair 31 38.4 Johnson 1,092 106.3 Polk 2,033 56.5 State 15,103 52.8 from Iowa Health Fact Book, 1999

  11. TEXAS TECH UNIVERSITY Health 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)

  12. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  13. TEXAS TECH UNIVERSITY Health 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

  14. TEXAS TECH UNIVERSITY Health 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

  15. TEXAS TECH UNIVERSITY Health 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

  16. TEXAS TECH UNIVERSITY Health 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

  17. Andersen’s Behavioral Model Population Characteristics Environment Behavior Outcomes Perceived health status Personal health practices Health care system Evaluated health status Predisposing Enabling Need Use of health services External environment Consumer satisfaction

  18. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  19. TEXAS TECH UNIVERSITY Health Services Research & Management 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)

  20. TEXAS TECH UNIVERSITY Health Services Research & Management Enabling factors • More mutable • Examples • Income • Health insurance status (whether have insurance) • Type of insurance coverage (Medicare or Medicaid) • Transportation (whether have a car)

  21. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  22. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  23. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  24. TEXAS TECH UNIVERSITY Health Services Research & Management Social - Psychological Models of Access

  25. TEXAS TECH UNIVERSITY Health 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

  26. TEXAS TECH UNIVERSITY Health 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.

  27. TEXAS TECH UNIVERSITY Health 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

  28. TEXAS TECH UNIVERSITY Health 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

  29. TEXAS TECH UNIVERSITY Health 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)

  30. TEXAS TECH UNIVERSITY Health 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)

  31. TEXAS TECH UNIVERSITY Health Services Research & Management Health Belief Model (Rosenstock) • Cue to action may also be necessary • media • advice from family

  32. Health Belief Model Likelihood of action Individual perceptions Modifying factors Demographics Perceived benefits Sociopsychologocical minus Structural variables (knowledge about disease) Perceived barriers Perceived susceptibility to disease X Perceived seriousness Perceived threat of disease Likelihood of taking recommended action Cues to action

  33. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  34. TEXAS TECH UNIVERSITY Health Services Research & Management 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

  35. TEXAS TECH UNIVERSITY Health Services Research & Management Theoretical Guide(a variation of the Behavioral Model) Health system factors Predisposing factors Location of Enabling factors physician Perceived Need

  36. TEXAS TECH UNIVERSITY Health Services Research & Management 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)

  37. TEXAS TECH UNIVERSITY Health Services Research & Management Predisposing - Demographic/Social Structural variables • 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

  38. TEXAS TECH UNIVERSITY Health Services Research & Management 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

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