Examining Access to Specialty
Care for California’s Uninsured
Suzanne Felt-Lisk, Megan McHugh, and
Melissa Thomas
AcademyHealth ARM, June 2004
Sponsor: California HealthCare
Foundation
Research Questions
1

How and how well are California’s
uninsured able to obtain specialty care?

Is access to specialty care for the
uninsured becoming easier or more
difficult?

How and how much does access to
specialty care vary from one community to
the next
Methods

Survey of all 101 FQHC Medical Directors
in CA

Survey of 64 hospital outpatient
departments

Case studies of 4 communities
– Site visits
– Focus groups of uninsured individuals who
needed specialty care
2
Findings

3
Access problems are widespread,
extend across a wide range of
specialties, and are worse for adults
than children
PERCENT OF FQHC MEDICAL DIRECTORS REPORTING PATIENTS
EXPERIENCE PROBLEMS IN OBTAINING SPECIALTY CARE
85%
66%
44%
39%
30%
27%
33%
20%
5%
9%
Uninsured
2%
Medi-Cal
Nevery/Rarely Experience Problems
Often/Always Experience Problems
Healthy Families
Private Insurance
Sometimes Experience Problems
Source: MPR Survey of FQHC Medical Directors in California, 2003. The reported figures are
estimates within plus or minus 5.5 percent
4
MOST PROBLEMATIC SPECIALTIES FOR
a
ADULTS AND CHILDREN
Adults
Allergy/Immunology
Dermatology
Endocrinology
Gastroenterology
Nephrology
Neurology
Orthopedics
Otolaryngology
Physical and
Occupational Therapy
Psychiatric
Pulmonology
Specialty Care for
Diabetes
Substance Abuse
Surgery (other than
vascular)
Urology
Vascular Surgery
Children
Allergy/Immunology
Dermatology
Neurology
Psychiatry
a
At least half of the surveyed Medical Directors reported their uninsured patients often or almost
always experienced problems obtaining these services.
5
Findings

6
Problems have worsened over the
past two years in many communities
and improved in few
– 50 percent reported specialty care
access was more difficult
– 35 percent reported it was about
the same
– 15 percent reported it was easier
Findings

7
Hospitals are a vital source of
specialty care for the uninsured,
including hospitals whose primary
focus is low-income populations, and
many other hospitals as well
REPORTED ACCESS AT HOSPITALS THAT SERVE AS SPECIALTY
CARE REFERRAL DESTINATIONS FOR THE UNINSURED
FQHCs Report
Access to Specialty Care Is…
Total
Number of
Hospitals
Rarely or
Never a
Problem
Sometimes
a Problem
Often or
Always a
Problem
Yes
70
19%
37%
44%
No
60
8%
45%
47%
Primary Hospital Focus is
Low-Income Populations
Total
130
14%
41%
45%
SOURCE: MPR survey of FQHC medical directors in California, 2003. Figures from this survey
are estimates within about plus or minus 5.5 percent.
8
Findings

9
Private physicians played a significant
role in 3 of 4 case study communities
SUBSTANTIAL DIFFERENCES BETWEEN REPORTED ACCESS BY THE
UNINSURED FOR FQHCS IN COMMUNITIES WITH LARGER AND
SMALLER HISPANIC POPULATIONS
Poor Access
Moderate Access
Adequate Access
Higher
Hispanica
Lower
Hispanica
Higher
Hispanic
Lower
Hispanic
Higher
Hispanic
Lower
Hispanic
(1)
(2)
(3)
(4)
(5)
(6)
Cardiology
60%
40
28
31
12
29
Gastroenterology
72%
57
24
24
4
20
Neurology
84%
62
8
19
8
19
Ophthalmology**
48%
41
40
20
12
39
Orthopedic Surgery*
81%
54
15
28
4
17
Other Types of Surgery
70%
45
17
39
13
16
Lab Services
35%
11
13
26
52
64
ADULTS
10
Findings

Community characteristics affect access:
– Strong relationships between FQHCs and
hospitals
– Community support
– Size of uninsured population and its
composition
– Supply of specialist physicians
11
Findings

Local efforts to improve access to
specialty care in the 4 case study
communities have limitations
– Adult access problems will remain
largely unaddressed by child insurance
expansions
– FQHC expansions promising for some
specialties but highly unlikely to be able
to meet all the needs
12
Implications
13

Helps provide insights into reasons for
worse clinical outcomes welldocumented for uninsured and lowincome individuals

Suggests a need for short- and
longer-term attention by local, state,
and national policymakers
Implications: Short-term & Local

Locally assess severity and nature of
specialty care access problems

Plan for improvement:
– Implement/expand local initiatives to
provide insurance
– Strengthen pc/hospital relationships
– Advanced training to pc providers
– Bring specialists to pc settings
– Build on existing efforts & experience
14
Implications: Longer-Term
15

State: Assist and motivate communities to
make local improvements

State: Consider policy change to
encourage physician volunteerism

National: Examine prevalence of problems
nationally and if problem is national,
consider changes similar to those listed for
states
Priorities for Future Research
16

Why the access disparity in communities
whose populations are 40% or more
Hispanic?

Further shape policy interventions

Document costs of underuse of specialists

Document cost of inefficiencies in current
system for uninsured referrals
Availability of Report & Issue Brief
 Report
and issue brief are on
California HealthCare Foundation
web site at
http://www.chcf.org/topics/
view.cfm?itemID=102587
17