TEXAS TECH UNIVERSITY
Health Services Research & Management
Today’s Topic:
Health Services Access
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
Data from Celinda Lake & W.D. McInturff
October 12, 1999
There is equal support for using the federal budget
surplus to help uninsured families and children and to
protect Medicare & Social Security.
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...
56%
55%
23%
Help Uninsured Families Cut Federal
&Children Get Health Ins. Income Taxes
20%
Pay Down The
National Debt
21%
Preserve Social Security Cut Federal
and Medicare
Income Taxes
20%
Pay Down The
National Debt
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.
In the last ten years/next ten years, do you think the number of uninsured
Americans has/will..?
Over The Last Ten Years
Over The Next Ten Years
59%
51%
Increased
16%
17%
Decreased
Stayed T he Same
18%
Increase
Decrease
21%
Stay T he Same
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; and
 There 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.
People find statements about the large
number of Americans affected by this issue
to be believable but over estimate the
number of Americans effected.
"Uninsured Americans – that is,
people with no health insurance at all."
Over 70 MILLION
Americans have gone
without health care
coverage for at least some
period of time during
the past three years.
76%
Forty-three million
Americans do not
have health coverage.
69%
More than 8 out of 10
uninsured Americans
are in working families.
60%
%T rue
Surprisingly, even when
reminded of Medicare and
Medicaid coverage,
Americans estimate 30% of
Americans have no health
coverage.
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.
Do you favor or oppose mak ing sure all families
and CHILDREN have access to affordable
health insurance coverage?
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?
65%
69%
Favor
90%
Don't Know/Refused
4%
Oppose
6%
January 1992*
October 1999
*Data is from Public Opinion Strategies & The Mellm an Group.
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%
13th Generation
(Ages 18-38)
(35%)
Baby Boomers
(Ages 39-56)
(36%)
75%
63%
Silent Generation
(Ages 57-74)
(20%)
% Yes
GI Generation
(Ages 75+)
(8%)
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?
81%
70%
55%
Republican
(33%)
Independent
(23%)
% Yes
Democrat
(39%)
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 talk ed about mak ing sure all families & CHILDREN have access to
affordable health insurance coverage, would you be...more lik ely or less lik ely to vote for this candidate
or would it mak e no difference in how you would vote?
Much More
Likely
25%
Somewhat More
Likely
29%
Don't Know/
Refused
6%
Somewhat Less
Likely
2%
Much Less
Likely
3%
Total More Likely 54%
Total Less Likely
5%
No Difference
36%
A lot of people's lives are touched by lack of
health insurance coverage.
43%
17%
12%
% Uninsured Today Age
18-64
(10% for Total
Population*)
% Insured Today, But
Uninsured Sometime Over
the Last 3 Years*
*All percentages are reflected as a percent of the total number of respondents.
% Insured For Three
Straight Years, But Know
Someone Uninsured
Sometime Over the Last 3
Years*
It's clear who the "at risk" sub-groups are for being
uninsured now or not having coverage sometime over
the last three years.
Uninsured Now
Service Workers
Single Women with Kids
Women 18-34
Single Men with kids
HH Income $20K-$40K
19%
17%
17%
15%
15%
HH Income Under $20K
Men 18-34
Self-Employed
Age 18-34
Work in Company With 11 to 100
Employees
24%
21%
19%
19%
Single/Divorced/Widow
15%
Work in Company With 10 or Less
Employees
15%
Medicaid Recipients
Have Children Under Age 4
Have Children Age 5-8
African Americans
Married Women with Kids
Have Children 18 or Under
Conservative Democrats
Blue Collar Workers
Soft Democrats
Democratic Men
HS or Less
Age 35-44
Insured Today, B ut Uninsured
Sometime Last 3 Years
24%
32%
23%
26%
26%
17%
32%
27%
25%
24%
23%
22%
22%
22%
21%
21%
21%
21%
A majority of Americans misidentify and
believe most uninsured are in households
where no one is working.
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...?
37% Employed people and people
from families in which
someone is employed
5%
Don't Know/Refused
Unemployed people and
people from families in
which no one is employed 58%
There are clear differences on people's
health care related activities and their
insurance coverage.
Uninsure d Now
Insure d Today, But
Uninsure d Sometime
in Last Thre e Ye ars
Insure d For Three
Straight Ye ars, But
Know Some one
Uninsure d
Sometime O ve r the
Last 3 Ye ars
Postponed T reatment
Because of Lack of
Coverage
48%
59%
15%
T ake Prescription Drug
Daily
25%
51%
49%
Spent One Night or More
As Hospital Inpatient
27%
44%
34%
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
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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)
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Andersen’s definition

“Actual use of personal health
services and everything that
facilitates or impedes the use of
personal health services”
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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
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Andersen’s dimensions of
access

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Potential
Realized
Equitable
Inequitable
Effective
Efficient
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Potential access

Structural characteristics of health system

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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)
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Ex: Hospital supply in Iowa
County
No. beds
Adair
31
Johnson
1,092
Polk
2,033
State
15,103
from Iowa Health Fact Book, 1999
No./10,000 residents
38.4
106.3
56.5
52.8
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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….


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Type (e.g. ambulatory, inpatient,
dental)
Site (e.g. physician office, hospital)
Purpose (e.g. primary, secondary,
tertiary)
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Ex: Inpatient hospital utilization,
1996
(per 1,000 population)
Char.
Discharges
Total
82.4
Under 15
37.3
45-64 yrs
113.7
65 +
268.7
Days
ALOS
469.9
5.7
212.3
5.7
621.4
5.5
1,818.0
7.0
from National Health Interview Survey, NCHS, CDC
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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
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Ex: Vaccinations of children
age 19-35 months (1996)
All
69%
White,
non-Hisp
72%
Black,
non-Hisp
67%
Hisp
62%
Amer.
Indian
82%
from National Center for Health Statistics and National Immunization Program,
National Immunization Survey, CDC
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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
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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
Environment
Health
care
system
External
environment
Population
Characteristics
Predisposing
Enabling
Need
Behavior
Personal
health
practices
Use of
health
services
Outcomes
Perceived
health status
Evaluated
health
status
Consumer
satisfaction
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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
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Predisposing factors


Fairly immutable
Examples

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Demographics (gender, marital status,
race)
Social structure (education, ethnicity, social
integration)
Beliefs (e.g. beliefs about the effectiveness
of medial care)
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Enabling factors

More mutable

Examples




Income
Health insurance status (whether have insurance)
Type of insurance coverage (Medicare or Medicaid)
Transportation (whether have a car)
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Need factors

Perceived need

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
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Subjective health status (Health-related quality of
life)
Symptoms
Discomfort
Evaluated need


Health care professional’s judgement about your
health status
Diagnosis
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Health behavior / service use

Personal health practices

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
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
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Types of outcomes

Perceived health status


Evaluated health status


Health-related quality of life
Health professional’s judgment
Consumer satisfaction

Satisfaction with technical and interpersonal
aspects of care
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Social - Psychological
Models of Access
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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
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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.
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The Sick Role’s
4 institutionalized expectations

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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
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Defining Sick (Mechanic)

4 dimensions of illness affect decision to
seek medical care

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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
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Health Belief Model
(Rosenstock)

A social-psychological theory

Focuses on evaluative, cognitive
variables that motivate an individual
to practice preventive health behavior
(Rosenstock, 1974)
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Health Belief Model
(Rosenstock)

4 factors influence health behavior
decisions

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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)
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Health Belief Model
(Rosenstock)

Cue to action may also be
necessary


media
advice from family
Health Belief Model
Individual
perceptions
Modifying factors
Demographics
Sociopsychologocical
Structural variables
(knowledge about
disease)
Perceived
susceptibility
to disease X
Perceived threat of
disease
Perceived
seriousness
Cues to action
Likelihood
of action
Perceived
benefits
minus
Perceived
barriers
Likelihood of
taking
recommended
action
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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
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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
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Theoretical Guide
(a variation of the Behavioral Model)
Health system factors
Predisposing factors
Enabling factors
Perceived Need
Location of
physician
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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)
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Predisposing -
Demographic/Social
Structural variables
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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
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Predisposing -
Health belief
variables

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

Believe family physicians care beneficial
Believe family physician care cost-beneficial
Believe specialty physician care beneficial
Believe specialty physician care costbeneficial
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Enabling variables
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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