Leon Wyszewianski

Access to Care: Remembering Old Lessons

More than 20 years ago, Penchansky and Thomas (1981) published an article titled “The Concept of Access: Definition and Relationship to Consumer Satisfaction.” In the opening sentence to this article, they note: “‘access’ is a major concern in health care policy and is one of the most frequently used words in discussions of the health care system.” The same is certainly true today. In many policy discussions, access is equated with health insurance coverage. Although those who have defined access have all included other, nonfinancial, aspects of access in their definitions (Donabedian 1973; Penchansky and Thomas 1981; Millman 1993), we must still often remind ourselves of the importance of each aspect and the interplay between the different aspects. As conceived by Penchansky and Thomas, access reflects the fit between characteristics and expectations of the providers and the clients. They grouped these characteristics into five As of access to care: affordability, availability, accessibility, accommodation, and acceptability. Affordability is determined by how the providers charges relate to the clients ability and willingness to pay for services. Availability measures the extent to which the provider has the requisite resources, such as personnel and technology, to meet the needs of the client. Accessibility refers to geographic accessibility, which is determined by how easily the client can physically reach the providers location. Accommodation reflects the extent to which the providers operation is organized in ways that meet the constraints and preferences of the client. Of greatest concern are hours of operation, how telephone communications are handled, and the clients ability to receive care without prior appointments.And finally, acceptability captures the extent to which the client is comfortable with the more immutable characteristics of the provider, and vice versa.These characteristics include the age, sex, social class, and ethnicity of the provider (and of the client), as well as the diagnosis and type of coverage of the client. We must also remember that these five As of access form a chain that is no stronger than its weakest link. For example, improving affordability by providing health insurance will not significantly improve access and utilization if the other four dimensions have not also been addressed. Often neglected are the characteristics of the provider and the client that influence acceptability. Taylor et al. (2002) estimate that providing universal coverage through a Medicare buy-in for women aged 50–62 would result in a modest increase in mammography rates, from 72.7 percent to 75–79 percent. Like the work by Hofer and Katz (1996), who compared mammography rates for women in Canada and the United States, this research highlights the role in achieving access of client socioeconomic characteristics that influence acceptability. Similarly, equating access with availability of resources will miss other characteristics of the provider and the clients that may be barriers to access. As Iwashyna et al. (2002) conclude, “intercounty heterogeneity in hospice use is substantial, and may not be related to the set-up of the medical care system.” Their research also finds that simply controlling for differences in the composition of measured individual-level characteristics did not explain variation in use. Not only is the mere presence of facilities not an adequate measure of availability, it misses the more important issue of goodness of fit, that is, the interaction between the characteristics of the providers and the expectations of the clients that determine the acceptability of the resources. Perhaps a more reliable measure of the goodness of fit between provider and client is whether someone has a regular physician and a regular site of care, since it can be seen as reflecting availability, accessibility, accommodation, and acceptability. The results of Xu (2002) highlight the importance of this goodness of fit between provider and client in influencing use of preventive services. However, the full picture on access does not emerge because the role of affordability in influencing utilization, controlling for differences in having a usual source of care, is not reported. The growing body of research investigating racial and ethnic differences in the utilization of various medical and dental care services points to the critical role played by all of the dimensions of access, particularly availability, accessibility, and acceptability. Although Gilbert et al. (2002) found that affordability was certainly a barrier to access to adequate dental care for African Americans and non-Hispanic whites in their sample, also important were other nonfinancial predictors that varied in both significance and effect between the two groups. The challenge to researchers is, first, to recognize the interdependence between the different dimensions of access, and second, and more difficult, to find appropriate measures of these dimensions. Only then will their findings provide the basis for policy changes that will be truly effective in improving access.

Equity in the distribution of quality of care.

This article examines whether the quality of health care services in the United States is equitably distributed across all groups in the population, especially groups defined by age, race, sex, and income characteristics. The framework within which the question is answered draws distinctions among structural, process, and outcome inequities. The available evidence suggests that all three types of inequity are present, at least to some extent. However, there are too many gaps and weaknesses in what is known about this issue to reveal systematic patterns or to support broad generalizations. The need for additional research on this issue is discussed, as are the policy implications of what is already known about equity in the distribution of quality of care.

Market-oriented cost-containment strategies and quality of care.

medical care services that has been suggested by politicians, by academicians, and most recently by the business community is to increase the influence of market forces on medical care decision-making. While the potential for success of this approach in achieving its aim of cost containment has been much discussed, the related question of what effects it may have on quality of care has received no systematic treatment. To begin filling this gap, this paper examines the implications for the quality of medical care of some general proposals designed to reduce health care expenditures by increasing the influence of market considerations in medical care decision-making. The proposals evaluated are represented by the work of Feldstein (1971), Pauly (1968, 1980), Enthoven (1978), and McClure (1978). These proposals principally depend on increasing cost-consciousness on the part of decisionmakers in the medical care process. These decisionmakers include the consumer (or patient), the provider, the insurer, and, in some cases, the employer. Further, increased costconsciousness may come at three decision points: 1) at the point of deciding what insurance policy to buy or which health care plan to

Health insurance coverage of the unemployed.

Of 1,332 unemployed individuals in the Detroit area interviewed in late 1983, 51% did not have health insurance. Lack of insurance was directly related to length of unemployment. Of those unemployed 3 months or less, 31% had no insurance, as compared with 56% of those unemployed more than 3 years. For the most part, these were not the chronically uninsured: 78% of them were insured when they were employed. Three fourths of those without insurance were not covered by Medicaid either. These findings suggest that during the latest economic recession, the problem of health insurance loss due to losing ones job was more severe than had been assumed by most policymakers.

The future of kidney transplantation. The effect of improvements in survival rate on the shortage of donated kidneys.

New drugs and other medical advances in organ transplantation are expected to increase the rate of retention of transplanted kidneys, or grafts, and therefore also raise patient survival rates. In particular, the immunosuppressive drug cyclosporine has been found to reduce the likelihood of rejection of a transplanted kidney by the immune system of the transplant recipient. A critical issue is the effect changes in the graft and patient survival rates will have on the current shortage of donated kidneys. On one hand, higher survival rates may decrease the demand for transplants, as fewer people require a second or third transplant following the failure of a previous one. On the other hand, however, demand for first-time transplants may increase as more end-stage renal disease (ESRD) patients perceive transplantation as a more successful, and therefore more desirable, procedure. We used a simulation model to estimate the net effect of these changes. The results show that, all else being held constant, the increase in the survival rate resulting from medical advances could alleviate the current kidney shortage. However, if higher survival rates lead to an increased demand for transplants, the net effect would be a substantial aggravation of the current shortage of donated kidneys. That would force regional organ procurement agencies and other concerned organizations to attempt unprecedented increases in kidney donations ranging from 50% to 300% over the current rate.

Characteristics of Catastrophic Hospital Expenditures

Financially catastrophic illness occurs relatively infrequently. Depending on how it is defined, in any one year it affects 1.0 to 2.0% of the non-institutionalized population but accounts for about 20% of health care expenditures. This report of a study of the incidence and characteristics of catastrophic inpatient episodes is based on the analysis of all discharges (586,319) from all hospitals (54) in Maryland during 1981 and all patients with multiple discharges (141,187) from 28 Maryland hospitals with unique patient identifiers during three years (1979–1981). The first set of analyses are based on discharges; for the second, the unit of observation is the patient.