Millions face obstacles in accessing medical care

Nearly 13 million of the roughly 110 million families in the United States—11.6 percent of all families—said they experienced difficulty or delays in obtaining medical care or did not get the care they needed during 1996, according to new estimates from the Medical Expenditure Panel Survey (MEPS) reported by the Agency for Health Care Policy and Research. The most common barrier, experienced by 7.6 million families or about 60 percent of all those reporting difficulty with access, was not being able to afford the care they needed.

Other reported barriers included insurance-related problems, experienced by 19.5 percent of families with access problems. These problems include an insurance plan not approving, covering, or paying for care; a preexisting medical condition (for which insurance coverage is often restricted); being unable to obtain referrals required by plans; or doctors refusing to accept an insurance plan. Obstacles reported by the remaining roughly 21 percent of families experiencing problems ranged from transportation problems to not being able to arrange for child care.

According to AHCPR Administrator John M. Eisenberg, M.D., these new estimates clearly indicate that access to care continues to be a significant problem. Dr. Eisenberg said delaying or foregoing needed care exacts a human as well as an economic toll. Health problems that might be resolved with timely medical care may only get worse and more expensive to treat if care is delayed.

Lack of health insurance places families at particularly high risk of encountering barriers. Uninsured families were more likely than the average family to experience problems obtaining needed health care. More than 27 percent, or 3.3 million uninsured families, experienced barriers, including the inability to afford care.

Similarly, Hispanic families were more likely than white or black families to encounter problems. Roughly 1.4 million Hispanic families (15 percent of all Hispanic families) reported barriers. For almost 7 in 10 of these Hispanic families, the primary access problem was that they could not afford the health care they needed.

AHCPR's Medical Expenditure Panel Survey also found that:

• Nearly 18 percent of the civilian noninstitutionalized population had no usual source of health care in 1996. This means more than 46 million Americans had no particular doctor's office, clinic, health center, or other place where they would usually go if they were sick or needed advice about their health.
• The groups most likely to be without a usual source of health care were uninsured persons under age 65 (16.7 million, or 38 percent of this group), young adults ages 18 to 24 (8.5 million, or 34 percent of young adults), and Hispanics (8.4 million, or 30 percent of Hispanics). Young children and the elderly were more likely than adults under age 65 to have a usual source of care. Even so, there were 1.3 million children under age 6 and 2.9 million persons age 65 and older with no usual source of care.
• Among the 82 percent of Americans who did have a usual source of care, nearly 9 of every 10 said they used office-based providers, and the rest said they got their care from hospital outpatient departments, clinics, or hospital emergency rooms. The most commonly used office-based providers were group or clinic practices and family or general practitioners.

These estimates are from the 1996 Medical Expenditure Panel Survey. AHCPR launched MEPS—the successor to its National Medical Expenditure Survey—to provide policymakers and others with up-to-date, highly detailed information on how Americans as a whole and different segments of the population use and pay for health care. This ongoing survey also looks at insurance coverage and other factors related to access to health care.

Detailed findings are in Access to Health Care in America—1996, MEPS Highlights 3 (AHCPR Publication No. 98-0002) and Access to Health Care in America—Sources and Barriers: 1996, MEPS Research Findings 3 (AHCPR Publication No. 98-0001), which includes detailed tables. Both are available from the AHCPR Publications Clearinghouse. The publications also are available through AHCPR's Web site, as are micro data files for persons wishing to conduct their own data analyses.

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Primary Care/Managed Care

Emergency diagnostic and treatment units may decrease hospitalization rates for adults with acute asthma

Emergency diagnostic and treatment units (EDTUs) may offer an alternative to inpatient hospitalization for adults suffering from a reversible disease such as acute asthma, according to a study conducted by Michael F. McDermott, M.D. and colleagues at Chicago's Cook County Hospital and the University of Illinois. The study, funded by the Agency for Health Care Policy and Research (HS07103 and HS07969), tested the hypothesis that selected asthma patients could avoid an inpatient stay by undergoing an intensive treatment protocol of up to 12 hours in an EDTU. In this study, most EDTU patients had clinical outcomes equivalent to the inpatients, overall lower costs, greater patient satisfaction, and an improved quality of life. The authors chose the term "emergency diagnostic and treatment unit" to reflect an evolution in these types of units, which more often are referred to as "observation units" or "holding units."

This research shows that more than half of the asthmatic patients now admitted to the hospital could be treated just as effectively in EDTUs at about half the cost, according to Dr. McDermott, who co-directs Cook County's EDTU and its Adult Asthma Clinic. The EDTU in this study used a protocol with specific entry and discharge criteria, and the EDTU patients also had to meet a prescribed schedule for therapy and response rates. These features ensure that the EDTU meets standards governing the use of observation units and make the intervention reproducible. The protocol also is likely to be effective for patients with less severe forms of asthma, according to the researchers.

Details are in "A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma," by Dr. McDermott, Daniel G. Murphy, M.D., Robert J. Zalenski, M.D., and others, in the October 13, 1997, Archives of Internal Medicine 157, pp. 2055-2062.

HMO primary care physicians refer as many women as men to specialists

In general, men are more likely than women to be referred to a specialist by their primary care physicians. But men and women enrolled in health maintenance organizations (HMOs) are referred at equal rates, concludes a recent study supported in part by the Agency for Health Care Policy and Research (HS09397).

Pressures exist in managed care organizations for primary care physicians to reduce their referral rates. But these results offer some assurance that patients enrolled in HMOs may be at less risk of lower access to specialists based solely on sex or insurance status compared with non-HMO patients, according to authors Peter Franks, M.D., of the University of Rochester, and Carolyn M. Clancy, M.D., Director of AHCPR's Center for Outcomes and Effectiveness Research and Acting Director of the Center for Primary Care Research. They used nearly 50,000 office visits of adult patients to primary care physicians reported in the National Ambulatory Care Survey for the years 1985 through 1992 to examine referrals by primary care physicians. The researchers adjusted their analysis to account for patient factors such as insurance status, diagnosis, and visit length; physician factors such as age, sex, and specialty; and practice factors, such as location, study year, and proportion of HMO patients.

Drs. Franks and Clancy found that overall, 4.5 percent of patients were referred to specialists compared with 7.5 percent of HMO enrollees. Those more likely to be referred included males; patients with fewer prescribed medications, not seen before for the presenting problem, and with a longer visit; and those seeing a less specialized physician, female physician, internist, or physician with a greater proportion of HMO patients. Among patients who had HMO insurance, there was no difference in referral rates for men and women, and patients who also had Medicaid or Medicare were more likely to be referred to specialty care.

Primary care physicians may adjust their practice style with respect to HMO patients over time through greater compliance with practice guidelines, an evolving relationship with consultants, or by referring more patients to reduce their workload. But as competition between health plans increases, managed care physicians assume a greater share of financial risk for patient care. Also, as greater numbers of Medicaid patients are enrolled in HMOs, pressures will increase to reduce the use of specialists. Vigilance will be needed to ensure that socioeconomic disparities do not increase, conclude the researchers.

Details are in "Referrals of adult patients from primary care: Demographic disparities and their relationship to HMO insurance," by Drs. Franks and Clancy, in the July 1997 Journal of Family Practice 45(1), pp. 47-53. Reprints (AHCPR Publication No. 97-R091) are available from AHCPR Publications Clearinghouse.

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Health Care Financing

Enrollees in Washington State's subsidized health insurance program did not have high use of services

An estimated 40 million people in the United States have no health insurance. Policymakers and health plan administrators are concerned that once insurance is provided to the currently uninsured, they will be high users of care because of chronic health problems or pent-up demand for health care. A recent study says these concerns may be unwarranted. Newly insured persons don't use any more health care services than already insured State employees or Medicaid recipients, according to the study, which was supported by the Agency for Health Care Policy and Research (HS06062).

The researchers evaluated Washington State's Basic Health Plan (BHP)—a subsidized health insurance program for low-income residents—from its inception in 1988 until 1992 in three managed care organizations operating in three counties. In 1992, the average monthly premium for BHP was $90 per person. However, for people with incomes less than twice the Federal poverty level, the average out-of-pocket monthly premium payment was $34 for a basic benefits package covering hospital and outpatient care, including preventive services and maternity care.

There was evidence of pent-up demand for care for those who had been without health insurance for more than a year. But overall, BHP members used health care services and had total expenditures that were comparable to those of middle-income State employees and Medicaid recipients. In fact, BHP members did not have high use of services in the first 6 to 12 months of plan enrollment, and their use was relatively stable during their first 2 years in the program.

Charges across all plans were highest for those without insurance for 1 to 5 years ($1,067) or more than 5 years ($1,333) and lowest for those uninsured for less than a year ($795) or never insured ($859). These trends were significant for plans in the counties of Spokane and Clallam, but not for the Pierce County plan, which had higher service use and charges than the other plans. These differences were due to characteristics of the managed care organization or to the style of practice in a particular county, according to the researchers. They conclude that access to care for the low-income, previously uninsured can be improved by programs using mainstream delivery systems.

For more details, see "Health care utilization for the 'newly insured': Results from the Washington Basic Health Plan," by Diane P. Martin, Ph.D., Paula Diehr, Ph.D., Allen Cheadle, Ph.D., and others, in the Summer 1997 Inquiry 34, pp. 129-142.

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Special Populations

Less than one in five nursing home residents has a written advance directive

The Patient Self-Determination Act (PSDA), passed in 1991, requires health care institutions to educate patients about advance directives and document their wishes for life-sustaining treatments in certain situations. Due to passage of the PSDA and increased debate about the use of cardiopulmonary resuscitation (CPR) in the severely impaired elderly, do-not-resuscitate (DNR) orders increased dramatically from 31 percent of nursing home patients in 1990 to nearly 52 percent in 1993 in 10 States studied, with all but one State having a 1.5- to 3-fold increase. Documentation of living wills in patients medical charts rose from 4 percent to 13 percent during the same time period. Do-not-hospitalize orders and orders to forgo artificial hydration and nutrition remained less than 8 percent in both 1990 and 1993, according to a study supported in part by the Agency for Health Care Policy and Research (NRSA training grant HS00011).

These findings highlight several important concerns. Less than one in five of the nursing home residents studied had a living will or durable power or attorney, suggesting that health care providers will need to rely on decisionmaking by surrogates (usually family, friends, or court-appointed guardian). Less than 1 in 10 patients had an order to forgo hospitalization, which for residents of long-term-care facilities may entail risk of hospital-induced problems as well as relocation stress. In 1993, fewer than 40 percent of residents of long-term-care facilities in Texas, Maryland, and Ohio had a DNR order, whereas Oregon, Minnesota, and Connecticut had DNR order rates of nearly 70 percent. This substantial across-State variation persisted even among residents with severe cognitive and functional impairment, for whom many would consider CPR futile treatment.

These findings suggest the need to increase consensus and develop recommendations about the appropriateness of CPR and hospital transfer for nursing home residents, conclude Catherine Hawes, Ph.D., of Research Triangle Institute, and her colleagues. Their findings were based on data collected from medical records, staff conversations, and interactions with nursing home residents of 270 long-term care facilities in 10 States (2,175 patients in 1990 and 2,088 patients from the same facilities in 1993).

For more information, see "Changes in advance care planning in nursing homes before and after the Patient Self-Determination Act: Report of a 10-State survey," by Joan M. Teno, M.D., M.S., Kenneth J. Branco, M.S.W., Ph.D., Vincent Mor, Ph.D., and others, in the August 1997 Journal of the American Geriatrics Society 45, pp. 939-944.

Degree of acculturation affects risky behavior among pregnant women of Mexican origin

Mexican-immigrant women are more likely than Mexican-American women, who have been in the United States many years, to abstain from alcohol, drug, and cigarette use during pregnancy. In addition, Mexican-immigrant women are more apt to have support from the baby's father, availability of social networks, and fewer stressful life events, all factors that are associated with favorable birth outcomes.

According to a recent study supported by the Agency for Health Care Policy and Research (HS05518), a higher degree of integration in the United States is associated with increased prenatal stress, which in turn is associated with fewer social supports and substance use. However, these behavioral risk factors do not appear to directly affect preterm births or birthweight, notes study leader Ruth E. Zambrana, Ph.D., of George Mason University, Fairfax, VA.

The researchers interviewed pregnant women 17 to 35 years of age: Mexican-immigrant women (those born in Mexico who had resided in the United States for no more than 7 years) and Mexican-American women (those born in Mexico or the United States who had resided in the United States since at least age 10). The women were interviewed at 22 community-based prenatal care clinics in Los Angeles County from 1987 through 1989. Acculturation was measured by English-language preference, literacy in English (reading and writing), years residing in Los Angeles, and education.

Mexican-American women reported more prenatal stress, less support from the baby's father, less positive attitudes toward their pregnancy, and more drug and alcohol use, and they had more medical risks. They initiated prenatal care about the same time as Mexican-immigrant women (during 13th week of pregnancy).

Yet there were no significant group differences in their infants' gestational age or birthweight. Among Mexican-Americans, 7.7 percent of infants were delivered preterm (less than 35 weeks gestation) or marginally preterm (36 or 37 weeks), and 4.6 percent had low birthweights. Among Mexican-immigrants, 8.4 percent of births were preterm or marginally preterm, and 2.6 percent had low birthweight infants.

Apparently, as women of Mexican origin become integrated into U.S. culture, they are at risk of experiencing a decrease in culture-specific protective behaviors. Research needs to focus on assessing the psychosocial and health behaviors that contribute to sustaining protective factors in Mexican-origin women that are highly associated with healthy infant outcomes, explains Dr. Zambrana.

See "Prenatal health behaviors and psychosocial risk factors in pregnant women of Mexican origin: The role of acculturation," by Dr. Zambrana, Susan C.M. Scrimshaw, Ph.D., Nancy Collins, Ph.D., and Christine Dunkel-Schetter, Ph.D., in the June 1997 American Journal of Public Health 87(6), pp. 1022-1026.

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AHCPR News and Notes

AHCPR announces first evidence report topics

The Agency for Health Care Policy and Research has announced the first set of topics assigned to the Agency's 12 Evidence-based Practice Centers (EPCs). The EPCs will systematically review the relevant scientific literature about these topics, conducting additional analyses, if appropriate. Their findings will be published as evidence reports or technology assessments, which will form the basis of other organizations guidelines, quality improvement projects, and purchasing decisions.

These state-of-the-science reports and technology assessments, once distributed, will help reduce inappropriate variations in medical care and improve the overall quality of the health care system, according to AHCPR Administrator John M. Eisenberg, M.D.

The EPCs will be conducting their research through partnerships and collaborations with managed care organizations, medical specialty societies, Federal purchasers, and others. This will help to ensure that the products produced by the EPCs are appropriate and useful as soon as they are completed, according to Douglas Kamerow, M.D., M.P.H., who oversees AHCPR's Evidence-based Practice Program. The topics were assigned as follows:

1. Pharmacotherapy for alcohol dependence. Research Triangle Institute and University of North Carolina at Chapel Hill, NC.
2. Management of stable angina. University of California, San Francisco, CA, and Stanford University, Stanford, CA.
3. Diagnosis of sleep apnea. MetaWorks, Inc., Boston, MA.
4. Treatment of attention deficit/hyperactivity disorder. McMaster University, Hamilton, Ontario, Canada
5. Rehabilitation of persons with traumatic brain injury. Oregon Health Sciences University, Portland, OR.
6. Testosterone suppression treatment for prostatic cancer. Blue Cross/Blue Shield Technical Evaluation Center, Chicago, IL.
7. Evaluation of cervical cytology. Duke University, Durham, NC.
8. Depression treatment with new drugs. University of Texas, San Antonio, TX.
9. Evaluation and treatment of new onset of atrial fibrillation in the elderly. Johns Hopkins University, Baltimore, MD.
10. Prevention and management of urinary complications in paralyzed persons. Southern California EPC, Santa Monica, CA.
11. Diagnosis and treatment of acute sinusitis. New England Medical Center, Boston, MA.
12. Diagnosis and treatment of dysphagia/swallowing problems in the elderly. ECRI, Plymouth Meeting, PA.

Call for papers issued for fourth "Building Bridges" conference

The American Association of Health Plans (AAHP), the Agency for Health Care Policy and Research, and the HMO Research Network have issued a call for abstracts to be considered for presentations in concurrent or poster sessions at the fourth annual conference, "Building Bridges Between the Managed Care and Health Services Research Communities." The conference will be held May 7-9, 1998, in Oakland, CA, and is designed to facilitate partnerships, advance communication, share information about research projects, and improve the understanding between health services researchers and the managed care industry.

Interested individuals are invited to submit abstracts detailing their work. The deadline for abstracts is January 16, 1998. For more information and abstract submission forms, contact Jill Arent, AAHP, (202) 778-3234, E-mail: jarent@aahp.org.

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