Access to Health Services

Goal

Improve access to comprehensive, quality health care services.

Overview

Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. This topic area focuses on four components of access to care: coverage, services, timeliness, and workforce.

Why Is Access to Health Services Important?

Access to health services means the timely use of personal health services to achieve the best health outcomes.1 It requires 3 distinct steps:

1. Gaining entry into the health care system.
2. Accessing a health care location where needed services are provided.
3. Finding a health care provider with whom the patient can communicate and trust.2

Access to health care impacts:

• Overall physical, social, and mental health status
• Prevention of disease and disability
• Detection and treatment of health conditions
• Quality of life
• Preventable death
• Life expectancy

Disparities in access to health services affect individuals and society. Limited access to health care impacts people's ability to reach their full potential, negatively affecting their quality of life. Barriers to services include:

• Lack of availability
• High cost
• Lack of insurance coverage

These barriers to accessing health services lead to:

• Unmet health needs
• Delays in receiving appropriate care
• Inability to get preventive services
• Hospitalizations that could have been prevented 3

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Understanding Access to Health Services

Access to health services encompasses four components: coverage, services, timeliness, and workforce.

Coverage

Health insurance coverage helps patients get into the health care system. Uninsured people are:

• Less likely to receive medical care
• More likely to die early
• More likely to have poor health status 4, 5, 6

Lack of adequate coverage makes it difficult for people to get the health care they need and, when they do get care, burdens them with large medical bills. Current policy efforts focus on the provision of insurance coverage as the principal means of ensuring access to health care among the general population. Other factors, described below, may be equally important to removing barriers to access and utilization of services.

Services

Improving health care services depends in part on ensuring that people have a usual and ongoing source of care. People with a usual source of care have better health outcomes and fewer disparities and costs.7, 8, 9

Having a primary care provider (PCP) as the usual source of care is especially important. PCPs can develop meaningful and sustained relationships with patients and provide integrated services while practicing in the context of family and community.10 Having a usual PCP is associated with:

• Greater patient trust in the provider
• Good patient-provider communication
• Increased likelihood that patients will receive appropriate care11, 12

Improving health care services includes increasing access to and use of evidence-based preventive services.13, 14 Clinical preventive services are services that:

• Prevent illness by detecting early warning signs or symptoms before they develop into a disease (primary prevention).
• Detect a disease at an earlier, and often more treatable, stage (secondary prevention).15

In addition to primary care and preventive services, emergency medical services (EMS) are a crucial link in the chain of care. EMS include basic and advanced life support.16 Within the last several years, complex problems facing the emergency care system have emerged.17 Ensuring that all persons have access to rapidly responding, prehospital EMS is an important goal in improving the health of the population.

Timeliness

Timeliness is the health care system's ability to provide health care quickly after a need is recognized. Measures of timeliness include:

• Time spent waiting in doctors' offices and emergency departments (EDs)
• Time between identifying a need for specific tests and treatments and actually receiving those services

Actual and perceived difficulties or delays in getting care when patients are ill or injured likely reflect significant barriers to care.18 Prolonged ED wait time:

• Decreases patient satisfaction.
• Increases the number of patients who leave before being seen.
• Is associated with clinically significant delays in care.

Causes for increased ED wait times include an increase in the number of patients going to EDs, with much of the increase due to visits by less acutely ill patients. At the same time, there is a decrease in the total number of EDs in the United States.19

Workforce

PCPs play an important role in the general health of the communities they serve. However, there has been a decrease in the number of medical students interested in working in primary care.20 To improve the Nation's heath, it is important to increase and track the number of practicing PCPs.

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Emerging Issues in Access to Health Services

Access to health care services in the United States is regarded as unreliable; many people do not receive the appropriate and timely care they need. The U.S. health care system, which is already strained, will face an influx of patients in 2014, when 32 million Americans will have health insurance for the first time. All of these issues, and others, make the measurement and development of new strategies and models essential.

Specific issues that should be monitored over the next decade include:

• Increasing and measuring access to appropriate, safe, and effective care, including clinical preventive services.
• Decreasing disparities and measuring access to care for diverse populations, including racial and ethnic minorities and older adults.
• Increasing and measuring access to safe long-term and palliative care services and access to quality emergency care.

References

1Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Millman M, editor. Washington: National Academies Press; 1993.

2Bierman A, Magari ES, Jette AM, et al. Assessing access as a first step toward improving the quality of care for very old adults. J Ambul Care Manage. 1998 Jul;121(3):17-26.

3Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report 2008. Chapter 3, Access to healthcare. Washington: AHRQ; 2008. Available from: http://www.ahrq.gov/qual/nhdr08/Chap3.htm

4Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073-84.

5Insuring America's health: Principles and recommendations. Acad Emerg Med. 2004;11(4):418-22.

6Durham J, Owen P, Bender B, et al. Self-assessed health status and selected behavioral risk factors among persons with and without healthcare coverage—United States, 1994-1995. MMWR. 1998 Mar;13;47(9):176-80.

7Starfield B, Shi L. The medical home, access to care, and insurance. Pediatrics. 2004;113(5 suppl):1493-8.

8De Maeseneer JM, De Prins L, Gosset C, et al. Provider continuity in family medicine: Does it make a difference for total health care costs? Ann Fam Med. 2003;1:144-8.

9US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2010, 2nd ed. With understanding and improving health and objectives for improving health. 2 vols. Washington: Government Printing Office; Nov 2000, p.45. Available from: http://www.healthypeople.gov

10Institute of Medicine. Primary care: America's health in a new era. Donaldson MS, Yordy KD, Lohr KN, editors. Washington: National Academies Press; 1996.

11Mainous AG 3rd, Baker R, Love MM, et al. Continuity of care and trust in one's physician: Evidence from primary care in the United States and the United Kingdom. Fam Med. 2001 Jan;33(1):22-7.

12Starfield B. Primary care: Balancing health needs, services and technology. New York: Oxford University Press; 1998.

13National Commission on Prevention Priorities. Preventive care: A national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention; Aug 2007.

14National Commission on Prevention Priorities. Data needed to assess use of high-value preventive care: A brief report from the National Commission on Prevention Priorities. Washington: Partnership for Prevention; Aug 2007.

15Rose DJ, Lantz PM, House JS, et al. Health care access and the use of clinical preventive services. Paper presented at: Annual Meeting of the American Sociological Association; 2006 Aug 10; Montreal, Quebec. Available from: http://www.uspreventiveservicestaskforce.org/uspstf08/methods/procmanual.htm

16Massachusetts General Hospital (MGH), Department of Emergency Medicine. Prehospital care: Emergency medical service [Internet]. Boston: MGH; 2010. Available from: http://www.mgh.harvard.edu/emergencymedicine/services/treatmentprograms.aspx?id=1433

17Institute of Medicine (IOM). Future of emergency care series: Emergency medical services: At the crossroads. Washington: IOM; 2006.

18Agency for Healthcare Research and Quality. National healthcare disparities report 2008 [Internet]. Washington: Agency for Healthcare Research and Quality; 2008. Chapter 3, Access to healthcare. (AHRQ publication; no. 09-0002). Available from: http://www.ahrq.gov/qual/nhdr08/Chap3.htm

19Hsai RY, Tabas JA. The increasing weight of increasing waits. Arch Intern Med. 2009 Nov 9;169(20):1826-1932.

20Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-82.

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