Ann H. Cary, Ph.D., M.P.H., R.N., A.C.C.C.
Professor and Associate Dean
School of Nursing
Louisiana State University Medical Center
A. Isabel Garcia, D.D.S., M.P.H.
Health Scientist Administrator and Project Officer
Agency for Health Care Policy and Research
Bruce W. Goldberg, M.D.
Director, Oregon Health Education and Training Center
Oregon Health Sciences University
Ann C. Jobe, M.D., M.S.N.
Associate Dean for Student Affairs
East Carolina University School of Medicine
Thurma McCann, M.D., M.P.H.
Director, Division of Healthy Start
Maternal and Child Health Bureau
Mary Beth Skupien, M.S., R.N.
Deputy Associate Director, Office of Health Programs
Indian Health Service
Thomas M. Troxel
Director, Clakamas County Public Health Division
Deanne R. Williams, C.N.M., M.S.
Director, Professional Services and Support
American College of Nurse-Midwives
“If We Fund It - Will They Come?”
Researching Non-Financial Barriers to Primary Health Care
“The greatest equity of access is said to exist when need, rather than structural or individual factors determine who gains entry to the health care system” (R.Andersen et al., Equity in Health Service: Empirical Analyses in Social Policy; 1975)
PROBLEM STATEMENT
Providing universal health insurance coverage and developing integrated delivery systems may fail to provide universal access to primary health care to all Americans. Even with new financing mechanisms, certain vulnerable populations may not achieve access to needed primary health services because they are susceptible to non-financial barriers to care.
For purposes of this paper, vulnerable populations include, but are not limited to, the poor, rural and frontier residents, the disabled, the frail elderly, at-risk pregnant women and their infants and children, the homeless, persons with HIV disease, migrant and seasonal farm workers, and undocumented persons; access to care is defined as the timely use of personal health services to achieve the best possible health outcomes (12); and non-financial barriers are those variables, separate from insurance coverage, that negatively impact ability to access primary health care.
At present, the limited knowledge of the role of non-financial barriers to primary health care comes from studies not designed specifically for the purpose or from findings reported in a manner that makes it impossible to assess how individual characteristics influence access. Few studies have developed models that predict the extent to which these non-financial barriers would affect access to primary health care if insurance benefits were extended to the entire population. Such policy relevant information is essential if we truly seek to ensure optimal health for all.
BACKGROUND
Overcoming inequality in health outcomes and access to medical services has been a central issue within U.S. health policy over the past thirty years. In the 1960’s and 1970’s national health policies expanded health care programs for the poor and elderly. In the 1990’s, health care reform activities are once again focusing on expanding access by providing insurance coverage for essential primary health services to all Americans.
At the same time, the United States has developed the strongest biomedical research establishment in the world. Yet, in spite of huge outlays of health care dollars going toward expensive, high tech services, measures of health status of Americans continue to lag behind those of other developed nations and millions of Americans continue to have difficulty obtaining primary health services.
Two common assumptions continue to guide our nation’s health care policy. First, that providing insurance coverage assures access to and utilization of primary health care services, and, second, that assuring access to medical care/physicians results in improved health status. Unfortunately, we are beginning to understand that providing insurance is only one step towards reducing barriers to access and, the providing medical care is but one factor in improving health status.
A limited number of studies have examined non-financial barriers to access to health care. For any individual these barriers might include education, language, personal experiences, attitudes and beliefs, unhealthy lifestyles, poor nutrition, provider’s attitudes and beliefs, transportation, social support, and/or health professional supply and distribution. In addition, race, ethnicity, gender, economic status, geography and environment may be important factors.
Addressing non-financial barriers to primary health care is critical if universal access is to be achieved. To significantly advance the health status of the American people, a new paradigm for research that includes an expanded primary care and health services research and policy agenda and one that examines non-financial barriers to access and utilization is essential.
RECOMMENDATIONS
Research initiatives in Primary Health Care must address the complex nature of access, utilization, and health outcomes where non-financial variables are framed, measured and interpreted. To build the scientific data base for understanding primary care outcomes, the 1994 Public Health Service Primary Care Policy Fellowship Working Group on Research recommends that:
Gaps in the specific understanding of the role of non-financial barriers to care have been identified as a “high priority” research need in the Healthy People 2000 report. In many cases studies have never been conducted and in others, studies have lacked reliability due to improper study design or systematic biases. Areas of funding should include support for multivariate design instruments and analysis methods which clarify the non-financial dimensions of utilization of health care and outcomes that promote the objectives of Healthy People 2000 related to clinical preventive measures. (6)
The 1993 Report of the Task Force on Building Capacity for Research in Primary Care (15) identified an acute need for increased support of research as well as development of a national infrastructure for research in primary care. Research support that expands the scientific basis for primary care will be needed to improve access to appropriate care, reduce costs, and improve health outcomes.
The FY93 Public Health Service (PHS) budget appropriation of $21 billion is approximately 3% of the Department of Health and Human Services’ total appropriation. Of this $21 billion, $10 billion is allocated to the National Institutes of Health (NIH) for biomedical research. In contrast, the entire outlay for health services research at the Agency for Health Care Policy and Research is less than $160 million. Investments made in biomedical research have led to significant advances such as immunizations, treatment for cancers, and treatment for hypertension. However, underfunding of primary care research has resulted in a lack of knowledge on how to organize primary care so that children are immunized, cancers are detected early, and health cut is delivered to vulnerable populations.
The July 1989 conference proceedings sponsored by the Brookings Institution in conjunction with the National Commission to Prevent Infant Mortality strongly recommended increased research focus on the social context of barriers to improved health outcomes. The case was made that in order to improve the health of many vulnerable groups, strategies and programs must go beyond a medical model and address underlying social conditions. This conference called for further investigation of the impact of non-financial barriers on delivery system programs such as:
Such initiatives might include studying: 1) the effectiveness of health education in improving access; 2) the role of home visiting in improving access; 3) the role of non-physician providers in improving access; and 4) further analysis of effectiveness of Community Oriented Primary Care. As another example, the need for developing a primary care research policy for migrant and seasonal farm workers in this decade is made evident from the startling evidence of gaps in service delivery and by the lack of reliable data on the health status of these workers (7).
The Institute of Medicine (IOM) study of access (12) reflects a strong reliance on use of outcomes variables illustrated in the definition of access. Clearly both utilization factors and health outcome indicators present cogent descriptions of the degree to which access has been achieved. The selection of uniform, scientifically unambiguous indicators of access allows for meaningful comparisons of the relationships of access, utilization and health outcomes across funded studies. By initially incorporating the IOM framework of 15 access indicators, the research community will compile data on the non-financial barriers to access which can be used in prediction, modeling and guideline development in the future.
This workgroup would include appropriate Public Health Service (PHS) agencies such as the Agency for Health Care Policy and Research (AHCPR), Health Resources and Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), Indian Health Service (IHS), and others outside of PHS such as Health Care Financing Administration (HCFA), Centers for Disease Control and Prevention (CDC), Administration for Children and Families (ACY), and the National Institutes of Health (NIH).
As part of our Fellowship, we have had the opportunity to visit and learn about several of the Agencies, Bureaus and Programs within the Department of Health and Human Services. A number of these groups mentioned that their Strategic Plan included research and/or demonstration projects related to access to health care. For example, HCFA’s Office of Research and Demonstrations Research Themes for 1995-96 focuses on meeting the health care needs of vulnerable populations, with emphasis on issues of access, delivery systems, and financing. SAMHSA’s demonstration projects to improve accessibility to mental health and substance abuse services were mentioned. It is apparent that many of the areas within the Department share similar research priorities but lack a coordinated focus or approach. The overall efforts of the Department would be enhanced with a coordinated, shared resource approach to research, demonstration projects and special initiatives related to access to primary health care.
Capacity building strategies for primary health care services researchers can be strengthened through strategic initiatives and processes which have demonstrated success in biomedical research training. Processes of Research Career Development, First and Clinical Investigator Awards support the initiation, expansion and enabling training opportunities essential to production a cadre of primary health care services research leaders. Technical support to assist the current workforce in redirecting the research activities within the primary health care services arena may more quickly ameliorate the urgent need for study data.
BIBLIOGRAPHY