BY RYAN N. SCHMIDT, PHD, MBA, MS, CMRP
ROBERT POSTERARO, MD, MBI, FACR
SHARON HUNT, MBA, FACHE
[dropcap]T[/dropcap]he purpose of this article is to highlight the challenges and concerns that surround the commonly heard term called “access” to care.
Often times, people simply associate access to care with whether or not an individual has health insurance. However, access to care has several components associated with it.
Access to health care was first defined by the Institute of Medicine (IOM) in 1993 as “the timely use of personal health services to achieve the best health outcomes.”
Attaining good access to care requires three discrete steps: (1) gaining entry into the health care system, (2) getting access to sites of care where patients can receive services and (3) finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.
Likewise, health care access is measured in several ways: (1) structural measures of the presence or absence of specific resources that facilitate care, (2) assessments by patients of how easily they can access health care and (3) utilization measures of the ultimate outcome of access to care.
As we think about access to care, it becomes clear that some characteristics of access seem more intuitive (direct) while other aspects are more educational (indirect). This distinction suggests a need for additional population-based dialogue about the topic. Further, rural communities are most impacted by access-related issues and the need for sustainment of health-related services.
A – AFFORDABILITY
Affordability is not only associated with one’s ability to pay for health care services. It also includes an employer’s legal requirements to include health care insurance within an employee’s benefits package. Employer-sponsored health insurance requires the employer to match the overall cost of the insurance premiums and share the fiscal responsibility. Further, those businesses with fewer employees are at a disadvantage to negotiate overall premium pricing. For example, a small business (more likely in the rural communities) with 60 employees cannot bargain insurance premiums comparative to a large corporation of 10,000 employees. Given this, it creates great cost variations for employees and often for companies that can least afford it.
C – COMMUNICATION
Communication is a key element when describing current concerns within health care. Physicians and nurses need to become better preventative educators, identifying health risk factors and appropriate health behaviors concerning the patient. Further, patients need to fully understand the risk factors being presented to include the fiscal implications of their own health. This becomes more difficult in rural communities as access to health professionals, impactful treatments and health technologies are more scarce.
C – CARE COORDINATION
Care coordination is directly correlated to communication and those health providers who provide it. The fundamental difference is care coordination focused on the clinician to clinician interpretation, treatment options and recommended modalities of treatment and how that is effectively coordinated for the patient. This includes the seamless movement of clinical information, insurance referrals and the appropriate and timely sharing of the patient record. The electronic medical record (EMR) and portability of such a record within and between health care facilities become more challenging in rural communities.
E – EDUCATION (INTERVENTION)
Education is often viewed as the solution in preventing the overall health decline of patients. This would include the public health education received and the level of education of the person to receive it or prevent illness. An overall healthier patient will reduce the cost of their health care while increasing the quality of their life.
However, the sole purpose of health education is to impact the overall outcome of the health of a patient. Education becomes the intervention of measurement and often proves to be quite ineffective and inefficient in influencing the behavior of a patient. This would mean that health education in itself does not significantly modify human behavior.
Additionally, those with lower levels of education are least likely to have access to health care services or to be able to afford the overall costs of unhealthy living. However, those same persons are the ones most likely to engage in unhealthy life choices given the conditions in which they are currently living and the influential environment in which they are living.
S – SHORTAGE (PHYSICIAN/NURSING)
Physicians and nurses are less likely to practice and stay in rural communities. The majority of physicians, nurses and, particularly, specialists that choose to practice in the rural communities were typically raised in that community and/or a rural community such as the one represented. The more specialized the physician/nurse, the greater the shortage in the rural communities.
The federal government has recognized this and developed incentives like loan repayment options through programs such as the National Health Service Corps. However, the physician/nursing shortage continues to create a hardship for those often in the greatest need.
S – SUSTAINMENT
Sustaining complex care for rural patients, typically geographically and fiscally separated from its urban counterparts, is of great concern.
Often, care is a continuum of treatment modalities facilitated by both physicians and the technology they represent. Rural patients often do not follow-up on their interventions (medications, labs, scans, etc…) given the geographic limitations and the continual collective requirement to address multi-faceted medical issues.
The cost of treatment, travel and absenteeism at work becomes a criteria for which a choice between maintaining employment and continued medical care is often made with great hesitation.
A – AGING
According to the U.S. Census Bureau, there are more than 44 million U.S. residents (13 percent of the population) age 65 years and older. The elderly account for more than 34 percent of the overall spending in health care, with nearly half of that spending occurring during the last six months of life.
As the US population continues to grow, there will be continued economic and political pressures to reduce or limit health care benefits and costly treatments. This is directly correlated to the lack of a youthful population (number of taxpayers in the nation impacted by lower national birth rates) to pay for elderly federal health services.
C – CHRONIC (DISEASE)
Chronic disease can be categorized into the following areas: (1) unmanaged (2) needs to be continually managed (3) difficult to manage (4) too costly to manage or (5) unmanageable.
Unfortunately, all too often the health of individuals become unmanaged (starting with lack of self-care), later developing into a state that needs to be continually managed. This continual management requires the intervention of physicians/nurses often as the gatekeepers to technological interventions such as pharmacological services.
Rural communities are often most impacted given the lack of services and the fiscal and geographic requirements to travel for care. This leads into a state of being difficult to manage given the overall cost to manage it and time needed to manage the condition. Inevitability, disease(s) tend to manifest if left unattended into an unmanageable situation.
C – COMORBIDITY (COMPLEXITY)
It is important to understand that a disease-state can include multiple diseases and/or conditions for which the management of these conditions become more complex. As the complexity of management increases, so does the number of specialists that a patient needs to see to manage their care.
Moreover, the management of this care is often coordinated between independent offices for which the times and dates of that care can vary and become even more difficult to manage.
Rural patients can become even more challenged in meeting multiple appointments on differing days given their commute to and from the urban areas in which the complex care is managed.
E – ENVIRONMENT
The environment in which one is raised and educated is often overlooked but should be considered more closely. The utilization of health care services is often related to access to care. However, persons may have grown up where access was not an option, therefore, services were not utilized, as would have otherwise been advised.
Given this, these persons often believe that you only use health care services under the conditions of emergent care (life, limb, or eye sight). Their experiences did not suggest that preventative measures, annual physicals or family health check-ups are necessary to prevent long-term problems.
Many preventable conditions are discovered through regular check-ups and the analysis of blood/urine samples discovered during check-ups. This is dependent on patients both coming to regular check-ups and communicating the symptoms they have experienced.
S – SOCIAL (DETERMINANTS)
Social determinants of health are, according to the World Health Organization (WHO), “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies and politics.”
Income level, educational attainment, race/ethnicity and health literacy all impact the ability of people to access health services and to meet their basic needs. Rural residents are more likely to experience some of the contributing social factors that impact health, such as poverty.
S – SERVICES (HUMAN)
Human services could include safe and affordable housing, income supports, food assistance, job training and other critical services that help the poor and vulnerable rural residents maintain their health and the health of their family members.
Addressing the social determinants of health through the provision of human services has the potential to help control health care costs and attain a more efficient health care system. Ensuring that patients who use the health care system frequently, such as those with chronic conditions, have their other needs met may lessen the stressors that contribute to chronic conditions, reduce the amount of health care resources they require and reduce unnecessary hospital readmissions.
Access to care (direct and indirect) is of national concern for reasons that far exceed simply providing insurance. Several factors influence the type of care a patient receives while this article highlights the correlative factors associated with the efficient and effective management of care.
Population and preventative health focuses on the relationship that should exist and be sustained between the patient and the physician/nurse who manages that care. Education through health literacy is necessary for patients to administer self-care through prevention while physician/nurse-led patient-centered accountability impact the time-sensitive treatment needed throughout the human lifespan.
Those living in rural areas are more likely to be negatively impacted given the long-term effects of mismanaged care and the current transition from transactional health care to population and preventative-based health care systems. Solution-centered dialogue surrounding the complexities of these challenges to include access issues is needed in order to effectively transition from conditions of chronic sickness to a state of physical and mental health wellness.