Meeting Patients on Their Own Terms

    • September 1, 2011

Although improving access to health care has long been equated with making it more affordable, a new study finds that more U.S. adults postpone or go without medical care for nonfinancial reasons than for financial reasons.

Addressing those nonfinancial barriers—such as inability to find a primary care physician, or limited office hours—will be key to realizing the promise of the federal health reform, says lead author Jeffrey T. Kullgren, M.D., M.S., M.P.H.

“Our study shows that access problems are much more complicated and widespread than just being able to afford care,” says Kullgren, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2009-2012) at the Philadelphia VA Medical Center and the University of Pennsylvania. “The nonfinancial barriers are so common that we really need to take them on, to make sure the national investment in health care reform actually translates into improvements in access.”

The idea for the study grew in part out of Kullgren’s work as a primary care physician at the Philadelphia VA Medical Center. “For many patients there, affordability issues loom large,” he says. “But many patients also have nonfinancial reasons they can’t get the health care they need when they need it. They may live a great distance from the doctor, and traveling is a challenge. They may work jobs that make it hard to go to a doctor’s office during a normal business day, where leaving work would mean they wouldn’t get paid or might risk losing their job.”

In the study, Kullgren and colleagues analyzed data from the 2007 Health Tracking Household Survey, a national telephone survey conducted by the Center for Studying Health System Change with funding from RWJF. The survey asked whether a respondent had postponed or had not gotten needed medical care in the previous 12 months and, if so, for what reasons. Researchers separated more than 15,000 responses into financial reasons (affordability) and nonfinancial reasons, and then grouped the nonfinancial reasons under four dimensions:

  • Accommodation—whether health care services (including office hours, appointment systems and phone consultations) are organized in ways that fit patients’ lives;
  • Availability—whether the volume of services and resources (including clinicians and facilities) is sufficient to meet patient demand;
  • Accessibility—whether patients can reach health care services using available transportation resources and within reasonable travel times and distances; and
  • Acceptability—whether patients are comfortable with the location of facilities and the characteristics of clinicians, such as cultural background, gender, and race/ethnicity.

While 18.5 percent of respondents said affordability issues had caused them to delay or forego needed care, 21 percent said they had delayed or gone without needed care for nonfinancial reasons. “With my primary care physician hat on, I knew those barriers existed, but it was surprising to me to learn that they existed even more often than the financial barriers,” Kullgren says. And because the survey only captured barriers that led to unmet need or delayed care, the findings “may well be an understatement” of how often these barriers impede access to care today, he says.

Nonfinancial barriers often overlapped with financial ones, Kullgren found: Two-thirds of adults who said affordability was a barrier to care also cited nonfinancial barriers, especially in terms of accommodation and availability of care. The study found that some nonfinancial barriers disproportionately burdened certain population groups. For example, accommodation barriers were reported more by women than by men and more by parents than by adults without children, while Blacks reported more accessibility barriers than Whites.

Kullgren said the study also found nonfinancial barriers particularly affected three population groups that stand to benefit most from reform: young adults, who can stay on their parents’ health insurance until age 26; lower-income adults, who may get Medicaid coverage or subsidies for health insurance premiums starting in 2014; and people with chronic conditions, who may benefit from new consumer insurance protections. Unless policy-makers take additional steps to address nonfinancial barriers facing these and other groups, Kullgren says, these barriers may limit how much health reform actually improves access to care.

Policy-makers and health care system leaders “need to really think critically about how we can reorient our health care system to better respond to people’s constraints, to meet patients on their terms,” Kullgren adds. For example, he says, accommodation issues—the most common nonfinancial barrier for U.S. adults—could be lessened by new care models such as patient-centered medical homes and on-site workplace clinics. But they also could be addressed more simply and immediately by expanding night and weekend hours for patient visits, and using technology instead of in-person visits to connect patients with providers where feasible. “At a time when there’s a lot of discussion about the size and role of government,” Kullgren says, “it’s important to note that lessening these kinds of barriers doesn’t have to mean more government intervention or spending, it may in some cases mean reorganizing existing services.”

Kullgren says other nonfinancial barriers could be reduced by incentivizing providers to enter specialties where there are shortages, by expanding telemedicine and transportation services for patients who live far from providers, and by requiring health plans that participate in state health care exchanges to take their own steps to insure an adequate supply of accessible, acceptable providers.

Because Kullgren designed the study and ran the analysis on existing data, the project required no separate research funding. It did require Kullgren to take dedicated time away from patient care, which he said was possible through the support of the U.S. Department of Veterans Affairs and RWJF. “As an organization, RWJF has been really on the front lines of trying to improve access to care in this country,” Kullgren says. “Their support of work like this study is critical to making sure people are able to get the care they need at the time they need it.”

The study, “Nonfinancial Barriers and Access to Care for US Adults," was published online in August in Health Services Research. Co-authors with Kullgren are Catherine G. McLaughlin, Ph.D.; Nandita Mitra, Ph.D.; and Katrina Armstrong, M.D., M.S.C.E.