1 Access to Quality Health Services

Access to quality care is important to eliminate health disparities and increase the quality and years of healthy life for all persons in the United States. This chapter focuses on four components of the health care system: clinical preventive care, primary care, emergency services, and long-term and rehabilitative care. Together with health care delivered by specialists and care received in hospital settings, these elements represent major components of the continuum of care. The public health system is important in each of these areas because it educates people about prevention and addresses the need to eliminate disparities by easing access to preventive services for people less able to use existing health services. It ensures the availability of primary care through direct funding of clinics and providers or by providing public insurance. It coordinates emergency services systems and oversees long-term and rehabilitative care. Tertiary services (for example, hospital and specialty care) currently are not included among the Healthy People 2010 objectives. The Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research, is working in conjunction with the Centers for Disease Control and Prevention (CDC) and other agencies of the U.S. Department of Health and Human Services to develop a National Report on Healthcare Quality, which will report annually on a broader array of quality measures that will complement Healthy People 2010.

Issues

Access to high-quality health care across each of the components in the continuum of care must be improved to realize the full potential of prevention. For example, success in reducing the burden of heart disease and narrowing the gap in heart disease outcomes between different racial groups will depend on several factors. These factors include ensuring access to clinical preventive services, such as blood pressure and cholesterol screening; effective primary care to educate people about modifiable risk factors, such as smoking, and to manage effectively chronic conditions like hypertension; high-quality emergency services to improve outcomes of acute cardiac events; and access to rehabilitative and long-term care for heart disease patients.

Major changes in the structure of the U.S. health care system, including the increasing influence of market forces, changes in payment and delivery systems, and welfare reform, have significant implications for vulnerable and at-risk populations. In light of these systems changes, Federal, State, and local public health agencies must redouble their efforts to address access barriers and reduce disparities for these populations. It is increasingly important that health care communication and services be provided in a culturally and linguistically sensitive manner. Adequate access to health care and related services can increase appropriate patient use of the health care system and, ultimately, improve health outcomes. Consequently, measures of access across a continuum of care are an important way to evaluate the quality of the Nation’s health care system.

Clinical preventive care. Clinical preventive services have a substantial impact on many of the leading causes of disease and death. People must have access to clinical preventive services that are effective in preventing disease (primary prevention) or in detecting asymptomatic disease or risk factors at early, treatable stages (secondary prevention). As in Healthy People 2000, the recommendations of the U.S. Preventive Services Task Force [1] serve as a guide to quality preventive health care. The task force was reconvened in 1998 and, in conjunction with AHRQ’s Evidence-Based Practice Centers (EPCs), will provide additional information regarding the effectiveness and cost-effectiveness of individual clinical preventive services.

Improving access to appropriate preventive care requires addressing many barriers, including those that involve the patient, provider, and system of care.[2], [3] Patient barriers include lack of knowledge, skepticism about the effectiveness of prevention, lack of a usual source of primary care, and lack of money to pay for preventive care. Although patient awareness and acceptance of some interventions are high (such as screening for breast cancer) other interventions (for example, colorectal cancer screening and sexually transmitted disease [STD] screening) are less uniformly accepted. A small but significant number of patients remain skeptical of even widely accepted preventive measures, such as immunizations. Having health insurance, a high income, and a primary care provider are strong predictors that a person will receive appropriate preventive care. Although reimbursement for common screening tests, such as mammograms and Pap tests, is provided by most health insurance plans (and is required by law in some States), reimbursement for effective counseling interventions, such as smoking cessation, is less common.[4]

Health provider barriers include limited time, lack of training in prevention, lack of perceived effectiveness of selected preventive services, and practice environments that fail to facilitate prevention. Although consensus is growing regarding the value of a range of preventive services, providers identify lack of time and reimbursement as specific barriers to more consistent delivery of counseling about behavioral risk factors such as diet and exercise.[5] Computerized or manual tracking systems, patient and clinician reminders, guidelines, and patient information materials can help providers improve delivery of necessary preventive care.[6]

System barriers can include lack of resources or attention devoted to prevention, lack of coverage or inadequate reimbursement for services, and lack of systems to track the quality of care.3 Systems interventions that can increase delivery of health care include offering clinical preventive services among standard covered benefits, providing feedback on performance to providers and practices, offering incentives for improved performance, and developing and implementing systems to identify and provide outreach to patients in need of services.2

Measuring and reporting how well preventive care is provided under different systems are essential first steps in motivating those systems that are not performing well to develop the information, tools, and incentives to improve care.[7] Significant progress in the delivery of clinical preventive services (CPS) is unlikely without appropriate data systems to allow providers and administrators to identify those services and populations most in need of better delivery. To be effective, preventive care also must be linked to systems to ensure appropriate followup services or counseling for patients identified through risk assessment or screening. Comprehensive national data to track what systems of care are doing to monitor and improve the delivery of CPS will not be available in the first half of the decade. Thus, this issue is not addressed in this focus area’s objectives but represents an important agenda for research and data collection for the coming decade.

Primary care. Improving primary care across the Nation depends in part on ensuring that people have a usual source of care. Having a primary care provider as the usual source of care is especially important because of the beneficial attributes of primary care. These benefits include the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.[8] Increasing the number and proportion of members of underrepresented racial and ethnic groups who are primary care providers also is important because they are more likely to practice in areas where health services are in short supply and in areas with high percentages of underrepresented racial and ethnic populations.

Emergency services. Prehospital emergency medical services (EMS), poison control centers (PCCs), and hospital-based emergency departments (EDs) are the most commonly sought sources of emergency care. Each year, they provide prompt first-contact care for millions of people regardless of their socioeconomic status, age, or special need. For many severely ill and injured persons, these settings are a crucial link in the chain of survival between the onset of symptoms and treatment in a hospital. For persons whose health problems are less pressing but who believe they need urgent medical attention, emergency services are a gateway to additional health care.

In addition to their central role in secondary and tertiary prevention, emergency services are increasingly contributing to primary prevention by providing immunizations and other preventive care in association with treatment for acute health problems.

Within the current health care delivery system, EDs are the only institutional providers required by Federal law to evaluate anyone seeking care.[9] They are expected at least to stabilize the most severely ill and injured patients, and they provide walk-in care for vast numbers of persons who face financial or other barriers to receiving care elsewhere.

Long-term care and rehabilitative services. People with physical or mental conditions that limit their capacity for self-care need long-term care and rehabilitative services. This population covers persons of all ages, from those who were born with physical or mental limitations or who developed such limitations later on in life, including those injured at any age, to those with diminishing functioning at older ages.[10] About 40 percent of the people in this population are under age 65 years.[11] The long-term care population includes individuals who need help or supervision to perform activities of daily living or instrumental activities of daily living.

The goals of long-term care services are to improve functioning, maintain existing functioning, or slow deterioration in functioning while delivering care in the least restrictive environment. Rehabilitative services, a critical component of long-term care, strive to return individuals to their optimal level of functioning. People in the long-term care population need access to a range of services, including nursing home care, home health care, adult day care, assisted living, and hospice care.

Trends

A significant measure of the access problem is the proportion of people who have health insurance. Following declines in the proportion of people with health insurance during the 1980s, the proportion has remained essentially level, at about 85 percent from 1989 to 1997 for persons under age 65 years.[12] Approximately 44.3 million persons lacked health insurance in 1998,[13] continuing an increase in the number of uninsured persons. At the same time, the proportion of adults with a usual source of care—an important predictor of access to needed services—fell from 83 percent to 78 percent between 1987 and 1992 before rising to 85 percent in 1998.[14] Although the lack of health insurance is clearly a major factor impeding access to care, having health insurance does not guarantee that health care will be accessible or affordable. Significant numbers of privately insured persons lack a usual source of care or report delays or difficulties in accessing needed care due to affordability or insurance problems.[15]

As a result of growing scientific evidence on the effectiveness of certain preventive services, 82 percent of employer-sponsored insurance plans include childhood immunizations, and 90 percent include Pap tests and mammograms. Nonetheless, gaps persist in coverage for effective preventive services, especially counseling.4

Concerns increasingly are focused on access to quality emergency services, long-term care, and rehabilitative services. Although emergency services are widely available in the United States, the range of services varies in accessibility and quality from region to region and, often, from neighborhood to neighborhood, raising additional concerns about care for vulnerable underserved populations. As the proportion of older people in the total U.S. population increases, the demand for quality long-term care services and facilities also will increase. Quality rehabilitative care needs are evident across all populations, and access to rehabilitative care is a significant problem for people who lack health insurance or who are underinsured and are unable to pay for the type and quality of health care they need.

During the 1990s and into the 21st century, increased attention has been paid at all levels of government as well as by the private sector to improving health care quality. The National Committee for Quality Assurance (NCQA), a managed care accreditation group, led a collaborative effort to develop the Health Plan Employer Data and Information Set (HEDIS), a widely used tool for evaluating health plan performance.[16] The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) also has developed performance measures. AHRQ has developed the Consumer Assessment of Health Plans Survey (CAHPS), an instrument to assess consumer experiences with health plans. AHRQ also has developed the Healthcare Cost and Utilization Project (HCUP), which makes available State and nationwide estimates of hospital use. These data can be used with the HCUP Quality Indicators to provide measures of ambulatory-care sensitive conditions, which can uncover potential problems in access to primary care services. Quality monitoring systems tend to emphasize measures that focus on delivery rates for clinical preventive services because access to and use of these services are an important indicator of the quality of health care providers and of delivery systems. The complementary National Report on Healthcare Quality will explore methods for integrating the data from these quality-monitoring systems with population-based data collected by the public sector.

The Federal Advisory Commission on Consumer Protection and Quality in the Health Care Industry was established in 1997 to study changes occurring in the health care system and recommend ways to ensure consumer protection and quality health care. The Commission’s report[17] provides a foundation for the emerging issues of the next decade in monitoring and reporting on quality of health care. It also includes a “Consumer Bill of Rights and Responsibilities,”[18] which is designed to strengthen consumer confidence in the health care system while holding participants in the system accountable for improving quality.

One essential step to improving quality is to reduce errors. The Institute of Medicine issued a report in December 1999 documenting the magnitude of medical errors in U.S. hospitals. The report recommended strategies to reduce such errors, including better reporting of errors.[19]

Disparities

Limitations in access to care extend beyond basic causes, such as a shortage of health care providers or a lack of facilities. Individuals also may lack a usual source of care or may face other barriers to receiving services, such as financial barriers (having no health insurance or being underinsured), structural barriers (no facilities or health care professionals nearby), and personal barriers (sexual orientation, cultural differences, language differences, not knowing what to do, or environmental challenges for people with disabilities). Patients with disabilities may face additional barriers arising from facilities that are not physically accessible or from the attitudes of clinicians. Hispanics, young adults, and uninsured persons are least likely to have a usual source of care.12 Hispanic persons and those with less than 12 years of education are least likely to have a usual primary care provider.[20] Certain people, such as those who are disabled, elderly, chronically ill, or HIV-infected, require access to health care providers who have the knowledge and skills to address their special needs.[21]

Substantial disparities remain in health insurance coverage for certain populations. Among the nonelderly population, approximately 33 percent of Hispanic persons lacked coverage in 1998, a rate that is more than double the national average. Mexican Americans had one of the highest uninsured rates at 40 percent. For adults under age 65 years, 34 percent of those below the poverty level were uninsured. Similar disparities exist in access to a specific source of ongoing care. An average of 85 percent of adults identified a specific source of ongoing care in 1998, but the proportions dropped to 76 percent for Hispanics and 77 percent for those below the poverty level.12

Opportunities

Increasing recognition of the critical role of preventive services across the continuum of care and the need for providers to incorporate preventive services into patient visits has led to the development of tools and projects designed to help providers and patients shift to a prevention-oriented health care system. HEDIS reports on the delivery of many clinical preventive services provided by participating health maintenance organizations (HMOs). The 1999 reporting set for HEDIS contained several measures of clinical preventive services, including childhood immunizations, adolescent immunizations, smoking cessation advice, influenza vaccinations for older adults, breast cancer screening, cervical cancer screening, and prenatal care in the first trimester. A CDC grant to the State of Massachusetts for a health assessment partnership has resulted in a collaborative effort in New England to increase HMO participation in HEDIS. The specific tools developed include the increased use of electronic birth certificates, which have assisted outreach programs to teach new mothers the value of periodic checkups for their infants.

One of the earliest and most recognized tool kits is the Clinician’s Handbook of Preventive Services,6 developed as part of the Put Prevention Into Practice initiative by the Office of Disease Prevention and Health Promotion and now the responsibility of AHRQ. It was produced as a companion to Healthy People 2000 and the U.S. Preventive Services Task Force Guide to Clinical Preventive Services.1 Under development is the CDC Guide to Community Preventive Services, due to be released in 2001.[22] The guide will assess the effectiveness of preventive services and interventions in community settings and at the clinical systems level. It will cover 15 topics in three areas: changing risk behaviors, such as eliminating tobacco use and increasing physical activity; reducing specific diseases and injuries, such as cancer and injuries from motor vehicle crashes; and addressing environmental challenges, such as changing the sociocultural environment.

Continued progress in the delivery of clinical preventive services will require better collection and reporting of data on the delivery of recommended services by providers and health plans. This information will allow providers and administrators to identify the services and groups of people where the biggest gaps exist in receiving needed health care services. The best information systems allow both cross-sectional comparisons of performance by providers, plans, systems, and localities as well as long-term analyses of the health and health care of individuals. These systems can facilitate interventions such as reminders for patients and providers, audit, and feedback, which have been shown to improve rates of immunization and screening.[23], [24]

In centralized health systems with stable populations (people who stay with one provider or health plan, for example), tracking of individuals has been used effectively for a limited number of services, primarily immunizations and cancer screenings. Expanding effective data collection efforts to cover additional services and to include more providers and health care systems is the current challenge. Measuring how well preventive care is provided under different systems is an essential first step in motivating those systems that are not performing well to develop the information, tools, and incentives to improve care.

Into the next decade, Healthy People and its partners will continue to promote communitywide efforts to provide clinical preventive services, using local leadership and insights to tailor and increase the accessibility of these services. Efforts will continue to promote the development of local prevention coalitions that include health departments, businesses, community institutions, and individuals from each community. Healthy People also will work to strengthen the capacity of States and localities to collect health data and conduct community health assessments for small geographic areas.

Advances in the use of genetic information may improve both clinical and preventive care by helping to identify high-risk individuals and populations who will benefit most from preventive services and other clinical interventions. It will be essential to develop policies that will ensure appropriate evaluation of new genetic services, quality assurance of available genetic technology, and access to genetic services of proven benefit.

Overcoming technological, financial, or organizational barriers that can slow or block access to emergency services and improving emergency care accessibility and quality will require the combined effort of health care providers, health plans, and health care consumers as well as government agencies at the Federal, Tribal, State, and local levels.

Interim Progress Toward Year 2000 Objectives

The proportion of adults under age 65 years without health care coverage has remained essentially the same, while the total number of uninsured persons has continued to increase. The proportion of the adult population with a specific source of primary care has increased, although Hispanic and African American adults and other subgroups continue to be less likely to have a specific source of primary care. Compared to 1991 and 1992 baseline data, the proportion of adults in 1995 who received selected recommended clinical preventive services (including tetanus boosters and routine mammograms) has increased. Progress also has been made in improving racial and ethnic representation in the health professions.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

Healthy People 2010 Objectives

Clinical Preventive Care

Baseline: 83 percent of persons under age 65 years were covered by health insurance in 1997 (age adjusted to the year 2000 standard population).

Persons Under Age 65 Years, 1997	Health Insurance
Persons Under Age 65 Years, 1997	Percent
TOTAL	83
Race and ethnicity
American Indian or Alaska Native	62
Asian or Pacific Islander	81
Asian	81
Native Hawaiian and other Pacific Islander	80
Black or African American	80
White	84

Hispanic or Latino	66
Cuban	79
Mexican American	61
Puerto Rican	81
Not Hispanic or Latino	85
Black or African American	80
White	86
Gender
Female	84
Male	81
Family income level
Poor	66
Near Poor	69
Middle/high income	91
Geographic location
Within MSA	83
Outside MSA	80
Disability status
Persons with disabilities	83
Persons without disabilities	83
Sexual orientation	DNC
Select populations
Age groups
10 to 24 years	DNA
10 to 14 years	DNA
15 to 19 years	DNA
20 to 24 years	DNA

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
MSA = Metropolitan statistical area.
Note: Age adjusted to the year 2000 standard population.

Access to health services—including preventive care, primary care, and tertiary care—often depends on whether a person has health insurance.[25], [26], [27] Uninsured people are less than half as likely as people with health insurance to have a primary care provider; to have received appropriate preventive care, such as recent mammograms or Pap tests; or to have had any recent medical visits. Lack of insurance also affects access to care for relatively serious medical conditions. Evidence suggests that lack of insurance over an extended period significantly increases the risk of premature death and that death rates among hospitalized patients without health insurance are significantly higher than among patients with insurance.[28] As demonstrated by a study of data from the National Health Interview Survey (NHIS), Medicaid expansions that increase the proportion of a State’s population eligible for Medicaid lead to increases in enrollment, enhanced utilization of medical services, and lower child death rates.[29] Another study showed that, among those without insurance, chronically ill persons are even less likely than those with acute conditions to get health care services they need.[30]

Insurance coverage for clinical preventive services improved substantially during the 1990s, but significant variations remain in the services covered, depending on the plan and type of insurance. In 1988, among employers who offer health insurance, only 26 percent of their employees were covered for adult physical examinations, 35 percent for well-child care (including immunizations), and 43 percent for preventive screening tests.[31] In contrast, a 1997 national survey of over 3,000 employers found that 88 percent of employer-sponsored plans covered well-baby care, 89 percent covered adult physical examinations, 92 percent covered gynecologic examinations, and 89 and 91 percent covered Pap tests and mammograms, respectively. Coverage was highest in HMO plans and lowest in indemnity insurance plans.4

Including effective clinical preventive services among the services routinely covered by insurance is an effective way to emphasize the importance of clinical preventive services as an integral part of health care.[32] The Balanced Budget Act of 1997 (Public Law 105-33) added colorectal cancer screening among other new preventive benefits under the Medicare program and expanded Medicare coverage of mammography and cervical cancer screening. Although health insurance coverage by itself is not sufficient to eliminate existing gaps in the delivery of preventive services, it is an important factor influencing who gets recommended services.[33], [34]

Selected clinical preventive services have a positive influence on personal health, and many are cost-effective in comparison with the treatment of disease.1, [35] Insurance coverage is especially problematic for counseling services, in part, because of the difficulty in proving the benefits of some counseling interventions. For example, only 22 percent of employer-sponsored plans cover medications or counseling for smoking cessation.4 The effectiveness of smoking cessation counseling, however, is supported by strong evidence, with more intensive interventions having the greatest impact and most favorable cost-effectiveness ratios.[36]

Data sources: National Survey on Family Growth (NSFG), CDC, NCHS; National Health Interview Survey (NHIS), CDC, NCHS.

Females Aged 15 to 44 Years With a Physician Visit in the Past Year, 1995	1-3f. Counseled About Unintended Pregnancy
	Percent
TOTAL	19
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	24
White	19

Hispanic or Latino	20
Not Hispanic or Latino	DNA
Black or African American	24
White	19
Education level (females aged 22 to 44 years)
Less than high school	15
High school graduate	20
At least some college	19
Sexual orientation	DNC
Select populations
Age groups
15 to 24 years	22
25 to 34 years	23
35 to 44 years	10

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Substantial gaps remain in the delivery of appropriate screening and counseling services related to health behaviors. Unhealthy diets, smoking, physical inactivity, and alcohol use account for a majority of preventable deaths in the United States.[37] Data indicate that risk assessment and counseling interventions are delivered less frequently than other preventive interventions (for example, cancer screenings).12 In addition, the attention physicians give to specific health-risk behaviors appears to be influenced by the socioeconomic status of their patients.[38] Although time is an important constraint in the primary care setting, evidence demonstrates that brief clinician counseling is effective in getting patients to stop smoking and reduce problem drinking.1, [39] In addition, more intensive dietary counseling can lead to reduced dietary fat and cholesterol intake and increased fruit and vegetable consumption.1 Effective primary care-based interventions to increase physical activity among patients have been more difficult to identify.1, [40]

Some evidence shows that provider counseling can increase the use of seat belts, child safety seats,and bicyclehelmets, especially when directed to parents of infants and young children.1 Brief counseling interventions aimed at high-risk individuals can increase condom use and prevent the spread of sexually transmitted diseases.[41]

Clinician counseling should be tailored to the individual risk factors, needs, preferences, and abilities of each patient.1 For some preventive interventions, such as hormone therapy in postmenopausal women, the optimal strategy depends on how individual women value potential benefits and risks. Counseling of perimenopausal and postmenopausal women should encourage shared decisionmaking based on individual risk factors and patient preferences.1

Primary Care


1-4.		Increase the proportion of persons who have a specific source of ongoing care.

Target and baseline:

Objective	Increase in Persons With Specific Source of Ongoing Care	1998 Baseline*	2010 Target
Objective	Increase in Persons With Specific Source of Ongoing Care	Percent
1-4a.	All ages	87	96
1-4b.	Children and youth aged 17 years and under	93	97
1-4c.	Adults aged 18 years and older	85	96

*Age adjusted to the year 2000 standard population.

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

Population by Age Group, 1998 (unless noted)	Specific Source of Ongoing Care
	1-4a. All Ages	1-4b. Aged 17 Years and Under	1-4c. Aged 18 Years and Older
	Percent
TOTAL	87	93	85
Race and ethnicity
American Indian or Alaska Native	82	89	79
Asian or Pacific Islander	84	89	81
Asian	84	89	82
Native Hawaiian and other Pacific Islander	83	90	82
Black or African American	86	91	84
White	88	95	86

Hispanic or Latino	79	86	76
Cuban	86	95	82
Mexican American	75	83	72
Puerto Rican	86	90	85
Not Hispanic or Latino	89	95	87
Black or African American	86	91	85
White	89	96	87
Gender
Female	91	93	90
Male	84	94	81
Family income level
Poor	80	88	77
Near Poor	82	90	79
Middle/high income	91	97	88
Geographic location
Urban	87	93	85
Rural	89

Number	Objective Short Title
Clinical Preventive Care
1-1	Persons with health insurance
1-2	Health insurance coverage for clinical preventive services
1-3	Counseling about health behaviors
Primary Care
1-4	Source of ongoing care
1-5	Usual primary care provider
1-6	Difficulties or delays in obtaining needed health care
1-7	Core competencies in health provider training
1-8	Racial and ethnic representation in health professions
1-9	Hospitalization for ambulatory-care-sensitive conditions
Emergency Services
1-10	Delay or difficulty in getting emergency care
1-11	Rapid prehospital emergency care
1-12	Single toll-free number for poison control centers
1-13	Trauma care systems
1-14	Special needs of children
Long-Term Care and Rehabilitative Services
1-15	Long-term care services
1-16	Pressure ulcers among nursing home residents

Objective	Increase in Counseling on Health Behaviors Among Persons at Risk With a Physician Visit in the Past Year	1995 Baseline	2010 Target
		Percent
1-3a.	Physical activity or exercise (adults aged 18 years and older)	Developmental
1-3b.	Diet and nutrition (adults aged 18 years and older)	Developmental
1-3c.	Smoking cessation (adult smokers aged 18 years and older)	Developmental
1-3d.	Reduced alcohol consumption (adults aged 18 years and older with excessive alcohol consumption)	Developmental
1-3e.	Childhood injury prevention: vehicle restraints and bicycle helmets (children aged 17 years and under)	Developmental
1-3f.	Unintended pregnancy (females aged 15 to 44 years)	19	50
1-3g.	Prevention of sexually transmitted diseases (males aged 15 to 49 years; females aged 15 to 44 years)	Developmental
1-3h.	Management of menopause (females aged 46 to 56 years)	Developmental

Access to Quality Health Services

Goal

Overview