A Shared Destiny Community Effects of Uninsurance (2003) / Chapter Skim
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3 Community Effects on Access to Care
3 Community Effects on Access to Care
Pages 82-119
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From page 82... ...
This may further strain the capacities of already overcrowded hospital emergency departments, and physicians' offices or even hospitals may be relocated away from areas of town or entire communities that have concentrations of uninsured persons. Such disruptions may reduce people's access to care and the quality of care they receive, regardless of their insurance status.
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From page 83... ...
ACCESS TO CARE Finding: Persons with low to moderate incomes (less than 250 percent of the federal poverty level) , nearly one-third of whom are uninsured, and uninsured persons have worse access to health care services in communities with high uninsured rates than they do in communities with lower rates.
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From page 84... ...
The authors examine measures of health care access including forgone or delayed care, no physician visit within the year, and having a regular source of care, as a function of uninsured rate (Brown et al., 2000, data for 1997~. Residents ofthe 12 MSAs with 1This analysis was unadjusted for the many individual and community-level covariates of uninsured rate.
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From page 85... ...
While analytically adjusting for measures of community demand for care (percentage in poverty, uninsured rate, and percentage enrolled in Medicaid) did not change the odds that low-income children and adults would have seen a physician in the past year, taking into account differences in a community's financial and structural capacity to deliver care (e.g., higher per capita income, lower unemployment, greater income inequality, number of public hospital beds per thousand population, number of community health centers per thousand population, lower degree of managed care penetration)
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From page 86... ...
These services are provided in diverse settings, ranging from general primary care and specialized health department clinics (e.g., immunization, family planning) , private physician offices, community health centers, hospital outpatient and emergency departments, and dedicated hospital primary care outpatient clinics (Donaldson et al., 1996~.
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From page 87... ...
See Box 3.2 for case studies of uninsurance and primary care in two of the country's largest urban areas. Shortages of physicians in rural and urban areas with relatively high uninsured rates can mean less access to primary care for all residents.
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From page 90... ...
Community Health Centers and Clinics Finding: Serving a high or increasing number of uninsured persons reduces a community health center's capacity to provide ambulatory care to all of its clients, insured as well as uninsured. By mission, community health centers (CHCs)
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From page 91... ...
Between 1980 and 2000, inflation-adjusted federal grant support for CHCs actually dropped 30 percent, even as the number of centers increased 22 percent and the number of uninsured patients served by CHCs grew by 54 percent (Markus et al., 2002~. As a result, changes in the Medicaid program both influence uninsured rates and affect the capacity of CHCs to serve all of the members of their target community.
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From page 92... ...
EMERGENCY MEDICAL SERVICES AND TRAUMA CARE Finding: Although hospital emergency department (ED) overcrowding is not primarily a consequence of uninsurance within a community, rising uninsured rates can worsen ED overcrowding and the
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From page 93... ...
The following sections discuss the hypothesized community effects on emergency medical services and trauma care for all members of a community with a sizable or growing uninsured population. Hospital Emergency Departments Hospital emergency medical services often do not, and frequently are not, expected to make a positive contribution to a hospital's overall financial margins, particularly as hospital accounting practices do not credit patient revenues from persons admitted through the emergency department, as some 40 to 60 percent of all admissions are (Bonnie et al., 1999~.
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From page 94... ...
patients (Malone and Dohan, 2000~. In many urban and rural areas, hospital emergency departments are often filled beyond capacity.
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From page 95... ...
In the late 1980s and early 1990s, the rising number of uninsured persons was clearly identified as contributing to the overcrowding of hospital emergency departments (Melnick et al., 1989; USGAO, 1993; McManus, 2001~. Their growing numbers resulted in diminished access to emergency medical services, at least at large urban teaching hospitals.
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From page 96... ...
Emergency department physicians and other personnel are thus caught between professional ethical standards and ideals of excellence and institutional pressures to minimize uncompensated care expenses. A financially unstable ED may even put its affiliated hospital in danger of closing (Malone and Dohan, 2000~.
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From page 97... ...
When a hospital cannot summon an appropriate on-call specialist, the emergency department is forced to transfer the patient needing specialty care to another facility, adding to the cost of care, delaying needed care, and potentially leading to needless suffering, disability, or even death. For example, in Phoenix, Arizona, which has a 17 percent uninsured rate (2001)
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From page 98... ...
When an individual hospital responds to ED overcrowding by diverting ambulances to other hospitals, it can trigger a wave of ED closures and ambulance diversions. When this occurs, the access to emergency medical care for all community residents is adversely affected.
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From page 99... ...
SPECIALTY CARE Finding: Relatively high uninsured rates are associated with the lessened availability of on-call specialty services to hospital emergency departments, and the decreased ability of primary care providers to obtain specialty referrals for patients who are members of medically underserved groups. Evidence about the relationship between uninsured rate and access to specialty services other than emergency medical care is limited.
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From page 100... ...
For example, while community health centers may have relationships with hospitals in the community that enable them to make specialty referrals for uninsured patients more easily than physicians in private practice, referrals may not come easily. In a study of access to care at 20 CHCs in 10 states, respondent providers reported that they had difficulty obtaining specialty referrals for all their patients, not only those who were uninsured (Fairbrother et al., 2002~.
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From page 101... ...
For private AHCs, particularly those that are not located in neighborhoods with high uninsured rates (e.g., central city) , one strategic response of hospitals to such cost pressures has been to eliminate specialty services with relatively poor rates of reimbursement, such as burn units, trauma care, pediatric and neonatal intensive care, emergency psychiatric inpatient services, and HIV/AIDS (Gaskin, 1999; Commonwealth Fund, 2001~.
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From page 102... ...
New Analysis of Hospital Services and Financial Margins Finding: Higher uninsured rates in urban areas are associated with lesser total inpatient capacity and fewer population-adjusted medical-surgical, psychiatric, and alcohol and chemical dependence beds. In rural areas, higher uninsured rates are associated with a lower number of population-adjusted intensive care unit (ICU)
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From page 103... ...
In comparison, hospitals in rural areas with relatively high uninsured rates are more likely to maintain inpatient capacity and services provision but to have lower financial margins. The Committee commissioned two analyses of hospital services and financial margins as a function of local uninsured rates, which are included in Appendix D
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From page 104... ...
, using hospital discharge data to approximate uninsured rates at the county level (Needleman and Gaskin, 2002~. Five types of dependent variables were chosen, to better understand the potential relationship between community uninsured rate and access to care not only for medically underserved, low-income or vulnerable populations but also for all community residents.
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From page 105... ...
the analysis to take into account hospital size changes some of these findings, yielding an association of higher uninsured rates with greater availability of neonatal intensive care units (NICUs) and angioplasty and erasing the association with financial margin.
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From page 106... ...
. For the rural analysis, services measures are weighted by the percentage of hospitals offering the service.
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From page 107... ...
COMMUNITY EFFECTS ONACCESS TO CARE endent 107 Rural (County) 2 Unweighted Weighted S.D.
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From page 108... ...
Inpatient Capacity (beds per 100,000 population) Total -2.67 -4.5 Medical—surgical —2.00 - 6 .1 ICU Psychiatric -0.61 -17.5 Alcohol and chemical dependence -0.19 -25.8 Services for Vulnerable Populations Psychiatric inpatient -1 .10 -14.
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From page 109... ...
. For the rural analysis, inpatient capacity is weighted by average county population and services by the percentage of hospitals offering the services.
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From page 110... ...
. renect the greater relative need tor neonatal intensive care in commumtles with higher uninsured rates, the fact that this need is usually accompanied by eligibility for public coverage, and the more extensive coverage of pregnant women and 1 1 1 1 - 0 1 0 newborns by public insurance programs, compared with public coverage of the population overall (Howell, 2001; IOM, 2002b)
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From page 111... ...
For the rural counties studied, higher uninsured rates are associated with lower inpatient capacity for ICU services and, where uninsured patients are not concentrated at specific hospitals, psychiatric inpatient services. A 4.4 percentagepoint higher uninsured rate (one standard deviation above the mean percent uninsured discharges of 4.4 percent for the 426 nonmetropolitan county observations)
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From page 112... ...
The hospital-level model indicates how the average individual hospital may respond to increased demand for hospital care from uninsured persons as measured by the MSA-wide uninsured rate. However, it is unlikely that the overall market response to uninsurance is merely the weighted average of individual hospital responses in the market.
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From page 113... ...
However, in rural counties where uninsured patients are relatively more concentrated in one or a few hospitals than is the county population overall, hospital margins both in the aggregate and by hospital are less affected by rural or county uninsured rates than those in counties where uninsured patients are more widely dispersed among local hospitals (Needleman and Gaskin, 2002~.7 7This finding may be weakened by the fact that many rural counties have only one hospital, especially in western states. Alternatively, if a county has more than one hospital, the concentration of uninsured patients in a single facility may be associated with that hospital having an external source of funding to care for uninsured persons.
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From page 114... ...
A hospital's decision to convert its ownership status may be motivated by the need for funds to continue operating, either independently or as one of a group of hospitals, or by the need to raise capital (Meyer et al., 1999; Needleman, 1999~. Local uninsured rates and the burden of uncompensated care costs to local and state government contributed to the conversions of three large urban public hospitals in Milwaukee, Wisconsin, Boston, Massachusetts, and Hillsborough County, Florida to private ownership during the 1990s (Bovbjerg et al., 2000b)
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From page 115... ...
The heterogeneity from community to community in the degree of concentration or dispersion of safety net arrangements is described briefly in Chapter 2. The relative influence of greater or lesser dispersion of uninsured patients on uninsured rate is hinted at in the Committee's commissioned papers and is likely to depend on the local configuration of health .
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From page 116... ...
Existing studies of the relationship between community uninsurance (state or MSA uninsured rate) and access to care offer preliminary evidence that, particularly for low- to moderate-income and uninsured populations, higher local uninsured rates are associated with worse access to care.
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From page 117... ...
3.3 Access to Specialty Care, Including Emergency Medical Services How does the local uninsured rate affect the availability of specialty services, including emergency medical services and trauma care for the community's insured as well as uninsured residents? The legal duty of hospital EDs and trauma units to screen and medically stabilize all patients regardless of ability to pay is one source of financial stress on hospitals.
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From page 118... ...
For example, findings for rural areas that the concentration of uninsured patients may lessen the size of the effect of local uninsured rate on inpatient capacity, services, and margins of all hospitals in the county, on average, suggests that such concentration of uncompensated care caseload among a few providers may be beneficial to the health care system as a whole. On the other hand, concentrating all care for uninsured persons in one facility, such as a county hospital, may both limit access to care, compared with more dispersed safety net arrangements, and lead to poor quality of care.
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From page 119... ...
Based on the evidence developed in this chapter, the Committee concludes that moderate- to lower-income residents of communities with higher uninsured rates are more likely than all residents to experience adverse spillover effects of uninsurance. The findings of the Committee's commissioned analyses, while preliminary, indicate that residents with moderate or higher incomes may also be at risk for diminished access to care.
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