Access to Health Care in America (1993) / Chapter Skim
Currently Skimming:
Appendix A: Developing Indicators of Access to Care: The Case for HIV Disease
Appendix A: Developing Indicators of Access to Care: The Case for HIV Disease
Pages 145-180
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 147... ...
projections are that as many as 153,000 persons were living with AIDS at the end of 1991 and that approximately 1 million persons are infected with the human immunodeficiency virus (HIV; CDC, 1991~. Cumulatively, 275,000 cases of AIDS will have been reported by the end of 1991.
|
From page 148... ...
. Because of both the rapid impoverishment of formerly employed persons who lose their private health insurance and the increasing prevalence of AIDS among the previously poor and uninsured, urban municipal and not-for-profit hospitals are disproportionately paying the price of the AIDS epidemic (Andrulis, 1989; Baily et al., 1990; Green and Arno, 19901.
|
From page 149... ...
Further conceptualization of these issues is required before specific indicators of reduced access can be suggested with any confidence. Following the model proposed by the IOM Committee for Monitoring Access to Personal Health Services in Chapter 2, this paper reviews the issues and existing knowledge about the presence of barriers to access to health services that confront persons with HIV disease.
|
From page 150... ...
ISSUES IN ASSESSING ACCESS TO PERSONAL HEALTH CARE Equitable access to health care services has been a major focus of health services research in the United States for four decades (Ginzberg, 19901. Research in the past two decades has emphasized factors associated with the rising costs of health care; now, as a result of growth in the number of uninsured over the past decade, access to care has once again emerged as a central topic in health services research.
|
From page 151... ...
No data are available to estimate the proportion of formerly employed persons with HIV disease who are paying their own health insurance premiums. There is also a dearth of data by which to quantify the rate at which loss of private insurance occurs following either onset of symptoms or formal AIDS diagnosis.
|
From page 152... ...
Access to personal health care services appears to be strongly linked to the availability of private insurance coverage. Zucconi and her colleagues surveyed HIV-positive men and found that the number of reported physician visits was strongly associated with being insured (Zucconi et al., 19891.
|
From page 153... ...
In contrast, nearly half of all outpatient visits by AIDS patients to private hospitals were covered by Medicaid in virtually all regions. Public hospitals, particularly in the South and West, were much more likely than private hospitals to incur "bad debt" or to use local financing to offer free outpatient clinic care to AIDS patients.
|
From page 154... ...
Expanding home services as a substitute for more expensive inpatient care is almost always the rationale. This means that publicly insured persons with AIDS in waivered states will have access to a broader, more diverse array of health care services than will be the case for all but the most fortunate patients with private insurance.
|
From page 155... ...
hospitals and asked them to estimate their n.~ nor inpatient dav and ner outpatient visit for treating AIDS patients. Across all regions, both public and private hospitals reported losing from $4 per patient day among private hospitals in the South to $386 per day among southern public hospitals.
|
From page 156... ...
Nursing homes have not played a prominent role in meeting the health and social service needs of AIDS patients in most communities in the United States. Only 4 of 47 skilled nursing facilities surveyed in Oregon in 1989 had served an AIDS patient (White and Berger, 19911.
|
From page 157... ...
or nursing homes, are to be paid a substantially higher rate than facilities serving other nursing home patients, both because they entail a new class of licensed facility and to encourage providers to offer this service for AIDS patients. Presumably, this effort will reduce the access barriers facing those with advanced HIV disease in New York.
|
From page 158... ...
Another example is the transformation in West Palm Beach County of hospital districts with their own taxing authorities into a countywide "health district" with spending authority to cover not only hospital care but home and community care as well. Although the referendum covered all aspects of health care for the poor and uninsured (there are no public hospitals in the county)
|
From page 159... ...
Structural Barriers Structural barriers to access to the personal health care system have traditionally included lack of a primary source of care, lack of appropriate service providers in one's area, distance from providers, and extended waiting time for providers. In each case, these structural barriers theoretically detract from the patient's ability and willingness to obtain, and then adhere to, appropriate medical care.
|
From page 160... ...
(However, few data are available concerning the relative proportion of persons with HIV disease served by hospital clinics, compared with private physicians' offices.) Among 408 respondents to the RWJF AHSP evaluation who were clients of a community-based social service agency, only 38 percent reported that their usual source of care was a private physician or health maintenance organizations, whereas 44 percent named the clinic at the local public hospital.
|
From page 161... ...
Indeed, being treated in multiple care settings may be more burdensome for the private patient, particularly as this inevitably involves travel from one location to another and not just shifting from clinic to clinic in the hospital. Using a public hospital clinic rather than a private physician as a regular source of care does not necessarily signify poorer quality or less continuity.
|
From page 162... ...
Data from the survey of RWJF AHSP participants whose regular source of care was the public hospital clinic revealed that 11 percent also saw a private physician and 9 percent reported a clinic visit to a different hospital. Among those with a private physician as their usual source of care, 16 percent reported also using the public hospital clinic.
|
From page 163... ...
Anecdotal evidence from conversations with staff from public hospitals and community-based organizations suggests that in most communities, only a handful of physicians are willing to treat HIV patients. In 1985, one-half of the physicians not specializing in radiology or pathology who responded to the AMA socioeconomic monitoring system survey reported that they had treated at least one HIV-positive patient.
|
From page 164... ...
Holmberg and colleagues (1990) found that as many as half of all AIDS patients were not receiving aerosolized pentamidine when it was the therapy of choice.
|
From page 165... ...
The RWJF evaluation survey found that among persons served by the public hospital clinic, whites, those with more education, and non-drug users reported more frequent clinic visits in the past three months than the average patient, even after controlling for disease advance, symptom severity, functional status, and living arrangements (Mor et al., 19921. The opposite set of relationships was observed when the dependent variable was the likelihood of using an emergency room; use was more likely among minorities, women, and drug users.
|
From page 166... ...
Attitudinal Barriers The attitudes of providers can influence patient access to the personal health care system. This statement applies to primary care medicine, specialty medical or surgical care, dental care, hospital care, nursing home, and home health aide care.
|
From page 167... ...
Yet even after exposure to a training program, one-third of medical students and twothirds of dental students said that they did not want to select a specialty that would bring them into contact with a high percentage of AIDS patients during their training. The authors suggest that these anxieties may influence the career choices of such students.
|
From page 168... ...
Compared with the large number of attitudinal studies, relatively little research addresses institutional policies regarding the treatment of AIDS patients. The major medical societies have explicit policy statements on the responsibility of physicians to treat patients with HIV disease (AMA Council on Ethical and Judicial Affairs, 1988; Emanuel, 19881.
|
From page 169... ...
Most felt that specialized facilities, such as those being fostered in New York, were the most appropriate setting for these patients. Administrators expressed concerns about possibly losing both staff and current residents if AIDS patients were admitted.
|
From page 170... ...
In addition, anecdotal evidence points to considerable out-of-state travel, particularly from states that have aggressive partner notification programs, to secure even greater anonymity in testing. Moreover, estimates of the at-risk population, whether gay men or intravenous drug users, are notoriously inaccurate; this means that the denomina
|
From page 171... ...
By using linked hospital discharge abstract record systems such as exist in New York, it is possible to identify an individual's first HIV-related hospitalization. By applying a disease staging system, the rate of presentation with advanced HIV disease at first hospitalization can be determined.
|
From page 172... ...
These rates can be derived from special statewide merged data sets such as the HIV Information System in Maryland, which links health department AIDS reporting information with Medicaid and Blue Cross/Blue Shield claims (including pharmaceuticals) and with hospital discharge abstracts (Hidalgo, 19901.
|
From page 173... ...
Intravenous drug users, for instance, may have compromised their health before being exposed to HIV. In addition, transmission by contaminated needles, rather than sexually, may be much more efficient at spreading the virus within an organism.
|
From page 174... ...
Those AIDS patients who die at home could be compared on the basis of gender, age, race, and geographic area as an indicator of the availability and use of home health and out-ofhospital services.
|
From page 175... ...
demonstrated that policies on hospices have affected the site of death of Medicare beneficiaries dying of cancer; the study used Medicare claims merged with death certificates. Some evidence suggests that AIDS patients also would prefer to die at home (Teno et al., 1992~.
|
From page 176... ...
1987b. State Medicaid policies and hospital care for AIDS patients.
|
From page 177... ...
1990. Improved short term survival of AIDS patients initially diagnosed with Pneumocystic carinii pneumonia.
|
From page 178... ...
1989. Willingness to provide care to AIDS patients in Ohio nursing homes.
|
From page 179... ...
1992. AIDS patients' preferences for communitybased care.
|
From page 180... ...
1991. Response of hospitals, skilled nursing facilities and home health agencies in Oregon to AIDS: Reports of nursing executives.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.