Healey, Bernard, J. Healey, King's College,

Fevzi Akinci, King's College, Richard B. English, Wyoming Valley Family Practice Residency, Anthony Veneziale, King's College,

Dawn Morton, King's College

Politicians at the Federal, State and local level have determined that access to the American health care system is the major health care issue facing our country. New research is finding that access to health care services is not the best predictor of good health.

Insurance coverage alone does not seem to guarantee that an individual will use the health care delivery system. The Comprehensive Health Insurance Program (CHIP) allows access to health services for young children in every state. The recent Kaiser Commission report found that twenty percent of eligible low-income children had not been enrolled in this program. The Department of Health and Human Services reports that $383 million dollars allocated to provide coverage for health insurance coverage for the poor remains unused by the states.

This study attempted to discover why individuals with health insurance decided to not use this coverage for scheduled appointments for themselves and their children. Part one of this study consisted of an analysis of 7,991 patients that missed a scheduled appointment at a Family Practice Residency Program in northeastern Pennsylvania. Then a questionnaire was developed and the medical record was abstracted and entered into a database for analysis.

It is important to note that almost 41 percent of the survey respondents failed to keep their appointments even though they had chosen the date and time for their return visit to the physician. EPSDT and mother-to-be appointments constituted 7.37 percent and 10.84 percent of the missed appointments respectively. Expected out-of pocket expenses appear to be an important factor affecting access to physician services in this study sample. Approximately 33 percent of the patients surveyed reported that their insurance plans have a co-pay or deductible for office visits.

The Family Practice Center has approximately 22,000 visits per year. The Center is designed to offer residents and interns the challenge of practicing medicine in the ambulatory setting--a skill essential to becoming a successful family physician. The Center is only a few minutes away from the Wyoming Valley Health Care System and it is a vital link in the network of regional health resources providing health care to a broad and diverse patient group.

According to Fuchs (1998) the most important problems facing the health care delivery system in this country are costs, access and health levels. Recent changes in the structure and delivery of the U.S. health care system challenge the definition of access. Having access to health insurance coverage and availability of health care providers in a given community have traditionally been the key measures of equitable access with special attention directed to getting into the system and receiving care. Therefore, the key health policy goal has been to increase the insurance coverage and the supply of healthcare providers to reduce financial and geographic barriers to healthcare. Many policies were implemented in the 1950s and 1960s to increase the numbers of physicians, to supply hospital beds in rural communities, and to create federal programs to assure access to health care services at least for the elderly and low-income people through Medicare and Medicaid (Williams & Torrens, 1999). During this time frame, access to health care services was considered an end goal of policy change.

Traditional measures of access may no longer adequate to address all public policy concerns in today’s rapidly changing marketplace. The current health care environment with heavy reliance on managed care demands information on the measures of effectiveness and value of services used, expanding the interest beyond the historical concern over coverage, system entry, and utilization. There is now growing interest in learning how covered benefits and services are defined, how access to them is determined, and more importantly whether the results reflect appropriate and effective use of care and ultimately improve the health of the populations served (Gold, 1998).

The fundamental goal of the U.S. health care system is to provide the mix of health services that will optimize the overall health of the population. The key to achieving this goal is to ensure that each person has access to an adequate level of health care while maintaining a continued commitment to improving the quality of health services provided.

Assuring access to health care, regardless of cause or source of need requires minimizing financial, geographic, and cultural barriers to care, distributing health care resources in a manner acceptable from an impartial point of view, and treating similar health care needs similarly, without regard to the patient's membership in a group or class. However, in the United States, significant barriers to access still exist at both the individual and system level. Shie and Singh (1998) note that one of the key reasons why the U.S., in spite of its tremendous advances in medical technology, trails behind other developed nations in health outcomes achieved is lack of access to basic health care for so many people. Advocating universal health insurance coverage, the authors argue that unless access is improved, it is unlikely that population-based indicators of health will improve.

Andersen’s (1995) behavioral model of health services utilization was the conceptual model that guided our study. The conceptual model presents a systems approach to understanding a population’s access to health care and has been used widely in health services research. According to this theoretical framework, the use of health services depends upon the individual’s predisposing, enabling, and need characteristics, together with health system and external environment factors. Predisposing factors such as age, gender, and race represent biological imperatives suggesting the likelihood that individuals will need health services. Social structural variables such as education and residence and the individual’s beliefs and attitudes about illness and medical care also represent predisposing factors. Enabling variables refer to factors that might either facilitate or impede the use of health services by individuals with a predisposition for utilization. Examples of enabling factors include both personal/family (e.g., income, health insurance, and household size) and community (e.g., urban or rural community and region of residence) resources available to the individual. Andersen (1995) notes that although some predisposing and enabling factors are necessary factors for utilization of health care services, they are not sufficient. Some need (perceived or evaluated) must be defined for use to actually take place. Need is usually found to be the strongest predictor and has been operationalized with a variety of health status measures.

The purpose of this study was to identify the determinants of return physician visits and to discover the reasons for missed return appointments with the physician.

The survey instrument was a questionnaire that contained questions about basic socio-demographic indicators, access problems related to health plan, appointment scheduling issues, type of office visits, mode of transportation, and some other access-related questions. A student intern was assigned to the Family Practice Residency Program of Northeastern Pennsylvania to contact a random sample of 1000 non-compliant patients by telephone. There was a final response of 641 surveys representing 64 percent response rate.

As can be seen from Table 1, approximately 64 percent of the patients surveyed were females with a significant portion being single (67 percent). The mean age of a survey respondent was 26, and almost 72 percent of the survey respondents were less than 36 years of age. Of all survey respondents, 46 percent have completed grades 9-12, and only 9 percent had college degrees.

The results of the analyses indicated that about 31 percent of the respondents failed to keep their re-check/follow-up appointments with their physicians. EPSTD and mother-to-be appointments constituted 5.3 percent and 4.6 percent of the missed appointments respectively. These survey estimates are consistent with the results obtained for the 7991 cases examined in the first part of this study. Of all 7991 patients, 20.44 percent missed their re-check/follow-up appointments. Similarly, EPSTD and mother-to-be appointments constituted 7.37 percent and 10.84 percent of the missed appointments respectively.

It is important to note that almost 41 percent of the survey respondents failed to keep their appointments although they themselves chose the time and date of the office visit. Expected out-of-pocket expenses appear to be an important factor affecting access to physician services in the study sample. Approximately one third (32.7 percent) of the patients surveyed reported that their insurance plans have a co-pay or deductible for office visits. Only a small percentage of the respondents (10.8 percent) needed to arrange childcare around their appointments and only 7.5 percent relied on public transportation to get to their appointments.

It was found by Fuchs (1998) that access to health services falls into two main categories: special and general. The special access problems involve the poor while the general access problems involve the availability of health services where the individual lives. Policy makers are attempting to solve both of these problems by legislating solutions. This study demonstrated that even with access to a physician, many patients do not return to their scheduled follow up appointment. The problem seems to be how to get individuals with guaranteed access to health services to actually use these services. The missing component of access to health care delivery seems to be information concerning the value of visiting one’s physician and not insurance coverage.

Having access to health insurance coverage alone does not predict utilization of services (i.e., realized access). It is important to educate respondents about the value of visiting one’s physician. In order to improve access to physician services in the study population, special attention needs to be devoted to single mothers with their unique access concerns (i.e., limited income, need to arrange child care, opportunity cost of taking time to see a provider, etc.). Patient co-pays and deductibles appear to be a major financial barrier indicated by 33 percent of the respondents. Perhaps, local health plans require relatively high co-payments based on national standards, which imposes a significant barrier because of historically lower wages and salaries in the area.

According to the recent nation-wide surveys conducted by the Center for Studying Health System Change, 13 percent of people with usual source of care changed their providers last year. Over two-thirds of those who changed their usual health care provider did so because of personal preferences, such as the desire to obtain better quality of care (Reed, 2000). It is important, therefore, for the Family Practice Center to assure that missed appointments do not reflect lowered perceived quality of the services by the center patients.

The focus of our health care system must become primary prevention including activities designed to prevent the onset of disease. One of the most important activities would be contact with a physician in order to remain well. In order for patients to become aware of the value of primary prevention they require information about compliance with physician recommendations.

Future research studies should incorporate broader indicators of access (i.e., income, type of health insurance, employment, race, lack of coverage or unapproved services, difficulty with obtaining referrals, difficulty with the length of time waiting to get the first scheduled visit, etc). This research should also measure the effectiveness of access (immediate or ultimate improvement in key health outcome indicators, such as mortality, morbidity, life-expectancy, functional status, and satisfaction).

Andersen, R.M. (1995). "Revisiting the Behavioral Model and Access to Medical Care: Does It Matter?" Journal of Health and Social Behavior, 36(March): 1-10.

Fuchs. (1998). Who Shall Live? Health, Economics, and Social Choice. World Scientific: New Jersey.

Gold, M. (1998). "Synopsis and Priorities for Future Efforts." Health Services Research, 33(3): 611-621.

Reed, M.C. (2000). "Why People Change Their Health Care Providers." Center for Studying Health System Change Data Bulletin, 16(May): 1-2.

Shie, L., and Singh, D.A. (1998). Delivering Health Care in America, A System Approach. Aspen Publishers, Inc.: Gaithersburg, Maryland.

Williams, S.J. and Torrens, P.R. (1999). Introduction to Health Services. Fifth Edition, Delmar Publishers: Albany, New York.