Economic Accessibilty to Healthcare: Is it an Issue in our Publicly-Funded Health System?

Jeannie Haggerty, PhDSt. Mary’s Research Centre

McGill Research Chair in Family & Community Medicine at St. Mary’s

Accessibility in Canada

Commonwealth and Statistics Canada surveys indicate that healthcare accessibility has declined in Canada

We now rank lowest among peer countries for primary care accessibility

Improving accessibility has been a major policy focus in Canada; focus on wait times.

Economic accessibility is off the radar

Canada Health Act

National principles for public health care insurance plans to qualify for full federal cash transfers for health

Public administration, universality, comprehensiveness, portability, accessibility

Accessibility: Insured persons must have reasonable and uniform access to services, free of financial and other barriers.

Accessibility: Definition Characteristics of health systems that

impede or promote the utilisation of services (Donabedian).

Characteristics of geographic availability, organisational processes, costs and acceptability that facilitate people’s capacity to reach and use services (Thomas & Penchansky) Geographic accessibility Organisatonal accessibility Economic accessibility Cultural accessibility

Economic accessibility

The extent to which direct and indirect costs represent barriers for people to reach and use health services that they need.

Accessibility: core attribute of primary health care First Contact Accessibility: The ease with which a

person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem

Accessibility-accommodation: The way primary healthcare resources are organized to accommodate a wide range of patients’ abilities to contact healthcare providers and reach healthcare services (telephone services, flexible appointment systems, hours of operation, and walk-in periods).

Accessibility: a counter-intuitive finding

2002 multilevel survey of primary health care practice, Quebec

100 sites, randomly selected: data from clinics, physicians, patients

Stratified geographically: metropolitan, suburban, rural, remote

Stratified by pratice type: community health clinic, group clinics, solo practice

Haggerty, Pineault, Gauthier et al, Multi-level PHC survey, 2002-2004, CHSRF funded

Accessibility: a counter-intuitive finding

Patient-reported accessibility improves with increasing rurality First contact – higher confidence in being

seen within one day Accommodation – better ratings of

location, opening hours, wait times, ability to speak to doctor by phone

Yet: longer distances, fewer local alternatives, restricted physician availability.

Explanatory hypotheses: A programme of research

The way rural services are organized makes them more accessible Types of organizational models Professional practices

Measurement artefact Expectations are lower in rural areas Tools not sensitive to rural barriers

Haggerty & Gauthier et al, Accessibility to healtcare for rural and remote communities, 2004-2009, CHSRF funded

Rural-Urban Measures of Accessibility: Objectives

To identify factors in rural areas that facilitate or impede initiation of first-contact care, ongoing primary care, and follow up of referrals to secondary care

To develop and validate additional measurement items of primary and secondary accessibility that are not addressed in existing questionnaires.

Haggerty, Levesque, Roberge. Accessibility Measures, 2005-2010, CHSRF funded

Rural-Urban Measures of Accessibility

Sequential mixed-method study1. Qualitative exploration of urban and

rural care-seeking trajectories2. Development and quantitative

validation of new measures3. Two administrations of measures to

random sample from urban and rural locations

Qualitative exploration of access barriers and facilitators in rural and urban contexts :Phase 1, 2004, Qualitative study

To identify factors in rural areas that facilitate or impede initiation of first-contact care, follow up of referrals to secondary care, and ongoing primary care

Qualitative exploration Focus groups Geographic contexts: two types of urban,

two types of rural Metropolitan (4), towns (2) Rural agricultural (2), scattered villages (3)

Interview schedule: focus on typical care trajectory and responses to barriers; probing for geographic, accommodation, cost and cultural elements

Results:

Major barriers/facilitators to access in typical care-seeking trajectory1. Regular source of care 2. Organizational accommodation3. Geographic access4. Personal resources (economic,

educational)

Consequences of barriers to care

Why is observed accessibiliy better in rural areas?

Social networks in rural areas result in better organizational accommodation and flexibility compared to urban areas

Long wait for appointment is the norm, as is individual accommodation

BUT: processes are not formalized, so not everyone has equal access.

Socio-economic status affects organizational and geographic access

Organizational Accommodation:

Information about the options  Role of practice secretary: assess urgency, suggest

care alternatives, give health advice, facilitate Personal information agency : individual’s capacity to

obtain information by own means; independent facilitator for access

Organizational flexibility Secretary accommodates individual requests to make

shorter waits for care: squeeze in between appointments, telephone consultation

Social network matters

Geographic accessibility: getting to care

Expressed in travel time and local availability of alternatives

Perception of distance as a barrier depends on: Personal mobility Personal access to transportation Type of problem Acceptability of provider Other opportunity costs

Not usually an issue in rural areas – except for those with few personal resources

Conclusion:

Low socio-economic status as generic barrier to health services (social exclusion) Low personal information agency Lack of personal transport makes

geographic distance a barrier Restricted social network reduces

organizational accommodation Indirect and direct costs impede care

Conclusion

Persons at risk of social exclusion are also at risk of poor accessibility

In Canada, little exploration of economic barriers to access

Development and quantitative validation of new measures:

To develop and validate additional measurement items of geographic, organizational and economic accessibility that are not addressed in existing questionnaires.

Explore the prevalence of economic barriers to care

Development of new measures Codes for barriers or facilitators from

qualitative analysis developed into quantitative « items »

Consequences, indicators of problem access: nuissance, emergency room, unmet needs, problem aggravation

Telephone administration to 750 respondents in metropolitan rural (Longueuil), agricultural (Montérégie), and remote areas (Côte-Nord)

Validation: analysis Exclusion of bad items (>5% missing, no

variation). Exploratory factor analysis to identify

constructs and sub-scales Predictive modelling against consequences:

nuissance, unmet needs, emergency room use, problem deterioration

Item response modelling to identify discriminatory capacity of items and differential item functioning by rural-urban

Quantitative component: test of new subscales, new instrument

Refinements made in light of analysis and new cognitive testing

Self-administered format Mailed to 368 of previous respondents

who accepted to be contacted (86% responded)

Results Accessibility Measure

Indicators of problem access

Can be divided into minor (nuissance) and major problems

Provide a good portrait of health care accessibility Nuissance Use of emergency room for system

reasons Unmet needs for care Problem aggravation due to delay

Organizational accommodation: Description New items (more discriminating for rural)

Ease of getting information to solve health problems Ease of contacting the clinic by phone Ease of getting medical advice by phone Ease of getting shorter-than-usual wait for appointment for

urgent care Available structures for rapid care Rating of usual wait for appointment Ease of talking to doctor by phone

Each unit increase in accessibility associated with decreased likelihood of Nuissance (OR=0.47) Unmet needs (OR=0.34) Problem aggravation (OR=0.40)

Effect stronger in rural areas

Geographic accessibility: Description 5-items

Perceived proximity of clinic Ease of getting there for urgent care and for routine

care, Travel time Number of local alternatives

Distance to clinic cited as reason for ER use (6%) and unmet need (10%)

Each unit increase in accessibility, decreased likelihood of : Nuissance (OR=0.42) Unmet need (OR=0.44)

Effects stronger in the poor

Prevalence of Economic Barriers

Payment for services (labs, exams or not covered by public insurance 20%

Usually have revenue loss when getting healthcare 22%

Usually have significant indirect costs when getting healthcare 24%

Economic accessibility:

Frequency cost-related unmet needs or difficulty (% ever among all vs. low-income) Don’t take prescribed meds Don’t do lab tests or exams Don’t get uninsured services Difficulty from income loss Difficuty from indirect costs

Items scored dichotomously (never vs. ever) and summed to indicate number of problems (range 0 to 5)

Economic Accessibility: Each unit increase in reported cost problem

(poor economic accessibility) associated with increased likelihood of: Nuissance: OR=1.8 (1.5 in poor) ER use: OR=1.9 (2.4 in poor) Unmet neet: OR=2.8 (3.3 in poor) Problem aggravation: OR=3.4 (5.9 in poor)

Examination of economic accessibility in an independent sample

Cohort of approximately 2500 adults in four Quebec local health networks, 2010.Compare poor and non-poor

Haggerty & Fortin, At the interface of the community and the Health system, 2008-2013, CIHR

Measure of self-perceived financial status

What word best describes your current financial situation

Very comfortable Comfortable Tight Very tight Poor

« poor »Bottom 25%

Health Status of poor vs. Non-poor

Poor Non-poor

Number of chronic illnesses 3.5 2.5

3+ chronic illness 56% 44%

Functional health status

Physical component 44 49

Mental component 45 50

Prevalence of cost related unmet needs: poor vs non-poor

Experienced difficulties in access because of costs

Poor Non-poor

Don’t take prescribed meds 18% 5%

Don’t do lab tests or exams 10% 4%

Don’t get uninsured services 25% 13%

Difficulty from income loss 21% 8%

Difficulty from indirect costs

13% 3%

80% of poor report at least one vs. 20% of non-poor

Indicators of problem access: Nuissance

Did you have to make several attempts to get the healthcare you needed?

But poor experienced lower organizational accessibility.

Poor Non-poor

Never 39% 47%

Rarely 47% 43%

Sometimes/often 14% 10%

Indicators of problem access: Use of Emergency room in last year

32% overall 16% for system-related reasons only

20% poor vs. 15% non-poor Top reasons (rank order)

No family physician or own not available Clinic not open when I could go Difficult to get appointment or wait too

long To get tests or see specialist within

reasonable time

Indicators of problem access:Unmet needs for care

Needed healthcare but didn’t get it 21% overall

17% poor vs 14% non-poor

Top reasons (rank order) Wait for appointment too long Difficult to make appointment Regular doctor or clinic not available Clinic hours not convenient

Indicators of problem access:Problem aggravation

Health problem became more serious because it took a long time to get healthcare

9% overall 15% poor vs. 7% non-poor

30% with at least one major access problem (ER use, unmet need, problem aggravation) 37% poor vs. 28% non-poor

Findings are coherent with other studies Commonwealth Survey 2001

Difficulty getting care off-hours, 19% poor vs. 13% non-poor

Difficulty seeing specialist 20% poor vs. 15% non-poor

Did not fill a prescription 22% poor vs. 7% nonpoor

Did not get needed dental 42% poor vs. 15% non-poor

Situation may be better in Quebec for some issues

Conclusion Accessibility to healthcare has

declined in Canada Our study confirms this

Policy focus is on organizational accessibility

BUT important inequities in access persist The poor get systematically poorer

access to health services

Accessibility: the Canada Health Act

In Quebec’s public insurance system, poor people face more financial, geographic and organizational barriers to getting timely services despite having greater health needs

We are not achieving uniform access to services as per the Canada Health Act

Liberalization of the CHA framework unfairly affects the poor

Conclusion and Implication

Economic accessibility IS an issue in our publicly-funded system

To make this a policy focus, we need to shake the myth that we have solved the problem of economic accessibility for necessary medical services in Canada

We need to evaluate the performance of the system in how well it does for those with limited ability to advocate for themselves