5
Recommendations

The purpose of this report is to lay a foundation for monitoring access to personal health care services. This effort, which by design has been limited in its focus, should be viewed as a first step toward developing a comprehensive set of national access indicators. Before presenting a compilation of the recommendations dispersed throughout the text, a set of crosscutting recommendations is offered to place the detailed recommendations in context.

RECOMMENDATIONS

Crosscutting Recommendations

The recommendations that follow are intended to improve the state of the art of monitoring, rather than provide explicit guidance on policies for financing medical care or delivering medical services. They arise out of the committee's general review of the indicators, trends in the data, measurement issues, and methodological problems involved in developing an access monitoring system.

State and Local Monitoring

States and local communities would benefit from a national access monitoring process. At the national level, the utilization and outcome indicators selected for this report are intended to be sensitive to the direction and



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Access to Health Care in America 5 Recommendations The purpose of this report is to lay a foundation for monitoring access to personal health care services. This effort, which by design has been limited in its focus, should be viewed as a first step toward developing a comprehensive set of national access indicators. Before presenting a compilation of the recommendations dispersed throughout the text, a set of crosscutting recommendations is offered to place the detailed recommendations in context. RECOMMENDATIONS Crosscutting Recommendations The recommendations that follow are intended to improve the state of the art of monitoring, rather than provide explicit guidance on policies for financing medical care or delivering medical services. They arise out of the committee's general review of the indicators, trends in the data, measurement issues, and methodological problems involved in developing an access monitoring system. State and Local Monitoring States and local communities would benefit from a national access monitoring process. At the national level, the utilization and outcome indicators selected for this report are intended to be sensitive to the direction and

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Access to Health Care in America extent of change in structural, financial, and personal barriers. At the state and local levels, these barriers are increasingly more definable in terms of a specific set of Medicaid benefits, institutional providers, population demographics, and physical features of the environment. (The advantage of proximity is being able to relate changes to more concrete circumstances.) However, local data are often incomplete, and resources may be insufficient to analyze the local data that do exist. The first step in addressing this problem is to identify clearly what data are needed (i.e., develop a monitoring framework) and how the data might be interpreted and then implement a cost-effective strategy for obtaining missing data. The committee has proposed a framework for monitoring access and has analyzed specific indicators, demonstrating how they might be related to barriers. As a first step, in instances in which local data exist, states and localities can compare themselves with the national averages. They can also use additional data (such as those in surveys intended to determine which physicians accept Medicaid) and their general familiarity with the contours of the local health care system to draw conclusions about access problems faced by their vulnerable populations. In addition, an understanding of what can be done with the data will contribute to decisions about whether to invest in new data collection. Understanding the potential payoffs and the extent to which emerging national trends apply to local circumstances will allow communities to determine their needs for data collection. The committee recognizes that constrained state and local public health budgets are likely to limit investment in major new surveys, hospital discharge systems, and cancer registries. To the extent that research and development costs can be borne by the federal government or by private foundations, the cost of implementing enhanced data systems could be reduced for local jurisdictions. The Federal Role Recommendation. The committee recommends that there be a federal organization responsible for monitoring access to personal health care services. This ongoing function should include the central collection, analysis, improvement, and dissemination of information on changes in access. The same organization should be responsible for providing technical assistance and consultation to local organizations that wish to conduct their own analyses of access indicators. This assistance will include activities to encourage improved technical capacity and, where appropriate, to promote consistent definitions and analytic approaches. It was beyond the scope of the IOM committee's charge to identify precisely what entity in the government or private sector should have continuing responsibility for both monitoring access to health care and improving

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Access to Health Care in America the state of the art. However, the committee agreed that overall responsibility should be assigned to the U.S. Department of Health and Human Services. The challenge for the Secretary of Health and Human Services will be to delegate authority to the appropriate agency within the department to ensure an institutionalization of the monitoring function. In the past, the following criteria (DeNeufville, 1975) have been important for successful institutionalization of social indicators throughout the federal government: the agencies that collect and manipulate the data should be respected and not subject to immediate political control, long-term financing and regular production of measures can be depended upon, the data are presented in a nonpolitical context, processes are established and followed for orderly changes in concepts and methods, and institutional arrangements exist to use and analyze the measure in connection with policies. In applying these criteria the Secretary will need to decide whether to use an existing unit or create a new organization. An existing unit has the advantages of a track record and experience in garnering support. The disadvantage is that the monitoring function would compete with established functions for resources and attention. The committee believes that the appropriate locus of responsibility for the access monitoring activity is the federal government. Nevertheless, it recognizes the important role that private foundations can play in stimulating government action and funding research and demonstration activities. Racial and Ethnic Differences Anyone reading this report will be struck by the persistent and in some cases widening disparities between access to health care for blacks and access for whites. Studies of health care access that compare the experience of whites with that of racial and ethnic minorities other than blacks frequently reveal similar disparities. When certain factors, such as insurance status and income, are taken into account, some of the disparities diminish. However, there is a continuing need to oversample minorities in national surveys as well as to conduct specialized surveys focused on them. Recommendation. Because it is not always feasible to improve the accuracy of national data bases in recording the race or ethnicity of patients, it will be necessary to mount studies that better reveal the nature of unexplained access problems for minorities.

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Access to Health Care in America FUTURE STEPS The following lists present specific recommendations of the committee by indicator, together with the groups (e.g., researchers) or bodies (e.g., Public Health Service) to which the recommendation most pertains. Objective 1: Promoting Successful Births Indicator: Prenatal Care Additional research (using revised birth records, among other sources) is needed to determine the relationships among medical risk factors, the content of prenatal care, and birth outcomes. (Researchers) The National Center for Health Statistics should expedite the analysis and release of data from the 1988 National Maternal and Infant Health Survey and the 1990 longitudinal follow-up study. In addition to the potential value of these data in clarifying a range of issues related to the use of health care by pregnant women and infants, they should also be used to validate the accuracy of birth records. (National Center for Health Statistics, Public Health Service, States) The National Center for Health Statistics and the states should consider including income and insurance data or, as an alternative, some indicator of poverty status on birth certificates. (Public Health Service, National Center for Health Statistics, States) Efforts should continue to reach agreement on what constitutes adequate prenatal care and how to measure its provision. (Localities, Public Health Service, Researchers, States) There is a need to enhance the capacity to conduct research on access barriers, such as lack of or inadequate insurance and low-income, and their effects on the use of prenatal care. To this end, the development of automated birth and death records, to facilitate small-area analysis of data, would be helpful. (Localities, Researchers, States) Indicator: Infant Mortality Until income and insurance data are available on birth and death records, efforts should continue to link zip code information on birth records to census income data. (Researchers) Research on how to measure infant mortality in ways that are sensitive to access should continue. The use of disease-specific death rates is one avenue that should be explored. (Researchers) Research should continue on the increasing disparity between black and white infant mortality, with particular focus on the effects of specific barriers. (Researchers)

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Access to Health Care in America Wherever possible, data on Hispanics should be collected and analyzed according to individual ethnic subgroups. (National Center for Health Statistics, Public Health Service, States) Indicator: Low Birthweight Research and data analysis should focus on the large and growing disparity between the incidence of low birthweight and very-low-birthweight infants among blacks and the incidence among other groups. (Researchers) Better data are needed on barriers to access, especially concerning maternal income and insurance status. In the interim it may be possible to use data from the National Maternal and Infant Health Survey or from states that have linked data from Medicaid and birth records. Efforts should also continue to link zip code information on birth records with census income data to allow small-area analyses. (National Center for Health Statistics, Public Health Service, Researchers) The Public Health Service should investigate ways to overcome delays between the collection of data and analysis and dissemination of vital statistics and survey information. (Public Health Service) Research should continue into the differences in birth outcomes between first- and subsequent-generation mothers to gain a better understanding of how culture affects health care. (Researchers) Indicator: Congenital Syphilis To identify the root causes of congenital syphilis, additional research is necessary to investigate how access problems contribute to the large disparities between the incidence of primary and secondary syphilis for whites and that for blacks. (Researchers) Further research is needed into the relationships among drug use, prenatal care, and congenital syphilis. The results of this research may allow interventions to be tailored to those afflicted by these complex social and health problems. (Researchers) Objective 2: Reducing the Incidence of Vaccine-Preventable Childhood Diseases Indicator: Preschool Immunization The federal government should sponsor a school-based immunization reporting system under which schools would report to state health departments when entering students had completed their immunization schedules. The data would be aggregated at the federal level to provide a retrospective

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Access to Health Care in America picture of the proportion of preschool children who are routinely immunized. (Centers for Disease Control, Public Health Service) Periodic supplements to the National Health Interview Survey on the topic of preschool immunization status should be continued, pending implementation of a school-based reporting system. (Centers for Disease Control, Public Health Service) Indicator: Incidence of Vaccine-Preventable Childhood Diseases Hospital admissions data and disease surveillance activities should be used more extensively to monitor outbreaks of infectious diseases. (Centers for Disease Control, Public Health Service, Researchers) Surveillance activities of the Centers for Disease Control should be strengthened, and efforts to encourage local reporting should be increased. (Centers for Disease Control, Public Health Service) Efforts to achieve more uniform and more complete reporting of infectious diseases, particularly among minorities, should be continued. (Centers for Disease Control, Public Health Service, States) Research on the relationships among race, barriers to access, and infectious diseases should be encouraged. (Researchers) Objective 3: Early Detection and Diagnosis of Treatable Diseases Indicator: Breast and Cervical Cancer Screening Procedures Surveys of screening services should explore in-depth why women do not seek screening. In particular, the surveys should assess the importance of access barriers, such as cost and lack of insurance coverage, to suboptimal use of screening. (Researchers) The Behavioral Risk Factor Surveillance Survey should include questions on income, insurance status, and regular source of care. The results of these surveys can be relied upon for analysis when data from prevention or cancer supplements to the National Health Information Survey are not available. (Centers for Disease Control, Public Health Service) Indicator: Incidence of Late-Stage Breast and Cervical Cancers States should be encouraged to include in their cancer registries more information on a patient's socioeconomic and insurance status so that the effects of these barriers on access to care can be analyzed. When these data have been collected, they should be incorporated into the Surveillance, Epidemiology, and End Result (SEER) program of the National Cancer Institute.

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Access to Health Care in America A clearinghouse is needed to compile data from all of the nation's tumor registries. (National Cancer Institute, Public Health Service) In the interim, zip code information from birth certificates and census data on income should be linked to assess the importance of income as an access barrier. (Researchers) Research is needed to determine why improvements in the rates of cancer screening among blacks are not reflected in improvements in early diagnosis, mortality rates, and survival compared with rates for whites. (Researchers) Objective 4: Reducing the Effects of Chronic Diseases and Prolonging Life Indicator: Continuing Care for Chronic Diseases A longitudinal survey of individuals with chronic diseases should be conducted. (National Center for Health Statistics) In the interim the National Health Interview Survey should incorporate questions about access either in its disease-specific supplements or in the core portion of the survey. (National Center for Health Statistics, Public Health Service) Indicator: High-Cost Discretionary Care The reasons some groups fail to use discretionary medical procedures need further attention. Resource barriers, patient and physician attitudes, and over- and underutilization of services need to be taken into account, along with financial barriers, if this indicator is to be correctly interpreted. (Health Care Financing Administration, Researchers) Additional referral-sensitive procedures should be explored to determine whether they might be added to the basic list. (Researchers) Indicator: Avoidable Hospitalization for Chronic Diseases All states should require hospitals to maintain discharge data bases. States should explore the feasibility of incorporating income data and information to help determine severity of illness on the hospital discharge record. (Researchers) Studies are needed on the dynamics of patient care-seeking behavior. These studies should focus on ambulatory-care-sensitive conditions and physician admitting practices. The results of such research would be useful for interpreting differences in admission rates among groups and the relative contributions of various access barriers to delayed or poor-quality care. (Researchers)

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Access to Health Care in America Indicator: Access-Related Excess Mortality The committee has demonstrated the potential of applying risk adjustments to mortality data to better understand the contribution of access problems to premature mortality. Further work is needed to develop models that can produce a more refined measure of access-related mortality. In addition, these models should be used to consider not only blacks but also other relevant population groups, such as other racial/ethnic groups and low-income populations. (Centers for Disease Control, Researchers) Improved models will require better and more up-to-date data on the mortality risks of various populations. In addition to continued epidemiological follow-up surveys, there is a need to determine whether useful information could be extracted from routine surveys, such as the National Health Interview Survey. (National Center for Health Statistics) Objective 5: Reducing Morbidity and Pain through Timely and Appropriate Treatment Indicator: Acute Medical Care The National Center for Health Statistics should explore methods that can be used to improve our understanding of what constitutes timely and appropriate use of physician services during episodes of acute illness. Indicator: Dental Services The National Health Interview Survey's supplements on dental services should gather more detailed information about income- and insurance-related barriers to care. The surveys should also distinguish more fully among the broad classes of procedures performed. (National Center for Health Statistics) Indicator: Avoidable Hospitalization for Acute Conditions Research should focus on factors that lead to the hospitalization of people with acute diseases. Surveys of patients and admitting physicians, both in the emergency room and in inpatient settings, are needed. (Researchers) REFERENCE DeNeufville, J. I. 1975. Social Indicators and Public Policy. New York: Elsevier.