|Healthcare ACCESS and Reform
Christina Cruz Dominguez
Steven Dominguez, MD, MPH
The major issues facing health care reform today are availability of resources,
finances, perceived and evaluated needs, demand, and market forces. Access plays
a pivotal role in each of these factors.
Access and the availability of resources are not synonymous. Availability of
resources is a subset of access. Availability of resources questions whether the
health manpower and technology are limited; whereas access questions global
issues. For instance, one may not have the personal finances, transportation, or the
“correct” medical problem to access needed medical services although medical care is
Personal finances questions whether the individual either is too poor to afford care
in an outpatient or inpatient setting or has a managed care plan that dictates when
and where they will receive medical services. For example, the self-employed
businessperson may not be able to afford to seek and obtain private medical
attention may either employ home remedies and cure his ailment, or present to an
emergency department and be admitted to the hospital with pneumonia. Likewise
the child who is denied the ability to see a physician for a sore throat in the
afternoon (HMO) presents to the emergency department in the middle of the night
and is intubated and admitted to the intensive care unit for epiglotitis.
Transportation is a major problem of access for the poor, the elderly, working
families, and inner city and rural families. Transportation problems are compounded
during inclement weather and times of natural or civil disaster. For example, having a
pediatric clinic one block from ones home that is open from nine to five weekdays
does not allow access if the working parent in a one car family works from eight to
Availability to a physician does not imply access to attain the demand for either the
perceived or evaluated need. For instance, a patient presenting with chest pain may
believe they are suffering a heart attack (perceived need), whereas the physician
diagnoses a dissecting thoracic aneurysm (evaluated need), however there are no
thoracic surgeons immediately available and the patient dies.
Finances is a broad term that encompasses personal, private and public moneys
allocated for health care resources. Inherent in this realm is the issue of access.
Access to medical services, ancillary services, pharmaceuticals and technology, and
the need for each is the current economic question. The current political debate
centers on the private (employer) and public financing of a basic benefit plan for
every US citizen, with personal financing of augmented benefits. This plan is
designed to provide increased access and uniformity in basic benefits while
controlling costs. Will this plan level the scales of inequity or further promulgate the
two tier system in terms of access, quality, and availability of cutting edge technology?
Perceived and evaluated need, and potential access are intertwined with both
mutable and immutable predisposing and enabling factors. For example, immutable
demographic and social variables such as age, gender, race/ethnicity, education and
occupation in conjunction with mutable beliefs about health (values, attitudes, and
knowledge) , mutable enabling factors (individual and community), and mutable need
for health services allows an estimation of the access and availability. For example,
an elderly white male farmer in Iowa may not consider plastic surgery for his
squamous cell carcinoma a necessity, whereas a single black male in Chicago may
demand plastic surgery for a minimally deviated septum. Thus health policy, planning
and implementation are based on the mutable factors that inherently are liable to
change through change in policies regarding organization and financing.
Demand is the consumption of health care services. Realized access utilizes demand
data to achieve understanding of the process and use of services and care, with
health outcomes as the endpoint prior to beginning the health policy cycle again. For
example, health policy initiates a direct health outcome or indirectly via potential
access by the individual or the system to produce a health outcome that will then
produce more health care policy, thus beginning the cycle again.
Market forces are the ying and yang of economic decisions in the health care field.
Market forces include the number and type of medical and ancillary services in a given
locality, hard and software technology available, patient payer mix, switching costs to
the patient, physician and society either real or inflated by lobbyists, and need and
Access is dependent on and a function of market forces in a weighted summation
fashion. For example, demand is dependent on need and is may be created or
increased by the supplier (physician/hospital); technology is dependent on need and
demand, switching costs, payer remuneration, and health care services; patient
payer mix determines the type and level of health care services, technology, and
demand; and switching costs are dependent on need, demand, remuneration, and
the type of medical and ancillary services available.
The problem of access in relation to cost and quality is enormous. The real problem
is how do you achieve equitable access, high quality and control costs at the same
time? No one advocates that any of the above three be sacrificed, i.e. low quality,
low cost and full access. But reality will prevail and there will be sacrifices.
Editor's Note: I see this problem as a pyramid, with each angle representing access,
cost, and quality respectively. The acuteness of a particular angle depends on stress
imposed by the other two. I believe that if we must sacrifice a factor, let that factor be
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