Availability of safety net providers and access to care of uninsured persons

OBJECTIVE: To understand how proximity to safety net clinics and hospitals affects a variety of measures of access to care and service use by uninsured persons. DATA SOURCES: The 1998-1999 Community Tracking Study household survey, administered primarily by telephone survey to households in 60 randomly selected communities, linked to data on community health centers, other free clinics, and safety net hospitals. STUDY DESIGN: Instrumental variable estimation of multivariate regression models of several measures of access to care (having a usual source of care, unmet or delayed medical care needs, ambulatory service use, and overnight hospital stays) against endogenous measures of distances to the nearest community health center and safety net hospital, controlling for characteristics of uninsured persons and other area characteristics that are related to access to care. The models are estimated with data from a nationally representative sample of uninsured people. PRINCIPAL FINDINGS: Shorter distances to the nearest safety net providers increase access to care for uninsured persons. Failure to account for the endogeneity of distance to safety net providers on access to care generally leads to finding little or no safety net effects on access. CONCLUSIONS: Closer proximity to the safety net increases access to care for uninsured persons. However, the improvements in access to care are relatively small compared with similar measures of access to care for insured persons. Modest expansion of the safety net is unlikely to provide a full substitute for insurance coverage expansions.     

Formation of patients' opinion regarding their satisfaction with hospital care

The study was carried out with the help of adapted questionnaire of WHO Regional Office for Europe by interviewing 516 adult residents of a big city. The role and place of ethiopsychological, deontological and organizational factors were determined in the formation of one of the components of end results--the degree of patient's satisfaction. The advisability of using interview surveys of population as one of the criteria in the organization of medical care to the population is emphasized.     

Strengthening the free care safety net

For many of the estimated 43 million people in this country who have no health insurance, free care is often the only health care available. With competition forcing hospitals to cut costs, consumer advocates face new challenges as they seek to ensure that free care remains available to all who need it. This issue of States of Health explores the problems facing both consumers who rely on free care and those who provide that care. It highlights what some advocates and communities are doing to address those concerns.     

State efforts to measure the health care safety net

This article describes the role states could play in a national effort to measure and monitor the public health safety net. The authors developed a data collection framework using information from five states on two components of the safety net: structure and demand. Because states are the primary vehicle for access expansions and programs to care for the poor, the authors suggest that they be the primary coordinating mechanism for data collection on the safety net. Because the necessary mechanisms for more uniform standards or criteria to evaluate state data collection activities and capacity remain undeveloped, they recommend using existing data to begin building state capacity to measure and monitor the safety net.     

Forty-eight hour access to primary care: practice factors predicting patients' perceptions

BACKGROUND: The government has proposed a 48-hour target for GP availability. Although many practices are moving towards delivering that goal, recent national patient surveys have reported a deterioration in patients' reports of doctor availability. What practice factors contribute to patients' perceptions of doctor availability? METHOD: A cross sectional patient survey (11,000 patients from 54 inner London practices, 7247 (66%) respondents) using the General Practice Assessment Survey. We asked patients how soon they could be seen in their practice following non-urgent consultation requests and related their aggregated responses to the characteristics of their practice. RESULTS: Three factors relating to practice administration and appointments systems operation independently predicted patients' reports of doctor availability. These were the proportion of patients asked to attend the surgery and wait to be seen, the proportion of patients seen using an emergency surgery arrangement, and the extent of practice computerization. CONCLUSION: Some practices may have difficulty in meeting the target for GP availability. Meeting the target will involve careful review of practice administrative procedures.     

Re-engineering the public hospital system: saving the safety net.

Cities across America are grappling with the problem of how to provide care for the indigent and those on Medicaid. All levels of government are reducing their public funding for health care of indigent persons, and the rapid growth of managed care is making traditional cost-shifting more difficult as it transforms the practice of medicine itself. These issues are most acute in cities like Los Angeles and New York, which traditionally have relied on public hospital systems to serve as a safety net. This article focuses on the changes being wrought at the largest health-care system in the country for indigents, the New York City Health and Hospitals Corporation (HHC), on the progress it made during the first 18 months of a major re-engineering process, and on potential options for its future reform.     

Using NAMCS to characterize the urban health care safety net

PURPOSE: Data from the National Ambulatory Medical Care Survey (NAMCS) have been used to describe many facets of ambulatory care, but have been underutilized in their application to the urban health care safety net. Our interest was in comparing the visit characteristics of inner city primary care practices in New York City with those of the rest of the country. METHODS: Data were collected in 15 primary care centers affiliated with the New York City Research & Improvement Networking Group (NYC RING), a practice-based research network. Physicians completed the cross-sectional survey after patient visits using a slightly augmented version of the standard NAMCS form. Results were then compared with a subset of the Centers for Disease Control and Prevention's public-use dataset for the 2002 NAMCS, selecting only visits to primary care providers and practices in metropolitan statistical areas (N=8,598). Variables of primary interest were visit lengths and diagnoses, adjusting for age and sex. RESULTS: Physicians in NYC RING collected data on 1,861 encounters. Compared with the national sample, our clinicians see 140% more diabetes visits, 70% more hypertension, and 90% more asthma, and provide 88% more dermatologic care and over 300% more reproductive health services. Visits were, on average, one minute longer in our inner city practices (p<.05), and were generally longer across all diagnosis categories than in the national sample. CONCLUSIONS: The prevalence of metabolic syndrome and environmentally-related conditions and the provision of more than average specialty care characterize safety net care in New York City.     

Geriatric patients' expectations of their physicians: findings from a tertiary care hospital in Pakistan

Background  

Geriatric health is a neglected and under-explored area internationally and in Pakistan. We aimed to ascertain the expectations of the geriatric patients from their physicians and the factors associated with patient satisfaction in this particular age bracket.     

Public housing relocations in Atlanta,Georgia, and declines in spatial access to safety net primary care

This analysis investigates changes in spatial access to safety-net primary care in a sample of US public housing residents relocating via the HOPE VI initiative from public housing complexes to voucher-subsidized rental units; substance misusers were oversampled. We used gravity-based models to measure spatial access to care, and used mixed models to assess pre-/post-relocation changes in access. Half the sample experienced declines in spatial access of ≥79.83%; declines did not vary by substance misuse status. Results suggest that future public housing relocation initiatives should partner with relocaters, particularly those in poor health, to help them find housing near safety-net clinics.     

Factors related to patients' satisfaction with their medical care

Patient satisfaction has become a frequently researched outcome measure of the quality of health-care delivery. This article reviews research of patient satisfaction after recent, identifiable medical care visits. Results of the reviewed studies are grouped into 13 factors of the medical care setting and of the physicians' competence and relationships to their patients which may be related to patient satisfaction. The factors with the clearest relationship to satisfaction include the accessibility of medical care, the organizational structure of clinics, treatment length, perceived competence of physicians, clarity and retention of physicians' communication to patients, physicians' affiliative behavior, physicians' control, and patients' expectations. Other factors with more complicated or no apparent relationship to satisfaction were mode of payment, clarity of patients' communication to physicians, physicians' personality, patients' sociodemographic characteristics, and patients' health status. The additive and potential interactive effects of these factors are discussed. Additional studies of the interactive aspects of the physician-patient raltionship are encouraged, and implications for further research are presented, with emphasis on sampling, measurement, and design issues.     

U.S. medical students' attitudes about patients' access to care

OBJECTIVE: Accessing adequate medical services remains a major struggle for many Americans, but U.S. medical students' beliefs regarding access to care have not been thoroughly examined. METHODS: All medical students in the Class of 2003 at 16 U.S. schools were eligible to complete three questionnaires during their medical training: during freshman orientation, orientation to wards, and their senior year (n=2316, response rate=80.3%). Students responded to three questions about health care provision. RESULTS: Overall, 35% of students strongly agreed that "physicians have a responsibility to take care of patients regardless of their ability to pay;" only 5% disagreed. Only 8% disagreed that "access to basic health care is a fundamental human right." We found the same significant associations with opinions on access as we did with "responsibility to treat," although the associations tended to be stronger for access. Only 10% of students agreed that "Managed care, as it is now delivered, is a good way to deliver health care to the U.S. population." CONCLUSION: Most U.S. medical students support universal access to medical care, though variations in this support, its decline with additional years of medical education, and concerns about managed care are noteworthy, and have policy implications for America's health and health care workforce.     

Universal access to health care would alter hospital planning

What would be the impact on hospitals of a federally mandated plan for universal access to health care? The author suggests that it could lead to fundamental changes in planning, marketing, patient mix and reimbursement patterns, especially considering that the uninsured population is larger in size, and less homogenous, than those receiving Medicare or Medicaid benefits.