The effect of fear on access to care among undocumented Latino immigrants.

The passage of California's Proposition 187 in 1994 intensified debate over health care access for the undocumented population. Under Proposition 187, physicians would have been required to report the undocumented immigrants to immigration authorities. Even before 187, some undocumented may have been wary to come in contact with the medical care system. This paper examines whether concerns about one's immigration status serves as a deterrent to seeking care. These concerns may be resurfacing, with changes under the 1996 welfare reform legislation and related amendments that affect eligibility of non-citizen immigrants for public programs and states' ability to provide care to undocumented immigrants. Therefore, representative in-person surveys of undocumented Latinos were conducted in Houston, El Paso, Fresno, and Los Angeles in neighborhoods with significant concentrations of Latinos. It was found that 39% of the undocumented adult immigrants expressed fear about receiving medical services because of undocumented status. Those reporting fear were likelier to report inability acquiring medical and dental care, prescription drugs, and eyeglasses. Hence it can be concluded that concern about immigration status decreases the likelihood of receiving care.

Health care use among undocumented Latino immigrants.

Using data from a 1996/1997 survey of undocumented Latino immigrants in four sites, we examine reasons for coming to the United States, use of health care services, and participation in government programs. We find that undocumented Latinos come to this country primarily for jobs. Their ambulatory health care use is low compared with that of all Latinos and all persons nationally, and their rates of hospitalization are comparable except for hospitalization for childbirth. Almost half of married undocumented Latinos have a child who is a U.S. citizen. Excluding undocumented immigrants from receiving government-funded health care services is unlikely to reduce the level of immigration and likely to affect the well-being of children who are U.S. citizens living in immigrant households.

Health insurance and access to care for symptomatic conditions.

BACKGROUND: The uninsured receive less medical care than the insured. However, it is not known whether the uninsured are less likely to seek medical care for highly "serious" or "morbid" symptoms. METHODS: Participants in the National Access to Care Survey were asked whether they had experienced any of 15 highly serious or morbid symptoms. Those who did were asked whether they received medical care and, if care was not received, whether care was thought to have been necessary. RESULTS: A total of 574 respondents (16.4%) reported 794 new serious or morbid symptoms. Of these, 499 people (86.9%) had health insurance, and they reported 691 new symptoms; 75 (13.1%) lacked health insurance, and they reported 103 symptoms. The uninsured were less likely to have received medical care and more likely to say they did not receive care even though they thought it was needed (P = .001). Medical care was received for 45.4% of symptoms for the insured and 24.3% for the uninsured; care was not thought to have been needed for 41.0% of symptoms for the insured and 45.6% for the uninsured; and care was thought necessary but was not received for 13.6% of symptoms for the insured and 30.1% for the uninsured. In multivariate analysis, the uninsured were much less likely to have received care than the insured (adjusted odds ratio, 0.43; 95% confidence interval, 0.23-0.81). CONCLUSION: Lack of health insurance is a major barrier to receiving medical care, even for highly serious and morbid symptoms.

National probability samples in studies of low-prevalence diseases. Part I: Perspectives and lessons from the HIV cost and services utilization study.

OBJECTIVE: To examine the trade-offs inherent in selecting a sample design for a national study of care for an uncommon disease, and the adaptations, opportunities and costs associated with the choice of national probability sampling in a study of HIV/AIDS. SETTING: A consortium of public and private funders, research organizations, community advocates, and local providers assembled to design and execute the study. DESIGN: Data collected by providers or collected for administrative purposes are limited by selectivity and concerns about validity. In studies based on convenience sampling, generalizability is uncertain. Multistage probability sampling through households may not produce sufficient cases of diseases that are not highly prevalent. In such cases, an attractive alternative design is multistage probability sampling through sites of care, in which all persons in the reference population have some chance of random selection through their medical providers, and in which included subjects are selected with known probability. DATA COLLECTION AND PRINCIPAL FINDINGS: Multistage national probability sampling through providers supplies uniquely valuable information, but will not represent populations not receiving medical care and may not provide sufficient cases in subpopulations of interest. Factors contributing to the substantial cost of such a design include the need to develop a sampling frame, the problems associated with recruitment of providers and subjects through medical providers, the need for buy-in from persons affected by the disease and their medical practitioners, as well as the need for a high participation rate. Broad representation from the national community of scholars with relevant expertise is desirable. Special problems are associated with organization of the research effort, with instrument development, and with data analysis and dissemination in such a consortium. CONCLUSIONS: Multistage probability sampling through providers can provide unbiased, nationally representative data on persons receiving regular medical care for uncommon diseases and can improve our ability to accurately study care and its outcomes for diseases such as HIV/AIDS. However, substantial costs and special circumstances are associated with the implementation of such efforts.

Why primary care physicians join HMOs.

OBJECTIVE: To determine the reasons why primary care physicians affiliate with health maintenance organizations (HMOs) and assess how these reasons vary with personal and practice characteristics. STUDY DESIGN: A 1996 national telephone/mail survey of primary care physicians who were affiliated with at least 1 HMO plan for more than 9 months. METHODS: Survey responses were assessed according to geographic region, age, income, level of involvement in managed care, and HMO penetration rate. The sample consisted of 210 primary care physicians who played a role in the decision to affiliate. RESULTS: The overwhelming reason primary care physicians affiliated with an HMO was to retain patients. Eighty-three percent reported this as one of the reasons for affiliating and 59% reported it as the primary reason. Physicians with the greatest portion of income from managed care and physicians practicing in areas with high HMO penetration were most likely to report quality of life issues--such as more personal time, more predictable work hours, or reduced administrative burden--as the rationale for HMO plan affiliation. CONCLUSIONS: These findings support the view that the majority of HMO-affiliated physicians join HMOs to avoid a perceived penalty associated with lack of affiliation, rather than for positive reasons. The data also suggest that physicians with managed care experience affiliate more often for quality of life reasons.

A revised measure of symptom-specific health care use.

The objective was to determine physicians' ratings of the clinical importance of common adult symptoms and to use these ratings to develop a new measure of symptom-specific use of health care services. We developed a list of common symptoms using the National Ambulatory Medical Care survey. We surveyed a random sample of internists, family physicians, general practitioners and emergency medicine physicians from the American Medical Association's Physician Masterfile and asked them to rate symptoms' seriousness, impact on quality of life and urgency of need for medical attention. The symptoms' prevalences were determined in a general population survey (National Access to Care Survey). Eleven items were classified as "serious" (median seriousness ratings of 7 or higher on scale from 1 to 10); most of these also were judged to have high impact on quality of life. Another 12 items that were not judged "serious" had median quality of life impact scores of 7 or higher and were classified as "morbid". Sixteen items did not meet criteria for either "serious" or "morbid" symptoms and were classified as "intermediate". Six other items had median seriousness and quality of life impact scores of 3 or less and were classified as "benign". A total of 24 of these items (7 "serious", 8 "morbid", 8 "intermediate" and 1 "benign") were selected to form the symptom-response measure. In the national survey, 26.3% reported one or more serious symptom, 30.6% reported one or more morbid symptom and 29.6% reported one or more intermediate symptom. This new instrument expands on earlier "symptom-response" measures by including a larger number and a broader spectrum of symptoms. This measure should be useful to assess differences in patterns of health care use for particularly serious or morbid conditions; such variations may indicate problems with access to medical care.

Access to care: how much difference does Medicaid make?

Using the 1994 Robert Wood Johnson Foundation National Access to Care Survey, we examine the likelihood of having a usual source of care, inability to obtain needed care, and number of physician visits for persons with private insurance, Medicaid coverage, and no insurance. Inability to obtain services is surprisingly consistent: For each service, Medicaid enrollees were about half as likely as uninsured persons and about twice as likely as privately insured persons were to report difficulty. For other access measures, access for those on Medicaid more closely resembles that of the privately insured than that of the uninsured.

Access to dental care in the United States.

The authors analyzed data from the 1994 National Access to Care Survey and estimated the extent of dental care wants in the U.S. population and in various population subgroups. The authors found that 8.5 percent of the population wanted, but did not readily obtain, dental care in 1994. The prevalence of unmet dental care wants varied by demographic and socioeconomic characteristics, and income and health insurance status. Findings suggest that financial barriers to access are significant in explaining the prevalence of wanted dental care.

Hospital-physician arrangements and hospital financial performance.

OBJECTIVES: The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance. METHODS: Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance. RESULTS: Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements. CONCLUSIONS: Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.

Choice of health plan: implications for access and satisfaction.

In this article, the authors examine why low-income persons choose a managed care plan and the effects of choice on access and satisfaction, using data from the 1995-96 Kaiser/Commonwealth Five-State Low-Income Survey. Two-thirds of those choosing a managed care plan cited costs or benefits as their primary reason. Logistic regressions indicate that choice of plan had a neutral or positive effect on access and satisfaction. Medicaid enrollees with choice were less likely than those without to have difficulty obtaining particular services, more likely to rate plan quality highly, and less likely to report major problems with plan rules.

Attitudes toward cost-containment features of managed care: differences among patient subgroups.

OBJECTIVE: To analyze the extent to which personal characteristics and circumstances affect attitudes toward cost-containment aspects of managed care. STUDY DESIGN: A national probability sample component of the 1994 Robert Wood Johnson Foundation National Access to Care Survey. METHODS: Telephone and in-person survey follow-up of 3480 persons who completed the 1993 National Health Interview Survey. Findings on respondents' attitudes toward three principal cost-saving features of managed care are reported. These features are choosing physicians from insurance company lists (LIST), accessing specialists through referrals only (SPECIALIST), and seeing a nurse sometimes instead of a physician (NURSE). Data were categorized and analyzed by different population subgroups. RESULTS: Respondents were divided almost equally in terms of how much they minded healthcare features of managed care, with approximately one third minding a lot, one third minding a little, and one third minding not at all. However, slightly more people minded LIST (42%) and NURSE (39%) features a lot. The respondent subgroups with the lowest proportion "minding a lot" were the uninsured poor and those already in managed care. Those groups minding the most were the elderly, those in fee-for-service plans, persons in poor health, and those with ischemic heart disease. CONCLUSIONS: Acceptance of managed care cost-containment features varies by consumer characteristics. Those who have the most to gain financially by cost-containment features and the least to lose in terms of their access to care mind the managed care features the least. Persons who object most strongly are those who are not financially constrained and who are in poor health.

Primary care case management for Medicaid recipients: evaluation of the Maryland Access to Care program.

A growing number of states are implementing Medicaid managed care programs, and primary care case management (PCCM) is an important component of many of these systems. In this paper, we present results of an evaluation of one such PCCM program--the Maryland Access to Care (MAC) program. The evaluation uses five years of Medicaid claims and eligibility data from the period before and after the program's introduction to determine the program's impact on expenditures and service utilization. Results indicate that the program increased the probability that a Medicaid enrollee would use primary care and preventive services, but had little impact on use of specialty or emergency room services. The gatekeeper program also was successful at controlling expenditures once an enrollee entered the health care system, largely through reductions in the use of ancillary services. The post-MAC increase in the probability of using services was so great, however, that all savings per user were negated, resulting in an estimated increase of about 3.4% in Medicaid expenditures for the MAC-eligible population.

Language, sociodemographics, and health care use of Hispanic adults.

This study examines the role of spoken language in access to health care for Hispanic adults. Analyzing the associations between personal characteristics and the use of Spanish as opposed to English reveals that monolingual Spanish speakers were more likely than others to be older, less educated, in poor health, uninsured, and in poverty. Further, Spanish speakers were less likely than English-speaking Hispanics to have a usual source of health care. Persons with no usual source of care were least likely to have seen a physician or to have had their blood pressure checked, whereas those with a regular doctor appeared to have the greatest access. The authors conclude that, whereas language is certainly associated with many barriers to health care, both economic well-being and having a usual source of care are of paramount importance for the Hispanic American population.

The growth in the US uninsured population: trends in Hispanic subgroups, 1977 to 1992.

This paper presents trends in the growth in the US uninsured population, using cross-sectional national estimates from 1977, 1987, 1989, and 1992 and focusing specifically on coverage problems experienced by Hispanic Americans. An examination of the composition of uninsured persons added between 1977 and 1992 shows that almost 40% of the difference is accounted for by persons of Hispanic origin, with those of Mexican origin alone constituting 27%. In addition, the annual average rate of growth in the uninsured Hispanic population between 1977 and 1992 was 9.7%, compared with only 2.3% for the uninsured non-Hispanic population.

Health care use by Hispanic adults: financial vs. non-financial determinants.

The purpose of this article is to assess the relative effects of financial and cultural factors, namely language spoken, on health care use by Hispanic adults. Using a national sample, we examine the determinants of having a usual source of care (USOC), use of physician visits, and likelihood of having blood pressure checked. Multivariate analysis reveals the following: Monolingual Spanish speakers were not significantly different from English speakers for the three dependent variables; having private insurance or Medicaid was positively related to all three dependent variables. We conclude that financial factors--primarily insurance--remain as the paramount barriers to care.

Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey.

This DataWatch presents findings on Americans' ability to obtain health care. Data from the 1994 National Access to Care Survey sponsored by The Robert Wood Johnson Foundation suggest that earlier studies have underestimated the access problems facing Americans by not asking about supplementary services such as prescription drugs, eyeglasses, dental care, and mental health care or counseling. Using this more inclusive definition of health care needs, we estimate that 16.1 percent of Americans were unable to obtain at least one service they believed they needed. While income is highly correlated with unmet need, most persons reporting access problems are not poor.

Expenditures for unintentional injuries among the elderly.

This article presents national estimates of the probability of having an unintentional injury, the types of medical care associated with unintentional injuries, and the costs of unintentional injuries that occurred in calendar year 1977 for persons aged 65 and older. Data come from the 1977 National Medical Care Expenditure Survey (NMCES) and the 1977 National Nursing Home Survey (NNHS). Among persons aged 65 and older, we found differences in the probability of having an unintentional injury by age, sex, and living arrangement, which suggests that unintentional injuries are not "accidental," or random, events. Our estimates indicate that total medical care expenditures for unintentional injuries for the elderly population in 1977 may have been over $2 billion. Using simple adjustments, we also estimated that the amount expended on injury-related medical care in 1984 might have been as high as $5 billion. Given the large amount of monetary, and presumably nonmonetary, costs associated with unintentional injuries, programs designed to reduce such injuries may well pay off in a cost-benefit or cost-effectiveness framework.