Eliminating health care inequities through strengthening access to care.

OBJECTIVE: To provide a research agenda and recommendations to address inequities in access to health care. DATA SOURCES AND STUDY SETTING: The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government. STUDY DESIGN: Multi-stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations. DATA COLLECTION/EXTRACTION METHODS: Through a stakeholder-engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased. PRINCIPAL FINDINGS: The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti-racist practices (e.g., co-production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access. CONCLUSIONS: AHRQ is well-positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations.

Patient-initiated e-mails to providers: associations with out-of-pocket visit costs, and impact on care-seeking and health.

OBJECTIVES: To understand when patients use secure e-mail messaging with healthcare providers across several types of questions or concerns, associations between out-of-pocket costs for in-person visits and use of secure messaging, and to examine patient-reported impacts on care-seeking behavior and overall health. STUDY DESIGN: Cross-sectional survey of patients in an integrated healthcare delivery system, with access to a patient portal to send secure e-mail messages to providers at no out-of-pocket cost. METHODS: The study included patients with a chronic condition (N = 1041). We described patient-reported preferences for contacting providers and patient-reported impact of e-mail use on phone calls, in-person visits, and overall health. We used multivariate analyses to examine patient characteristics associated with using e-mail as a first contact method, and effects on care-seeking and health. RESULTS: Overall, 56% of patients sent their provider an e-mail within 1 year, and 46% reported e-mail as their first method of contact for 1 or more types of medical concerns. After adjustment, higher out-of-pocket costs for in-person visits were significantly associated with choosing e-mail as a first method of contact (P < .05). Among patients who had e-mailed their provider, 42% reported that it reduced their phone contacts, 36% reduced in-person office visits and 32% reported e-mailing improved their overall health. CONCLUSIONS: Patients reported using e-mail broadly to initiate conversations with their providers, and patients with higher out-of-pocket costs for in-person visits were more likely to choose e-mail as a first contact method. Use of secure e-mails reduced patients' use of other types of healthcare and resulted in improved overall health.

Financial barriers to care among low-income children with asthma: health care reform implications.

IMPORTANCE: The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts. OBJECTIVE: To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma. DESIGN, SETTING, AND PARTICIPANTS: A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (e.g., ≥$75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (i.e., Medicaid or Children's Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (i.e., income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics. MAIN OUTCOMES AND MEASURES: Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care. RESULTS: After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physician's office visit (3.8% vs. 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs. 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their children's care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their children's asthma care. CONCLUSIONS AND RELEVANCE: Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACA's low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.

Consumer-directed health plans with health savings accounts: whose skin is in the game and how do costs affect care seeking?

BACKGROUND: Employers are increasingly offering high-deductible health insurance plans with associated health savings accounts (HSAs), but there is limited information on account contributions or effects on patient care seeking. OBJECTIVE: We examined HSA contributions and their source, patient-reported effects of costs on care seeking, and reports of financial burden. RESEARCH DESIGN: We conducted telephone interviews with 488 adult members of small group of employer-sponsored HSA-eligible plans within an integrated delivery system. PRINCIPAL FINDINGS: HSA contribution sources and amounts varied with 32% receiving an employer contribution and also making their own employee contribution, 35% only receiving an employer contribution (no employee contribution), 19% only making their own contribution (no employer contribution), and 14% with no HSA contribution from either source. After adjustment for respondent characteristics, those who made their own HSA contributions in addition to their employer's contribution were significantly more likely to report that costs affected their care-seeking behavior, compared with those with only employer contributions (39% vs. 31% for emergency department and 60% vs. 49% for office visits, all P<0.05). Respondents who contributed to their HSA or who paid out-of-pocket for care were significantly more likely to report financial burdens than those with only employer contributions (P<0.05). CONCLUSIONS: The majority of consumers receive employer contributions to their HSA, but few have fully funded accounts. Those with only an employer contribution reported fewer changes in their care-seeking behavior and were less likely to report experiencing financial burdens.

Early experiences with e-health services (1999-2002): promise, reality, and implications.

BACKGROUND: E-health services may improve the quality and efficiency of care; however, there is little quantitative data on e-health use. OBJECTIVE: The objective of this study was to examine trends in e-health use and user characteristics. RESEARCH DESIGN: This was a longitudinal study of e-health use (1999-2002) within an integrated delivery system (IDS). We classified 4 e-health services into transactional (drug refills and appointment scheduling) and care-related (medical and medication advice) services. SUBJECTS: Approximately 3.3 million members of a large, prepaid IDS. MEASUREMENTS: Amount and frequency of e-health use over time and characteristics of users. RESULTS: The number of members registered for access to e-health increased from 20,617 (0.7% of all members) in Q1 1999 to 270,987 (8.6%) in Q3 2002. Between Q1 and Q3 2002, 42,845 members (1.3%) used the drug refill service and 55,901 (1.7%) used the appointment scheduling service compared with 10,756 members (0.3%) who used the medical advice service and 3069 (0.1%) who used the medication advice service. Over the same period, transactional service users averaged 3.5 uses/user versus 1.6 uses/user among care-related service users. Members most likely to use e-health services had a high level of clinical need, a regular primary care provider, were 30 to 64 years old, female, white, and lived in a nonlow socioeconomic status neighborhood. These findings were consistent across e-health service types. CONCLUSIONS: Although use of all e-health services grew rapidly, use of care-related services lagged significantly behind use of transactional services. Subjects with greater clinical need and better ties to the health system were more likely to use both types of e-health services.