Economic Accessibilty to Healthcare: Is it an Issue in our Publicly-Funded Health System?

1. Economic Accessibilty to Healthcare: Is it an Issue in our Publicly-Funded Health System? Jeannie Haggerty, PhD St. Mary’s Research Centre McGill Research Chair in Family & Community Medicine at St. Mary’s

2. Accessibility in Canada • Commonwealth and Statistics Canada surveys indicate that healthcare accessibility has declined in Canada • We now rank lowest among peer countries for primary care accessibility • Improving accessibility has been a major policy focus in Canada; focus on wait times. • Economic accessibility is off the radar

3. Canada Health Act • National principles for public health care insurance plans to qualify for full federal cash transfers for health • Public administration, universality, comprehensiveness, portability, accessibility • Accessibility: Insured persons must have reasonable and uniform access to services, free of financial and other barriers.

4. Accessibility: Definition • Characteristics of health systems that impede or promote the utilisation of services (Donabedian). • Characteristics of geographic availability, organisational processes, costs and acceptability that facilitate people’s capacity to reach and use services (Thomas & Penchansky) • Geographic accessibility • Organisatonal accessibility • Economic accessibility • Cultural accessibility

5. Economic accessibility • The extent to which direct and indirect costs represent barriers for people to reach and use health services that they need.

6. Accessibility: core attribute of primary health care • First Contact Accessibility: The ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem • Accessibility-accommodation:The way primary healthcare resources are organized to accommodate a wide range of patients’ abilities to contact healthcare providers and reach healthcare services (telephone services, flexible appointment systems, hours of operation, and walk-in periods).

7. Accessibility: a counter-intuitive finding • 2002 multilevel survey of primary health care practice, Quebec • 100 sites, randomly selected: data from clinics, physicians, patients • Stratified geographically: metropolitan, suburban, rural, remote • Stratified by pratice type: community health clinic, group clinics, solo practice Haggerty, Pineault, Gauthier et al, Multi-level PHC survey, 2002-2004, CHSRF funded

8. Accessibility: a counter-intuitive finding • Patient-reported accessibility improves with increasing rurality • First contact – higher confidence in being seen within one day • Accommodation – better ratings of location, opening hours, wait times, ability to speak to doctor by phone • Yet: longer distances, fewer local alternatives, restricted physician availability.

9. Explanatory hypotheses: A programme of research • The way rural services are organized makes them more accessible • Types of organizational models • Professional practices • Measurement artefact • Expectations are lower in rural areas • Tools not sensitive to rural barriers Haggerty & Gauthier et al, Accessibility to healtcare for rural and remote communities, 2004-2009, CHSRF funded

10. Rural-Urban Measures of Accessibility: Objectives • To identify factors in rural areas that facilitate or impede initiation of first-contact care, ongoing primary care, and follow up of referrals to secondary care • To develop and validate additional measurement items of primary and secondary accessibility that are not addressed in existing questionnaires. Haggerty, Levesque, Roberge. Accessibility Measures, 2005-2010, CHSRF funded

11. Rural-Urban Measures of Accessibility Sequential mixed-method study • Qualitative exploration of urban and rural care-seeking trajectories • Development and quantitative validation of new measures • Two administrations of measures to random sample from urban and rural locations

12. Qualitative exploration of access barriers and facilitators in rural and urban contexts :Phase 1, 2004, Qualitative study To identify factors in rural areas that facilitate or impede initiation of first-contact care, follow up of referrals to secondary care, and ongoing primary care

13. Qualitative exploration • Focus groups • Geographic contexts: two types of urban, two types of rural • Metropolitan (4), towns (2) • Rural agricultural (2), scattered villages (3) • Interview schedule: focus on typical care trajectory and responses to barriers; probing for geographic, accommodation, cost and cultural elements

14. Results: • Major barriers/facilitators to access in typical care-seeking trajectory • Regular source of care • Organizational accommodation • Geographic access • Personal resources (economic, educational) • Consequences of barriers to care

15. Why is observed accessibiliy better in rural areas? • Social networks in rural areas result in better organizational accommodation and flexibility compared to urban areas • Long wait for appointment is the norm, as is individual accommodation • BUT: processes are not formalized, so not everyone has equal access. • Socio-economic status affects organizational and geographic access

16. Organizational Accommodation: • Information about the options  • Role of practice secretary: assess urgency, suggest care alternatives, give health advice, facilitate • Personal information agency : individual’s capacity to obtain information by own means; independent facilitator for access • Organizational flexibility • Secretary accommodates individual requests to make shorter waits for care: squeeze in between appointments, telephone consultation • Social network matters

17. Geographic accessibility: getting to care • Expressed in travel time and local availability of alternatives • Perception of distance as a barrier depends on: • Personal mobility • Personal access to transportation • Type of problem • Acceptability of provider • Other opportunity costs • Not usually an issue in rural areas – except for those with few personal resources

18. Conclusion: • Low socio-economic status as generic barrier to health services (social exclusion) • Low personal information agency • Lack of personal transport makes geographic distance a barrier • Restricted social network reduces organizational accommodation • Indirect and direct costs impede care

19. Conclusion • Persons at risk of social exclusion are also at risk of poor accessibility • In Canada, little exploration of economic barriers to access

20. Development and quantitative validation of new measures: To develop and validate additional measurement items of geographic, organizational and economic accessibility that are not addressed in existing questionnaires. Explore the prevalence of economic barriers to care

21. Development of new measures • Codes for barriers or facilitators from qualitative analysis developed into quantitative « items » • Consequences, indicators of problem access: nuissance, emergency room, unmet needs, problem aggravation • Telephone administration to 750 respondents in metropolitan rural (Longueuil), agricultural (Montérégie), and remote areas (Côte-Nord)

22. Validation: analysis • Exclusion of bad items (>5% missing, no variation). • Exploratory factor analysis to identify constructs and sub-scales • Predictive modelling against consequences: nuissance, unmet needs, emergency room use, problem deterioration • Item response modelling to identify discriminatory capacity of items and differential item functioning by rural-urban

23. Quantitative component: test of new subscales, new instrument • Refinements made in light of analysis and new cognitive testing • Self-administered format • Mailed to 368 of previous respondents who accepted to be contacted (86% responded)

24. Results Accessibility Measure

25. Indicators of problem access • Can be divided into minor (nuissance) and major problems • Provide a good portrait of health care accessibility • Nuissance • Use of emergency room for system reasons • Unmet needs for care • Problem aggravation due to delay

26. Organizational accommodation: Description • New items (more discriminating for rural) • Ease of getting information to solve health problems • Ease of contacting the clinic by phone • Ease of getting medical advice by phone • Ease of getting shorter-than-usual wait for appointment for urgent care • Available structures for rapid care • Rating of usual wait for appointment • Ease of talking to doctor by phone • Each unit increase in accessibility associated with decreased likelihood of • Nuissance (OR=0.47) • Unmet needs (OR=0.34) • Problem aggravation (OR=0.40) Effect stronger in rural areas

27. Geographic accessibility: Description • 5-items • Perceived proximity of clinic • Ease of getting there for urgent care and for routine care, • Travel time • Number of local alternatives • Distance to clinic cited as reason for ER use (6%) and unmet need (10%) • Each unit increase in accessibility, decreased likelihood of : • Nuissance (OR=0.42) • Unmet need (OR=0.44) Effects stronger in the poor

28. Prevalence of Economic Barriers • Payment for services (labs, exams or not covered by public insurance • 20% • Usually have revenue loss when getting healthcare • 22% • Usually have significant indirect costs when getting healthcare • 24%

29. Economic accessibility: • Frequency cost-related unmet needs or difficulty (% ever among all vs. low-income) • Don’t take prescribed meds • Don’t do lab tests or exams • Don’t get uninsured services • Difficulty from income loss • Difficuty from indirect costs • Items scored dichotomously (never vs. ever) and summed to indicate number of problems (range 0 to 5)

30. Economic Accessibility: • Each unit increase in reported cost problem (poor economic accessibility) associated with increased likelihood of: • Nuissance: OR=1.8 (1.5 in poor) • ER use: OR=1.9 (2.4 in poor) • Unmet neet: OR=2.8 (3.3 in poor) • Problem aggravation: OR=3.4 (5.9 in poor)

31. Examination of economic accessibility in an independent sample Cohort of approximately 2500 adults in four Quebec local health networks, 2010. Compare poor and non-poor Haggerty & Fortin, At the interface of the community and the Health system, 2008-2013, CIHR

32. Measure of self-perceived financial status • What word best describes your current financial situation • Very comfortable • Comfortable • Tight • Very tight • Poor « poor » Bottom 25%

33. Health Status of poor vs. Non-poor

34. Prevalence of cost related unmet needs: poor vs non-poor Experienced difficulties in access because of costs 80% of poor report at least one vs. 20% of non-poor

35. Indicators of problem access: Nuissance • Did you have to make several attempts to get the healthcare you needed? • But poor experienced lower organizational accessibility.

36. Indicators of problem access: Use of Emergency room in last year • 32% overall • 16% for system-related reasons only • 20% poor vs. 15% non-poor • Top reasons (rank order) • No family physician or own not available • Clinic not open when I could go • Difficult to get appointment or wait too long • To get tests or see specialist within reasonable time

37. Indicators of problem access:Unmet needs for care • Needed healthcare but didn’t get it • 21% overall • 17% poor vs 14% non-poor • Top reasons (rank order) • Wait for appointment too long • Difficult to make appointment • Regular doctor or clinic not available • Clinic hours not convenient

38. Indicators of problem access:Problem aggravation • Health problem became more serious because it took a long time to get healthcare • 9% overall • 15% poor vs. 7% non-poor • 30% with at least one major access problem (ER use, unmet need, problem aggravation) • 37% poor vs. 28% non-poor

39. Findings are coherent with other studies • Commonwealth Survey 2001 • Difficulty getting care off-hours, 19% poor vs. 13% non-poor • Difficulty seeing specialist 20% poor vs. 15% non-poor • Did not fill a prescription 22% poor vs. 7% nonpoor • Did not get needed dental 42% poor vs. 15% non-poor • Situation may be better in Quebec for some issues

40. Conclusion • Accessibility to healthcare has declined in Canada • Our study confirms this • Policy focus is on organizational accessibility • BUT important inequities in access persist • The poor get systematically poorer access to health services

41. Accessibility: the Canada Health Act • In Quebec’s public insurance system, poor people face more financial, geographic and organizational barriers to getting timely services despite having greater health needs • We are not achieving uniform access to services as per the Canada Health Act • Liberalization of the CHA framework unfairly affects the poor

42. Conclusion and Implication • Economic accessibility IS an issue in our publicly-funded system • To make this a policy focus, we need to shake the myth that we have solved the problem of economic accessibility for necessary medical services in Canada • We need to evaluate the performance of the system in how well it does for those with limited ability to advocate for themselves