Vernellia R. Randall
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| IV. Healthcare Process: Inequities in Access and
Responsiveness
excerpted Wrom: GYOKSTTZRCLBDXRQBGJSNBOHMKHJYFMYXOEAIJ Equitable Health Systems: Cultural and Structural Issues for Latino Elders, 29 American Journal of Law and Medicine 247-267 (2003) (159 Footnotes Omitted) Health outcomes are not the only measure of equity in healthcare systems. The process by which the system provides those services is also important, independent of the health outcomes. The WHO's framework for assessing healthcare systems therefore includes "responsiveness" as the second indicator of health systems. The dignity, autonomy and confidentiality that health systems afford those who use them are indicators of the process or way in which services are delivered. The OECD adds an explicit measure of access as a criterion in the process of care in the WHO framework. By dividing access into availability, accessibility and acceptability of care, an evaluative framework for the process of care criteria integrates the OECD structural issues with the WHO interpersonal issues. "Availability" commonly refers to the physical presence of medical services for potential users, as well as the operating hours and services offered at the facility. The creation of community health centers and the designation of medically underserved areas in the 1960s were both attempts to correct geographic disparities in the availability of medical services for low income and minority populations. Elderly persons who live in designated health professional shortage areas (HPSAs) are likely to have impaired availability because of the undersupply of providers and, as a consequence, receive less necessary care than those living outside of shortage areas. Elderly Latinos continue to experience difficulty in obtaining care because it is not available nearby. Among older Latinos in urban areas who are in Medicare fee-for-service, 17ave to travel over thirty minutes to reach their primary care provider, compared to fewer than 7% for non-Latino whites. Although travel time is not statistically different for Latinos and non-Latino whites in Medicare Health Maintenance Organizations (HMOs) in urban areas, older Latinos in both HMOs and fee-for-service categories were less satisfied than older whites with the ease of getting to their doctor. In rural communities, persons living in predominately Latino areas have fewer doctors per person and are further from hospital services than similar communities that are predominately non-Latino white. Older Latinos also have much lower satisfaction levels than non-Latino whites with the night and evening hours of their providers in both fee-for-service and managed care settings. These data suggest that the level of services available to older Latinos is less than that available to older non-Latino whites, which increases the difficulty of obtaining needed medical services and thereby creates inequities in the process of care. "Accessibility" refers to the means that people have to obtain medical services. The most commonly cited accessibility barrier is financing, and extensive research documents the barriers to medical care for non-elderly persons who do not have health insurance. Even though almost all older persons are covered by Medicare and therefore are "insured," Medicare's uncovered services, copayments, deductibles and premiums actually mean that almost half of all beneficiaries' total medical care costs are not covered by the program. Average out-of-pocket healthcare, not including nursing home or home healthcare costs, exceeded $2,430 spending per older person in 1999. Financial barriers are particularly strong for elders with chronic health conditions and without employer-subsidized supplemental coverage or Medicaid. Latino elders are more likely than non-Latino whites to report delaying medical care because of the cost of care when they are in Medicare fee-for-service, which requires much higher copayments and deductibles than HMOs. National data on medical care spending by older Latinos is sparse, but available data show barriers to healthcare for low-income elders. Low-income elders are significantly more likely to report delaying or not receiving necessary medical and dental care. In 1993, about one-quarter of all older persons reporting family incomes below $10,000 also reported that they had unmet medical or dental needs. This compares with 13% of those with family incomes of $10,000 to $19,999, and 6% of those with family incomes of $20,000 to $34,999 who reported not receiving needed care. Other accessibility barriers can include transportation difficulties, long waiting times to get appointments, bureaucratic barriers for securing needed referrals to specialists and complicated paperwork for obtaining services or reimbursement from supplemental insurance policies. Transportation barriers are more common among Latino than non-Latino white elders, perhaps because the lower economic profile of Latino elders reduces automobile ownership and availability. Less research has been done on the impact of other organizational barriers to accessibility for Latino elders, but lower levels of education, English ability and income would suggest that they would be particularly susceptible to bureaucratic or reimbursement barriers to care. "Acceptability" of care refers to the extent to which services meet users' value orientations. This domain of access is most commonly measured through surveys of user satisfaction and is important because potential users may not make use of available and accessible healthcare services if those services do not appear appropriate or meaningful to them. Acceptability is also the subdomain of our schema that most closely maps the WHO's definition of responsiveness. Acceptability also appears to have attracted the most policy activity in recent years. The concern with acceptability for Latinos falls primarily into the area called "cultural competence." The U.S. Department of Health and Human Service's Office of Minority Health published an extensive set of guidelines on cultural competence, and the language-related components are now codified by the U.S. Office of Civil Rights as a "[p]olicy guidance on the prohibition against national origin discrimination as it affects persons with limited English abilities." This statement notes that persons with "limited English proficiency" (LEP) may not receive information they can understand about public services they are eligible for, and when they try to use those services, they may encounter communications difficulties that reduce the efficacy of the service. "Services denied, delayed, or provided under adverse circumstances have serious and sometimes life threatening consequences for an LEP person and generally will constitute discrimination on the basis of national origin, in violation of Title VI." The issue of language is particularly important for Latino elderly, 86% of whom speak a language other than English at home, and 38% of whom do not speak English well or at all. A number of structural or organizational issues that go beyond language and culture affect the acceptability of care for older Latinos. These include the institutional organization of care, continuity of care, and societal discrimination and policies that shape older Latinos' comfort and trust in the medical care system. The institutional context within which care is provided has an effect on the level of satisfaction of older Latinos. Older Latinos in Medicare HMOs report lower levels of satisfaction with their care than non- Latino whites, while both groups have similar levels of satisfaction when they are in the Medicare fee-for-service program. Many of the satisfaction indicators were lower for older Latinos in HMOs than those in fee-for-service. The perception that their doctors were not rushed, for example, was 26% in fee- for-service, but only 12% in HMOs. The higher dissatisfaction in HMOs for Latino elders remained even after controlling for education, health status, income and other variables commonly associated with satisfaction with care. The responsiveness of a healthcare system to the expectations of older Latinos may be based on the way that the delivery of care is organized and the incentives that the organization provides, which maybe independent of the cultural competency of the staff. The organization of our medical care system also shapes the extent to which there is continuity of care between patients and providers. Continuity of care in HMOs is hindered in those plans with high rates of new patients leaving within a few months after signing up, as well as when doctors drop plans. In addition, those in fee-for-service whose usual source of care is not a doctor's office, such as those who normally use clinics or hospital outpatient departments, are more likely to see different doctors at each visit; only 62% of older Latinos report a doctor's office as their usual source of care compared with 83% of non-Latino whites. Continuity of care is important in building a relationship between provider and patient that promotes trust and a better therapeutic relationship, especially for Latinos and African Americans. Among urban older Latinos, about one-third of those in fee-for-service have seen the same physician for under three years, and about three-fifths of those in HMOs have seen the same physician for under three years, rates that are about 10igher than for comparable non-Latino whites. To the extent that this disadvantage in continuity of care is the result of high turnovers of patients and doctors in HMOs that attract Latinos and higher rates of clinic use in fee-for-service, this inequitable continuity of care is the outcome of the organization of medical care in the United States. In addition, some of the "unacceptable" elements of medical care are likely caused by perceptions of broader social discrimination that makes minorities distrustful of established social institutions. A national survey of adult Latinos of all ages found that 82% felt that discrimination against Latinos in American society was a current problem, and 40% reported that they or someone close to them had been discriminated against because of their ethnicity in the previous five years. In the area of healthcare, families with immigrant members have faced concerns about using public programs because of worries that the use will make it difficult for them or their family members to gain permanent residence or even citizenship. Being a "public charge" has been a worry even for those not legally subject to the provisions under immigration law because of past unevenness in its enforcement and publicity about its applicability. Thus, making older Latino healthcare recipients comfortable with using appropriate health services may also require systemic changes in society that eliminate the fear of using public services as well as broader ethnic discrimination. These issues could be considered structural barriers to acceptability since they transcend conventional considerations of cultural competence. Finally, provider stereotypes of patients affect how doctors interact and treat patients. A variety of studies have shown that doctors are less participatory in their decision making with patients of color than with whites, and it is likely that these practice styles are influenced by stereotypes of the patients. Ironically, programs designed to promote cultural competency could promote stereotypical thinking by practitioners, so care must be taken to assure that practitioners are taught to understand each patient's attitudes and behaviors rather than fixed generalizations about entire groups. When promoting equitable healthcare for racial and ethnic groups focuses on language or other cultural barriers, it is critical to remember that these deterrents to adequate healthcare assume the availability and accessibility of those services. Issues of cultural competence have been long ignored and deserve policy attention, but we risk diverting attention and resources from availability and accessibility if making services culturally competent is the only effort towards achieving equity of health services.
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