One in seven adult women in the United States lacks health insurance, which creates a general barrier to getting medical care of any kind (U.S. Census Bureau, 2002). Some other barriers to receiving appropriate care are less obvious. Non-financial barriers that may prevent people from “getting to the door” of a health-care provider include geography (travel distance), language, fear and distrust of health care providers, and difficulties getting through appointment or “gatekeeper” systems. Once “in the door,” other barriers to access may surface when attempting to navigate the system: for example, getting from a primary care provider to a specialist. This is especially problematic for referral to mental health and psychosocial services. Within the system, providers may lack information about the diagnosis and management of distress, have difficulty communicating with patients or understanding their problems due to cultural differences, or have insufficient staff to adequately explore patients’ psychosocial needs and provide referral to needed services. The cancer care system is complex, and for breast cancer, it may involve the surgeon, radiologist, and oncologist at different times (see Chapter 5 for a description of breast cancer care). Consequently, various barriers that serve to limit access may surface during each phase of care. These barriers to optimal care are themselves a potential source of psychosocial distress for many women (Hinestrosa, workshop presentation, 2002).
Access, as defined by the Institute of Medicine (IOM, 1993), is the timely use of personal health services leading to the best possible health outcomes. This definition of access implies the use of health services, the quality of such services, and the degree to which access has been achieved. The test of equity of access involves first determining whether there are systematic differences in use and outcomes among groups in United States society and, if there are, the reasons for these differences (IOM, 1993). Some of the factors that have been investigated as possibly affecting access to mental health services include:
Health insurance coverage and type of coverage;
Cost, including health insurance and out-of-pocket costs;
Attributes of the health care delivery system (e.g., geographic distribution of cancer care facilities, lack of service coordination; separation of medical and behavioral (mental) health in different and unrelated contracts);
Attributes of individuals (lack of knowledge or misperceptions about mental health services; linguistic or cultural attributes); and
Attributes of health-care providers (e.g., lack of knowledge about mental health resources; communication styles).
This section of the report describes these barriers in the context of access to mental health services among women with breast cancer.