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Access to Health Care in America Access to Health Care in America Committee on Monitoring Access to Personal Health Care Services INSTITUTE OF MEDICINE Michael Millman, Ph.D., Editor NATIONAL ACADEMY PRESS Washington, D.C. 1993
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Access to Health Care in America NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W., Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. This project was supported by the Kellogg Endowment Fund, the Johnson & Johnson Foundation, the Baxter Foundation, the Robert Wood Johnson Foundation (Grant #18455), the Health Care Services Administration (Contract #75-05-0080), Department of Health and Human Services, and Institute of Medicine internal funds. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Monitoring Access to Personal Health Care Services. Access to health care in America / Committee on Monitoring Access to Personal Health Care Services, Institute of Medicine ; Michael Millman, editor. p. cm. Includes bibliographical references and index. ISBN 0-309-04742-0 1. Health services accessibility—United States—Evaluation. I. Millman, Michael L. II. Title. [DNLM: 1. Health Services Accessibility—United States. W 76 1592a] RA407.3.I58 1993 362.1'0973—dc20 DNLM/DLC 92-48299 for Library of Congress CIP Copyright 1993 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logo-type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. First Printing, March 1993 Second Printing, February 1994
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Access to Health Care in America COMMITTEE ON MONITORING ACCESS TO PERSONAL HEALTH CARE SERVICES JACK HADLEY (Chair), Co-Director, Georgetown University Center for Health Policy Studies, Washington, D.C. LU ANN ADAY, Associate Professor of Behavioral Sciences, University of Texas School of Public Health, Houston JOHN BILLINGS, Health Policy Consultant, New York, New York CHARLES BRECHER, Professor, New York University, and member, Citizens Budget Commission, Scarsdale, New York TIMOTHY S. CAREY, Assistant Professor of Medicine, University of North Carolina at Chapel Hill, North Carolina ALAN B. COHEN, Vice President, The Robert Wood Johnson Foundation, Princeton, New Jersey EZRA C. DAVIDSON, Jr.,* Professor and Chairman, King/Drew Medical Center, Los Angeles, California CHESTER W. DOUGLASS, Professor and Chairman, Department of Dental Care Administration, Harvard School of Dental Medicine, Boston, Massachusetts ARNOLD M. EPSTEIN, Associate Professor of Medicine and Health Care Policy, Harvard University School of Medicine, Boston, Massachusetts JOHN G. LOEB, Deputy Executive Director, Health Management Corporation, Philadelphia, Pennsylvania JOANNE E. LUKOMNIK, Special Assistant to the Dean, Albert Einstein College of Medicine, New York, New York JANET B. MITCHELL, President, Center for Health Economics, Waltham, Massachusetts IRA MOSCOVICE, Professor and Associate Director, Division of Health Services Research and Policy, University of Minnesota, Minneapolis DONALD L. PATRICK, Professor, School of Public Health and Community Medicine, University of Washington, Seattle FERNANDO M. TREVINO, Dean and Professor, School of Health Professions, Southwest Texas State University, San Marcos GEORGE VAN AMBURG, State Registrar and Chief, Center for Health Statistics, Lansing, Michigan JOSEPH WESTERMEYER, Professor and Head, Department of Psychiatry and Behavioral Sciences, University of Oklahoma, Oklahoma City * Member, Institute of Medicine
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Access to Health Care in America Study Staff MICHAEL L. MILLMAN, Study Director DEE SUTTON, Study Secretary KARL D. YORDY, Director, Division of Health Care Services DON TILLER, Administrative Assistant, Division of Health Care Services HOLLY DAWKINS, Research Assistant, Division of Health Care Services SUSANAH GINSBERG, Consultant GREG W. PEARSON, Consultant ROBERT A. WALKINGTON, Consultant
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Access to Health Care in America Contents SUMMARY 1 General Conclusions on the State of Access, 3 Defining Access, 4 The Committee's Indicators and Progress Toward Access Objectives, 5 Objective 1: Promoting Successful Birth Outcomes, 5 Objective 2: Reducing the Incidence of Vaccine-Preventable Childhood Diseases, 7 Objective 3: Early Detection and Diagnosis of Treatable Diseases, 8 Objective 4: Reducing the Effects of Chronic Disease and Prolonging Life, 11 Objective 5: Reducing Morbidity and Pain Through Timely and Appropriate Treatment, 14 Recommendations, 16 1 INTRODUCTION 19 Background, 20 Developing a Set of Indicators, 21 Relationship of Access Monitoring to Other Relevant Activities, 22 Major Data Sources: Their Uses and Limitations, 23 Strengths and Weaknesses, 25 Crosscutting Issues, 28 References, 29
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Access to Health Care in America 2 A MODEL FOR MONITORING ACCESS 31 Defining Access, 32 Measuring Access, 34 Indicators, 34 Utilization and Its Relationship to Health Care, 37 Barriers to Access, 39 References, 44 3 USING INDICATORS TO MONITOR NATIONAL OBJECTIVES FOR HEALTH CARE 46 Objective 1: Promoting Successful Birth Outcomes, 49 Utilization Indicator: Adequacy of Prenatal Care, 49 Outcome Indicator: Infant Mortality, 56 Outcome Indicator: Low Birthweight, 61 Outcome Indicator: Congenital Syphilis, 66 Objective 2: Reducing the Incidence of Vaccine-Preventable Childhood Diseases, 69 Utilization Indicator: Preschool Immunization, 69 Outcome Indicator: Incidence of Vaccine-Preventable Childhood Diseases, 75 Objective 3: Early Detection and Diagnosis of Treatable Diseases, 79 Utilization Indicators: Breast and Cervical Cancer Screening Procedures, 79 Outcome Indicator: Incidence of Late-Stage Breast and Cervical Cancers, 86 Objective 4: Reducing the Effects of Chronic Diseases and Prolonging Life, 91 Utilization Indicator: Continuing Care for Chronic Diseases, 91 Utilization Indicator: Use of High-Cost Discretionary Care, 98 Outcome Indicator: Avoidable Hospitalization for Chronic Diseases, 102 Outcome Indicator: Access-Related Excess Mortality, 106 Objective 5: Reducing Morbidity and Pain Through Timely and Appropriate Treatment, 112 Utilization Indicator: Percentage of Healthy Individuals Who Do Not Contact a Physician During an Acute Episode of Illness, 112 Utilization Indicator: Dental Services, 115 Outcome Indicator: Avoidable Hospitalization for Acute Conditions, 121 References, 124
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Access to Health Care in America 4 FUTURE INDICATORS 130 Access to Health Care for People with Disabilities, 132 Family Violence, 133 Emergency Services, 134 Post-Acute-Care Services for the Elderly, 134 Prescription Drugs, 135 References, 136 5 RECOMMENDATIONS 137 Crosscutting Recommendations, 137 Future Steps, 140 Objective 1: Promoting Successful Births, 140 Objective 2: Reducing the Incidence of Vaccine-Preventable Childhood Diseases, 141 Objective 3: Early Detection and Diagnosis of Treatable Diseases, 142 Objective 4: Reducing the Effects of Chronic Diseases and Prolonging Life, 143 Objective 5: Reducing Morbidity and Pain Through Timely and Appropriate Treatment, 144 Reference, 144 APPENDIXES A Developing Indicators of Access to Care: The Case for HIV Disease Vincent Mor 147 B Developing Indicators of Access to Care: Waiting Lists for Drug Abuse Treatment Don C. Des Jarlais and Samuuel R. Friedman 181 C Developing Indicators of Access to Care: The Case for Migrants and the Homeless Joanne E. Lukomnik 199 D "Ambulatory-Care-Sensitive" Conditions and "Referral-Sensitive" Surgeries 219 INDEX 223
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Access to Health Care in America ACCESS TO HEALTH CARE IN AMERICA
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