Access to Care

Background

Access to comprehensive, quality health care services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all District residents [1]. Access to health services has to do with the ability and ease individuals and communities have to gain access to appropriate affordable and quality health care services. While quality of care is discussed separately, access is measured here by factors such as ability to pay, location of facilities and services, hours of operation, physical and cultural barriers, and the time it takes to receive services (i.e., services, coverage, and timeliness).

While not the cure-all for improved population health outcomes, access to health care services is particularly important in view of the fact that the leading causes of death in the District are largely the result of chronic diseases, which can often be reduced through prevention, early diagnosis, and treatment [2]. Ensuring that all residents have access to equitable care will help to reduce differences in health outcomes among various racial, ethnic, gender and socioeconomic groups.

The DC Healthy People 2020 goal for Access to Care is:

1. Every District resident has access to affordable, person-centric, and quality health care services in an appropriate setting.

Barriers to health services lead to [1]:

• Unmet health needs

• Delays in receiving appropriate care

• Inability to get preventive services

• Financial burdens

• Preventable hospitalizations

Services & Provider Availability

Improving access to health care services depends in part on ensuring that people have a usual place of care to access clinical services. That is, a provider or facility where individuals regularly receive clinical healthcare. People with a usual source of care have better health outcomes, fewer disparities, and lower costs [1].

The results from the 2018 DC Primary Care Needs Assessment found that the District has an ample supply of providers to meet the primary care needs of DC residents. However, there are inequities in the distribution of providers geographically across the city. Specifically, Wards 4 and 7 currently have provider capacity that is less than half of the primary care capacity needed to serve the residents in these respective wards [3].

The District’s primary care supply is substantially reliant on physicians compared to other provider types. Nationally, physicians account for 71% of the primary care workforce capacity. In DC, they represent over 81% of the provider visit capacity; in Wards 7 and 8, physicians represented over 90% of primary care capacity [3].

Source: 2018 DC Primary Care Needs Assessment

Another key finding was that use of primary care services is not defined by location or travel time for Medicaid patients. Medicaid patients, regardless of where they live, generally travel for their care and often bypass care providers that are located closer to their residence [3].

The District is home to seven acute care hospitals serving patients from throughout the region. Data before April 2019 include Providence Hospital, which has since closed. The 2017 DC Health Systems Plan outlines characteristics, capacity and utilization of the District's health system. One main finding was that inappropriate use of the emergency room was especially high for residents of Wards 7 and 8 and parts of 4 and 5 [4].

DC Primary Care Provider by Location, 2016

Source: 2018 DC Primary Care Needs Assessment

Distribution of DC Hospital and Surgical Centers, 2017 

Source: 2017 DC Health Systems Plan

Coverage & Cost of Care

Health insurance coverage helps patients gain entry into the health care system. Lack of adequate coverage makes it difficult for people to get the health care they need and, when they do get care, burdens them with large medical bills [1]. The extent to which a person has insurance that helps to pay for needed acute services, as well as access to a full continuum of high-quality, timely and accessible preventive and disease management or follow-up services, has shown to be critical to overall health and well-being [4]. Yet, cost can be a barrier to care even for those who have insurance [5].

The District has the second highest insurance coverage rate in the nation, but DC residents of color continue to face barriers to accessing care. In 2016, 10.6 % of Black District residents and 15.4% of Hispanic/Latinx District residents reported that there was a time in the past year that they needed to see a doctor, but could not because of cost, compared to 5.9% of White District residents. Geographically, residents in Ward 7 and Ward 8 were 2-3 times more likely to report that the cost of health care prevented them from seeing a doctor than residents in the rest of the city [6].

In the 2019 DC Community Health Needs Assessment (CHNA) Survey, 26% of respondents who had trouble accessing care indicated that cost of care was a barrier for them, second only to long wait times for appointments.

Timeliness

Timeliness, an important factor in improving access to care, is the health care system's ability to provide health care quickly after a need is recognized. The delay in time between identifying a need for a specific test or treatment and the actual time those services are received can negatively impact an individual's health (increased emotional distress, increased complications, increased hospitalizations) and increase the cost of care [1].

In the 2019 DC CHNA Survey, for respondents indicating they had encountered barriers accessing health care services, the most frequently indicated barrier was long wait times for appointments, with 27% citing this as a barrier for them. Eleven percent indicated that the long wait in the provider's waiting room was an additional barrier.

Barriers to Care

Access to care is characterized by factors that either enhance or inhibit the individual’s ability to get to the site where care is provided, and to receive appropriate services once there. Barriers to accessibility include, but are not limited to, the following examples:

•   Financial barriers – provider’s lack of insurance participation, affordability and cost of services.

•   Spatial barriers – location of available services, lack of reasonable transportation options, and proximity to the target population.

•   Physical barriers – ADA non-compliant buildings, surrounding streets and grounds that hinder ease in reaching available services (e.g., highway or busy freeway, hills, railroad tracks).

•   Temporal barriers – hours of operation that are not appropriate for a given population, travel times via various transportation modes to reach the location of services, and patient wait times for rendering services.

•    Accommodation barriers – cultural or linguistically inappropriate/inadequate administrative systems, care provision, facilities, or  patient/provider relationships [4].

During both the 2018 DC Primary Care Needs Assessment and the 2017 DC Health Systems Plan, when interviewees and community forum participants were asked what they thought were the leading barriers to care, nearly without exception they cited social determinants of health as being the leading barriers to access and engagement in care. Housing, poverty, transportation, food access, and language/culture were the top five issues identified in order of priority and impact, with health literacy/education and safety & violence also emerging as barriers [3, 4].

In the 2019 CHNA Survey, respondents were asked if there were any factors in the past year that made it more difficult for them or anyone in their households to get the health care services they needed. In the chart below are the leading barriers identified by respondents:

Health Literacy 

There is extensive research showing the challenges associated with low health literacy, including adverse health outcomes, and the opportunities that can be realized when patients are able to understand and act on the information communicated by clinicians [3]. Too often information is provided using language that contains medical jargon and is too complex for most patients to understand. Information is sometimes communicated in ways that are untimely, rushed, culturally inappropriate, intimidating, or disorganized. Participants in the community forum held for Spanish-speakers discussed the particular challenges they face when accessing services without bilingual and culturally competent providers. It is clear that low health literacy is strongly correlated with adverse health outcomes, especially during transitions of care [4].

Cultural barriers and strengths

One of the strengths of DC’s primary care system is the extent to which certain providers are able to tailor their services to specific segments of the population in ways that promote engagement, enhance access, and improve the quality of care. For example, La Clinica del Pueblo and Mary’s Center provide bi-lingual and bi-cultural services that are specifically tailored to meet the needs of Spanish-speaking populations, and thus, see a large portion of DC’s Hispanic/Latinx community. Mary’s Center also serves a large share of DC’s other immigrant populations, such as those from Ethiopia and Eritrea [4].

Transportation

Interviewees and community forum participants stated that those living on the perimeter of DC, particularly in southeast, face more significant barriers to care than those living in other areas of DC. Many of these barriers are related to travel distances, transportation barriers (particularly at rush hour), cost, and cultural/linguistic barriers. For example, residents in the Ward 8 community forum reported that it can take as much as 1 to 2 hours on public transportation to travel the 3–5 mile distance between their home and their preferred hospital in the downtown area [3, 4].

Promising Practices & Policies:

Health in All Policies (HiAP) is a collaborative approach that integrates and articulates health considerations into policymaking across sectors to improve the health of all communities and people. HiAP recognizes that health is created by a multitude of factors beyond healthcare and, in many cases, beyond the scope of traditional public health activities. The HiAP approach provides one way to achieve the National Prevention Strategy and Healthy People 2020 goals and enhance the potential for state, territorial, and local health departments to improve health outcomes. The HiAP approach may also be effective in identifying gaps in evidence and achieving health equity [7].

Citations & Additional Data Resources

1. Healthy People 2020. Access to Health Services. 2016

2. DC Healthy People 2020. Access to Health Services. 2016

3. DC Primary Care Needs Assessment 2018

4. DC Health System Plan 2017

5. County Health Rankings. Access to Care. 2018

6. DC BRFSS 2016

7. DC Office of Health Equity


Photo Credits:  

Photo by Hush Naidoo on Unsplash

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