1. U.S. Health Care Delivery: Underserved Populations

2. Objectives Discuss and describe underserved populations that are more vulnerable to poor health and illness due to barriers to care – Identify population groups that are vulnerable – Understand the health needs of vulnerable populations – Learn about the major challenges faced by vulnerable populations

3. We Have a Problem… “It is an understatement to say that health care quality in the United States is nowhere near as good as it could or should be. We also have wide racial, socioeconomic, and geographic inequities in how health care is delivered in this country.” – Carolyn M. Clancy, MD Director, Agency for Health care Research and Quality U.S. Department of Health & Human Services

4. What are Underserved Populations? Population groups in the United States that face greater challenges than the general population in accessing timely and needed health care services – Greater risk of poor physical, psychological, and/or social health (Aday 1994)

5. Why Do Underserved Populations Exist? Experience greater barriers in… Access to care Financing of care Racial or cultural acceptance Unequal social conditions Unequal economic conditions Unequal health conditions Unequal geographic conditions

6. Who are Underserved Populations? Groups that are more vulnerable than the general population – Racial & ethnic minorities – Children – Women – Rural residents – Uninsured – Homeless – Mentally ill – Chronically ill – Disabled – Those with HIV/AIDS

7. Why Should We Care About Underserved or Vulnerable Populations? It depends on your point of view… – Market justice philosophy? – Social justice philosophy?

8. Why Should We Care About Underserved or Vulnerable Populations? Is vulnerability a personal problem? “Vulnerability does not represent a personal deficiency of special populations but rather the interaction effects of multiple factors, over many of which individuals have little or no control” (Aday, 1999) “…justifies the role of society as a whole to address the concerns of vulnerable populations”

9. How is Vulnerability Determined? Convergence of factors… – (1) Predisposing characteristics Propensity to use services – (2) Enabling characteristics Means individuals have available to them for the use of services – (3) Need characteristics Health status and risk

10. Vulnerability: Predisposing Characteristics Demographic characteristics, belief systems, social structures Difficult to change – individuals have relatively little control over predisposing attributes Influence vulnerability because they are associated with social position, status, access to resources, health behaviors, and variations in health status

11. Vulnerability: Predisposing Characteristics Race and ethnicity Gender Age Geographic distribution

12. Vulnerability: Predisposing Characteristics Compared to their white counterparts, racial/ethnic minorities are shown to: Have poorer ACCESS to care, Receive poorer QUALITY care, Experience greater HEALTH STATUS deficits

13. Vulnerability: Predisposing Characteristics “Racial and ethnic disparities in the quality of health care delivered in the United States are well documented” (Thorlby et al., 2011) – Blacks, American Indians, and Alaska Natives received poorer quality of care than whites on 40% of core measures – Hispanics received poorer quality of care than non-Hispanic whites on 60% of core measures – http://www.ahrq.gov/research/findings/nhqrdr/in dex.html http://www.ahrq.gov/research/findings/nhqrdr/in dex.html

15. Distribution of core quality measures

16. Distribution of core access measures

17. Overall Quality is Mostly Improving

18. But Relative Quality is Not Changing

19. Less Improvement in Access

20. Relative Access is Unchanged

23. Vulnerability: Predisposing Characteristics Gender – Women have a longer life expectancy than men in the United States… but they also suffer greater morbidity and poorer health outcomes – More acute and chronic illnesses… Greater number of short- & long-term disabilities – Pronounced differences between men and women for heart disease, stroke, and mental illness (e.g., anxiety disorders & depression)

25. Ambulatory care visits due to adverse effects of care Adults with major depressive episode receiving depression treatment (past 12 months)

26. Vulnerability: Predisposing Characteristics Age – Children’s health maintains unique aspects: Developmental vulnerability …how do changes affect a child’s development? Dependency …who does a child depend on for health care? New morbidities …what new conditions threaten a child’s health?

28. Vulnerability: Predisposing Characteristics Geographic distribution …RURAL AREAS How does geographic distribution affect access to health? BARRIERS: PovertyLong distances Rural topography Weather conditions Availability of personal transportation Shortage of health professionals

29. Vulnerability: Predisposing Characteristics “We know that compared with their national counterparts, rural residents are more likely to be elderly, poor, in fair or poor health, and to have chronic conditions. Rural residents are less likely to receive recommended preventive services and report, on average, fewer visits to health care providers.” – Carolyn M. Clancy, MD, AHRQ Director 20% of Americans live in rural areas – 9% of American physicians practice in such areas

30. Vulnerability: Predisposing Characteristics Measures to improve access to care in rural areas – National Health Service Corps – Health Manpower/Professional Shortage Areas – Medically Underserved Areas – Community and Migrant Health Centers – Rural Health Clinics Act

31. What are rural health clinics (RHCs)? A Rural Health Clinic is a federally qualified health clinic (FQHC) certified to receive special Medicare and Medicaid reimbursement. CMS provides advantageous reimbursement as a strategy to increase rural Medicare and Medicaid patients' access to primary care services. Use of both physicians and mid-levels

33. Vulnerability: Predisposing Characteristics Medically Underserved Areas (MUA) – Based on the Index of Medical Underservice (IMU) – Scale from 0 (completely underserved) to 100 (best served/least underserved) – IMU of 62.0 or less qualifies as MUA – Four variables Ratio of primary care physicians to 1,000 population Infant mortality rate Percentage of population below poverty level Percentage of population aged 65 or older

34. Vulnerability: Predisposing Characteristics Medically Underserved Populations (MUP) – Also based on Index of Medical Underservice – IMU of 62.0 or less qualifies as MUP – Same process and data elements as for MUAs except the population is now the population of the requested group within the area rather than the total resident civilian population of the area e.g., only the number of FTE primary care physicians serving the requested population group

36. Vulnerability: Predisposing Characteristics Health Professional Shortage Areas (HPSA) – Designated as having shortage of primary care, dental, or mental health providers Primary care: Ratio of population to FTE primary care physicians greater than 3,500 to 1 Dental: Ratio greater than 5,000 to 1 Mental health: greater than 6,000 to 1 – May be urban or rural areas, population groups, or medical or other public facilities – http://www.hrsa.gov/shortage/ http://www.hrsa.gov/shortage/

38. Vulnerability: Predisposing Characteristics Health Professional Shortage Areas (HPSA) – Nearly 6,500 Primary Care HPSAs Affecting 66.7 million, requiring 17,762 practitioners 373 in Texas, 6 in Bexar County – Over 4,800 Dental HPSAs Affecting 52.2 million, requiring 10,169 practitioners 239 in Texas, 3 in Bexar County – Over 3,900 Mental Health HPSAs Affecting 95 million, requiring 6,226 practitioners 332 in Texas, 4 in Bexar County

39. Vulnerability: Enabling Characteristics Socioeconomic status – Social position, access to resources, income, education, employment status, occupation Individual assets – Human capital, skills, wealth, inheritance Mediating factors – Health insurance, access to health care, quality of health care

40. Vulnerability: Enabling Characteristics 36.5 million poor people in America – 24% Blacks, 21% Hispanics, 10% Asians, 8% White Poor people received lower quality of care than high-income people on about 80% of core measures Poor people have worse access to care than high-income people on all core measures

43. Vulnerability: Enabling Characteristics Uninsured – What characteristics describe many of the uninsured? Income? Education? Employment? Age? Ethnicity? How do the uninsured affect those who have insurance or can pay for care?

45. Vulnerability: Enabling Characteristics Homeless – What barriers are faced to appropriate care? Finance: paying for care or satisfying insurance eligibility requirements Transportation: access to medical facilities Living conditions: proper sanitation, medication storage, appropriate food for healthy diet – Untreated acute and chronic medical, mental health, and substance abuse problems – Greater risk of assault, victimization, and exposure to harmful environmental elements

46. Vulnerability: Enabling Characteristics Measures to help eliminate socioeconomic differences that jeopardize health – Community Health Center Program – National Health Service Corps – Public Housing Primary Care Program – Healthy Schools, Healthy Communities Program – Health Care for the Homeless Program

47. Vulnerability: Need Characteristics Self-perceived health status – Self-perceived physical and mental health Professionally-evaluated health status – Professional diagnoses of disease and illness Quality-of-life indicators – Activities of daily living (ADL) performance Social limitations Cognitive limitations Limitations in work, housework, and school

48. Vulnerability: Need Characteristics Certain subpopulation groups are at higher health risks to: – Physical health High-risk mothers & infants, Chronically ill and disabled, Persons with HIV/AIDS – Mental health Mentally ill and disabled, Alcohol or substance abusers, Suicide- or homicide-prone – Social well-being Abusive families, Homeless, Refugees, Immigrant

49. Vulnerability: Need Characteristics Mental health – Significant burden on health & productivity – Phobias, substance abuse, affective disorders – Mental illness is a risk factor for death from suicide, cardiovascular disease, and cancer – Most mental health services provided in the general medicine sector: the “de facto mental health service system” Specialty mental health services + general counseling services

50. Vulnerability: Need Characteristics Chronic illness and/or disability – Every person is vulnerable during his/her lifetime – Major chronic disease killers: Cardiovascular disease, Cancer, Diabetes, COPD – What is “chronic”? …a disease or injury with long-term (3 months) conditions or symptoms – Unique challenges: Health care system’s orientation to treat acute illness Tobacco use, physical inactivity, poor nutrition, lack of regular screening for certain cancers

51. Vulnerability: Need Characteristics HIV/AIDS – Acquired immunodeficiency syndrome (AIDS) is caused by Human immunodeficiency virus (HIV) – Causes immune system suppression – Question: are AIDS cases still underreported? Poor reporting standards, Patients’ denial of risk behaviors, Absence or decreased access to health care preventing diagnosis of HIV – Combination antiretroviral therapy Effective in delaying progression of HIV to AIDS Prohibitive costs: $12,000 per year

52. Some Examples of Efforts to Care for Vulnerable Populations Integrated Health Outreach System & Promotoras http://www.youtube.com/watch?v=zN5TcrOQ-hs&feature=relmfuhttp://www.youtube.com/watch?v=zN5TcrOQ-hs&feature=relmfu Caring Across Communities http://www.youtube.com/watch?v=Su2WRPUG- f8&feature=BFa&list=PL980E23206527EC51&index=26 http://www.youtube.com/watch?v=Su2WRPUG- f8&feature=BFa&list=PL980E23206527EC51&index=26 First Place for Youth http://www.youtube.com/watch?v=mh- KcCMxk3E&feature=BFa&list=PL980E23206527EC51 http://www.youtube.com/watch?v=mh- KcCMxk3E&feature=BFa&list=PL980E23206527EC51 In SHAPE http://www.youtube.com/watch?v=H4jvOm- 7yC0&feature=BFa&list=PL980E23206527EC51 http://www.youtube.com/watch?v=H4jvOm- 7yC0&feature=BFa&list=PL980E23206527EC51 Community Advocacy Program http://www.youtube.com/watch?v=egrm6csKERg&feature=BFa&list=PL98 0E23206527EC51 http://www.youtube.com/watch?v=egrm6csKERg&feature=BFa&list=PL98 0E23206527EC51

53. More examples Health Leads – http://www.youtube.com/watch?v=pSo4ililQ58 &feature=BFa&list=PL980E23206527EC51 http://www.youtube.com/watch?v=pSo4ililQ58 &feature=BFa&list=PL980E23206527EC51 Child First – http://www.youtube.com/watch?v=EZ33vjcK3hk &feature=BFa&list=PL980E23206527EC51 http://www.youtube.com/watch?v=EZ33vjcK3hk &feature=BFa&list=PL980E23206527EC51 St. Vincent de Paul Society – http://www.youtube.com/watch?v=hdFH2InciEc &feature=BFa&list=PL980E23206527EC51 http://www.youtube.com/watch?v=hdFH2InciEc &feature=BFa&list=PL980E23206527EC51

54. What We’ve Learned Major characteristics of U.S. population groups that face challenges and barriers in accessing health care – Organized along predisposing, enabling, and need characteristics Importance of addressing unique health concerns of U.S. subpopulation groups