Department of Family & Community Medicine STFM Health Care Forum April 25, 2007 Kevin Grumbach, MD Department of Family & Community Medicine UCSF

Quality Cost Access

Dimensions of Access Financial Structural Geographic What’s covered, to what degree, affordability Structural Available human and capital resources Geographic Language and culture Others

Assessing Access Specific health services and sectors 1° - 2° - 3° care Physicians, pharmaceuticals, nurses, long term care, etc Specific services/populations (abortion, HIV care, etc) Appropriateness of access (quality) “Average” access vs equity of access

Data From International Comparions UK: comprehensive public coverage with minimal out of pocket payments Canada: universal public insurance for physicians and hospital care, more uncovered services and OOP payments US:

Source: Commonwealth Fund 2001 International Survey

Source: Commonwealth Fund 2001 International Survey

Primary Care Access Source: 2002 Joint Canada/US Survey of Health

Source: Commonwealth Fund 2001 International Survey

MRI Units and CT Scanners per Million Population, 2001 Source: OECD

Coronary Artery Bypass Graft Surgery Rates, 1989 Source: Anderson et al. JAMA 1993;269:1661

Regionalization of CABG in High Volume Hospitals *at least 500 CABG operations annually Source: Grumbach et al. JAMA 1996;274:1282

Persons on Dialysis per 100,000 Population, 2000 Source: OECD

Kidney Transplantation Among Patients With End Stage Renal Disease Source: Hornberger et al. Med Care 1997;35:686

Access and Income Status: % of Adults Not Getting Medical Care Due to Cost

Access and Income Status: % Reporting Difficulty Seeing a Specialist

Access and Income Status: % Reporting Overall Medical Care as Excellent or Very Good

% With a Regular Doctor Source: 2002 Joint Canada/US Survey of Health

Source: Blendon, HealthAffairs 2003 (22/3)

Physician Attitudes of Problems with Medical Practice US Canada Patients can’t afford necessary care 73% 25% Limited supply of facilities 14% 50% Hassles with billing 78% 24%

1988 2001 Source: Blendon, HealthAffairs 2002 (21/3)

Getting More, Complaining More: Canadians With MI Attitudes and Experiences at 30 day F/U, By SES Group Source: Alter DA et al. JAMA 2004;291:1100

Insured But Not Equal: Medicaid vs Private Insurance

Patients Hospitalized in NY With MI: Odds of Receiving Cardiac Procedures During Initial Hospitalization Source: Philbin EF et al. Am J Public Health 2001;91:1082.

% of California Physicians in Urban Areas Accepting New Medicaid Patients Source: UCSF California Physician Surveys

Medicare vs Private Insurance vs Uninsured

Summary Points Compared with US, UK & Canadian systems Lessen overall financial access barriers Reduce disparities in access (and quality) based on SES Have less regressive financing of health care Less reliance on rationing based on ability to pay means more reliance on other methods of rationing/cost control Capacity, supply Has effects on convenience and timeliness, not necessarily as apparent on quality and outcomes Too much access can be bad for your health

Summary Points Waiting times in public systems often serve as the political “access meter” in the access/quality vs cost control debate Poor people appreciate equity more than rich people do Maintaining social solidarity fundamental to successful universal programs Not all coverage is equal in multipayer systems Equal coverage vs “good enough” coverage Americans rate Medicare as the “access leader”