Examining Access to Specialty Care for California’s Uninsured

1. Examining Access to Specialty Care for California’s Uninsured Suzanne Felt-Lisk, Megan McHugh, and Melissa Thomas AcademyHealth ARM, June 2004 Sponsor: California HealthCare Foundation

2. Research Questions • How and how well are California’s uninsured able to obtain specialty care? • Is access to specialty care for the uninsured becoming easier or more difficult? • How and how much does access to specialty care vary from one community to the next

3. Methods • Survey of all 101 FQHC Medical Directors in CA • Survey of 64 hospital outpatient departments • Case studies of 4 communities • Site visits • Focus groups of uninsured individuals who needed specialty care

4. Findings • Access problems are widespread, extend across a wide range of specialties, and are worse for adults than children

5. PERCENT OF FQHC MEDICAL DIRECTORS REPORTING PATIENTS EXPERIENCE PROBLEMS IN OBTAINING SPECIALTY CARE 85% 66% 44% 39% 33% 30% 27% 20% 9% 5% 2% Source: MPR Survey of FQHC Medical Directors in California, 2003. The reported figures are estimates within plus or minus 5.5 percent

6. MOST PROBLEMATIC SPECIALTIES FOR ADULTS AND CHILDRENa aAt least half of the surveyed Medical Directors reported their uninsured patients often or almost always experienced problems obtaining these services.

7. Findings • Problems have worsened over the past two years in many communities and improved in few • 50 percent reported specialty care access was more difficult • 35 percent reported it was about the same • 15 percent reported it was easier

8. Findings • Hospitals are a vital source of specialty care for the uninsured, including hospitals whose primary focus is low-income populations, and many other hospitals as well

9. REPORTED ACCESS AT HOSPITALS THAT SERVE AS SPECIALTY CARE REFERRAL DESTINATIONS FOR THE UNINSURED

10. Findings • Private physicians played a significant role in 3 of 4 case study communities

11. SUBSTANTIAL DIFFERENCES BETWEEN REPORTED ACCESS BY THE UNINSURED FOR FQHCS IN COMMUNITIES WITH LARGER AND SMALLER HISPANIC POPULATIONS

12. Findings • Community characteristics affect access: • Strong relationships between FQHCs and hospitals • Community support • Size of uninsured population and its composition • Supply of specialist physicians

13. Findings • Local efforts to improve access to specialty care in the 4 case study communities have limitations • Adult access problems will remain largely unaddressed by child insurance expansions • FQHC expansions promising for some specialties but highly unlikely to be able to meet all the needs

14. Implications • Helps provide insights into reasons for worse clinical outcomes well-documented for uninsured and low-income individuals • Suggests a need for short- and longer-term attention by local, state, and national policymakers

15. Implications: Short-term & Local • Locally assess severity and nature of specialty care access problems • Plan for improvement: • Implement/expand local initiatives to provide insurance • Strengthen pc/hospital relationships • Advanced training to pc providers • Bring specialists to pc settings • Build on existing efforts & experience

16. Implications: Longer-Term • State: Assist and motivate communities to make local improvements • State: Consider policy change to encourage physician volunteerism • National: Examine prevalence of problems nationally and if problem is national, consider changes similar to those listed for states

17. Priorities for Future Research • Why the access disparity in communities whose populations are 40% or more Hispanic? • Further shape policy interventions • Document costs of underuse of specialists • Document cost of inefficiencies in current system for uninsured referrals

18. Availability of Report & Issue Brief • Report and issue brief are on California HealthCare Foundation web site at http://www.chcf.org/topics/ view.cfm?itemID=102587