In the first session in the second series
of assessments of Healthy People 2010, ADM John
O. Agwunobi, Assistant Secretary for Health, chaired a
focus area Progress Review on Access to Quality Health
Services. He was assisted by staff of the lead agencies
for this Healthy People 2010 focus area—the
Health Resources and Services Administration (HRSA) and
the Agency for Healthcare Research and Quality (AHRQ).
In his introduction to the Progress Review participants,
ADM Agwunobi noted that the Access objectives address services
within four components of the healthcare system: clinical
preventive care, primary care, emergency services, and
long-term and rehabilitative care. He stated that ensuring
high standards and readily available care is essential
to achieving the two overarching goals of Healthy People
2010—eliminating health disparities and increasing
quality and years of life for all Americans. Also participating
in the review were representatives of other U.S. Department
of Health and Human Services (HHS) offices and agencies.
The complete text for the Access to Quality Health Services
focus area of Healthy People 2010 is available
online at www.healthypeople.gov/document/html/volume1/01access.htm.
For comparison, the report on the first-round progress
review (held on June 4, 2002) is archived at
www.healthypeople.gov/data/2010prog/focus01/2002fa01.htm
The meeting agenda, tabulated data for all focus area
objectives, charts, and other materials used in the Progress
Review can be found at a companion site maintained by
the National Center for Health Statistics (NCHS)/Centers
for Disease Control and Prevention (CDC): www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa01-atqhs2.htm.
Data Trends
Richard Klein of the NCHS Division of Health Promotion
Statistics summarized the status of the 16 Healthy
People 2010 objectives in the Access focus area
as follows: little progress on a large scale overall,
but no notable retrograde movements; new data since the
first-round Progress Review for five objectives; no updates
since the baseline for five objectives; and, as reported
in the earlier Progress Review, one objective (1-12;
24-hour toll-free access nationwide to poison control
centers) with a target that has been met. In general,
relative health disparities between population groups
have remained much the same, even when their objectives
have registered progress overall. However, increases
in disparity were noted for Hispanics with regard to
having a source of ongoing care (Obj. 1-4) and a usual
primary care provider (Obj. 1-5). About three quarters
of objectives and subobjectives with data beyond the
baseline year are moving toward their targets. Mr. Klein
then reported in greater detail on progress achieved
toward meeting the targets of selected objectives in
the focus area.
The proportion of persons under age 65 with health insurance
varied from 83 percent to 84 percent from 1997 (baseline)
to 2004. Among poor people, the proportion increased
from 66 percent in 1997 to 69 percent in 2004.
Certain age groups showed improvement in coverage during
that time span: an increase from 86 percent to 91 percent
among persons aged 10 to 14 years and an increase from
80 percent to 85 percent among those aged 15 to 19 years.
The 2010 target is 100 percent (Obj. 1-1). In 2001, the
first year for which data became available on subobjectives
1-3a, b, c, and d, the age-adjusted proportion of adults
aged 18 and older who had been counseled by their provider
about four kinds of health behaviors varied by the targeted
behavior as follows: physical activity or exercise—45
percent (target 54 percent); diet and nutrition—43
percent (target 56 percent); smoking cessation—66
percent (target 72 percent); and risky drinking—11
percent (target 17 percent). For the first three behaviors,
the highest proportion of counselees was in the 45- to
64-year age group; for the fourth behavior, risky drinking,
the highest proportion was in the 65- to 74-year age
group (16 percent), with only 7 percent of young adults
aged 18 to 24 years receiving counseling. In another
component of this objective, 24 percent of females aged
15 to 44 years received counseling about unintended pregnancy
in 2002, compared with 19 percent in 1995. The target
is 50 percent (Obj. 1-3f). Also, 40 percent of females
aged 45 to 57 years received counseling about management
of menopause in 2001, the first year for which data became
available. The target is 42 percent (Obj. 1-3h).
In 2003, 78 percent of the total population had a usual
primary care provider, a small proportional increase
from 77 percent in 1996. Among racial and ethnic groups
for whom data were available in 2003, Hispanics, at 63
percent, ranked lowest in access to primary care providers.
Males, at 74 percent, lagged behind females, at 81 percent,
and adults with less than a high school education had
a comparatively low access rate of 68 percent. In terms
of disability status, 85 percent of persons with activity
limitations had a usual provider, marking a comparatively
large contrast with the 77 percent of persons without
activity limitations who had such a provider. The target
for all groups is 85 percent (Obj. 1-5). In 2001, 12
percent of the total population experienced difficulty
or delay in obtaining needed health care, the same percentage
as in 1996. The target is 7 percent (Obj. 1-6). Notable
among the groups that experienced relatively high degrees
of difficulty or delay were Hispanics (14 percent); females
(13 percent, compared with males at 10 percent); the
poor (19 percent); and people with activity limitations
(19 percent). In the school year 2003–2004, the
proportion of degrees granted by health profession schools
to members of under-represented racial and ethnic groups
was as follows: American Indians/Alaska Natives—0.5
percent, compared with 0.6 percent in 1996–1997;
blacks—7.4 percent, compared with 6.5 percent in
1996–1997; and Hispanics—5.9 percent, compared
with 5.2 percent in 1996–1997. The targets for
these groups are, respectively, 1.0 percent, 13.0 percent,
and 12.0 percent (Objs. 1-8a, c, d). In 2003, the rate
of hospital admissions for uncontrolled diabetes in people
aged 18 to 64 years was 7.8 per 10,000 people, compared
with 7.2 per 10,000 in 1996. In terms of health insurance
status, the rate for Medicaid patients was 30.0 per 10,000,
compared with 3.9 per 10,000 for privately insured patients,
and 6.7 per 10,000 for uninsured patients. These rates
show a relatively large increase from 1996, when the
rate for Medicaid admissions had been 23.5 per 10,000.
The target is 5.4 per 10,000 people (Obj. 1-9b).
In 2002, the first year for which data became available,
30 states had in place processes to monitor and evaluate
trauma system outcomes. The target is all 50 states and
the District of Columbia (Obj. 1-13h). In 2001, data
also became available on the age-adjusted proportion
(9.6 percent) of persons aged 65 and older with long-term
care needs who do not have access to home health care.
The proportion of blacks in that category without such
access was 17.3 percent and of Hispanics, 14.8 percent.
Among the poor, 13.6 percent lacked access, compared
with 7.7 percent of those with middle or high income.
Persons in the category who lived outside metropolitan
statistical areas (MSAs) fared relatively better (at
7.5 percent lacking access) than those within MSAs (10.4
percent lacking access). The target is 7.7 percent (Obj.
1-15a).
Key Challenges and Current Strategies
In the presentations that followed the data overview,
the principal themes were introduced by representatives
of the two co-lead agencies—Elizabeth Duke, Administrator
of HRSA, and Carolyn Clancy, Director of AHRQ. These
agency representatives set the stage for discussions
among participants in the review by identifying a number
of barriers to achieving the objectives and citing activities
under way to meet these challenges, including the following:
Challenges
The costs of early death and poor health among
the uninsured are estimated to total between $65 billion
and $130 billion. An April 2006 survey found that half
of all young adults in the United States go without health
insurance and that more than 15 million Americans were
uninsured for 4 consecutive years.
Almost 50 percent of bankruptcy filings are
due to medical expenses. Over a 10-year period ending
in the early part of this decade, healthcare costs in
the United States rose an average of 8 percent yearly.
About 20 percent of the U.S. population reside
in localities federally designated as Health Professional
Shortage Areas (HPSAs). Shortages in the healthcare workforce,
especially in nursing, have a negative impact on continuity
of care, patient waiting times, and access to after-hours
care.
Underuse of multidisciplinary teams in primary
care and the continued use of a system focused on disease
care rather than on health care in a broader sense create
an environment that discourages any counseling dialog
between providers and patients.
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From 1993 to 2003, the population increased by 12
percent. During this period, emergency room visits
increased by 27 percent, and 425 emergency departments
were closed, imposing increasing strain on those
that remain. Hospitals that are still open have a
smaller total number of inpatient beds than a decade
ago. Emergency department overcrowding has also depleted
the surge capacity needed to deal with a natural
disaster or terrorism event.
In some instances, expanded access to health
care can result in increased rates of adverse health
outcomes (e.g., diagnosis of previously undiagnosed conditions,
doctor visits, hospitalizations, etc.).
The aging of the population makes long-term
care (LTC) services increasingly important. Persons with
LTC needs require the help of other persons to perform
activities associated with personal care and the routine
needs of daily living.
Strategies and Opportunities
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The 2005 National Healthcare Quality Report
(2005 NHQR) is a comprehensive national overview
of the quality of health care in the United States.
With 179 measures to monitor progress, the 2005
NHQR focuses on 46 core measures that represent
the most important and scientifically sound measures
of four components of quality—effectiveness,
patient safety, timeliness, and patient centeredness.
The 2005 NHQR is a product of collaboration
among agencies across HHS, in which AHRQ plays a
leading role.
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The companion 2005 National Healthcare Disparities
Report (2005 NHDR) uses the same core measures
as the 2005 NHQR to monitor the nation’s
progress toward eliminating disparities in both quality
and access to health care for both the general population
and for congressionally designated priority populations.
The 2005 NHDR includes an additional 13
core measures of access and adds two components of
quality to the 2005 NHQR’s four core
measures. The additional components are facilitators
and barriers to health care and healthcare utilization.
AHRQ’s initiative on health information
technology (HIT) includes more than $166 million in grants
and contracts in 41 states to support and stimulate investment
in HIT, especially in rural and underserved areas. AHRQ
also works with HRSA to integrate HIT systems in health
centers to improve patient safety.
HRSA has been engaged since 2001 in an unprecedented
expansion of the health center network. To date, 865
health center sites have been created or expanded, for
a total of about 3,800 sites throughout the system. The
number of patients treated each year by community, migrant,
homeless, public housing, and school-based health centers
increased by nearly 2.9 million, from about 10 million
in 2001 to about 14 million in 2005. The latest estimate
is that, in 2006, the system will serve 14.6 million
patients who are mostly minorities of low income.
HRSA’s Diabetes Prevention Pilot Collaborative
has greatly reduced the time required to translate scientific
gains to practice, improved the success rate of treating
prediabetic patients, and reduced the untoward consequences
of failure to treat such patients with full success.
HRSA’s pilot projects typically ensure a high degree
of patient involvement in their own care and provide
for a team approach in their healthcare providers’
followup strategies.
With its headquarters in HRSA, the National
Health Service Corps (NHSC) marks its 35th anniversary
this year and is currently fielding more than 3,900 physicians,
dentists, nurses, and other healthcare professionals
to deliver primary health care in HPSAs to more than
5 million people nationwide. Almost four out of five
NHSC clinicians remain in the communities to which they
are assigned after their term of service is over, a testament
to their commitment to their medically underserved patients.
A national toll-free telephone number (1-800-222-1222)
able to access 61 poison control centers is fully operational
24 hours a day in all states, Puerto Rico, and the District
of Columbia. Dialing the number connects a caller to
a poison control center in his or her geographic area.
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The year 2006 is the fifth consecutive year that
HRSA has provided funding through the Hospital Preparedness
Program to health departments in all states and territories.
Currently four metropolitan areas also receive funding.
This year, the program’s focus is on efforts
to improve the capability of local and regional healthcare
systems to address a variety of public health and
health promotion topics.
AHRQ has developed an elder-care-based knowledge
transfer partnership with the Administration on Aging,
CDC, and the Centers for Medicare and Medicaid Services
to establish and support a learning network for teams
of state and local officials and program managers to
increase the use of evidence-based prevention in community-based
settings that are linked to public health and clinical
settings.
Approaches for Consideration
Participants in the review made the following suggestions
for public health professionals and policymakers to consider
as steps that might enable further progress to be made
toward achievement of the objectives for Access to Quality
Health Services:
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To provide a sharper focus for public policy, continue
research on efforts to quantify Goal 1 of Healthy
People 2010, “Increase quality and years
of healthy life,” recognizing the wide range
of issues of measurement and interpretation that
are involved with developing summary measures of
health.
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Encourage the use of health information technology,
which is conditioned on continuing education to foster
the acceptance and proficiency in the use of such
tools.
In all programs relating to clinical care, seek
to foster and strengthen the recognition and application
of sound public health concepts and practices.
To aid in controlling and decreasing the prevalence
of chronic diseases, promote the concept and application
of a “medical home” for people with chronic
illnesses (i.e., a customary setting for interaction
with primary care providers). Make use of clinical and
community linkages in these efforts.
Encourage healthcare institutions to make greater
use of financial incentives (e.g., rewards and bonuses)
to effect improvement in the performance of healthcare
providers they employ.
In public information and outreach activities
relating to accessibility and quality of healthcare services,
highlight proven best practices in a succinct and pointed
form that lends itself to wide media coverage.
Whether healthcare professionals are in private
practice or in institutional settings, seek to make them
aware of the central and critical role they play in ensuring
that patients have timely and effective access to health
services. Work to decrease the communication gaps that
exist.
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With a view to reducing and eliminating health disparities,
explore in greater depth the interplay of varying
factors in the lives of Hispanics in the United States—such
as location, background, immigration status, folk
practices, literacy, conditions of employment, income,
and education—which can disadvantage them in
obtaining access to high-quality health care.
With healthcare costs rising less steeply than
in the past, seize the opportunity to direct additional
resources to the translation into practice of lessons
learned about enhancing access to quality health services.
Contacts for information about Healthy
People 2010 focus area 1—Access to Quality
Health Services:
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[Signed August 15, 2006]
Admiral John O. Agwunobi, M.D., M.B.A., M.P.H.
Assistant Secretary for Health
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