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• W2731177537 abstract "A primary reason for increased government involvement in health care delivery resides in the acknowledge difficulty of the poor in obtalning adequate care. In the absence of knowledwl about how health, health care, socio-economic status, race, ethnicity and geographic location are related, however, pclicies aimed at implementing right to health care concepts threaten to squander redources without achieving.any benefit for the poor. .Summaries of several research projects bearing on these relationships are reviewed. These include a model relating health status to demand for health care, analyses of urban physician office distriPution, the efficacy of comprehensive care, the effects of air pollution and radiation on health, the role of paramedics in the delivery of primary care, and a three tiered moddl for an urban medical care delivery system. Health care has been identified as a right of citizenship in recent federal legislation, in the speeches of prominent politicians and in the professional writings of numerous researchers and academicians. The health of the poor is at the center of the controversy. The poor are seen to be captured in a perverse cycle: because they are poor they are unhealthy, because they cannot afford high quality care or cannot locate it easily they remain unhealthy, being unhealthy they cannot wurk or learn, are therefore forced to remain poor, and the cycle is closed-poverty yields ill health, ill health perpetuates poverty. 1/ That health and income are associated has been amply demonstrated. We know that the poor have worse health than the nonpoor and that the nonpoor receive different medical care than the poor. But we have no idea of which is cause and which is effect. We don't know how health and health care interrelate with socio-economic status, race, and ethnicity or what policies hold the greatest promise o: improving health. Policies whose objectives are implementation of the right to health care have assumed that increased medical care is critical to attain better health. There is little evidence that radically increasing medical care for the poor will result in major improvements in health.. There is even the possibility that policies whose goals are the equilization of health can have a counter productive effect and lead to a lowering of health levels. This will be the case if they involve taking resources away from one group, such as children, and reallocating them to another, such as the aged as has occurred with medicare. Without a clear understanding of the processes prompting demand for medical care and of the non-medical factors influencing the effectiveness of care, attempts at implementing a public right to medical care concept will be hit or miss operations. 3 Their efficiency and long range effects upon the overall well being of the population will be impossible to predict. Unless we can determine the components crucial to the attainment of health and can estimate their role in attaining and preserving health, we run the risk of squandering our resources and making no progress. Medicare and Medicaid caused large scale changes in health care delivery, with effects on overall health and the cost .af health. Before initiating changes of such a magnitude, it behooves us to examine the nature of the change we can expect from these alterations and haw much we are willing to allocate to achieve a given change in the distribution of health via this mgchanism. Improving health may be only one objective for medical care policy decisions. Redistributing income to the poor as part of a medical care program is another perfectly reasonable objective. However, more efficient techniques exist to achieve such goals, e.g., graduated taxes or income subsidies. Here we limit our concern to the goal of improved health. In our research we have been concerned with clarifying these issues. We have attempted to determine what variables effect health and what variables effect the delivery of health care. In the following sections, we review some of our recent work. Our approach revolves around the specification of a model relating the health status of a population to.its demand for care and the various ways in which this demand can be satisfied or left unsatisfied. With the aid of the model we have attempted to differentiate between the medical professional's concept of need (the objective medical state of an individual) and the economist's concept of demand (the iudividualls request for care at same institution). We have been led to examine the variables tnfluencing the decisions of 4 individuals to seek care, to accept care and to follow through with care as well as the efficacy of care. We have operated under the assumption that it is important to attack the health problems of the poor from a unified framework. We believe that it can be misleading to consider separate aspects of the problem and treat each in an ad hoc fashion, e.g., to relocate physicians so they are closer to the poor in no way guarantees that the poor will come to these relocated providers, to receive care. Often achieving the subgoal has little effect on improving health status. In what follows we describe our model of the delivery system briefly and then amplify portions in terms of research in ambplatory care which we have accomplished. A Model of the Delivery of Medical Care A population can be characterized in terms of its underlying health status, i.e., the distribution of the kinds and severity of illnesses present in the population at some given moment.2/ The National Health Survey is one attempt to specify the underlying health status of the entire nation. This health status is dependent on several factors. It is likely that the most important non-medical factors are the population's genetic makeup, personal habits and life style, demographic and socioeconomic characteristics, the nature of the physical envIronment and the prevalence of pathologens. There have been attempts to characterize the nature of this dependence and to isolate the effects of the crucial variables and to identify the ways in which health status would be expected to change if one or another of the factors were manipu1ated:11 In our model health status depends on these background variables and the amount of medical intervention. If medical care is more effective than all other variables, bringing middle class medical care to the poor should cause their health status to approximate that of the more affluent. Alternatively, if these other variables tend to reduce the effectiveness of care or are in themselves more important than direct medical care, the provision of facilities comparable to those servicing the nonpoor will have little effect on health status. It is important to distinguish between facilities and actual receipt of car,e. One can provide facilities, but it is more difficult to ensure that the people needing care get it. For example, while innocalations might produce large reductions in morbidity, they are useless unless a way can be found to gain the cooperation of the people. We cannot force care upon recipients. Rather, we must wait for care to be demanded. Most medical care delivered to individuals, especially preventive and acute care, is P.ctive--it requires some action on the part of the recipient of care. For example, the patient must seek care, must decide whether to accept the care prescribed, and, frequently, must decide whether to adhere to an extended care regiment. A population's linderlying health status, socio-cultural variables (such as attitudes towards medical care) will interact with the general cost of attaining medical care and lead to a proportion of the population saeking medical care by presenting themselves at physicians offices, emergency rooms and clinics. For example, where attitudes towards medical care are contrary, i.e., when the efficacy of medical care in curing or preventing illness is questioned, fewer individuals will appear at a ph7siciansl office seeking care. Variations in the underlying health status will effect both the quantity and quality of the care demanded. Some of the individuals seeking care will have severe medical problems and will be in danger of dying unless sophisticated and costly techniques are quickly brought to bear; most will have relatively minor, easily treated symptoms, or be seeking preventive care; and some will simply be in need of information having no treatable medical problem. .In general, the greater the incidence of severe symptoms the greater the expected demand and the more elaborate the treatment facilities which will be required to treat the presentations adequately. given some level of health status or distribution of symptoms severity, the expressed demand for care will be dependent not only upon the payment to the provider of care bilt also the associated time, transportation, lost wages, and fees paid to traverse the distance and to receive the care, as well as the psychological cost associated with the process. Thus, individuals are more likely to seek care at an institution which is geographically accessible, does not inconvenience them with long waits or poorly scheduled hours, is inexpensive, presents an encouraging milieu, and pravides hospitable patient-provider encounters. Although most conditions are self-limiting, many become more severe when treatment is delayed and require more expensive and elaborate treatment because of their advanced nature or the onset of complications. In the extreme, the system can be so inaccessible that people literally die without seeking care or can be so accessible that few severe medical problems are ever presented." @default.
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• W2731177537 date "1971-09-01" @default.
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• W2731177537 title "Studies in the Delivery of Ambulatory Care." @default.
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