American Medical Association Science News Updates are made available to the public after 3 PM Central time (US) on the first 4 Tuesdays of each month. We also provide a list of previous news releases.

THIS WEEK'S CONTENTS

JAMA REPORTS
(ACCESS TO CARE THEME ISSUE)

• MANY UNINSURED ADULTS DO NOT RECEIVE NEEDED MEDICAL CARE
• COMPREHENSIVE FOLLOW-UP CARE FOR HIGH-RISK INFANTS EFFECTIVE METHOD TO REDUCE LIFE-THREATENING ILLNESSES
• INSURANCE ALONE DOES NOT AUTOMATICALLY LEAD TO HIGH-QUALITY CARE

MANY UNINSURED ADULTS DO NOT RECEIVE NEEDED MEDICAL CARE
Unmet Health Needs Greatest Among People Uninsured More Than 1 Year

CHICAGO—American adults without health insurance are less likely than insured adults to receive preventive care or routine checkups, and more likely to report they could not see a physician because of cost, according to an article in the October 25 issue of the Journal of the American Medical Association, a theme issue on access to care.

John Z. Ayanian, MD, MPP, of Brigham and Women's Hospital and the Harvard Medical School, Boston, Mass, and colleagues, compared survey data to estimate the unmet health needs of insured and uninsured US adults. The study population was representative of more than 163 million US adults aged 18 to 64 years residing in households during 1998 and approximately 161 million comparable adults in 1997. The study included 105 764 people aged 18 to 64 years surveyed in 1997, and 117 364 surveyed in 1998 who were classified as long-term uninsured (without health insurance for a year or longer), short-term uninsured (without insurance for less than a year), or insured. Data came from the Behavioral Risk Factor Surveillance System (BRFSS), a federally funded survey designed by the Centers for Disease Control and Prevention (CDC) in collaboration with state health departments. Since 1994, all 50 states and the District of Columbia have administered the BRFSS survey and submitted data to the CDC.

According to background information cited in the study, approximately 33 million US adults aged 18 to 64 were without health insurance in 1998. Prior studies have documented that lacking health insurance is associated with important clinical consequences. Uninsured adults are more likely than insured adults to report poor health status, delay seeking medical care, and forgo necessary care for potentially serious symptoms. Uninsured adults receive fewer screening services for cancer and cardiovascular risk factors, present with later-stage diagnoses of cancer, and experience more avoidable hospitalizations. They also face an increased risk of death, particularly when hospitalized or diagnosed as having breast cancer.

Among Americans surveyed for the BRFSS in 1998, 9.7% were long-term uninsured, 4.3% were short-term uninsured, and 86% were insured. Proportions of uninsured individuals were higher among younger adults, men, blacks, Hispanics, residents of the South and West, those with less education and lower incomes, and those who were self-employed, unemployed, or not in the labor force. Adults whose self-reported health status was good, fair, or poor were 2 to 3 times more likely to have been uninsured for 1 year or longer than those who reported excellent or very good health.

"Long-term and short-term uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost," the authors write. Cost kept 26.8% of long-term uninsured and 21.7% of short-term uninsured adults from seeing a physician, compared with 8.2% of insured adults. This was especially true among those in poor or fair health.

"Long-term uninsured adults in general were much more likely than short-term uninsured and insured adults not to have had a routine checkup in the last 2 years," the authors write. A full 42.8% of long-term uninsured adults said they had not had a routine checkup over the previous 2 years, compared with 22.3% of short-term uninsured and 17.8% of insured adults.

Long-term uninsured adults also received fewer preventive services, including cancer screening, cardiovascular risk reduction, and diabetes management. "Long-term uninsured adults were significantly more likely than insured adults to have unmet needs for each of these services, except for glycosylated hemoglobin measurements and pneumococcal vaccinations among adults with diabetes and HIV screening among those with self-perceived risk. For clinical services such as breast cancer or hypertension screening, long-term uninsured adults were 3 to 4 times more likely not to have received these services," the authors write.

"Alarmingly high proportions of long-term uninsured adults in poor or fair health reported forgoing needed care, including about two thirds of those in poor health and half of those in fair health," the authors assert. "These findings challenge the views of a growing proportion of Americans—from 43% in 1993 to 57% in 1999—who believe that uninsured people are able to get the care they need from physicians and hospitals."

The authors believe that providing insurance to improve access to care for long-term uninsured adults, particularly those with major health risks, could have substantial clinical benefits.

"The federal and state governments have begun to extend affordable health insurance to uninsured children in the United States by expanding Medicaid and launching the Children's Health Insurance Program. In contrast, the unmet health needs of 33 million uninsured adults continue to fester in the health care system without a cohesive political response by the federal government or most states. Concerted and collaborative action by policymakers and health care professionals will be required to address these persistent needs," they conclude.

Editor's Note: This study was funded by the American College of Physicians-American Society of Internal Medicine.

Go back to the top.

COMPREHENSIVE FOLLOW-UP CARE FOR HIGH-RISK INFANTS EFFECTIVE METHOD TO REDUCE LIFE-THREATENING ILLNESSES
Comprehensive Care Results in Better Outcomes Without Increasing Costs

CHICAGO—A program that provided more comprehensive follow-up care for high-risk infants, including 24-hour access to care, had better outcomes and lower overall costs estimates when compared with routine follow-up care, according to an article in the October 25 issue of the Journal of the American Medical Association), a theme issue on access to care.

R. Sue Broyles, MD, from the University of Texas Southwestern Medical Center at Dallas, and colleagues studied 887 high-risk infants who were randomly assigned to receive either routine follow-up or comprehensive follow-up care. For the purpose of this study, the researchers defined high-risk infants as either having a very-low-birth-weight (less than 1000 g or less than approximately 2 lbs, 3 oz) or having a weight between 1001 g and 1500 g (between approximately 2 pounds, 3 oz and 3 lbs, 5 oz) who needed a mechanical ventilator (a device that supports breathing) in the first 48 hours after birth.

The researchers found that comprehensive care resulted in an average of 3.1 more clinic visits and 6.7 more telephone conversations with clinic staff. The number of deaths in the 2 groups were similar (11 in the comprehensive care group vs 13 in the routine care group), but high-risk infants assigned to receive comprehensive follow-up care had 48% fewer life-threatening illnesses (33 vs 63), had 57% fewer intensive care admissions (23 vs 53), and spent 42% fewer days in an intensive care unit (254 vs 440 days).

The estimated average cost per infant for all care received for the 1-year period after discharge from the hospital nursery was $6265 for infants in the comprehensive care group and $9913 for infants who received routine follow-up care.

The authors note "Our findings demonstrate that comprehensive follow-up care provided by highly experienced caregivers can be highly effective in reducing life-threatening illnesses without increasing the overall costs of care for high-risk inner-city infants. Follow-up clinics that serve such infants should consider developing a comprehensive-care program."

Routine follow-up care was available 2 mornings per week and included well-baby care (for example, immunizations, social services, and assessment of the child's development) and care for chronic conditions. Comprehensive follow-up care was available 5 days per week and included all the components of routine follow-up care plus care for acute illnesses (illnesses with a sudden onset) and 24-hour access to a nurse practitioner or physician's assistant.

Citing previous studies, the authors note that "Neonatal follow-up programs were originally developed to survey the outcome of high-risk infants, assess the effects of perinatal insults (medical problems that were discovered around the time of birth) and care, and identify infants needing referral for care of ongoing problems. Unfortunately, this approach has often been associated with a substantial loss to follow-up among families of lower socioeconomic status. Moreover, this approach does not address the needs of very-low-birth-weight infants of any socioeconomic situation who lack access to a physician skilled in managing the pulmonary, gastrointestinal, nutritional, neurological, developmental and other problems common among these infants. Some follow-up programs now provide well-baby care and care for chronic illnesses. However, care for acute illnesses typically is not provided. Without prompt, effective treatment, minor illnesses or complications may quickly become life-threatening in these vulnerable infants. This problem is likely to contribute to their increased mortality, morbidity, and cost of care throughout infancy."

Editor's Note: Financial support was provided by a grant from the Agency for Healthcare Research and Quality and by funds provided by the North Texas Chapter of the National Foundation March of Dimes.

Go back to the top.

INSURANCE ALONE DOES NOT AUTOMATICALLY LEAD TO HIGH-QUALITY CARE
Efforts Needed to Eliminate "Voltage Drops" in US Health Care System

CHICAGO—The availability of insurance coverage alone is not enough to close the gap between the potential for high-quality health care and the reality of care delivered in the United States, according to an article in the October 25 issue of the Journal of the American Medical Association, a theme issue on access to care.

John M. Eisenberg, MD, of the Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Md, and Elaine J. Power, MPP, of the National Forum for Healthcare Quality Measurement and Reporting, Washington, DC, explore points of vulnerability at which the potential to achieve high-quality care can be lost.

"Just as voltage can be lost in an electrical system as the current passes through resistance, there are many voltage drops between the availability of insurance and the delivery of high-quality care and between the capacity to serve and the service that meets people's needs," they write. The authors address the following "voltage drop" points:

ACCESS TO INSURANCE COVERAGE
"Experts estimate that more than 42 million Americans—roughly 1 in 6—are without health insurance," the authors write.

More than 20% of African Americans and almost 32% of Hispanics do not have health insurance, compared with 12% of whites. Almost 32% of adults aged 19 to 24 are uninsured. Among children in families with single working parents, only 55% have private insurance coverage.

ENROLLMENT IN AVAILABLE INSURANCE PLANS
"Among those with access to employment-based insurance, only 89% are actually covered by a health care plan," the authors write. "One reason is that insurance can be costly, especially for low-wage workers."

ACCESS TO COVERED SERVICES AND PROVIDERS
"Certain services may not be covered; certain physicians and hospitals may not be included among those participating in a plan or contracting with it; a provider may be unwilling to accept payment rates. Cost-sharing requirements may deter patients from seeking care," the authors write.

CHOICE OF PLANS AND PROVIDERS
"Individuals and purchasers acting on their behalf should be able to exercise their preference for quality by choosing plans and providers that offer the best value—the highest quality care that, from their perspective, is worth the cost," the authors write. "Yet, in the current US health care system, most people do not have this choice or do not have the information that allows them to exercise it in a meaningful way."

ACCESS TO A CONSISTENT SOURCE OF PRIMARY CARE
More than 14% of non-elderly adults with private insurance and 13% of those with public insurance do not have a regular source of primary care. "Reasons may be as simple as patient choice (people in good health may forgo contact with health care provider) or as complex as disruptions in available sources of care stemming from hospital closures, changes in managed care contracts, or an employer's shift from one insurer and provider network to another," the authors write.

People with a regular source of care are much more likely to receive preventive care services, and may be more likely to receive care for chronic and acute conditions.

ACCESS TO REFERRAL SERVICES
Even if individuals are insured and have a regular source of primary care, they may not have access to important specialty services. "In a survey by the Kaiser Family Foundation, nearly 9 out of 10 physicians claimed that some of their patients had been denied coverage for services they had ordered during the past 2 years. Sixty-five percent of denials for a mental health service and 50% of denials for referrals to specialists were rated by the physicians as resulting in a serious health decline for the patient," the authors write.

DELIVERY OF HIGH-QUALITY HEALTH CARE SERVICES
Even when all the voltage drops in achieving insurance coverage, choice, and access are addressed, the authors assert evidence abounds that the care delivered to patients is not as good as it can be.

"We have done well to develop some valid measures—a few ways to test the voltage of quality that is being delivered to patients in the health care system," the authors write. "We now need to progress to more consistent and broadly applicable measures that allow us to track the quality of care and to focus on areas for improvement, especially for vulnerable populations."

"Preventing these voltage drops between insurance and quality of care will require a multi-pronged effort to ensure not only that insurance is available but also that it is taken, not only that appropriate services are covered but also that informed choices can be made, and not only that primary care and specialty services are accessible but also that quality care is delivered," they conclude. "Doing so will not only prevent voltage drops but also will transform the nation's health care."

Editor's Note: The views expressed in this article are those of the authors and do not necessarily represent the position of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the National Quality Forum.

Go back to the top.

© 1995-1999 American Medical Association. All rights reserved.