29 October 2015 8:19 AM 3 This chapter presents basic trends as well as research and policy issues related to health care access. We define access as actual use of personal health services and everything that facilitates or impedes their use. It is the link between health services systems and the populations they serve. Access means not only visiting a medical care provider but also getting to the right services at the right time to promote improved health outcomes. Conceptualizing and measuring access is the key to understanding and making health policy in a number of ways: (1) predicting use of health services, (2) promoting social justice, and (3) improving effectiveness and efficiency of health service delivery. The chapter presents a conceptual framework for understanding the multiple dimensions of access to medical care. The various types of access are considered and related to their policy purposes. Examples of key access measures are given, and trend data are used to track changes that have occurred over time in these access indicators. The chapter addresses the questions: Is access improving or declining in the United States? for whom? according to what measures? It concludes by discussing future access indicators and research directions.

Improving Access to Care in America: Individual and Contextual Indicators.

We have estimated the effects of various prototypical health-insurance options on demand for medical services. The data indicate that under full coverage or 25 per cent maximum coinsurance...

/pdf/policy-options-and-the-impact-of-national-health-insurance-52693fhh3o.pdf

Policy options and the impact of national health insurance.

Most previous studies comparing the efficiency of new health practitioners with that of physicians have used the visit as the basic unit of output. Several researchers have noted, though, that the episode is a conceptually superior output unit in several respects, although it is more complex to deal with methodologically. This study demonstrates the application of episode-based methods for comparing the efficiency of physicians with that of nurse practitioners. Data are drawn from the information system of the Columbia Medical Plan and from observations of provider time inputs. The analysis is confined to care episodes for otitis media and sore throat in the Department of Pediatrics. Results indicate that per episode costs with nurse practitioners as the initial provider are approximately 20 per cent below the costs of episodes in which physicians are the initial provider. Examination of a limited amount of data on patient-reported measures of effectiveness indicates that while nurse practitioners' care is less costly, it is not less effective. These findings are particularly interesting in light of recent doubts expressed about cost-savings from using new health practitioners, and particularly nurse practitioners, in group practice settings.

Episode-based efficiency comparisons for physicians and nurse practitioners.

OBJECTIVES To examine the impact of the degree of electronic health record (EHR) use and delegation of EHR tasks on clinician productivity in ambulatory settings. STUDY DESIGN We examined EHR use in primary care practices that implemented a web-based EHR from athenahealth (n = 42) over 3 years (695 practice-month observations). Practices were predominantly small and spread throughout the country. Data came from athenahealth practice management system and EHR task logs. METHODS We developed monthly measures of EHR use and delegation to support staff from task logs. Productivity was measured using work relative value units (RVUs). Using fixed effects models, we assessed the independent impacts on productivity of EHR use and delegation. We then explored the interaction between these 2 strategies and the role of practice size. RESULTS Greater EHR use and greater delegation were independently associated with higher levels of productivity. An increase in EHR use of 1 standard deviation resulted in a 5.3% increase in RVUs per clinician workday; an increase in delegation of EHR tasks of 1 standard deviation resulted in an 11.0% increase in RVUs per clinician workday (P <.05 for both). Further, EHR use and delegation had a positive joint impact on productivity in large practices (coefficient, 0.058; P <.05), but a negative joint impact on productivity in small practices (coefficient, -0.142; P <.01). CONCLUSIONS Clinicians in practices that increased EHR use and delegated EHR tasks were more productive, but practice size determined whether the 2 strategies were complements or substitutes.

The impact of electronic health record use on physician productivity

Students of the American health-care delivery system are generally agreed that, under its present organization, the system will be unable to accommodate any of the more ambitious national health-insurance schemes now before Congress It is argued that the current system is actually a fragmented "nonsystem" that fails to deliver the right mix of care to the right people and at the right time As a result, it is argued, the health-maintenance services received by the average American tend to be of dubious overall quality and are unnecessarily costly To eliminate these shortcomings, a great number of reforms have been proposed, the bulk of which, however, fall into one of the following major types: (a) a shift away from the fee-for-service mode of paying for health services and toward prepayment of comprehensive health care, (b) the substitution of paramedical for medical manpower and of capital for all types of manpower, (c) the consolidation of small provider facilities (especially solo medical practices) into larger production units, and (d) the integration of provider facilities in centrally directed regional systems In this essay, the various reform proposals that have been proposed at one time or another are explored against the backdrop of pertinent empirical research available at this time This exploration leads to the disappointing conclusion that far too many of the proposed reorganization schemesparticularly the much touted idea of a nationwide network of presumably competitive Health Maintenance Organizations-appear to have been proffered more on the basis of intuition or faith than on the basis of convincing empirical evidence At the risk of appearing timid and of exasperating the impatient reformer, the author concludes that a great deal more empirical information needs to be gathered on the behavior of the participants in the health-care sector and on the technical constraints under which that sector operates before one can confidently develop and follow a coherent blueprint for a reorganization of the American health-care system

Proposed changes in the organization of health-care delivery: an overview and critique.

The purpose of this paper is to explore the implications of employing "physicians' assistants" in delivering primary medical care. It seeks to identify the optimal role of paramedical personnel and to assess the impact of efficient delegation of tasks on the productivity of the physician, his opportunities for leisure, and the cost of care. The technical opportunities for delegation and the specific demands for medical services imposed on the primary care practice are identified. These data are then analyzed in an activity analysis model of the practice to identify and assess the implications of efficient patterns of delegation.

An analysis of the optimal use of inputs in the production of medical services

This paper presents an activity analysis model of primary medical care which, through the use of integer constraints, captures both the technology of ambulatory care and the institutional restriction that labor inputs must be employed in discrete units. The result is that staffing patterns and optimal choice of techniques depend on the scale of practice. Empirical experiments demonstrate this relationship and, furthermore, reveal that introduction of physician extenders into the medical care system increases the scale at which economies of staffing are obtained and raises the diseconomies of suboptimal practice.

Fredrick L. Golladay

Papers

An analysis of the optimal use of inputs in the production of medical services

Scale Economies in the Delivery of Medical Care: A Mixed Integer Programming Analysis of Efficient Manpower Utilization