David Radley, Cathy Schoen
D. C. Radley and C. Schoen, "Geographic Variation in Access to Care—The Relationship with Quality," New England Journal of Medicine, published online June 13, 2012.
Much research attention has focused on regional variations in health care costs and use of health care services across the United States, primarily based on Medicare experience. Less attention has focused on geographic variations in access and the implications for quality of care and health outcomes. Analyzing data from the Commonwealth Fund report, Rising to the Challenge: Results from a Scorecard on Local Health System Performance, 2012, this perspective finds widespread differences across local areas in residents’ ability to access care, with implications for receipt of preventive care and outcomes.
The study found that where a person lives matters. The proportion of uninsured adults (ages 18 to 64) ranged from 5 percent in Massachusetts’ three local areas to more than half in two local areas in Texas. Wide variation was also seen in the proportion of adults who went without care because of cost (5% to 33%) and among adults age 50 or older or with a chronic disease who visited a doctor in the previous two years (67% to 95%). Although the uninsured were at greatest risk, among the insured there was wide variation in having a regular source of care and receipt of recommend preventive care across the country. For example, the percentage of adults age 50 or older who received recommended screenings for cancer and other preventive care ranged from 31 percent to 58 percent among insured adults across local areas, and the percentage of insured adult diabetics who received recommended care for their condition ranged from 28 percent to 71 percent. The authors note that findings indicate that health insurance alone is not sufficient—comprehensiveness and affordability of coverage, as well as access to primary care, are also important.
The analysis also found that areas with poor access to care had relatively poor-quality care on a number of indicators, including the number of unsafe prescriptions among Medicare beneficiaries, avoidable emergency department visits, and deaths from conditions that are potentially preventable with timely care.
The researchers conclude that health insurance expansions and other reforms enacted under the Affordable Care Act should improve access to care as well as its quality by guaranteeing essential benefits and strengthening primary care. Ultimately, they suggest that improvement will depend on collaborations among local clinicians, hospital leaders, insurance companies, policymakers, and other community stakeholders.