Impact of Behavioral Health Problems on Access to Care and Health Services Utilization

Article excerpt

Introduction

Access to health care services has become a key performance benchmark in most health care systems. This is especially important in the current era of capped budgets and reductions in Medicare and Medicaid reimbursement. In many large metropolitan areas, the safety net is in peril as downsizing has become necessary [Zuckerman, et al., 2001]. Some areas of the country have no public hospital to serve as this safety net. Thus, community hospitals have had to absorb the additional workload [Health System Change, 1998-99]. In such areas, Medicaid patients report difficulty obtaining appointments with private pediatricians and primary care providers. According to data from the National Comorbidity Survey, for those respondents with three or more lifetime psychiatric disorders, only 60 percent ever receive any care for those illnesses, only one-third receive care for a current episode, and only one-fifth receive any specialty mental health care for the current episode [Kessler, et al., 1994]. Thus, it appears that access to care for behavioral health problems is a particularly problematic area in the current health care system. The Community Tracking Study, which tracks changes in the U.S. health system in 60 sites representative of the nation, reported that 16 percent of patients in metropolitan areas believed that their doctor might not refer them to a specialist when needed. Twenty-five percent of physicians stated that it was not always possible to provide high-quality care to all of their patients. Of the primary care physicians: 20 percent reported difficulty in obtaining referrals to high-quality specialists for their patients, though medically necessary [Health System Change, 1998-99].

Conducted as part of a 25-year follow-up study of Vietnam veterans and a sample of matched non-veterans, the first objective of this study was to measure the impact of behavioral health problems, such as posttraumatic stress disorder, depression, drug use, and alcohol use, on access to care and health services utilization for veterans and non-veterans. The second objective was to determine the relative contribution of health system measures in the prediction of self-reported health services utilization for veterans and non-veterans and identify any differences in that contribution between inpatient utilization and outpatient utilization.

Background

Common barriers to care identified in studies of health services utilization include language, culture, child care or adult care costs, travel distance and associated travel cost, living in a rural area or poor community, lack of health insurance or funds to pay for treatment, lack of a regular source of care, inconvenient office or clinic hours, and personal obligations [Gresenz, et al., 2000; McFall, et al., 2000; Fourtney, et al., 1999; Li, et al., 1999; Grella, 1997]. Additional barriers, specifically faced by patients with behavioral health problems, include lack of knowledge of the range of available treatment options, lack of knowledge of the mental health benefits they are entitled to, fear of rejection by the health care system due to the social stigma and labeling associated with substance abuse and mental disorders, confidentiality concerns, perception of symptoms as somatic rather than psychiatric in origin, and difficulty negotiating the health care system due to a psychiatric diagnosis [Mickus, et al., 2000; Copeland, 1997].

Recent analyses focusing on behavioral health care have also identified factors which appear to improve access to such care. One example is greater health maintenance organization (HMO) presence [Gresenz, et al., 2000; Norquist and Wells, 1991; Manning, et al., 1987]. Greater HMO presence was originally feared to lower access to specialty care. It is conjectured that HMO's may affect access by changing help-seeking patterns, educating the community through advertising, or fostering increased competition among doctors vying for fee-for-service patients, resulting in reduced fees. …