28 February 2012 ~ 2 Comments

The Complex Process of Getting Health Care in America

Author: dunawaya

Accessing health care in this country can be a complex process for many of us. The first question we often ask ourselves is, “Do I need to see a doctor?” We tend to answer that question with a series of other questions. How much will it cost (especially if I don’t have insurance)? Will my insurance (if I have insurance) cover the visit and possible treatment? Can we afford to seek treatment? Can we find a doctor that will be able to address our need? Will seeing a doctor help the problem?” And there are other questions too.

It has become increasingly complex for people to answer these questions in ways that will lead them to good choices. Many people are choosing not to seek treatment. In the U.S., even those of us who are chronically ill may choose not to seek treatment because of cost, inefficient and poorly organized treatment, or mistakes made by the health providers once we do seek treatment (Schoen, et al). Our diversity complicates our choices. How does my ability to speak English and/or access to translation, mental health, age, sexual orientation, comfort level with the treatment process and understanding of costs affect my decision whether or not to seek health care?

Health systems have struggled with these issues for years, but often the changes they have made increased the level of complexity, solving some issues and creating others (Fennell & Adams). I am more interested in the role our communities can play and how we can support those efforts. How do we as communities of diverse people figure out how to help each other access services and support each other in ways that improve our health outcomes?

I had a chance to do some interviews in small community for a wellness project a couple of years ago that illustrates how complex it can be to access health services. Almost everyone in the sample was dealing with some sort of a chronic condition. One line of questions had to do with how people in the community accessed health care. I visited with 27 people and had many different responses. There were three local choices: a critical access hospital, a federally qualified health center, and private practice family doctors.  Fourteen of the 27 used some combination of the local providers to meet their basic needs. Others went to somewhat larger communities within 50 miles of where they lived and some went to St. Louis, Kansas City or Columbia depending on their insurance and personal preferences. No one was able to meet all health care needs locally. Most relied on family members to help them make decisions about what to do and where to go. But what do you do if your family is not close or able to assist?

For rural areas the increase in the spatial distribution of services adds to the complexity of the system and points to a need to think about how communities can coordinate access to care for their members. One rural community formed an ambulance/shuttle service using local resources to get people without transportation to a full service hospital 60 miles away. The police department provided a car they were retiring, the 911system provided dispatching, OATS, the local transportation program for disabled or underserved populations, provided drivers and they created a local system that expanded the health choices for people in the community. Most of us will need more support but transportation is an important component.

Who can help me access care if I don’t know the language or understand how to locate and access the services I need? A common response in the Latino community is the use of promotoras de salud  (health promoters). I had a chance to work with a promotoras project that served as a link to health services. The promotoras got to know the health providers in the community that would likely serve the people they supported. The promotoras then served as brokers of information to the Latino community, helped people access the right services, attend appointments with clients to provide support and translation and help their clients ask good questions. They also followed up with people to be sure they understood and followed up with their treatment plans. We found that 89 percent of those who use promotoras actually followed through with recommended treatment. Those who didn’t cited lack of resources for follow-up appointments and medications as the reasons why.

In urban areas, sometimes it can be difficult to access the services you need when you need them. This is often because the clinics they can access don’t provide all the services they need. In addition, each clinic has it’s own set of requirements to qualify for care. One group of low-income African American women whose members had a variety of chronic illnesses formed their own mutual support group to study and understand their local health options. They literally mapped the available services in the community, identified the criteria to access those services, put themselves in position to qualify and then helped each other utilize those services when necessary.

There are many community approaches that can help improve access and provide a level of brokering between those of us who struggle with the complexity of accessing health services and the services themselves.  As we look at promising larger scale interventions to simplify access and improve services such as the medical home models being tested now, let’s not forget that we are a really diverse place and that diversity will require a range of options to help people access the care they need.

How do we encourage, assess, and support the development of these innovative practices? The State of Minnesota has created a community health worker program that develops, trains and supports a range of community health worker initiatives across the state that have had a positive impact in addressing a range of health issues (BCBS Foundation).  Are there ways we can support similar efforts here in Missouri?

Steve Jeanetta is a faculty member of the rural sociology department at the University of Missouri. He has a PhD from UMSTL and his research focuses on community development, community participation and land-use issues.

The opinions and views expressed in this blog and/or comments are those of the author(s) and do not reflect any position of the Center or the University.

References

BCBS Foundation of Minnesota (2010) Community health workers in Minnesota: Bridging barriers, expanding access and improving health. Blue Cross Blue Shield Foundation of Minnesota: Minneapolis, MN. Retrieved from http://www.bcbsmnfoundation.org/pages-mediacenter-tier3-Publications?oid=7146

Fennell, M.L. & Adams, C.M. (2011). US Health-Care Organizations: Complexity turbulence, and multilevel change. Annual Review of Sociology, 37: 205-219.

Schoen, C., Osborn, R., How, S.K.H., Doty, M.M., & Peugh, J. (2008). Chronic condition: Experiences of patients with complex health care needs, in eight countries, 2008. Health Affairs, 28(1): published online before print November 2008, doi:10.13177/htlthaff.28.1.w1.

2 Responses to “The Complex Process of Getting Health Care in America”

  1. Eduardo Crespi, RN, BSN 28 February 2012 at 7:10 pm Permalink

    Great article. Thank you Dr. Jeanetta.

  2. Bro Charles 3 March 2012 at 7:12 am Permalink

    I like the overview of the thoughts about this real subject.I HAVE FOUND THAT THE LACK OF DOCTORS IN ANY RACE CAN & WILL HAVE SOME AFFECT ON THE OUTCOMES IN THE COMMUNICATIONS OF TREATMENT AS IN THE EXAMPLE GIVEN.IN SOME OF THE EARLY TRAINING OF DOCTORS, AFRICANS WERE CONSIDER NOT ALL HUMAN OR NOT HUMAN AT ALL. ADD ON THE TESTING WITHOUT CONSENT. WHEN YOU HAVE A PEOPLE IN A SYSTEM THAT SEE THEM THAT WAY, IT CAN MAKE IT HARD SOMETIME TO GET PEOPLE TO ACCEPT “NEW” OR “CHANGE WAYS”. THE RESULTS SOMETIME LEADS TO DISCONNECT. NOT EVERYBODY, SOME. GOD BLESS. Bro Charles


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