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Access to care:
Are there lessons from medicine?
Maria Goddard
Professor of Health Economics
Director
Centre for Health Economics
University of York
Outline
• Access in health care context.
• Equity focus.
• Economics perspective.
What is Access? / Equity of Access?
Equal access to care for people in equal need.
NOT necessarily the same as:
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equal provision
equal expenditure
equal inputs
equal utilisation
equal outcomes
Access
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Utilisation is usually the proxy.
Does it capture quality?
Use of alternatives?
Is “more” necessarily “better”?
Need
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Level of illness or capacity to benefit?
Clinical concept only?
How to measure health status?
At what stage to measure?
Differences between health and
dental care and other services
• Health care is "different" from other services/goods:
– demand for health care unpredictable
– lack of knowledge of individual about quality
– "externalities", eg, communicable disease
• Dental care is "different" from health care:
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less frequent occurrence, more predictable
infrequent “emergency” aspect
more "experience" based
major preventive focus
role of price
Demand for dental care
may therefore be more
responsive to price than
demand for health care.
Stylised demand and supply
“Price”
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“Quantity”
Demand
• Real price/cost of access.
• Perceptions:
– price/costs;
– availability;
– efficacy.
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Health beliefs and behaviour.
"Voice".
Availability of alternatives.
First contact versus subsequent care.
What do we know about
demand for health care?
• Different picture for acute and preventive
care.
• Preventive:
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beliefs/motivation
"candidacy"
information, communication
“navigation”
time and access costs
follow-up, completion of treatment
distance
Supply
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Exclusion of whole groups.
Costs of access.
Quality may vary.
Lack of information.
Professional gatekeeper role.
Incentive structure.
What do we know about
supply of health care?
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Role of incentives for providers.
“Too little” versus “too much” care.
Role of professional beliefs
“candidacy”.
“Permeability” of services.
Registration may not always be effective.
Interaction of
demand and supply
• “Inverse Prevention Law”.
• Increases in “supply” have variable
impacts.
• “One size fits all” interventions can
increase inequities of access.
Lessons?
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Prevention versus acute.
Demand, supply and their interaction.
Candidacy, navigation, permeability.
“More” not necessarily “better”.
Incentives matter