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Access Issues Within VA Offer Challenges, Research Opportunities

Access is one of the key "domains of value" for VHA. As access is largely determined by the structure and functioning of the health care system, health services research is uniquely positioned to investigate this aspect of health care.

The Merriam-Webster dictionary defines access as: "permission, liberty, or ability to approach or communicate with a person or thing," or "freedom or ability to obtain or make use of something." Reflecting on this definition, it is apparent that access has several dimensions.

Dimensions of Access

Geographical. The first aspect is geographical access. Is a particular health care service available within a given geographical area? Traveling long distances for care can represent a significant barrier to obtaining needed services. VHA began as a hospital benefit but has gradually expanded to include the full spectrum of care. Veterans live in every community in the country, often far from the nearest VA Medical Center. The development of Community Based Outpatient Clinics (CBOCs) was an effort on the part of VHA to improve the geographical availability of its services.

CBOCs have been successful in improving access to primary care, but providing VHA primary care far from VHA specialty and hospital services creates significant difficulties for VHA primary care providers. The geographic distance between primary and specialty care services delivery also has contributed to the growth of dual care, with patients receiving care in multiple (VA and non-VA) systems. The recent creation of an Office of Rural Health in the Office of Policy and Planning reflects the continued concern over providing VA care to patients in sparsely populated areas far from urban centers.

Financial. The necessary financial resources are a prerequisite to obtaining health care. In the United States, the lack of health insurance represents the greatest barrier to accessing health care for millions of citizens and has been the focus of much policy and political debate. One of the strengths of VHA has been the relative freedom from financial barriers to care once a patient is enrolled in the system, and it is often considered an "equal access system." Nevertheless, the presence of copayments, the size of copayments, and decisions about inclusion or exclusion of priority groups are all issues that reflect financial influences on access even within the VA. These issues are ripe for investigation.

Cultural. Ethnic or socioeconomic factors can contribute to financial and geographical barriers, but cultural differences may also play a role in access. Differences in cultural expectations and communication styles between patients and health care providers can result in significant difficulties in patients obtaining the care they need or desire. These cultural differences can arise on the basis of ethnicity, socioeconomic status, gender, religion, age, and other factors. The difficulties that vulnerable populations, such as those with severe mental illness and the homeless, experience in accessing care can be considered in this category as well.

Timeliness. Another barrier to access is delay in receiving needed services. While services may be geographically available, affordable, and culturally accessible, long appointment wait times and treatment delays can lead to disruptions in patient care. This barrier has been a particular concern for the VA.

Important research questions arise for all these areas. How can researchers define andmeasure these dimensions? To what degree does health care utilization vary across these dimensions? What effect does this variation have on actual health care outcomes? What effect do changes in health services delivery have? For example, VA needs to better understand the impact on access of the presence of CBOCs, variation in copayments, creation of women's clinics, and Advanced Clinic Access initiatives.

A search of the HSR&D publication database found 170 citations where the word 'access' appeared. Of these citations, 62 were for publications in peer reviewed journals These publications fall into the following general subject areas (with some articles covering more than one area): cultural factors such as race and vulnerable populations (23 citations); access to health care in general or specific health care services such as rehabilitation, or automated external defibrillator (18); access to mental health services (11); geographical factors (11); communication technologies such as the Internet (6); insurance (3); and timeliness (1).

While this simple search no doubt identified only a portion of relevant articles, the results are of interest. The extensive effort by VA HSR&D to evaluate cultural factors on access is impressive. This includes numerous studies on vulnerable populations, including those with mental illness and HIV, and their access to care. Access to mental health services has been a particular focus of activity, and a variety of these publications explore geographical factors. Given the relatively small influence economic factors have on access within VA, the number of publications in this area is not surprising. The paucity of research on timeliness represents an important opportunity for HSR&D.

When discussing access, Dr. Jonathan Perlin, former Under Secretary for Health, would frequently say "Without access there is no quality." His message is a salient reminder of the need for VA HSR&D to maintain its rigorous focus on improving our understanding of the key access challenges experienced by veterans, especially those related to geographic, financial, cultural, and timeliness barriers.