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The Importance of Quality Care For The Medically Underserved

Health outcomes for the uninsured and underserved are well-documented to be significantly poorer than health outcomes for their privately insured counterparts. Underserved patients receive less medical care, and often receive lower quality medical care.(1) Both of these disadvantages are summed up with the following quote from a recent Newsweek article:

“What insurance (and the lack of it) often represents, as numerous studies have shown, is the difference between care and no care, between an early cancer diagnosis and a late diagnosis, between properly managing a chronic condition like asthma and waiting until a dangerous attack occurs. For some… what insurance represented was nothing less than the difference between life and death…Uninsured patients are 50 percent more likely to die of traumatic injuries than those with health insurance.”(2)

Even when underserved patients do seek medical care, they are at a disadvantage:

“The Institute of Medicine (IOM) recently reviewed the relationship between insurance status and the health of American adults. For hospital-based care, the IOM Report focused on traumatic injuries and acute cardiovascular disease, two conditions for which most people receive hospital care whether or not they are insured. It concluded that uninsured patients are less likely to be admitted to the hospital, receive fewer services when admitted, and are more likely to die than insured patients.”(3)

Local public health efforts must attack these health disparities from two fronts, working both to connect patients with health resources including preventive health care, and to ensure the quality of medical care is equal to that of privately insured, paying patients.

Find local resources that provide sustained care

Preventive care, or simply having a usual source of care, has been widely associated with better baseline health.(4), (5) It is difficult to overstate the importance of regular health monitoring, and public health initiatives must therefore strive to connect underserved patients with continuous, high quality care.

“Health insurance is most likely to improve health outcomes if the coverage is continuous and enrollees have access to high-quality providers and sites of care with adequate facilities and services. While Medicaid has been found to improve access to and use of services, it is not always associated with better health outcomes. The committee concludes that this lesser effectiveness of Medicaid with respect to health outcomes is in part due to the intermittent nature of the coverage it provides.”(6)

Because many patients cannot pay for such care themselves, public health initiatives must connect patients with local resources that will facilitate access to such health care. Free clinics that provide free or low-cost medical care to the uninsured and underinsured are an important resource for the medically underserved. Although special attention must be paid to the quality of care delivered at these clinics,(7) they have proven to be an indispensible element of the health care safety net for the disadvantaged.(8) In addition to free clinics, some regions have volunteer-based health care programs, such as Health Kentucky, which includes programs that sponsor free physician visits, pharmaceuticals, home care, and hospice services. Additionally, there are specialty-specific health coverage programs, such as VisionUSA, Eye Care America, the American Kidney Fund, the Washington Colon Health Program, and more. Many programs are region or state-specific, so public health groups must research programs available to their target population. Finally, there are some government assistance programs available for uninsured patients, such as CHIP, which sponsors healthcare for uninsured children of low-income families.

Ensure the quality of medical care

Access to some form of medical care by no means ensures the health status of underserved patients.

“A surprisingly large number of uninsured people have been able to establish a regular, ongoing relationship with either a health service facility or an individual provider as a ‘usual source of care’... [but] access to a usual source of care is not a guarantee of prevention services, nor does it ensure availability of prescriptions, specialty care, certain needed procedures, or home care services.”(9)

In addition to being consistent, medical care must be complete and of high quality. Because there are many aspects to health care delivery, the quality of health care must be assessed at multiple levels. The Institute of Medicine has identified six aims of quality medical care:(10)

• Safety: Providers must ensure that the medical care intended to benefit their patients is not causing harm. This is particularly applicable to student-run clinics, where high turnover rates, understaffing and a desire to learn clinical skills may lead medical students to practice beyond their training.(11) Free health clinics must include medical care by doctors, not by medical students, as well as referrals to specialists as needed, just as any private paying patient would receive.
• Effectiveness: Medical treatments must be based on scientific knowledge, and must produce beneficial, measurable results.
• Patient-centered: Care must be responsive to individual patient preferences, needs and values. Patients have authority over their own medical care, and their input must guide clinical decision-making.
• Timeliness: Patients requiring medical attention should have access to timely health care to avoid potentially harmful delays.(12) Equally important is patient access to timely follow-up care.
• Efficiency: Quality health care avoids wasting finances, time, equipment, and energy.
• Equitability: The quality of medical care must be consistent across patients of all genders, ethnicities, socioeconomic statuses, and other personal characteristics. This includes access to referrals, prescription medications, medical facilities, and specialty care equal to that of privately insured or paying patients.

It is documented that medical care is often inequitable. For example, a patient’s ability to pay often dictates their rehabilitation placement, discharge location, and follow-up care.(13), (14) The existence of disparate health care quality based on insurance status is well documented:

“A recent survey of internists found that, while 92 percent of physicians believed they could provide acceptable quality of care to insured patients, only 74 percent believed they could offer the same level of care to uninsured patients.”(15)

The reason cited for this reluctance is the worry that the “resources necessary to complement their professional services, such as pharmaceuticals, diagnostic testing, and specialty referrals may not be available.”(16) In other words, providing medical exams without supporting follow-up care is insufficient. Even the medical exams themselves can be unequal, based on the resources of a particular clinical facility. Complete medical exams require a great deal of specialized equipment that is generally unavailable to physicians providing ad hoc medical care in the community. Public health initiatives must aim to address these gaps in health care, as incomplete medical care is not equitable or ethical.

Footnotes

Public Health Course

• Table of Contents
• Module 1
• Module 2
• Module 3
• Module 4
• Module 5