Abstract
BackgroundUtilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Although patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements.MethodsThe sample included 6,772 adults aged 18 years and older who participated in the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. A sequential logit model was used to account for movement in all stages of utilization: use of any health services (i.e., first stage), having a perceived need for specialty care (i.e., second stage), and utilization of specialty care (i.e., third stage). In the sequential logit model, all stages are nested within the previous stage.ResultsGender, race/ethnicity, education and poor health had significant explanatory effects with regard to use of any health services and having a perceived need for specialty care, however racial/ethnic, gender, and educational disparities were not present in utilization of specialty care. After controlling for use of any health services and having a perceived need for specialty care, inability to pay for specialty care via income (AOR = 1.334, CI = 1.10 to 1.62) or health insurance (unstable insurance: AOR = 0.26, CI = 0.14 to 0.48; no insurance: AOR = 0.12, CI = 0.07 to 0.20) were significant barriers to utilization of specialty care.ConclusionsUse of a sequential logit model to examine utilization of specialty care resulted in a detailed representation of utilization behaviors and patient characteristics that impact these behaviors at all stages within the health care system. After controlling for sequential movements within the health care system, the biggest barrier to utilizing specialty care is the inability to pay, while racial, gender, and educational disparities diminish to non-significance. Findings from this study represent how Americans use the health care system and more precisely reveals the disparities and inequalities in the U.S. health care system.
Highlights
Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system
Statistical Analysis We modeled the effects of sequential movements within the health care system in three stages: (1) use of any health services, (2) perceived need for specialty care, and (3) utilization of specialty care (Figure 1)
Results for the dependent variables show that 89% of respondents used any health services within the past two years, 42% had perceived a need for specialty care after using any health services, and 89% utilized specialty care after having a perceived need for specialty care
Summary
Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements. Studies show that income and education impact utilization of specialty care by influencing knowledge and understanding for the need of specialized care [8,11,12,13]. In addition to disparities in specialty care utilization, patients who are uninsured, underinsured, or economically disadvantaged experience barriers to accessing specialty care services (e.g., lack of physician referrals) [4,5,23] most often because specialty care involves expensive treatments and procedures that require extensive resources
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