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Adolescents, health services, and access to care
JOURNAL OF ADOLESCENT HEALTH 2000;27:293–294
FROM THE EDITORIAL BOARD
Adolescents, Health Services, and Access to Care
In “The Ecology of Medical Care,” Kerr White asks whether “…the available quantity, quality, and distribution of medical care is optimum in the opinion of consumers?” (1).“ Unfortunately, as quality, cost, and access struggle to find balance in the actions of payers, insurers, and patients, many adolescent health clinicians remain sideline players, if that. Our nations’ health objectives call for screening and health promotion, and various guidelines recommend annual counseling about and screening for preventable health problems for adolescents (2). Clinical preventive services delivery in ambulatory care settings are also among those services most often used by young people and their families. From a broad perspective on youth, health services are but one of the multitude of environmental, community, family and individual factors that affect the developmental trajectory of youth. However, improving the health care system is more easily within our reach than interventions into some of the less mutable factors in adolescents’ lives. Access to care has been associated with reduction in risky behaviors, improvements in health, and is an indicator of equity (3). In 1992, the Office of Technology Adolescent Health report called on Congress to consider ”improving U.S. adolescents’ access to health services.“ (4). But adolescents and young adults still have worse access to health care than all other age groups in the US. In the late 90’s, 15% of our nation’s adolescents still were unable to identify a regular source of care (5,6). Knowledge about the availability of services, transportation and distance, confidentiality, ability to pay, and lack of insurance remain important issues affecting adolescents’ access. Many adolescents do not have access to mental health or reproductive health services, especially in poorer communities. As many as 27% of adolescents report ever missing needed care, most often owing to lack of insurance, and confidentiality concerns, or fear of embarrassment or disclosure (6). Even those who receive preventive visits often do not receive recommended
counseling or screening. More than 80% of adolescents have seen their clinician within the last year, but nearly half of the visits did not include an opportunity for the teenager to talk privately with their physician, and fewer than half of those who thought they should talk with their doctor about pregnancy prevention or sexually transmitted diseases (STDs) had ever done so (6). Thus, a substantial portion of visits could not possibly have provided confidential counseling or screening for preventable risky behaviors. Managed care quality measures, such as the Health Plan Employer Data and Information Set (HEDIS), include an annual preventive care visit measure for adolescents. However, to assess the quality of care provided, it is important to look at the content of care delivered, and not just utilization. In the last year, the Centers for Disease Control and Prevention Youth Risk Behavior Surveillance System (YRBSS) added two core items to help understand adolescents’ experience with care: when adolescents last had a care visit, and whether they had received counseling about HIV and STDs. Additionally, the Foundation for Accountability and the National Commission on Quality Accreditation Child and Adolescent Health Measurement Initiative has developed and tested quality measures to help families, purchasers, and providers assess adolescent preventive care (7). These efforts begin to recognize the importance of understanding adolescents’ access, both from the perspective of capacity to provide needed care, and whether services are used effectively. If widely adopted, these measures should lead to improved accountability, better public health surveillance, better care, and an increased likelihood that positive, healthy behaviors will continue into adulthood. Public policy must help support improvements in our health care system so that more adolescents get quality care. Public insurance programs, including Medicaid and the new State Children’s Health Programs provide an opportunity to increase the number of adolescents with insurance coverage. The first
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/00/$–see front matter PII S1054-139X(00)00187-7
294
KLEIN
challenge for these programs is to enroll eligible children and adolescents. But as insurance coverage reaches a greater proportion of poor and near poor adolescents, understanding and addressing adolescents’ non-financial barriers becomes increasingly important. Insurance coverage must allow children and youth to develop relationships with their providers, and must support systems which enable providers to track preventive visits and provide information and support to families. Unless the care provided to adolescents includes confidential screening and counseling, opportunities to provide effective prevention will continue to be missed. The small number of adolescent health specialists (approximately 1/27,000 U.S. adolescents) suggests that one of the most important roles for adolescent health professionals must be to help improve the care provided by all clinicians. We must increasingly involve ourselves in advocacy and in both consumer and professional education towards national, state and community solutions to improve health care systems and better meet adolescents’ needs. Improving the health of adolescents involves family responsibility, professional education, and quality of care issues. Parents have a critically important role, both individually and as employee/beneficiaries and purchasers of health plans. Every adolescent’s parent or guardian should be encouraged to ensure that their teenager has private, confidential time during their health care encounters to promote healthy, responsible behavior, and provide accurate information about health risks, so that youth at risk are identified and offered appropriate help. Professionals must learn the skills, and have the right incentives to care for adolescents and their families, and provide high quality services to all youth. Additionally, public health surveillance and health care quality assurance activities in states and insurance
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
plans should use measures that assess adolescents’ experiences with care, ensuring that confidential counseling opportunities are provided to all teens. We cannot remain on the sidelines. Coordinated efforts by all are needed to improve access and quality for adolescents. Fully integrating teenagers and adolescent health care into the health care system will lead to benefits that will last far into the future. Respectfully submitted, Jonathan D. Klein, MD, MPH Division of Adolescent Medicine MCHB Leadership Education in Adolescent Health Program University of Rochester School of Medicine and Dentistry 601 Elmwood Ave., Box 690 Rochester, NY 14642 [email protected]
References 1. White KL, Williams TF, Greenberg BG. The Ecology of Medical Care. N Eng J Med 1961;265:885–92. 2. http://www.health.gov/healthypeople/Document. (8/14/00). 3. Klein JD, Slap GB, Elster B, et al. Access to health care for adolescents. J. Adolesc Health 1992,13:162–70. 4. U.S. Congress, Office of Technology Assessment, Adolescent Health - Volume I: Summary and Policy Options, OTA-H-468. Washington, DC: U.S. Government Printing Office, April 1991. 5. Newacheck PW, Brindis CD, Cart CU, et al. Adolescent health insurance coverage: recent changes and access to care. Pediatrics. 1999;104(2 Pt 1):195–202. 6. Klein JD, Wilson KM, McNulty M, et al. Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. J. Adolesc Health 1999;25(2):120 –30. 7. Available at: http://www.facet.org/cahmiweb/teen/teenhome. htm. Accessed September 8, 2000.
FROM THE EDITORIAL BOARD
Adolescents, Health Services, and Access to Care
In “The Ecology of Medical Care,” Kerr White asks whether “…the available quantity, quality, and distribution of medical care is optimum in the opinion of consumers?” (1).“ Unfortunately, as quality, cost, and access struggle to find balance in the actions of payers, insurers, and patients, many adolescent health clinicians remain sideline players, if that. Our nations’ health objectives call for screening and health promotion, and various guidelines recommend annual counseling about and screening for preventable health problems for adolescents (2). Clinical preventive services delivery in ambulatory care settings are also among those services most often used by young people and their families. From a broad perspective on youth, health services are but one of the multitude of environmental, community, family and individual factors that affect the developmental trajectory of youth. However, improving the health care system is more easily within our reach than interventions into some of the less mutable factors in adolescents’ lives. Access to care has been associated with reduction in risky behaviors, improvements in health, and is an indicator of equity (3). In 1992, the Office of Technology Adolescent Health report called on Congress to consider ”improving U.S. adolescents’ access to health services.“ (4). But adolescents and young adults still have worse access to health care than all other age groups in the US. In the late 90’s, 15% of our nation’s adolescents still were unable to identify a regular source of care (5,6). Knowledge about the availability of services, transportation and distance, confidentiality, ability to pay, and lack of insurance remain important issues affecting adolescents’ access. Many adolescents do not have access to mental health or reproductive health services, especially in poorer communities. As many as 27% of adolescents report ever missing needed care, most often owing to lack of insurance, and confidentiality concerns, or fear of embarrassment or disclosure (6). Even those who receive preventive visits often do not receive recommended
counseling or screening. More than 80% of adolescents have seen their clinician within the last year, but nearly half of the visits did not include an opportunity for the teenager to talk privately with their physician, and fewer than half of those who thought they should talk with their doctor about pregnancy prevention or sexually transmitted diseases (STDs) had ever done so (6). Thus, a substantial portion of visits could not possibly have provided confidential counseling or screening for preventable risky behaviors. Managed care quality measures, such as the Health Plan Employer Data and Information Set (HEDIS), include an annual preventive care visit measure for adolescents. However, to assess the quality of care provided, it is important to look at the content of care delivered, and not just utilization. In the last year, the Centers for Disease Control and Prevention Youth Risk Behavior Surveillance System (YRBSS) added two core items to help understand adolescents’ experience with care: when adolescents last had a care visit, and whether they had received counseling about HIV and STDs. Additionally, the Foundation for Accountability and the National Commission on Quality Accreditation Child and Adolescent Health Measurement Initiative has developed and tested quality measures to help families, purchasers, and providers assess adolescent preventive care (7). These efforts begin to recognize the importance of understanding adolescents’ access, both from the perspective of capacity to provide needed care, and whether services are used effectively. If widely adopted, these measures should lead to improved accountability, better public health surveillance, better care, and an increased likelihood that positive, healthy behaviors will continue into adulthood. Public policy must help support improvements in our health care system so that more adolescents get quality care. Public insurance programs, including Medicaid and the new State Children’s Health Programs provide an opportunity to increase the number of adolescents with insurance coverage. The first
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/00/$–see front matter PII S1054-139X(00)00187-7
294
KLEIN
challenge for these programs is to enroll eligible children and adolescents. But as insurance coverage reaches a greater proportion of poor and near poor adolescents, understanding and addressing adolescents’ non-financial barriers becomes increasingly important. Insurance coverage must allow children and youth to develop relationships with their providers, and must support systems which enable providers to track preventive visits and provide information and support to families. Unless the care provided to adolescents includes confidential screening and counseling, opportunities to provide effective prevention will continue to be missed. The small number of adolescent health specialists (approximately 1/27,000 U.S. adolescents) suggests that one of the most important roles for adolescent health professionals must be to help improve the care provided by all clinicians. We must increasingly involve ourselves in advocacy and in both consumer and professional education towards national, state and community solutions to improve health care systems and better meet adolescents’ needs. Improving the health of adolescents involves family responsibility, professional education, and quality of care issues. Parents have a critically important role, both individually and as employee/beneficiaries and purchasers of health plans. Every adolescent’s parent or guardian should be encouraged to ensure that their teenager has private, confidential time during their health care encounters to promote healthy, responsible behavior, and provide accurate information about health risks, so that youth at risk are identified and offered appropriate help. Professionals must learn the skills, and have the right incentives to care for adolescents and their families, and provide high quality services to all youth. Additionally, public health surveillance and health care quality assurance activities in states and insurance
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
plans should use measures that assess adolescents’ experiences with care, ensuring that confidential counseling opportunities are provided to all teens. We cannot remain on the sidelines. Coordinated efforts by all are needed to improve access and quality for adolescents. Fully integrating teenagers and adolescent health care into the health care system will lead to benefits that will last far into the future. Respectfully submitted, Jonathan D. Klein, MD, MPH Division of Adolescent Medicine MCHB Leadership Education in Adolescent Health Program University of Rochester School of Medicine and Dentistry 601 Elmwood Ave., Box 690 Rochester, NY 14642 [email protected]
References 1. White KL, Williams TF, Greenberg BG. The Ecology of Medical Care. N Eng J Med 1961;265:885–92. 2. http://www.health.gov/healthypeople/Document. (8/14/00). 3. Klein JD, Slap GB, Elster B, et al. Access to health care for adolescents. J. Adolesc Health 1992,13:162–70. 4. U.S. Congress, Office of Technology Assessment, Adolescent Health - Volume I: Summary and Policy Options, OTA-H-468. Washington, DC: U.S. Government Printing Office, April 1991. 5. Newacheck PW, Brindis CD, Cart CU, et al. Adolescent health insurance coverage: recent changes and access to care. Pediatrics. 1999;104(2 Pt 1):195–202. 6. Klein JD, Wilson KM, McNulty M, et al. Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. J. Adolesc Health 1999;25(2):120 –30. 7. Available at: http://www.facet.org/cahmiweb/teen/teenhome. htm. Accessed September 8, 2000.