Research on specialty care:Examination of sequential movements within health care services

Background. Access to specialty care is not a discrete behavior but rather a behavior of sequential movements within the health care system. However, prior studies have overlooked the important fact that access to specialty care is not an isolated and discrete behavior, but rather, a behavior that is part of a sequential movement within the US health care system. Thus, unlike previous studies of health services utilization, this study examines the sequential movements of health services utilization.

Objectives. The objectives of this study are (1) to examine sequential movements of utilization using Andersen's Behavior Model and (2) to analyze utilization of specialty care after receiving a referral.

Methods. Data for this study were obtained from the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. The starting sample included 6,773 adults aged 18 years and older. A sequential logit model was used to account for the effects of predisposing, enabling and need factors in all movement stages of utilization.

Results. Enabling resources are the main barriers to accessing specialty care. Once receipt of a referral is controlled, inability to pay for specialty care via income or health insurance is a significant barrier in utilization of specialty care.

Conclusions. Use of a sequential logit model to examine utilization of specialty care resulted in a more accurate representation of utilization behaviors. Our study demonstrates the importance of controlling for receiving a referral. Our findings indicate that enabling resources, not predisposing characteristics, are the main barriers to accessing specialty care. Once receipt of a referral is controlled, enabling resources have the greatest effect on accessing specialty care. Inability to pay for specialty care, through low income or health insurance, is the most significant barrier to utilization of specialty care. By introducing the physician referral as a factor in utilization, this study presents a more accurate description of trends in specialty care utilization and will subsequently reduce long-term negative health effects. This study not only adds significantly to the body of literature on access of specialty care, but provides a statistical methodology to best examine the relationship between sociodemographic variables and access to specialty care while accounting for the current U. S. health care system. This is important given the constraints placed on patients, which most likely requires that patients first see a primary care physician in order to gain access to specialists.