Poor asthma-related health care access and utilization for Latinos of Puerto Rican and Dominican descent have been documented (Canino et al., 2006
; Cohen et al., 2006
; Ortega & Calderon, 2000
; Ortega, Gergen, 2002
; Stingone & Claudio, 2006
). The current study is a preliminary investigation of factors that may contribute to the ethnic differences in health care access and utilization. Thus, the current study sought not only to document health care disparities between ethnic groups (i.e., Latinos vs. NLWs) but also investigate how these differences vary based on place of residence (e.g., mainland United States vs. island). Furthermore, we examined whether differences in health care access and utilization patterns would persist after controlling for predisposing, enabling, and need factors.
Asthma is a complex illness, and its presentation is multidetermined and may vary according to both contextual and individual factors. Understanding mechanisms driving differences in health care access and utilization is important in informing targeted interventions, particularly in our attempts to reduce health disparities. This question is a difficult one to answer given that individual and contextual factors are often confounded. It is impossible to completely disentangle the role of various factors, given the complex nature of factors contributing to asthma’s presentation even within groups of similar backgrounds. Examining groups of individuals who are similar on the basis of some characteristics (e.g., ethnicity) but vary with respect to others (e.g., health care context), however, may refine this understanding.
Overall, the findings of this study support that there are health care access and utilization disparities, both across ethnic groups and within ethnic groups, depending on place of residence, supporting the potential role of both individual and contextual factors. Differences in health care access and utilization patterns persisted even after controlling for predisposing, enabling, and need factors. Specifically, Latinos residing in PR were less likely to report either having an identified place for regular care (compared with both RI NLW and Latinos residing in RI) or a consistent provider for asthma (compared with Latinos residing in RI). Latinos residing in both PR and RI were more likely to receive asthma care from a primary care physician and less likely to receive care from a specialist compared with NLWs. Latinos residing in PR demonstrated higher utilization, in terms of asthma-related physician and ED visits, than both Latinos and NLWs residing in RI; these high utilization rates were observed after accounting for multiple confounding factors. They were also significantly more likely to receive asthma care from the ED than both the other groups, and compared with RI Latinos, they were more likely to be hospitalized. These findings were particularly interesting given that in our clinic sample of island Puerto Rican children, 40% had private insurance and 52% had public insurance compared with 77% of RI Latino children having public insurance and 9% having private insurance. However, it is possible that island participants may have overreported private insurance because Medicaid is managed by independent practice groups.
An interesting consideration related to individual factors is the role of parent’s perceptions of their child’s asthma severity in making decisions regarding health care utilization. Parents’ perceptions of their children’s levels of severity may contribute to utilization behaviors, particularly for ED and primary care use. For example, if a parent does not perceive her child to have moderate or severe asthma, then she may be less assertive in making a primary care appointment for asthma. Alternatively, if a parent perceives her child to have very severe asthma, she may be more inclined to use the ED. Differences in parental perception and asthma beliefs may partially explain higher utilization patterns among Latino families. It should be noted, however, that reported differences in hospitalization rates reflect physician, as opposed to parental, decision making. Thus, an interesting area for future inquiry is to explore the associations between parental and clinician ratings, with the use of objective measures, and to determine their influences in health care seeking decisions. In addition, understanding the determinants of parental severity estimation, such as parental worry, fear and disease knowledge, and parent–child communication regarding symptoms, would be useful in understanding the motivators for health care utilization.
Findings from the current study also indicate the potential role of contextual factors in health care access and utilization patterns. Island children were found to have lower access to regular asthma care and higher rates of ED use, even after controlling for individual factors, such as parent-rated asthma severity and socioeconomic status, than both groups of mainland children. The health care systems between PR and RI are different, in terms of delivery, accessibility, and financial arrangements, especially for those children receiving public insurance. For example, in PR, individuals of low socioeconomic status are covered under an island-wide program partly funded by Medicaid in which families are not required to pay for covered medication. There is a disproportionate high enrollment of Puerto Rican children in public health plans, since approximately 42% of families live below the poverty level (Guzman, 2001
), which makes them eligible for the island-wide Puerto Rican Public Health Plan. Under this system, the government contracts with managed care organizations (MCOs) by a negotiated capitation payment. The MCOs then contract with provider groups (e.g., independent provider associations), and many of these subcontracts pass financial risk for treatment cost down to primary care provider groups. Under the current policy, primary care providers are directly financially responsible for medication costs and referrals to specialists.
While such arrangements are sometimes observed in the states (e.g., MCO MediCal subcontracts to physician groups in California), the capitation levels in PR are much lower so that passing the financial risk down to providers constitutes a major barrier to use of expensive medication. As a result, financial incentives to primary care providers in PR may discourage them from prescribing inhaled steroids or other expensive controller therapy. It is possible that the observed low use of controller medication is attributable to the high use of ED care, where physicians are focused on treating acute symptoms and not necessarily chronic disease management. Furthermore, in PR, patients receive free medication in the ED. In addition, none of the outpatient clinics operate outside of regular office hours and very few are open on the weekends, forcing many working poor island Puerto Ricans to use the ED to avoid missing work. In contrast, in RI, the public health plans operate more similarly to private health plans, in which physicians bill for office visits, and the plans tend to cover most or all of the medication costs. Additionally, community health centers have more flexible hours, including evening and weekend appointments.
Thus, the differences observed between island children and mainland Latino children may be related to differences in the health care delivery systems between sites. While we controlled for important predisposing and enabling factors, the relatively lower utilization rates among RI Latinos, in terms of number of physician visits for asthma, also may be a result of system, policy, economic, and geographic barriers that were not accounted for in this study. It is important to note, however, that RI Latinos were more likely to receive care in private physicians’ offices, and they were more likely to identify a regular location for receiving asthma care, and to have a consistent provider compared with island Puerto Ricans. These may be indicators of good health care quality and partly explain the lower utilization and ED rates in RI. Conversely, the health care utilization patterns in PR characterized by higher ED and lower specialty care utilization rates may be indicative of less optimal management and care of asthma.
As in any observational study, especially those using clinical samples, there are limitations in our findings. First, because of health care/clinic differences between RI and PR, we were not able to apply equivalent recruitment strategies across sites. The RI site used a broader range of recruitment sources (e.g., grassroots, educational programs) that may have introduced some unknown selection biases. Moreover, as our study participants in both sites were recruited from clinics and because we did not use a probability sampling design, generalization to target populations should be interpreted in the context of these sampling strategies. We may not have accessed children who were not receiving any care at all for their asthma. These factors suggest caution in generalizing our findings to the overall population of children with asthma, particularly those with the lowest levels of health care access. Finally, there may be additional factors not directly assessed in this study (e.g., beliefs about asthma, knowledge of health care or environmental exacerbation triggers such as tobacco smoke and pet dander) that may affect access and utilization patterns among the groups examined in this study. Despite these limitations, however, and given the dearth of health services data on PR and Dominican children with asthma, groups that have demonstrated high risk, our findings lend some insight into potential health care disparities experienced by these populations.