Top Challenges Impacting Patient Access to Healthcare

Limited appointment availability, office hours

Many healthcare organizations offer a typical set of office hours for patient visits. But for the working adult or parent, a clinic that is open between 8 a.m. and 6 p.m. is not always useful. Patients need convenient office hours that allow them to visit the doctor outside of their work or school schedules.

Aside from care quality, access to convenient care is one of the top drivers for patient care site decisions. Patients want to be able to access their healthcare when they want and need it.

Healthcare organizations are overcoming these barriers by expanding their office hours. Extending office hours is one of the fundamental pillars of the patient-centered medical home (PCMH).

Additionally, some organizations are utilizing health IT and connected health to allow patients to seek medical advice without needing to come into the office. Telehealth allows a patient to receive medical treatment without being beholden to an office schedule that does not fit the patient’s needs.

Urgent care centers and retail clinics are also emerging players allowing patients to connect to care outside of a doctor’s office hours.

However, these are simply fixes. Organizations that can manipulate their office hours or stagger appointments in such a way that patients can access their clinicians at convenient times will likely see more patient access.

Geographic, clinician shortage issues

Patients living in rural areas are disproportionately more likely to struggle to access their clinician than a patient living in an urban or suburban area.

As of 2020, about 57 million Americans lived in a rural area, according to Statista. These individuals face a litany of challenges, ranging from where they live to having enough doctors to provide care.

“Rural residents often encounter barriers to healthcare that limit their ability to obtain the care they need,” according to the Rural Health Information Hub. “In order for rural residents to have sufficient access, necessary and appropriate healthcare services must be available and obtainable in a timely manner.”

Although the care access challenges rural residents face are varied, they primarily fall into two buckets: geographic distance from a healthcare provider and provider shortages.

Per 2020 figures from the University of Minnesota School of Public Health, geographic barriers and travel distances still beleaguer rural residents. Individuals in rural areas traveled an average of 40.8 miles to their radiation treatment, while those in urban areas traveled about 15.4 miles, an assessment of patient data and Google Maps algorithms showed.

This trend occurred largely because treatment facilities were further away for those living in rural areas, the team added. The closest radiation facility was an average of 21.9 miles away from an individual living in a rural setting; for those in urban areas, that number was 4.8 miles.

Telemedicine, which saw a boom during the pandemic, has proven effective for closing some of this gap. Healthcare providers can leverage direct-to-consumer telehealth to help rural patients access low-acuity care, like chronic care management, from home. Additionally, telehealth services are effective for connecting smaller hospitals with larger academic medical centers during medical emergencies.

But patients living in rural areas must also contend with clinician shortages. The patient-to-primary care physician ratio in rural areas is 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas, according to statistics from the National Rural Health Association.

And as the nation sees an impending clinician shortage even in urban areas, patients in rural regions feel the pinch even harder. Figures published in a 2020 JAMA Network Open article showed that although the primary care provider workforce is bulking up nationwide, the workforce disparity between rural and urban areas is growing.

Healthcare professionals are calling for policy changes that help funnel more resources to workforce-strapped rural organizations. Additionally, legislative fixes to expand scope of practice laws for advanced practice registered nurses and physician assistants could help close some care gaps.

Transportation barriers

Even when a patient has access to a provider and can schedule an appointment, transportation barriers can keep patients from seeing their clinicians. Patients who are physically unable to drive, who face financial barriers, or who otherwise cannot obtain transportation to the clinician office often go without care.

Per AHA statistics, approximately 3.5 million patients go without care because they cannot access transportation to their providers. Transportation is a critical social determinant of health that has recently gained nationwide attention.

Healthcare organizations have begun to address this issue, viewing transportation as a key social determinant of health for which they both have a viable solution and a provable return on investment. Through partnerships with non-emergency medical transportation providers and emerging rideshare companies like Uber and Lyft, healthcare providers and payers have designed programs to get their patients on the road to recovery.

These types of partnerships have both improved patient access to care and cut overall healthcare costs, researchers from RAND Corporation said in a 2021 report.

As the medical transportation landscape begins to expand its footprint through both traditional and non-traditional players, the doors to addressing other social determinants of health are opening. That’s a key step forward, considering most of health and wellness happen outside the walls of the hospital or clinic.

Meal delivery programs and transportation to social services are new avenues to expand the definition of patient access to care that, in time, may prove more return on investment.

Limited education about care sites

Oftentimes, patient care access issues are not about getting a foot in the door. Instead, it’s about getting a foot in the right door. While it is essential for healthcare organizations to remove obstacles barring patients from getting to the office, it is equally important for organizations to make sure patients are getting to the right type of facility.

This is especially critical as health systems begin to integrate alternative treatment sites into their repertoires. Patients can choose to access care at an urgent care center, a retail clinic, a microhospital, a freestanding emergency department, and numerous other emerging treatment facilities.

While these growing care options are a positive step forward for patient care access, it is essential that medical providers deliver the proper patient education that helps patients identify the appropriate facility for their needs.

In June 2021, researchers from Washington University School of Medicine found that patients don’t always appropriately access the emergency department, with high-acuity cases foregoing ED care while lower-acuity cases continue to visit EDs.

The study, published in Health Affairs, a 35 percent decrease in ED utilization during the first COVID-19 lockdown, with decreases ranging between 40 and 52 percent, depending on acuity.

The researchers did note that ED utilization for low-acuity cases was more prevalent than anticipated for a pandemic lockdown. Low-acuity ED utilization only dropped by about 50 percent, even though it could be expected it would have gone down by much more.

Patient access to lower-acuity settings, like their primary care providers or urgent care clinics, may have been hindered during the pandemic and thus driven patients to continue visiting the ED for low-acuity needs.

The researchers said better patient education about care access—particularly, when an ED visit is and is not necessary—will be key.

“Furthermore, it is not always apparent at the outset of a particular constellation of symptoms whether it is of benign etiology or requires ED evaluation,” they wrote. “Therefore, policy makers and clinical leaders must inform the public of health conditions that require timely ED care and improve access to alternative, lower-risk settings of care.”

Previous reporting from CityMD likewise showed that patients largely don’t know where they should receive care for various different symptoms. When presented with different scenarios, patients struggled to regularly identify the proper care site for certain health needs.

Medical professionals can educate their patients on the specific uses for different care sites. For example, dire healthcare situations will require a visit to the ED, while pain from a potential sprained ankle may be better off treated in an urgent care clinic.

Clinician offices and hospitals can display this information in their own facilities and offer patient education materials. However, access education should also be a part of different care facilities’ marketing plans. An urgent care center should make it widely-known which types of ailments they are best suited for treating.

Connecting patients with the right care at the right time is an important value-based care principle. When a patient can easily access a primary care or wellness visit, she may see a diminished likelihood of developing a more concerning illness down the line.

Healthcare organizations need to have the right patient-centered mechanisms in place that ensure patients can easily access those care services.

High healthcare costs

The high cost of healthcare, particularly high out-of-pocket patient costs, is a well-documented care access barrier. When patients cannot afford medical care or find themselves choosing between medical care and paying for other utilities like rent, mortgage, or food, they often go without healthcare access.

In December 2021, a West Health and Gallup poll found that three in 10 Americans cite high out-of-pocket costs as a patient care access barrier. Those patients told the poll that they skipped medical care due to high costs at least once in the previous three months.

The survey of over 6,500 respondents also showed out-of-pocket healthcare costs are a problem even for the richest people. Among those households making more than $120,000 annually, 20 percent said they did not access healthcare in the past three months due to high costs.

These figures represent a peak for the nation. The overall rate of cost-related delayed care is the highest it’s been since the start of the COVID-19 pandemic. For the richest households, the rate of cost-related delayed care is 3 percent higher than it was between March and October of 2021.

The US is fairly unique in this problem, separate data has shown. Per 2020 reporting from The Commonwealth Fund, the United States has the starkest income-based health disparities compared to other similarly developed nations. In total, 38 percent of US adults have skipped a medical visit, test, treatment, follow-up, or prescription fill within the last year because of cost. Fifty percent of low-income adults skipped care because of cost and 27 percent of high-income earners said the same, The Commonwealth Fund reported in Health Affairs.

Notably, that 27 percent of high-income earners skipping care is a higher rate of skipped care than any other similarly developed nation in the study, regardless of income. For most nations, under 27 percent of their poorest patients are forced to skip care due to costs. In other words, healthcare is about as cost-prohibitive for the wealthiest Americans as it is for the poorest patients in other countries.

Social determinants of health barriers

In addition to healthcare industry hurdles, many patients face a number of social determinants of health that make it harder for them to get into the doctor’s office.

Those social determinants of health may include some issues already covered in this article, like rurality and geography or income and cost of care or transportation access. But social determinants of health also encompass a number of other challenges.

Race, or racial discrimination, has resulted in patient access to care problems. Decades-old racist policies like redlining have led to unequal healthcare access and thus unequal healthcare outcomes, numerous studies have found.

Redlining was set in policy in 1938 to designate “desirable” and “undesirable” neighborhoods for lending and investment, creating both racial segregation and disparities in access to resources and services, like healthcare.

In October 2020, the Primary Care Development Corporation found that neighborhoods that were formerly redlined had a poverty rate 3.6 times higher than of more “desirable” census tracts, and the proportion of Black people living in these areas was 9.1 times higher than in those A-rated census tracts.

Meanwhile, the rate of uninsurance—which can directly impact access to healthcare and healthcare affordability—was much higher in formerly redlined districts, with 17.8 percent of adults in those areas saying they don’t have payer coverage. Only 6.4 percent of those living in A-rated census tracts said the same.

Codified racism like redlining has also been linked to maternal health disparities and poorer COVID-19 infection rates and outcomes.

But it’s not just racist policy that bars patient access to care; implicit bias can also instill distrust in medicine and dissuade patients of color from accessing care. In April 2021, data from the Robert Wood Johnson Foundation and the Urban Institute showed that one in 10 Black patients reported discrimination during a healthcare encounter.

That implicit bias or explicit discrimination can have harmful impacts on the patient experience and discourage patients from getting healthcare in the future, according to Garth Graham, the current director and global health of healthcare and public health at Google/Youtube.

“It's not just the historical nature to speak a lot of times, it's the legacy of individual interactions with the clinical system,” Graham, who formerly worked for CVS Health and Aetna, said in a past interview. “It’s the, at the many times challenging, lack of cultural competency that has been present for a long time in communities and how that plays out.”

In other words, limited patient trust among Black communities doesn’t just stem from memories of Tuskegee or eugenics, although those events certainly have left their stain. It’s the word-of-mouth tales about poor healthcare interactions and negative interpersonal exchanges with clinicians that have truly cemented this poor patient-provider relationship.

The medical industry must consider both the implications of racism previously codified in legal policy, as well as the current specter of implicit and explicit bias. Supporting health equity, cultural responsiveness, and implicit bias training will be key to this effort, as well as investing social services that can help ameliorate the latent impacts of past policymaking.