Forgoing Physician Visits Because of Cost: A Source of Health Disparities for Elderly People With Disabilities?

Article Outline

• Abstract
• Methods
  • Data Source and Study Population
  • Outcome Variables
  • Independent Variables
    • Predisposing factors
    • Enabling factors
    • Perceived health need factors
    • Evaluated health need factors
  • Statistical Analysis
  • Data Imputation
• Results
  • Characteristics of Study Participants
  • Disparities in Access to Health Care
    • Determinants of forgoing physician visits because of cost
• Discussion
  • Study Limitations
• Conclusions
• References
• Copyright

Abstract 

Lee JC, Heinemann AW. Forgoing physician visits because of cost: a source of health disparities for elderly people with disabilities?

Objective

To examine disparities in having a usual source of care and forgoing physician visits because of cost between elderly people (age ≥65y) with and without disabilities after consecutively controlling for predisposing, enabling, and perceived and evaluated health need factors using the Andersen behavioral model, and to identify the determinants of such disparities.

Design

Cross-sectional analysis.

Setting

Community.

Participants

Nationally representative sample of community-dwelling adults age 65 years or greater in the United States from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) (N=93,933).

Interventions

Not applicable.

Main Outcome Measures

Responses to 2 BRFSS questions: (1) whether the respondent had a health care provider, and (2) whether the respondent had forgone seeing a physician because of cost in the past 12 months.

Results

After controlling for the aforementioned factors, elderly persons with disabilities were more likely than their counterparts without disabilities to have a usual source of care (adjusted odds ratio [AOR]=1.33; 95% confidence interval [CI], 1.08–1.64), and those with disabilities were more likely to forgo physician visits because of cost (AOR=1.64; 95% CI, 1.31–2.04). The unadjusted odds of forgoing physician visits (odds ratio [OR]=2.13; 95% CI, 1.87–2.43) did not decrease after controlling for predisposing factors (AOR=2.32; 95% CI, 1.96–2.75), whereas the odds were attenuated after controlling for enabling factors (AOR=2.18; 95% CI, 1.84–2.59), perceived health need (AOR=1.70; 95% CI, 1.37–2.12), and evaluated health need (AOR=1.64; 95% CI, 1.31–2.04).

Conclusions

Although elderly people with disabilities were more likely than their counterparts without disabilities to have a usual source of care, those with disabilities were more likely to forgo physician visits because of cost. Elderly persons with greater perceived health needs were most likely to experience the disparity.

Key Words: Aged, Rehabilitation

List of Abbreviations: AOR, adjusted odds ratio, BRFSS, Behavioral Risk Factor Surveillance System, CI, confidence interval, MI, multiple imputation, OR, odds ratio

HEALTH DISPARITIES AFFECTING vulnerable populations have gained increasing attention, reflecting an appreciation of the fundamental role of health. Research on health disparities involves ethical judgment because health disparity includes the determination of whether a disparity is avoidable, unjust, or unfair.¹, ², ³ Concerns about health disparities reflect social values pertaining to distributive justice and human rights¹, ⁴, ⁵, ⁶ and are particularly relevant to people with disabilities.⁷

The impact of disability on society increases with the growth of the elderly population. The number of elderly people aged 65 years or older is projected to increase to 72.1 million in 2030, which will account for almost 20 percent of the total U.S. population.⁸ In addition, the oldest-old, age 85 years and older, are the fastest growing segment of the U.S. older population.⁹ The rapid increase of elderly adults requires preparation for adequate health services and long-term care of the population. This preparation becomes more urgent given that increased longevity is accompanied by greater prevalence of chronic diseases and conditions.¹⁰

Providing adequate health care access to elderly persons with disabilities is a prerequisite to ensuring healthy aging. Persons with disabilities use health care services more frequently than their counterparts without disabilities.¹¹, ¹², ¹³ Ensuring adequate health care access is more important for elderly people with disabilities than those without disabilities because of their risk of developing additional health-related challenges. Secondary health conditions are more prevalent among those with disabilities.¹⁴, ¹⁵, ¹⁶

The rapid increase of the U.S. older population and association between older age and disability highlight the critical need for research on disparities in health care access for elderly adults with disabilities. Nonetheless, there is a dearth of research on the disparities for this vulnerable population. This might be related to the fact that elderly Americans age 65 years and older are almost universally covered by Medicare. However, Medicare covers only 45% of health care expenses (total medical and long-term care expenses) for both institutionalized and noninstitutionalized beneficiaries.¹⁷ Medicare alone does not provide sufficient coverage for elderly people with disabilities. Examining the nature, extent, and determinants of disparities is vital to developing successful policies. Evidence-based policies are critical to eliminate and prevent health disparities and effectively allocate limited resources. This study investigates 2 issues pertaining to health care access for elderly people with disabilities: having a usual source of care and forgoing physician visits because of cost.

This study used the Andersen¹⁸ behavioral model of health services access and use as a framework in guiding the selection of variables and the examination of the determinants of the disparities. We focused on the model's population characteristics, which are composed of predisposing, enabling, and health need factors. Predisposing factors are sociodemographic factors that predispose persons to access health care services. Enabling factors are means of facilitating or impeding health care access, such as income or health insurance. Perceived health need factors are how people perceive their health status, while evaluated health need factors refer to professional judgment about people's health conditions or illnesses and their need for medical treatment.¹⁸

This study has 2 objectives: (1) to examine disparities in having a usual source of care and forgoing physician visits because of cost between elderly people with and without disabilities after controlling for predisposing, enabling, and perceived and evaluated health need factors, and (2) to investigate to what extent such disparities could be accounted for by the aforementioned factors. This study defines disparities as differences in the 2 areas of health care access between those with and without disabilities after adjusting for these factors. Although persons with disabilities use more health care services than those without disabilities,¹¹, ¹², ¹³ people with disabilities encounter great disadvantages in education, employment, or income.¹⁹, ²⁰, ²¹ These inequities can have negative impacts on health care access for people with disabilities. Delayed care because of financial concerns would be critical for elderly people with disabilities because of their poorer health conditions and vulnerability to developing secondary health conditions. We were interested in the determinants of disparities between elderly adults with and without disabilities as well as the effect of disability status. Hence, we adjusted for as many factors as available in the data that could affect health care access, which can be called the residual direct effect approach.²²

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Methods 

Data Source and Study Population 

The 2006 BRFSS provided the data for this study. This ongoing, annual cross-sectional survey of community-dwelling civilians age 18 years and older uses a nationally representative sample of all households with a telephone.²³ The survey recruits 1 adult per household; it does not use a proxy respondent. A variety of health-related information is collected, including health status, health conditions, health risk behaviors, preventive health practices, and access to health care.²³, ²⁴

This study focused on 93,933 respondents age 65 to 99 years in the 50 states and the District of Columbia. The BRFSS uses 2 questions to measure disability: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”^24(p10) We defined as disabled respondents who answered yes to either question. Thus, people with disabilities were those having activity limitation or special equipment use, which is broader than disability measures of other national surveys, such as the National Health Interview Survey or Survey of Income and Program Participation.²⁵ Activity limitation is independently associated with increased health care costs among elderly Medicare beneficiaries age 65 years and older.²⁶

Outcome Variables 

The survey measured whether respondents had a usual source of care with the question, “Do you have one person you think of as your personal doctor or health care provider?”^24(p6) Forgoing physician visits because of cost was measured with the question, “Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”^24(p6) The answers to these questions were dichotomized as yes or no.

Independent Variables 

Predisposing factors 

Predisposing factors included sex, age, race, marital status, and education level. Age was categorized as 65 to 74 years, 75 to 84 years, or 85 years and older. Race was grouped into 4 categories: non-Hispanic white, non-Hispanic black, Hispanic, and other race or multiracial. Marital status was categorized as married or a member of an unmarried couple; divorced, widowed, or separated; and never married. Education level was grouped into 4 categories: college degree or more, some college or technical school, high school degree or General Educational Development, and less than high school.

Enabling factors 

Enabling factors included annual household income, social and emotional support, and health insurance. Income was grouped into 5 categories: less than $15,000, $15,000 to less than $25,000, $25,000 to less than $35,000, $35,000 to less than $50,000, and $50,000 or more. Social and emotional support was measured with the question, “How often do you get the social and emotional support you need?”^24(p26) The answers were grouped into 3 categories: usually or always, sometimes, and rarely or never. BRFSS measures health insurance coverage with the question, “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?”^24(p6) The answers were dichotomized as yes or no.

Perceived health need factors 

Perceived health need factors included self-reported general health status, physical health, and mental health. Self-reported general health status was measured with the question, “Would you say that in general your health is—”^24(p5) The answers were dichotomized as good, very good, or excellent; or fair or poor. For physical health and mental health, BRFSS asked respondents how many days during the past 30 days their physical health or mental health had not been good. Respondents' physical health was measured with the question, “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?”^24(p6) Mental health was measured with the question, “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”^24(p6)

Evaluated health need factors 

Evaluated health need factors included 5 chronic diseases (diabetes, asthma, heart attack, coronary heart disease, stroke). Respondents were asked if they had ever been told by a doctor, nurse, or other health professional that they had the chronic diseases; responses were dichotomized as yes or no. Women who had diabetes only during pregnancy were not classified as diabetic.

Statistical Analysis 

Weighted descriptive statistics for elderly people with disabilities were compared with their counterparts without disabilities using chi-square tests. Five logistic regression models were conducted consecutively to examine whether disparities exist between elderly people with and without disabilities after controlling for predisposing, enabling, and perceived and evaluated health needs. Model 1 included only disability status, model 2 included disability status and predisposing factors, model 3 expanded model 2 to include enabling factors, model 4 expanded model 3 to include perceived health need factors, and model 5 included evaluated health need factors as well as all the earlier factors. We also tested for interactions between disability status and age, physical health, and mental health. Because the analyses did not yield significant interactions, this study reports only main effects. Statistical analyses were conducted using SAS-callable SUDAAN version 10.0^a to account for the complex survey design and weighting adjustment. This study used Taylor series linearization for variance estimation. Because BRFSS is a national probability sample, the weighted sample is used in all statistical analyses to reflect the population. A significance level of .05 and 95% CIs were used.

Data Imputation 

Analyses restricted to observed data are based on the assumption that missing data are not associated with both missing data and observed data.²⁷, ²⁸ That is, data are completely missing at random, and the observed cases are a random sample of the study population.²⁷, ²⁹ This strong assumption is seldom applicable to complex surveys, in which complex patterns of nonresponse appear frequently. MI was performed using the IVEware software package^b in order to account for missing data.

The responses—“don't know/not sure” and “refused”—were treated as missing to avoid distorted results.³⁰ All independent variables had less than 4 weighted percent missing data, with 0 to 3.8%, except for annual household income (22.4%) and social and emotional support (8.8%). Because MI theory requires that all available variables related to missing data should be included in imputations,³¹ MI was used for both outcome and independent variables. Five multiply imputed data sets were obtained through 10 iterations for each data set, a procedure adopted by other investigators.²⁸, ³² To assess the effect of data imputation, we conducted a sensitivity analysis by comparing complete-case analysis using only observed cases and the analysis of multiply imputed data sets. The sensitivity analysis showed comparable findings between these 2 analyses.

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Results 

Characteristics of Study Participants 

Table 1 illustrates characteristics of study participants by disability status. Compared with their counterparts without disabilities, a larger portion of elderly people with disabilities was female, was older, and had lower socioeconomic status. A significantly larger percentage of elderly adults with disabilities reported having poorer perceived health status and more chronic health conditions.

Table 1. Characteristics of Elderly People With and Without Disabilities Age ≥65y

NOTE. Data from Centers for Disease Control and Prevention.²³

⁎Mean (SE).

Disparities in Access to Health Care 

As shown in table 2 (model 1), elderly persons with disabilities were more likely to have a usual source of care compared with their counterparts without disabilities (OR=1.71; 95% CI, 1.51–1.94). After controlling for all factors (model 5), those with disabilities were still more likely to have a usual source of care (AOR=1.33; 95% CI, 1.08–1.64) although the odds were reduced.

Table 2. AORs of Having a Usual Source of Care for Elderly People Age ≥65y

NOTE. Data from Centers for Disease Control and Prevention.

⁎Model 1 = disability status.

†Model 2 = model 1 + sex + age + race + marital status + education level, which controlled for predisposing factors.

‡Model 3 = model 2 + annual household income + social and emotional support, which controlled for predisposing and enabling factors.

§Model 4 = model 3 + general health status + physical health + mental health, which controlled for predisposing, enabling, and perceived health need factors.

∥Model 5 = model 4 + diabetes + asthma + heart attack + coronary heart disease + stroke, which controlled for predisposing, enabling, and perceived and evaluated health need factors.

¶Statistical significance at the P <.05 level.

Table 3 (model 1) shows that elderly adults with disabilities were more likely to forgo physician visits because of cost without adjusting for any factors (OR=2.13; 95% CI, 1.87–2.43). Model 5 shows that this disparity remained after controlling for all behavioral factors (AOR=1.64; 95% CI, 1.31–2.04).

Table 3. AORs of Forging Physician Visits Because of Cost for Elderly People Age ≥65y

Data from Centers for Disease Control and Prevention.²³

NOTE. Reference categories in brackets.

⁎Model 1 = disability status.

†Model 2 = model 1 + sex + age + race + marital status + education level, which controlled for predisposing factors.

‡Model 3 = model 2 + annual household income + social and emotional support, which controlled for predisposing and enabling factors.

§Model 4 = model 3 + general health status + physical health + mental health, which controlled for predisposing, enabling, and perceived health need factors.

∥Model 5 = model 4 + diabetes + asthma + heart attack + coronary heart disease + stroke, which controlled for predisposing, enabling, and perceived and evaluated health need factors.

¶Statistical significance at P <.05 level.

Determinants of forgoing physician visits because of cost 

Because respondents with disabilities faced a disparity in postponing doctor visits, not in having a usual source of care, we focus on the determinants of forgoing physician visits. Table 3 shows the extent to which forgoing physician visits was accounted for by behavioral factors: predisposing (model 2), enabling (model 3), perceived health need (model 4), and evaluated health need (model 5).

Predisposing factors collectively increased the odds of forgoing physician visits by 19% (AOR=2.32; 95% CI, 1.96–2.75), although race and education level were associated with financial difficulty (model 2). Model 3 shows that although race and less than high school education remained statistically significant, the extent of the effects lessened. Compared with those age 65 to 74 years, elderly adults age 75 to 84 years were less likely to forgo physician visits because of cost, but the oldest adult group, 85 years or older, did not. In addition, household income less than $35,000, less frequent or absent social and emotional support, and no health insurance were associated with postponed physician visits because of cost. In particular, those without health insurance had significantly higher odds of forgoing physician visits (AOR=4.08; 95% CI, 3.09–5.39). Enabling factors in model 3 collectively attenuated the odds of postponing physician visits by 14% (AOR=2.18; 95% CI, 1.84–2.59) when controlling for predisposing factors.

Perceived health need factors in model 4 collectively decreased the odds of forgoing seeing a physician by almost 50% after adjusting for predisposing and enabling factors (AOR=1.70; 95% CI, 1.37–2.12). General health status and physical and mental health were independently associated with the risk of forgoing physician visits. Last, evaluated health need factors in model 5 collectively played a minimal role in decreasing the odds of forgoing physician visits, controlling for all other behavioral factors (AOR=1.64; 95% CI, 1.31–2.04). Of the 5 chronic diseases, only asthma and stroke were significantly associated with the risk of delaying physician visits (AOR=1.24; 95% CI, 1.03–1.50 for asthma; AOR=1.26; 95% CI, 1.04–1.52 for stroke). All perceived health need factors remained statistically significant in model 5, and the extent of the associations was essentially identical in models 4 and 5.

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Discussion 

The virtually universal coverage of Medicare for elderly Americans age 65 years or older helps reduce disparities in access to health care among elderly people compared with their younger counterparts.³³ However, this study found that elderly adults with disabilities are more likely to forgo physician visits because of cost than elderly adults without disabilities. This finding suggests that Medicare coverage is limited to address health care needs of elderly adults with disabilities. High health care costs increase with disability²⁶, ³⁴, ³⁵, ³⁶ and age.³⁴, ³⁵, ³⁶ Higher out-of-pocket expenditure is incurred with disability or its severity.³⁴, ³⁷ These suggest that elderly people with disabilities experience a greater financial burden. Yet Medicare does not provide comprehensive coverage, including dental care and vision care.³⁸ In addition, Medicare beneficiaries incur substantial out-of-pocket costs. Medicare has relatively high deductibles, copayments, and premiums, and does not have annual cap on out-of-pocket spending.³⁸

Under the 2010 health care reform legislation, payments to Medicare Advantage will be gradually reduced to the level of payments to traditional Medicare fee-for-service.³⁸ Because Medicare Advantage provides more comprehensive, affordable coverage for those with disabilities than Medigap policies, reduced payments to Medicare Advantage beneficiaries may reduce coverage options.³⁹ Policymakers should consider the impact of coverage rules on elderly persons with disabilities who may forgo physician visits because of cost.

This study could not evaluate the extent to which supplemental health insurance attenuates the effects reported here. Compared with those with supplemental health insurance, people who rely on Medicare alone are 5 times more likely to experience delayed care because of cost.⁴⁰ Working-age people with disabilities have higher unemployment rates than their counterparts without disabilities.²⁰, ²¹ Consequently, elderly people with chronic disabilities without an employment history are less likely to have supplemental health coverage such as employer-sponsored retiree insurance. Although recent health reform legislation prohibits insurers from denying people with pre-existing conditions, chronic unemployment is likely to limit access to Medicare Advantage or Medigap plans.

Perceived health care needs played the biggest role in explaining the disparity in the physician visits. Elderly adults with disabilities reported far worse health compared with those without disabilities. Although evaluated health need factors had only a small collective impact on forgone physician visits, BRFSS does not have a comprehensive measure of evaluated health care needs. As a result, other chronic diseases prevalent among elderly adults, such as hypertension, arthritis, or cancers, might affect health care access for elderly adults. These findings suggest that the health status and health care needs of elderly people with disabilities should be targeted in order to reduce the disparities in forgoing physician visits because of cost.

Efforts to encourage health promotion and productive aging such as through active engagement via volunteering, recreation, or developing and maintaining social relationships may enhance physical and mental health for elderly adults with disabilities. Health care systems should also be designed to address health care needs of elderly adults with disabilities better. Medicare coverage of wellness visit under the health care reform legislation reflects recognition in the benefits of prevention services.

Enabling factors—income, health insurance, and social and emotional support—played the second largest role in decreasing the disparity, but the extent of the impact was much smaller than perceived health need factors. Health insurance and income play a significant role in accessing health care. Yet Medicare provides coverage for over 97% of Americans age 65 years and older.⁴¹ The impact of low income on health care access is likely attenuated by Medicare.

Appropriate training of health care providers and reform of the health care delivery system may be needed to reduce disparities in forgoing physician visits. Many health care providers are not trained to work with people with disabilities.⁴², ⁴³, ⁴⁴ Health care providers lack knowledge of and sensitivity to disability,³⁴, ⁴⁵, ⁴⁶, ⁴⁷ and the lack of professional skills complicates health care access for elderly people with disabilities. Even providers with adequate training have few incentives to provide proper health care services for those with disabilities.⁴⁴ The health care reform legislation requires disability awareness training for medical professionals. Coupled with disability competency training among health care providers, adequate reimbursement mechanisms for physicians may help to reduce forgone physician visits among elderly persons with disabilities.

Study Limitations 

Several limitations should be considered in interpreting the findings of this study.

First, careful attention should be given to the limitations related to the participation of people with disabilities in national population surveys. Given that BRFSS is a telephone survey and people age up to 99 years are targeted in the survey, elderly people with disabilities, especially those with cognitive disabilities or hearing problems, could encounter obstacles to participating in the survey. In addition, BRFSS uses only 2 questions to measure disability, focusing on any activity limitation and use of special equipment because of any health problem. These questions do not allow for measuring the duration and severity of disability. As a result, compared with other national surveys with more extensive disability measures, BRFSS is likely to characterize as disabled a different subpopulation. The potential underrepresentation of persons with disabilities should serve as conservative estimation of the disparity reported in this study.

The median response rate for the 2006 BRFSS was 51.4%.⁴⁸ This response rate creates a risk for potential bias in the findings. Nonetheless, the extent of bias is a function of the amount of nonresponse and the differences between survey respondents and nonrespondents.⁴⁸ Thus, if nonrespondents have highly similar characteristics of interest compared with those of the respondents, it is unlikely that nonresponse bias will result from even a low response rate.⁴⁸

Several factors that could affect health care access for elderly people with disabilities were not examined. Time since onset of disability can affect education, employment, social relationships, or community participation. These factors can impact employment and the quality of the benefits, including the types and coverage of health insurance. Although health insurance status and coverage have a significant role in health care access, BRFSS does not measure types and sources of health insurance. Furthermore, some elderly persons with disabilities living in poverty, especially in rural areas, may have difficulty obtaining health care, causing additional financial difficulty.

This study controlled for only 5 chronic illnesses in examining the impact of evaluated health need factors. They were chosen because they were not sex-specific and were assessed in every state. Other acute or chronic diseases may impact health care access for elderly adults.

Finally, although BRFSS collects a sizable volume of information related to health, it uses a cross-sectional design. Changes over time and causal effects cannot be identified. Therefore, causation should not be inferred in interpreting the findings of this study.

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Conclusions 

Elderly people with disabilities were more likely to have a usual source of care compared with elderly adults without disabilities, but they were more likely to forgo physician visits because of cost. Forgone physician visits were mostly explained by perceived health needs of those with disabilities; poorer health and resultant health needs are likely to engender forgone physician visits. Poor health and greater health needs must be ameliorated in order to reduce the disparity that elderly adults with disabilities experience.

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• a RTI International, Research Triangle Park, 3040 E Cornwallis Rd, NC 27703.
• b Survey Methodology Program, Survey Research Center, Institute of Social Research, University of Michigan, 1355 ISR Bldg, P.O. Box 1248, Ann Arbor, MI 48106.