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Assessing Use of Primary Health Care Services by Very Low-Income Adults in a Managed Care Program
Allison L. Diamant, MD, MSHS;
Robert H. Brook, MD, ScD;
Arlene Fink, PhD;
Lillian Gelberg, MD, MSPH
Arch Intern Med. 2001;161:1222-1227.
ABSTRACT
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Objective To assess the effect of providing free health care services to low-income
adults.
Methods We measured access to primary care services by enrollees with 4 chronic
medical conditions in the General Relief Health Care Program (GRHCP), a program
designed for adults receiving General Relief (GR). Implemented by the Los
Angeles County Health Department in October 1995, the GRHCP is composed of
private and public health care facilities. As adults registered for GR, they
were asked to complete a baseline health survey, were enrolled in the GRHCP,
and assigned a health care provider. A total of 8520 surveys were completed
between September and November 1996 (98% response rate). The analyses of this
article are limited to individuals (N = 2164) who reported a history of hypertension,
diabetes mellitus, a nonresolving cough, or substance dependence. We reviewed
medical records to determine whether new GR recipients had visited their designated
GRHCP provider within 4 months of enrollment and used multivariate logistic
regression to assess the effect of individual patient factors on the use of
free health care.
Results A total of 17% of individuals visited their assigned GRHCP provider
within 4 months of enrollment. In multivariate analysis, patients were more
likely to have made a visit if they were younger than 50 years, were female,
were Asian/Pacific Islander, reported needing to see a physician, or had seen
a physician within 12 months.
Conclusions It is not sufficient to merely supply the name and address of a health
care provider to this population. More aggressive efforts should be attempted
to increase utilization of services for patients with medical conditions responsive
to ambulatory care.
INTRODUCTION
AT THE SAME TIME that many privately insured individuals have made the
transition to managed care, the number of uninsured has continued to rise.
In response, some state and local governments have implemented programs that
provide health care to low-income children and adults.1-9
Increasingly, these programs have been based on managed care models. The goals
of these programs are to (1) expand access to needed health care, (2) optimize
the quality of health care provided, and (3) limit the costs of medical care.3-4,10 This article reports
an assessment of a program specifically designed to provide free and accessible
primary care services to poor, uninsured adults who were not receiving Medicaid
but were eligible for public assistance (ie, General Relief [GR]) in a large
urban county).
Beginning in October 1995, adults in Los Angeles County, California,
who were receiving GR benefits were enrolled in a county-organized health
care network, the General Relief Health Care Program (GRHCP). Before October
1995, most of these individuals relied on Los Angeles County Department of
Health Services facilities, including emergency departments, for their medical
care and were uninsured for health care.11-12
The GRHCP was designed to establish a usual source or site of care for enrollees
and thereby increase access to primary care services. The GRHCP assigned a
health care provider to newly registered GR beneficiaries, and individuals
were instructed to go to that provider for both their urgent and routine primary
health care needs.
The first primary care physicians who joined the GRHCP were within private
community organizations or were individual practitioners; later, 4 traditional
Department of Health Services facilities were added to the program. However,
Los Angeles County Department of Health Services retained responsibility for
providing specialty, emergency, and hospital care to patients referred to
them by the GRHCP provider. At the time of this study, the GRHCP was composed
of a network of 11 community health care organizations and 4 Department of
Health Services facilities. One of the original community health care organizations
in the GRHCP was composed of 4 clinics and an independent practice association
that included more than 25 individual physicians.
Our study had 2 main objectives: (1) to measure use of free primary
care services in the form of a visit by GRHCP enrollees to their designated
care provider and (2) to assess which characteristics of enrollees were associated
with their use of health care services. We focused on a sample of very low-income
adults on GR with at least 1 of 4 marker conditions: hypertension, diabetes
mellitus, a nonresolving cough, and substance dependence. We selected these
conditions because of (1) their prevalence in the population, (2) the potential
for serious complications if untreated, (3) the known benefit of regular health
care in treating them, and (4) the existence of accepted standards of care
for treatment.13-19
METHODS
STUDY SAMPLE
To apply for GR (ie, public assistance, welfare benefits) in Los Angeles
County, adults submit their application to an eligibility worker at 1 of the
14 Department of Public Social Services offices. Beginning in October 1995,
applicants judged to be eligible for GR were referred to the health benefits
representative at that site. The GR beneficiaries may have been found later
to be eligible for Medicaid but at the time of application were only eligible
for the GRHCP. The health benefits representatives were responsible for explaining
the GRHCP to the new GR beneficiaries, including their eligibility for free
health care through this system. The beneficiaries were asked to complete
a baseline health history questionnaire, developed by the Los Angeles County
Department of Health Services. Adults chose or were assigned to a specific
GRHCP provider organization based on the location of the Department of Public
and Social Services office at which they had registered for GR benefits. The
health benefits representative recorded this information on the health questionnaire.
A total of 8520 baseline health history surveys were completed by adults
who met with a health benefits representative between September 1, 1996, and
November 31, 1996 (response rate, 98%). Adults were eligible for inclusion
in our study if they reported a history of 1 or more of 4 medical conditions—hypertension,
diabetes mellitus, a nonresolving cough, or substance dependency—on
the baseline health history questionnaire20-21
and a GRHCP provider was recorded on their baseline health history (n = 2771).
Because of logistic constraints (25 individual practices), we did not include
in our study GR beneficiaries assigned to the independent practice association
(n = 533). In addition, we excluded patients if information identifying their
GRHCP provider (n = 66) or their date of registration (n = 8) was incomplete
or missing. Our study sample comprised 2164 low-income adults.
DATA COLLECTION
Between July 1997 and April 1998, we attempted to locate the medical
records for each person in our sample. From the baseline health history questionnaire,
we obtained the name of each individual's designated GRHCP primary care provider.
We provided clinic staff with a list of individual patient identifiers (ie,
name and Social Security number). If a provider organization had more than
1 site, we sent the pertinent patient lists to all of the sites to determine
if medical records existed for those patients. We reviewed each medical record
obtained to determine whether the patient had made a visit to his/her designated
GRHCP provider within 4 months of enrollment. Only a few of the providers
had a computerized appointment system, which allowed us to review the appointment
records for the 4-month period beginning on the date the baseline health history
questionnaire was completed. We chose a 4-month window as the interval from
the time of enrollment in GR to their appointment with a GRHCP provider after
extensive discussions with both primary care providers and specialists who
care for patients with the 4 medical conditions included in this study. In
addition, this time window is consistent with published guidelines for the
care of patients with hypertension and diabetes.
At each site we worked with clinic staff to locate medical records for
all study patients designated to receive care at that site. We checked file
rooms, physicians' offices, and other patient care locations. If we determined
that a patient had been seen at that site, but we were unable to review the
medical record at our initial visit, we asked the clinic staff to find the
chart, and we scheduled a return visit to that site. We assessed the test-retest
reliability of our method for measuring patients' use of free primary care
services by submitting the same patient lists to a limited number of clinic
sites at a later date. No new medical records were identified, and all previously
reviewed medical records were eventually reobtained.
OUTCOME VARIABLE
Our outcome variable was a visit to a designated GRHCP provider within
4 months of enrollment in the GRHCP.
EXPLANATORY VARIABLES
We used information obtained from individuals' baseline health history
questionnaire: age, sex, race/ethnicity, preferred language, education, and
current residential status (housed in one's own home or apartment or with
family or friends vs homeless, such as living in a hotel or motel, in a shelter,
in a residential treatment facility, on the streets, near a freeway, or in
an abandoned building); type of transportation to a medical appointment (public,
private, or none other than walking); any history as a survivor of violence;
psychiatric history ( 1lifetime overnight hospitalizations at a psychiatric
facility); current use of tobacco; health status; a patient's reported need
to see a physician; and prior use of health services (ie, last visit to a
provider and use of prescription medications).
STATISTICAL ANALYSES
To measure use of primary care services through the GRHCP, we calculated
the proportion of our sample who had made 1 or more visits to their designated
provider within 4 months of enrollment in the GRHCP. We then used the  2 and Fisher exact tests to assess the associations between our outcome
variable and the explanatory variables. We used multivariate logistic regression
(relative risks and 95% confidence intervals) to measure the effect of the
explanatory variables on the outcome of having made a visit to a designated
GRHCP provider within 4 months of enrollment. We included independent variables
in the multivariate logistic regression if they were part of conceptual models
that have been used to predict the use of care22-25
or if they were significantly associated with the outcome variable in the
bivariate analyses (P<.05). The independent variables
in the model were as follows: age, sex, race/ethnicity, homeless status, current
tobacco use, health status, perceived need to see a physician, usual site
for health care (clinic, emergency department, private physician), current
use of prescription medications, and visit to a physician within 1 year before
entering the program. SAS 6.12 statistical software (SAS Institute Inc, Cary,
NC) was used for all analyses.
HUMAN SUBJECTS PROTECTION
We submitted the study protocol to the Human Subjects Protection Committee
of the University of California at Los Angeles and received institutional
review board approval. In addition, the study protocol was presented to representatives
of all the GRHCP provider organizations and was submitted as required to their
individual institutional review boards for approval. We obtained permission
to collect data from the Los Angeles County Department of Health Services
sites by applying to the institutional review board at the Los Angeles County–University
of Southern California Medical Center.
RESULTS
SAMPLE CHARACTERISTICS
Table 1 describes our study
sample. The median age of the sample was between 35 and 40 years, and 36%
were female, 48% African American, 29% Latino/Hispanic, 15% white, 1% Asian/Pacific
Islander, and 7% multiracial and other. Less than half of the sample were
high school graduates, a similar proportion were homeless, and 12% preferred
a language other than English. Seventy percent rated their health status as
fair or poor, and an equal proportion reported they thought they needed to
see a physician. Eighteen percent had ever been hospitalized overnight at
a psychiatric facility, and 77% had seen a physician within the preceding
year.
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Table 1. Patient Characteristics*
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OUTCOME: VISIT TO A GRHCP PROVIDER
A total of 358 (17%) of the study sample visited their GRHCP provider
within 4 months of enrolling in the program. However, as Figure 1 shows, visit rates varied by medical condition.
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Percentage of General Relief (GR) beneficiaries who visited their
designated General Relief Health Care Program provider within 4 months of
enrollment.
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About one quarter of patients with diabetes or persistent cough visited
their provider within the 4-month window. However, only 18% of patients with
hypertension and 12% of patients with substance dependence did so. Bivariate
analysis revealed that individuals who had made at least 1 visit to their
designated GRHCP provider were more likely to be older than 50 years, female,
and Asian/Pacific Islander (Table 2).
In addition, individuals were more likely to have made a visit to their GRHCP
provider if they were not homeless, reported fair or poor health status, stated
a perceived need to see a physician, had a private physician as their prior
usual source of care, reported using prescription medications, or had visited
a physician within the preceding 12 months. Individuals were less likely to
have made a visit if they reported regular tobacco use. Education, mode of
transportation, a history of having been a survivor of violence, or a history
of psychiatric hospitalization were not significantly associated with having
made a visit within 4 months.
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Table 2. Use of Primary Care Services Through the General Relief Health
Care Program: Bivariate Analyses of a Documented Visit to an Assigned Health
Care Provider Within 4 Months of Enrollment
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Results of the multivariate logistic regression analyses are found in Table 3. Women and adults older than 50
years were about a third more likely to have visited their designated GRHCP
provider within the 4-month window of interest. Those who had seen a physician
in the preceding 12 months were about half again more likely. The most powerful
effect was perceived need to see a physician; patients who expressed such
a need were more than 75% more likely than others to have made a physician
visit. Factors that were not independently associated with having made a visit
included the following: current residential status, smoking, self-rated health
status, having a prior usual source for health care, and current use of prescription
medications. Because prior use may account for most of future use, we reran
the multivariate model, excluding prior use, and found no differences.
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Table 3. Multivariate Analyses to Assess Characteristics of Patients
Who Made Visits to a Designated General Relief Health Care Program Provider
Within 4 Months of Enrollment
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COMMENT
The GRHCP represents an important attempt by local government to provide
health care for adults at high risk for poor health because of poverty. To
increase access to health care for very low-income adults receiving GR benefits
and to optimize the geographic distribution of services available through
this new program, the county contracted with community health care providers
throughout Los Angeles County. Many GRHCP providers had extensive experience
caring for very low-income adults and were located in areas that had previously
been identified as underserved.
However, as this study demonstrates, the provision of free primary care
services to very low-income adults does not guarantee that the services will
be used. We found that only 17% of very low-income adult patients with a medical
condition shown to benefit from regular ongoing medical care had visited their
designated health care provider within 4 months of enrollment, despite the
fact that these patients were enrolled in a publicly funded managed care program
that was geographically dispersed and free of charge. We also found that the
proportion of individuals who made a visit to their assigned provider varied
considerably by medical condition. Those with diabetes were the most likely
to have made a visit within the 4-month time frame; those with a history of
substance dependence were the least likely; however, in the multivariate model,
the individual medical conditions did not have significant main effects.
We attempted to identify characteristics that could be used to explain
use or lack of use of primary care services by very low-income adults who
were enrolled in a program that provided them medical care free of charge.
Although prior research has shown that sociodemographic factors such as sex,
age, and race/ethnicity are associated with differential access to health
care—women and the elderly are more likely than men and younger adults
to seek care, but they may report greater difficulty receiving care—other
barriers to care also exist.1, 25-31
These barriers may take the form of competing or conflicting needs, including
a lack of housing, food, transportation, and child care, as well as fears
for personal safety.32-34
In these analyses, we studied the effects of specific competing needs (housing
status and mode of transportation) but were unable to include others such
as food and child care due to limited information. Although we found significant
bivariate associations for health behaviors and competing needs with use of
health care, these factors were not significant when we controlled for demographic
and other explanatory variables, including patients' prior usual site for
health care.
Surprisingly, although poor health status has been shown to predict
adults' use of health care and although it has been documented that low-income
populations tend to have worse health status,35-37
self-rated health status was not a significant predictor of use after adjusting
for other variables. However, adults who indicated a need to see a physician
were almost twice as likely to have made a visit to their GRHCP provider within
4 months than those who did not report a need to be seen. Of note, slightly
more than two thirds of adults who did not make a visit to their assigned
GRHCP provider reported a need to see a physician; the highest rate of perceived
need was among patients with diabetes and the lowest among patients with substance
dependence. We did not measure the beneficiaries' understanding of the services
available, the presence of barriers to seeking services through the GRHCP,
or the ability to obtain health care elsewhere, and all of these unmeasured
attributes could have contributed to the low use rate.
Prior research has demonstrated that having a regular source for health
care improves access to and use of health care28, 38-39
and reduces the number of hospitalizations for ambulatory sensitive conditions
(eg, diabetes, hypertension, asthma, congestive heart failure).28, 40-41
In addition, prior use of health care has been shown to predict current and
future use.39 We found that an individual's
prior use of health care, including where he/she previously received care,
current use of prescription medications, and the duration since the last visit
to a physician, was associated on bivariate analysis with current use of care.
However, in our multivariate analysis, only a visit to a health care provider
within the preceding year remained significant.
Our study has 4 limitations. First, we relied on patient self-report
to identify individuals with 1 of the 4 medical conditions of interest for
this study; thus, we did not include people who had the condition but did
not know it. If we had included this group, visit rates would probably have
been even lower. There may also be the possibility of overreporting, although
patients' perceptions of need related to having 1 or more of the 4 conditions
would have been expected to increase use in the form of a visit to a designated
GRHCP provider. Prior research has demonstrated that homeless adults accurately
report the presence or absence of ambulatory medical conditions.20-21
Second, we were not able to obtain information about whether individuals
sought primary care services from someone other than their designated GRHCP
provider. According to Los Angeles County Department of Health Services regulations,
providers other than a patient's designated GRHCP provider were not reimbursed
for primary care services provided to GR recipients. In addition, because
data were obtained by patient survey only at the time of their enrollment
into the GRHCP, we were unable to determine if they made visits outside the
GRHCP subsequent to their enrollment into it.
Third, we relied on obtaining and reviewing the medical record to determine
if a visit had been made within the designated 4-month window. Our inability
to obtain medical records could have caused us to underreport the proportion
of people who had made a visit to their provider. However, we assessed our
ability to obtain specific medical records and found very high test-retest
reliability.
Fourth, the study sample was not population based but relied on identifying
GR registrants who met with a health benefits representative and completed
the baseline health survey. Thus, the study sample may not be representative
of all very low-income adults or even all GR recipients.
CONCLUSIONS
We believe that providing a free health care benefit at the time a GR
applicant is enrolled in the welfare program represents an innovative approach
to increasing appropriate use of primary health care services by very low-income
adults. However, although necessary, this attempt is not sufficient to increase
use of care to medically appropriate rates. Our study results suggest that
the current program needs to be enhanced. Although evidence does not currently
exist for the effectiveness of any of the following enhancements, they are
listed herein for consideration. Of course, their impact would need to be
carefully evaluated. At the time of enrollment in the welfare program, the
beneficiary's medical history could be checked and a specific medical appointment
made (1) for all beneficiaries or, if that is not possible, (2) for those
beneficiaries who either expressed a need for a physician visit or had a chronic
condition whose care required such an appointment. In addition, we suggest
that education about the need for routine and continuous medical care will
also be provided to patients who have treatable medical conditions but who
also express no need to see a physician.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
Dr Diamant's work on this article was funded as a Robert Wood Johnson
Clinical Scholar and a National Research Service Award Primary Care Research
fellow. Dr Gelberg is a Robert Wood Johnson Generalist Physician Faculty Scholar.
We thank staff at the Los Angeles County Department of Health Services
for their assistance with this project and David Klein for programming.
This work does not necessarily represent the opinions of the funding
organizations or of the institutions with which the authors are affiliated.
Corresponding author and reprints: Allison L. Diamant, MD, MSHS,
UCLA, Department of Medicine, Division of General Internal Medicine and Health
Services Research, 911 Broxton Ave, Los Angeles, CA 90095 (e-mail: adiamant{at}mednet.ucla.edu).
From the Department of Medicine, Division of General Internal Medicine
and Health Services Research (Drs Diamant, Brook, and Fink), Department of
Medicine, Division of Geriatrics (Dr Brook), and Department of Family Medicine
(Dr Gelberg), UCLA, Los Angeles, Calif; and RAND-Health, Santa Monica, Calif
(Dr Brook).
REFERENCES
| |
1. Freeman HE, Aiken LH, Blendon RJ, et al. Uninsured working-age adults: characteristics and consequences. Health Serv Res. 1990;24:811-823.
ISI
| PUBMED
2. Mirvis DM, Chang CF, Hall CJ, Zaar GT, Applegate WB. TennCare—health system reform for Tennessee. JAMA. 1995;274:1235-1241.
ABSTRACT
3. Rotwein S, Boulmetis M, Boben PJ, et al. Medicaid and state health care reform. Health Care Financ Rev. 1995;16:105-120.
PUBMED
4. Gold M, Sparer M, Chu K. Medicaid managed care: lessons from five states. Health Aff (Millwood). 1996;15:153-166.
ABSTRACT
5. Gold M. Markets and public programs: insights from Oregon and Tennessee. J Health Polit Policy Law. 1997;22:633-666.
6. Long WJ, Kirsch D. A government purchaser perspective: TennCare—strengthening the
safety net. Cancer. 1998;82(suppl 10):2000-2002.
7. Lyons W, Scheb II JM. Managed care and Medicaid reform in Tennessee. J Health Care Poor Underserved. 1999;10:328-337.
PUBMED
8. Rocha CJ, Kabalka LE. A comparison study of access to health care under a Medicaid managed
care program. Health Soc Work. 1999;24:169-179.
PUBMED
9. Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. Managed care in three states: experiences of low-income African Americans
and Hispanics. Inquiry. 1999;36:318-331.
ISI
| PUBMED
10. Blendon RJ, Aiken LH, Freeman HE, Kirkman-Liff BL, Murphy JW. Uncompensated care by hospitals or public insurance for the poor: does
it make a difference? N Engl J Med. 1986;314:1160-1163.
ABSTRACT
11. Cousineau MR, Robertson MJ. Health status and access to health services among the urban homeless. Am J Public Health. 1986;76:561-563.
FREE FULL TEXT
12. Cousineau MR. Health status of and access to health services by residents of urban
encampments in Los Angeles. J Health Care Poor Underserved. 1997;8:70-82.
ISI
| PUBMED
13. Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure. The Fifth Report of the Joint National Committee
on Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, Md: National Institutes of Health; 1993.
14. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and
progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977.
FREE FULL TEXT
15. Risks and benefits of intensive management in non-insulin-dependent
diabetes mellitus: The Fifth Regenstrief Conference. Ann Intern Med. 1996;124(1 pt 2):81-186.
16. Chung KF, Lalloo UG. Diagnosis and management of chronic persistent dry cough. Postgrad Med J. 1996;72:594-598.
ABSTRACT
17. Ing AJ, Breslin AB. The patient with chronic cough. Med J Aust. 1997;166:491-496.
PUBMED
18. McGarvey LP, Heaney LG, MacMahon J. A retrospective survey of diagnosis and management of patients presenting
with chronic cough to a general chest clinic. Int J Clin Pract. 1998;52:158-161.
ISI
| PUBMED
19. French CL, Irwin RS, Curley FJ, Krikorian CJ. Impact of chronic cough on quality of life. Arch Intern Med. 1998;158:1657-1661.
FREE FULL TEXT
20. Gelberg L, Siecke N. Accuracy of homeless adults' self-reports. Med Care. 1997;35:287-290.
FULL TEXT
|
ISI
| PUBMED
21. Andersen R, Kasper J, Frankel MR. Total Survey Error. San Francisco, Calif: Jossey-Bass Publishers; 1979.
22. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9:208-220.
PUBMED
23. Andersen RM. Revisiting the behavioral model and access to medical care: does it
matter? J Health Soc Behav. 1995;36:1-10.
FULL TEXT
|
ISI
| PUBMED
24. Aday LA, Awe WC. Health sources utilization models. In: Gochman DS, ed. Handbook of Health Research
Vol. 1: Determinants of Health Behavior: Personal and Social. New York,
NY: Plenum Press; 1995.
25. Lambrew JM, DeFirese GH, Carey TS, et al. The effects of having a regular doctor on access to primary care. Med Care. 1996;34:138-151.
FULL TEXT
|
ISI
| PUBMED
26. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Inequities in health services among insured Americans: do working-age
adults have less access to medical care than the elderly? N Engl J Med. 1988;318:1507-1512.
ABSTRACT
27. Weissman JS, Stern R, Fielding SL, et al. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114:325-331.
28. Institute of Medicine Committee on Monitoring Access to Personal Health
Care Services, Millman M, ed. Access to Health Care in America. Washington, DC: National Academy Press; 1993.
29. Cykert S, Kissling G, Layson R, Hansen C. Health insurance does not guarantee access to primary care: a national
study of physicians' acceptance of publicly insured patients. J Gen Intern Med. 1995;10:345-348.
PUBMED
30. Berk Ml, Schur CL, Cantor JC. Ability to obtain health care: recent estimates from the Robert Wood
Johnson Foundation National Access to Care Survey. Health Aff (Millwood). 1995;14:139-146.
ABSTRACT
31. Cunningham WE, Hays RD, Williams KW, Beck KC, Dixon WJ, Shapiro MF. Access to medical care and health related quality of life for low-income
persons with symptomatic human immunodeficiency virus. Med Care. 1995;33:739-754.
ISI
| PUBMED
32. Himmelstein DU, Woolhandler S. Care denied: U.S. residents who are unable to obtain needed medical
services. Am J Public Health. 1995;85:341-344.
FREE FULL TEXT
33. Gelberg L, Doblin BH, Leake BD. Ambulatory health services provided to low-income and homeless adult
patients in a major community health center. J Gen Intern Med. 1996;11:156-162.
ISI
| PUBMED
34. Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults
in Los Angeles. Am J Public Health. 1997;87:217-220.
FREE FULL TEXT
35. Adler NE, Boyce WT, Chesney MA, et al. Socioeconomic inequalities in health. JAMA. 1993;269:3140-3145.
ABSTRACT
36. Krieger N, Rowley D, Herman AA, et al. Racism, sexism, and social class: implications for studies of health
disease and wellbeing. Am J Prev Med. 1993;9:82-122.
ISI
| PUBMED
37. Pamuk E, Mukuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook: Health,
United States, 1998. Hyattsville, Md: National Center for Health Statistics; 1998.
38. Gallagher TC, Andersen RM, Koegel P, Gelberg L. Determinants of regular source of care among homeless adults in Los
Angeles. Med Care. 1997;35:814-830.
FULL TEXT
|
ISI
| PUBMED
39. Stewart AL, Grumbach K, Osmond DH, Vranizan K, Komaromy M, Bindman AB. Primary care and patient perceptions of access to care. J Fam Pract. 1997;44:177-185.
ISI
| PUBMED
40. Epstein AM, Stern RS, Weissman JS. Do the poor cost more? a multihospital study of patient's socioeconomic
status and use of hospital resources. N Engl J Med. 1990;322:1122-1128.
ABSTRACT
41. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274:305-311.
ABSTRACT
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