Access to Care | AHC Policy Brief

CA Strategic Plan

Recommendations

Public Support

Youth Involvement
& Development

Access to Care

Service Coordination

Families

Communities

Schools

Data

Outcome Areas

Injury Prevention

Mental Health and Suicide

Nutrition & Physical Activity

Alcohol, Tobacco
& Other Drugs

Teen Pregnancy & STI’s

Oral Health

Environmental
& Occupational Health

Out of Home Youth –
Resources on Mental Health

Access to Care | Overview

Ensure access to comprehensive, youth-friendly
health services

This is Chapter 2, Recommendation 3 of California's adolescent health strategic plan. To view the full plan, click here.

Although physical health problems are relatively rare in adolescence, the social and developmental changes of adolescence create a variety of health risks and risk behaviors. Health services can make a critical difference between a healthy adolescence and one that is disrupted by serious physical, psychological, or social problems. Yet adolescents and young adults have the lowest rates of health service utilization of any age group. For example, in 1996, only 18% of adolescents ages 15 to 20 received a medical screen through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, whereas 76% of eligible infants were screened.³⁶ The low utilization of health services among teens is due to a variety of factors including lack of health coverage, concerns about confidentiality, lack of health services that are comfortable and convenient for youth, and lack of public recognition of the importance of preventive care for adolescents.

Comprehensive health services provided to adolescents prevent the development of long-term health issues that are expensive to treat. Comprehensive care for adolescents must include:

primary care
reproductive health
mental health services
substance abuse prevention and treatment

immunization
oral health
case management
psychosocial supports
health education

Health coverage

View Indicator

Health insurance is a critical first step in providing youth with access to health care. Uninsured youth are 3.5 times more likely than insured youth to go without needed health care, and six times more likely to have no usual health care provider.³⁷ In 1998, among California’s 9.7 million children and youth, approximately 54% had employer-based health coverage, 20% had Medi-Cal, 4% purchased coverage privately, and 21% (2 million) were uninsured.³⁸ With the national average of uninsured children and youth at 15%, California has a significantly larger gap in health insurance for children and youth.

Figure 2.1

Of the state’s uninsured young people, 41% are eligible for Medi-Cal and approximately 32% are eligible for the Healthy Families program (Figure 2.1).³⁸ More effective enrollment in existing programs could result in a 73% reduction in the number of uninsured children and youth. The remaining uninsured children and youth are not eligible for public programs because they are undocumented or because their family income is above the eligibility level—currently 250% of the federal poverty level.

California’s Family Planning, Access, Care and Treatment program (Family PACT), implemented in January of 1997, has become an important source of publicly funded health care for teens. Although Family PACT is not insurance coverage, it enables teens with family incomes under 200% of poverty to access comprehensive clinical family planning services and primary care when they are unable to use services through Medi-Cal or Healthy Families. All Medi-Cal providers may enroll in Family PACT to provide and be reimbursed for these services under the program. There are currently over 2,800 providers participating in the Family PACT program.

Many youth, even those with public or private health insurance coverage, lack access to comprehensive health care benefits. In particular, behavioral health services (mental health and substance abuse treatment) have been found to be difficult to access and inadequate in scope. The amount of the health insurance premium dedicated to behavioral health services in a typical employer-based health plan is small and has been declining—from 6.1% to 3.1% between 1988 and 1997.³⁹ The median level of outpatient mental health coverage is 20 visits, but the number of covered visits can be as low as 10 in some HMOs.³⁸ Mental health inpatient treatment can be difficult to obtain, especially for teens with special health care needs or physical disabilities which many mental health facilities are not prepared to handle. Access to mental health services often requires a crisis, such as a suicide attempt, making prevention and early intervention difficult.

Dental services are also often excluded from health care coverage. Nationally, almost 30% of children and adolescents who have health insurance do not have dental insurance. A needs assessment by the Dental Health Foundation found that approximately 44% of the 10th grade students they surveyed did not have dental health coverage. Both Medi-Cal and Healthy Families offer comprehensive dental benefits for youth under age 21. However, in 1990, less than 40% of dentists in California treated Medi-Cal patients, falling below the national standard of 50%.⁴⁰

Quality of Care

There are several recognized standards for adolescent preventive care such as EPSDT guidelines, the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS), and the federal Maternal and Child Health Bureau’s Bright Futures: National Guidelines for Health Supervision of Infants, Children, and Adolescents.⁴¹Clinical preventive services guidelines for children and adolescents also have been developed by the American Academy of Pediatrics, the American Academy of Family Physicians and the CDC’s Preventive Services Task Force. Overall, these guidelines offer comparable recommendations for preventive services, including screening, health counseling, and broadening the scope of traditional medical care to address the many important behavioral issues facing adolescents.⁴²

Obstacles to implementation of these guidelines include inadequate reimbursement, lack of time, and inadequate provider training. California’s model for EPSDT, the Child Health and Disability Prevention program (CHDP), does not reimburse for all of the examinations recommended by GAPS. Whereas annual examinations are recommended by GAPS during the adolescent years, CHDP covers only one examination between the ages of 13 and 16, and another between 17 and 20. Moreover, health screening and counseling require time, but often are not reimbursable. Inadequate capitation rates and the cost-saving emphasis of managed care are forcing physicians to spend less time with patients. Thus, although 72% of adolescents in California see a physician at least once a year, these visits average less than 15 minutes.⁴³

To provide quality health care to teens, providers need to learn to communicate effectively with them, and to ask about sensitive issues such as sexual and substance-use histories. They also must understand the needs of gay/lesbian, foster care, runaway and other groups of youth with special needs. Training in non-medical issues such as these is not typically emphasized in medical education. Many practitioners (e.g., pediatricians, internists, nurse practitioners) receive little training in adolescent health issues and are not comfortable with these topics. In addition, adolescent medicine specialists are in short supply. Adolescent medicine was established as a new sub-specialty of both Pediatrics and Internal Medicine in 1994. As of August 1999, only 49 California physicians were board certified in Adolescent Medicine.⁴⁴

Quality assurance requirements for managed care organizations, using reporting systems such as HEDIS (Health Employer Data Information Systems), are a potential leverage point for improving the care adolescents receive. HEDIS 3.0, released in 1996, includes four adolescent-specific measures. Of these, two have been implemented: a preventive services visit within the previous 12 months, and adolescent immunization status. Two additional measures are currently in the developmental phase: physician counseling regarding substance use, and chlamydia screening for young women aged 15 to 25 years. The Foundation for Accountability is working with the National Committee for Quality Assurance to develop an Adolescent Preventive Care Measurement Set for youth ages 14 to 18. In addition, the RAND Corporation has developed a set of indicators to assess the quality of adolescent care, and the National Adolescent Health Information Center at the University of California, San Francisco has developed a checklist for assisting managed care organizations with improving adolescent health care.^45,46

Youth-friendliness

Because of developmental characteristics, a desire for independence, concerns about confidentiality, and lack of experience in negotiating complex health systems, adolescents need to be able to access health care from multiple entry points, including community-based centers, school-based and school-linked health centers, physicians’ offices, family planning clinics, HMOs, and hospitals.⁴⁷ Yet, among the 8,000 schools in California, only 92 have school-based health centers. These health centers and other safety-net providers are struggling to survive in the new, highly competitive health care marketplace.

The characteristics of youth-friendly services—services that youth can and want to use—will vary by community. However, there are several important characteristics that emerge repeatedly. The most crucial is confidentiality. Teens will not access care or raise sensitive concerns if they fear the information will be shared with parents or find its way to peers through gossip or careless conversation in the clinic. Secondly, the overall environment makes a critical difference in how teens respond. Teens are comfortable when staff enjoy working with them, welcome them, do not treat them with suspicion, listen to them, and answer their questions in a straightforward manner. Language and culture are also important issues for California’s increasing population of immigrant and non-English speaking youth. Transportation to service locations can be a barrier for all adolescents, but particularly for those who live in rural communities that are geographically isolated or lack adequate public transportation. In addition, some teens prefer to go outside their communities for medical care, making public transportation a crucial link to health care.

Involving youth in the design of services and in their delivery can greatly enhance the “teen friendliness” of medical, mental health, health education and other services. Recent approaches include involving teens as peer health educators, as staff in medical settings, and as members of advisory and planning groups. However, although the involvement of peers as staff or educators has been successful, it does not appeal to all teen patients. Concerns about confidentiality make some teens more comfortable with people whom they are less likely to see in other settings.

Strategies

1. Promote comprehensive, high-quality health care, and improve the diversity and skills of adolescent health providers.

Adopt nationally recognized professional guidelines for adolescent health care as the standard of care for all publicly- and privately-funded health care.
Develop models and tools that can be disseminated at the local level to assist providers in establishing effective programs for adolescents.
Increase the number of racially and ethnically diverse professionals working with adolescents by providing funding for scholarships, mentoring programs, and outreach to potential professionals.
Increase offerings in the area of adolescent health within continuing medical education programs.

2. Ensure an adequate supply of services and providers.

Establish parity between mental and physical (including dental) health services within public and private health plans.
Ensure the availability of inpatient services for youth who have a combination of medical and mental health disorders.
Create a workgroup at the state level to conduct periodic cost analyses and make recommendations for adjusting capitation rates under public programs so that they are adequate for all services—including prevention, counseling, and education—recommended by nationally recognized professional guidelines for adolescent health care.
Expand provider pools in publicly financed health services by including all providers, both public and private, and by employing billing methods that are easy to use.
Establish mechanisms by which school-based health centers can receive reimbursement under state programs, and create a grant program to support school-based health centers.

3. Make health care easy and comfortable for all teens to access.

Publicize the type of confidential health services available to all teens in California through state- and local-level outreach and education. Dedicate funding for Medi-Cal/Healthy Families outreach to adolescents and their families as distinct from general outreach to children.
Ensure that all publicly financed health services for adolescents include point-of-service eligibility and on-site self-enrollment. Eliminate co-payments and premiums for all youth.
Enable minors to consent to general, non-emergency, primary medical care.
Promote health and social services that respond to the needs of teens in the community, considering factors such as: confidentiality, location, hours, transportation, language and cultural competence, youth-friendly environments, and staff gender and ethnicity.
Ensure that services are provided in a manner that protects the rights of minors.
Inform health plan members about health professionals who have been trained in adolescent medicine or specialize in serving teens.

4. Involve adolescents in the planning and delivery of health services.

Establish adolescent advisory councils, conduct needs assessments and focus groups with clients, and expand peer provider training opportunities.
Require and fund grantees to involve youth in program planning for state and foundation initiatives.
Develop “report cards” to capture youth evaluations of service providing agencies and reward those that do well.

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