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Objective: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research., Study Design: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance., Patients and Methods: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions., Results: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance., Conclusions: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

Objective: The behavioral model of utilization, developed by Andersen, Aday, and others, is one of the most frequently used frameworks for analyzing the factors that are associated with patient utilization of healthcare services. However, the use of the model for examining the context within which utilization occurs-the role of the environment and provider-related factors-has been largely neglected., Objective: To conduct a systematic review and analysis to determine if studies of medical care utilization that have used the behavioral model during the last 20 years have included environmental and provider-related variables and the methods used to analyze these variables. We discuss barriers to the use of these contextual variables and potential solutions., Data Sources: The Social Science Citation Index and Science Citation Index. We included all articles from 1975-1995 that cited any of three key articles on the behavioral model, that included all articles that were empirical analyses and studies of formal medical care utilization, and articles that specifically stated their use of the behavioral model (n = 139)., Study Design: Design was a systematic literature review., Data Analysis: We used a structured review process to code articles on whether they included contextual variables: (1) environmental variables (characteristics of the healthcare delivery system, external environment, and community-level enabling factors); and (2) provider-related variables (patient factors that may be influenced by providers and provider characteristics that interact with patient characteristics to influence utilization). We also examined the methods used in studies that included contextual variables., Principal Findings: Forty-five percent of the studies included environmental variables and 51 percent included provider-related variables. Few studies examined specific measures of the healthcare system or provider characteristics or used methods other than simple regression analysis with hierarchical entry of variables. Only 14 percent of studies analyzed the context of healthcare by including both environmental and provider-related variables as well as using relevant methods., Conclusions: By assessing whether and how contextual variables are used, we are able to highlight the contributions made by studies using these approaches, to identify variables and methods that have been relatively underused, and to suggest solutions to barriers in using contextual variables.

In summary, a substantial proportion of Hispanic and low-income chronically ill children with special needs have neither private insurance nor Medicaid coverage. Those who averaged the fewest doctor visits during the past year for their condition (such as black or low-income children) also tended to be more likely to be hospitalized. Children who did not live with a biological mother or biological mother and father were least likely to have been to a physician or to be taking prescribed medications for their condition. These analyses pinpoint chronically ill children with special needs who are likely to have the least access to routine medical care. Further research is warranted to estimate the probable impact of the differential nonresponse and underreporting by minority and low-income respondents on these estimates.

This study examined why and for whom family physicians are likely to require HIV screening according to general policies or procedures, based on a national survey of 2,660 family practice physicians. Of those contacted, 1,678 responded, yielding a response rate of 63.7%. The study also examined whether attitudes toward screening differed for physicians in different types of practices, of varying educational backgrounds, and with differing opinions regarding treating persons with AIDS (PWAs). The results showed that required screening was most strongly endorsed for pregnant women who had other risk factors and for i.v. drug users. Those physicians who most favored mandatory screening were also most likely to favor the mandatory reporting of AIDS cases to public health officials. They also had the least formal medical training (were not residency trained or board certified) and expressed the greatest apprehension regarding their own and their staff's preparedness and willingness to treat PWAs. A major implication of the findings is that family physicians and others who do mandatory testing should be provided opportunities, through residency training, board-certification preparation, or continuing medical education, to learn how to care for those patients they test who turn out to be seropositive.

The most current research literature on the access of Hispanics to medical care is reviewed, and data from a 1982 national survey by Louis Harris and Associates on access to health care are presented to document current levels of access to health care of the Hispanic population. Through telephone interviews, 4,800 families were contacted, yielding a total sample of 6,610 persons. According to the survey's data, the ability of Hispanics to obtain health services is hampered by relatively low incomes, lack of health insurance coverage, and ties to a particular physician. However, Hispanics do not differ significantly from whites in their use of hospitals, physicians, or outpatient departments and emergency rooms. Hispanics are less satisfied than whites on a host of measures describing the most recent medical visit. These levels of dissatisfaction with the visit are similar to those of blacks. The recession and public care service cutbacks did not appear to result in a substantial reduction in the volume of medical care received by Hispanics and blacks. Still, the services available to minorities are viewed by them as less effective in meeting their needs in comparison with how whites view the services they receive. Further, the 1982 survey reveals particular difficulties and barriers for Hispanics in obtaining needed medical services. More than one-fifth of the Hispanic families had one or more significant problems in obtaining needed services.

Predictors of family and caregiver stress are identified and used to construct a profile of families at greatest risk of experiencing stress when providing home care for their ventilator-assisted children (VAC).

This paper examines the dimensions of the access concept with particular attention to the extent to which more parsimonious indicators of access can be developed. This process is especially useful to health policy makers, planners and researchers in need of cost-effective social indicators of access to monitor the need for and impact of innovative health care programs. Three stages of data reduction are used in the analysis, resulting in a reduced set of key indicators of the concept. Implication for subsequent data collection and measurement of access are discussed.

Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.

The authors explore the utility of applying social survey data (a) to evaluate the impact of existing health programs and (b) to rank-order priorities concerning future health care policies. Based on national survey data from 1963, 1970, and 1976, they concluded that although Medicare and Medicaid have enabled more people to see a physician than ever before, a large proportion of the population still registers dissatisfaction with the health care they received--particularly with respect to their out-of-pocket costs for obtaining it. However, national health insurance options favored by the majority of the population--particularly those who can best afford the cost of care--suggest preferences for programs that incorporate some mix of existing modes of financing rather than those that provide for substantial restructuring of the current system.

This article presents national data on a social-indicator-type measure of access to medical care, prior to and after the introduction of Medicare and Medicaid in the United States. The analyses confirm that the access of the poor, especially those with a regular source of medical care did improve, relative to the non-poor, between 1963 and 1970. Access for middle-class and low-income persons with no usual doctor and the high-income with a regular family physician declined considerably over this period, however. One explanation of these findings proffered is that after Medicare and Medicaid were introduced, providers may have begun to ration the number of visits by the "well-to-do" to accommodate the influx of low-income patients with newly acquired purchasing power and a backlog of unmet need. Many poor with no previously established source of care continued to experience barriers to entry. Much more sophisticated analyses are required to test this and other propositions suggested here, however.