Socio-economic difference s in care use : a sociological perspective on access and triage

1. Socio-economic differences in care use : a sociological perspective on access and triage Vincent Lorant Institut Santé et Société

2. Objectives • Acess differences and inequities in health care use • IOM framework • Application to Europe : Ecuiy III project • Sociological concepts to understand inequities among elderly • Bad patients, ageism and triage Institut Santé et Société

3. Access • Access describes the health care system, not the demand • Initially access = health insurance+availability • Definitions are context-specific • USA : health insurance (Aday & Andersen and the SBM) • Europe : co-payment (Le Grand) • But free care does not remove all hurdles to care • Example : low expected quality reduces access • Access according to IOM • Structural • Financial • Individual Institut Santé et Société

4. Institut Santé et Société Gold, HSR, 1998

5. Inequity in care use • GP medecine is pro-poor in most EU countries • Specialty medicine is pro-rich • Countries with gatekeeping : more inequities in speciality medicine (but NL) • Bismarckian health care system have lower inequities • Scandinavian countries do not have lower inequalities in mortality than other western european countries (Macenbach, NEJM 2008) Institut Santé et Société Van Doorslaer, Health Economics 2004

6. Institut Santé et Société Van Doorslaer, Health Economics 2004

7. A sociological perspective on inequity • Inequity and inequality are descriptive concepts • Health insurance and copayment are part of the answers • They are not sufficient • A sociological perspective on bad patients : • Bad patients are not legitimately sick • Bad patients resist the health providers hegemony • Bad patients have lower interest Institut Santé et Société

8. I. Bad patients are not legitimately sick • Health care is part of the social response to the disease • The magnitude of the response depends on how much it is considered as • serious from the society point of view • legitimate from the society point of view • Seriousness : • Social relationships and daily activities • Role functioning • Social reaction may differ between groups : ageism • Legitimacy : • Responsibility • Stigmatised diseases • Chronic disease : patient should not expect a cure • Each society has its ilegitimate disease • Ex : AIDS, STD, Drug addicts, COPD • And for elderly ? Freidson, Profession of Medicine : a study of sociology of applied knowledge, 1988 Institut Santé et Société

9. Ageism • Discrimination against elderly for age reasons • Normalisation of symptoms • Overlooking side-effects of medication • Undertreatment of depression • Reduction in role and functions is perceived as normal • Elderly reified as conservative • Baby talk Institut Santé et Société

10. II. Bad patients resist Institut Santé et Société

11. The voice of medicine and the voice of lifeworld • Medical consumption is the problem • Medicine is just a discourse claiming a scienfic background • Medicine produces knowledge reinforcing the control of the bodies by the state • Non medical problems turned medical • Medicalisation of health behaviours • Medicalisation of life cycle • Medicalisation of life events • Patients resist this hegemony • Lay knowledge • Alternative medicine • Patients organisation • Shared decision-making Institut Santé et Société

12. Bad patients • Few contacts • Refuse treatments or institutionalisation (nursing homes) • Resist medical requests • Question medical knowledge • Have bizarre explanations for their disease • Are willing to be partner in their treatment Institut Santé et Société

13. III. Bad patients have a lower value Institut Santé et Société

14. Triage • In case of rationing, providers have to select or refer patients • They use « local justice » criteria • Most of these criteria are clinically defined • But patients have different worth and triage aims at identifying worthy patients Institut Santé et Société Dodier & Camus, SHI 1998; Vassy C, SHI 2001

15. Patients with low value • No vital risk • Common or uninteresting clinical case • Do not match the service • Social demands • Chronic diseases • This value depends on the institution identity and specialty • Teaching vs. non-teaching hospital Institut Santé et Société Dodier & Camus, SHI 1998; Vassy C, SHI 2001

16. What is an interesting patient ? Interv.: C’est quoi un patient intéressant pour toi ? Méd.urg : D’abord c’est un cas où je me sens utile, où je peux appliquer ce que j’ai appris durant ces dernières années. Méd.urg : Si ce n’est pas une urgence, n’importe qui d’autre peut s’en occuper. Dodier & Camus, SHI 1998 Institut Santé et Société

17. Care pathways • Patients helpseeking do not always match available care formal pathways : • Geographical accessibility • Time • Financial accessibility • Existing networks of care • As a consequence, some services become buffer-zone : emergency, geriatry, psychiatry • « Care coordination » : power struggle between providers • Care pathways maybe just about how to get rid of unwhished patients Institut Santé et Société

18. Implications of triage • Local justice critieria can influence : • Waiting times • Care times • Referrals • Care’s denial • Patient categorisation : «crooks », «normal rubish », « outpatient case » Institut Santé et Société

19. Conclusions • Access is not only about copayment • Beware before jumping to gatekeeping • Monitor quality of care for « illegitimate » diseases • Understand why patients resist care • Care pathways : opportunity or new discrimination • Fight ageism Institut Santé et Société