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INTRODUCTION

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"Everyone in a complex system has a slightly different interpretation. The more interpretations we gather, the easier it becomes to gain a sense of the whole."

—Margaret J. Wheatley

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*Mr. Ketterman's Case

I know that Mr. and Mrs. Ketterman have had to pay for their assisted living facility themselves, and that a physical therapist comes into the facility to see many of the residents. They are confused about what services Mr. Ketterman is eligible for under his Medicare insurance and what he is entitled to from the facility. They are also trying to decide if he should be admitted to a nursing home. They would like my advice about the best way to get him the services he needs, at the lowest cost to them. (See Appendix for Mr. Ketterman's health history.)

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Sociologists suggest that disease, and therefore health, are fundamentally impacted by access to resources, which allow the ability to avoid risk or minimize the effects of disease once it has occurred.1 It is important to recognize that the ability to access services can be modified by financial, social, and cultural factors.2,3,4,5,6 Andersen7 developed a behavioral model that has been used over the years to understand why patients use health services and what factors impact their ability to access these services. In his initial model, proposed in the 1960s,8 he described three factors that primarily impact a patient's access to care:

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  1. predisposing characteristics, such as age, race/ethnicity, gender, education level, and health beliefs;

  2. enabling resources, such as income level, insurance coverage, proximity to services, and having a regular source of care; and

  3. need, such as health and functional status (Fig. 9-1).

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Figure 9-1

Andersen's Behavioral Model. (Redrawn from: Andersen RM. Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav. 1995;36:1–10.)

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There is ample evidence in the current literature to support that many of these factors do, in fact, impact the patient's circumstance regarding access to health care.9,10,11,12,13,14,15,16,17,18,19,20,21,22,23 Later, Andersen recognized that in addition to these three factors there were other things that impacted the patient's use of services, such as the external environment (physical—air/water quality, food supply—politics and the economy) and the health care system (health policies and resources).7

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The United States (U.S.) health care system consists of a large and complex collection of federal, state, and local government organizations, private entities, and practitioners, all of whom provide or pay for a wide array of health care services. The United States is the only large industrialized country in the world ...

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