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Research Highlight

Ensuring Veterans' access to health services is a national and Veterans Affairs (VA) priority. Delayed or missed encounters may increase risks for adverse outcomes. Concerns about distance effects on access are not new. In this article, I discuss distance and access, noting relevant findings and outlining the concept of access and implications for research.

Responding to widespread concerns regarding wait times, Congress passed the Veterans Access, Choice, and Accountability Act of 2014. The Act directs VA to establish the Veterans Choice Program to furnish services through qualified non-VA providers for eligible Veterans who cannot be seen within 30 days or whose driving distance to the nearest VA medical facility exceeds 40 miles.

Planning for mental health services has long considered geographic factors. In 1850, Edward Jarvis noted, in the language of the period, that "an insane asylum is, and must be, to a certain extent, a local institution. People will avail themselves of its privileges in some proportion to their nearness to it."1 Whereas New Yorkers had considered locating a "grand… establishment" centrally, in Utica, to "offer equal advantages to... all parts of the State," Jarvis reasoned that although the facility might receive all who needed care from Oneida county, it would not serve "more than a fifth or a fourth of those of Rockland and Clinton." Jarvis described an early "law" of health services: a distance-decay relationship, whereby the likelihood of utilization diminishes at greater distances from providers.

Jarvis's work has guided analyses specific to individuals with mental illness who receive VA care. For example, studies indicate that living farther from VA providers is associated with having fewer outpatient visit days; less treatment retention; less receipt of psychotherapy and greater receipt of antidepressant medications following initial depression diagnosis; and less initiation of mental health intensive case management services among eligible patients.

Analyses also document other responses to distance barriers. When individuals with schizophrenia and bipolar disorder relocate, they are more likely to move closer to VA providers. And among individuals with serious mental illness, clinic trip chaining or coordination is greater for those who live farther from VA providers, as indicated by greater average number of clinic encounters per visit day. Similar findings have been documented for other VA patient populations. Distance is also associated with less timely follow-up after myocardial infarction, less receipt of needed liver transplants, less specialty care among patients with HIV, and less receipt of VA care among Medicare-eligible Veterans. Increased VA travel reimbursement is associated with greater receipt of medications and outpatient encounters.

Access is often poorly conceptualized in the research and policy literature. My understanding of access builds from the writings of Avedis Donabedian, and Penchansky and Thomas's "Five 'A's of Access."2, 3 To begin, it is understood that the health care process is situated in a sociocultural, organizational, and physical context. Access may affect utilization in terms of contact with providers, volume of services, and continuity of care. Access is conceptually distinct from utilization and outcomes, although these may offer helpful validators of access.

Most essentially, access represents a general concept that refers to specific dimensions of the fit between characteristics of potential clients and providers. Penchansky and Thomas validated a taxonomy of access with these dimensions: affordability, availability, acceptability, accommodation, and accessibility. Distance to care represents a measure of geographic accessibility, what Rashid Bashshur has called "the friction of space."

John Fortney and colleagues recently proposed an update to this framework. This updated view includes discussion of fit in terms of the "ease" of having virtual or face-to-face interactions. This update may focus health system efforts. It remains important for our understandings of access to consider provider responses to potential clients.

Several points follow from this conceptual understanding of access. Access should be understood in terms of multiple specific dimensions. People can have different degrees of access; access is not all-or-nothing. And individuals may differ in their "fit thresholds" as a function of their resources, preferences, and experiences. This approach is at the core of patient-centered care.

The concept of access as "fit" can guide researchers to consider varied influences on treatment seeking and continuation behavior; the importance of client preferences and circumstances; the role of clinicians' perspectives and behaviors; and the impact of services organization and delivery practices.

Over the past 20 years, VA has advanced substantially as an accessible health system. Notable examples include the expansion of contact points, services integration, enhanced travel reimbursement, expansion of telehealth, and provision of outreach and home-based services. The Veterans Choice Program presents important new opportunities to further enhance access and meet the needs of Veterans.

1. Jarvis E. "The Influence of Distance from and Proximity to an Insane Hospital, on Its Use by Any People," Boston Medical and Surgical Journal 1850; 42(11):209–22.

2. Penchansky R, Thomas JW. "The Concept of Access: Definition and Relationship to Consumer Satisfaction," Medical Care 1981; 19(2):127-40.

3. McCarthy JF, Blow FC. "Older Patients with Serious Mental Illness: Sensitivity to Distance Barriers for Outpatient Care," Medical Care 2004; 42:1073-80.

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