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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
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 "grandâ€¦ 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
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
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
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
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):209â€“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.