Defining and Targeting Health Care Access Barriers

Abstract

The impact of social and economic determinants of health status and the existence of racial and ethnic health care access disparities have been well-documented. This paper describes a model, the Health Care Access Barriers Model (HCAB), which provides a taxonomy and practical framework for the classification, analysis and reporting of those modifiable health care access barriers that are associated with health care disparities. The model describes three categories of modifiable health care access barriers: financial, structural, and cognitive. The three types of barriers are reciprocally reinforcing and affect health care access individually or in concert. These barriers are associated with screening, late presentation to care, and lack of treatment, which in turn result in poor health outcomes and health disparities. By targeting those barriers that are measurable and modifiable the model facilitates root-cause analysis and intervention design.

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Journal of Health Care for the Poor and Underserved 22 (2011): 562–575.
ORIGINAL PAPER
Dening and Targeting Health Care Access Barriers
J. Emilio Carrillo, MD, MPH
Victor A. Carrillo, MPA
Hector R. Perez, BA
Debbie Salas-Lopez, MD, MPH, FACP
Ana Natale-Pereira, MD, MPH
Alex T. Byron, BA
Abstract: e impact of social and economic determinants of health status and the exis-
tence of racial and ethnic health care access disparities have been well-documented. is
paper describes a model, the Health Care Access Barriers Model (HCAB), which provides
a taxonomy and practical framework for the classication, analysis and reporting of those
modiable health care access barriers that are associated with health care disparities. e
model describes three categories of modiable health care access barriers: nancial, struc-
tural, and cognitive. e three types of barriers are reciprocally reinforcing and aect health
care access individually or in concert. ese barriers are associated with screening, late
presentation to care, and lack of treatment, which in turn result in poor health outcomes
and health disparities. By targeting those barriers that are measurable and modiable the
model facilitates root-cause analysis and intervention design.
Key words: Health disparities, cultural competence, racial/ethnic disparities, health care
access barriers, cause of disparities, access barriers model.
The impact of social and economic determinants of health status and the existence
of racial and ethnic health care access disparities have been well-documented.1,2,3
Increasingly, multifactorial models are being presented to explain the causes for such
disparities.4,5,6,7 Health care access barriers play an important role in understanding the
causes of disparities.8 is paper describes a model, the Health Care Access Barriers
Model (HCAB), which provides a taxonomy and practical framework for the clas-
sication, analysis and reporting of those health care access barriers frequently faced
by populations that exhibit adverse health disparities. e model is equally applicable
across all racial and ethnic groups and specically targets those access barriers which
J. Emilio Carrillo and ViCtor Carrillo are aliated with NewYork-Presbyterian Hospital,
Weill Medical College of Cornell University, in New York City. Dr. Carrillo can be reached there at 177
Fort Washington Ave., Room IHS-228, New York, NY 10032; (212) 305-1079 (oce); ecarrill@nyp.org.
HECtor PErEz is aliated with Columbia University Medical Center, DEbbiE SalaS-loPEz
with Lehigh Valley Hospital and Health Network (Lehigh, Penn.), ana natalE-PErEira with the
University of Medicine & Dentistry of New Jersey in Newark, and alEx byron with Weill Cornell
Medical College.

563
J Carrillo, V Carrillo, Perez, Salas-Lopez, Natale-Pereira, and Byron
are modiable in order to support the design of community-based interventions that
may lead to reduced disparities.
e HCAB model has been used to design community-based health interventions
to reduce the complications of diabetes mellitus in a high prevalence community
and to improve cancer screening among Latinas.9,10 In our community health work,
we used the HCAB model to facilitate the realignment of prevention and health care
services provided by a major academic medical center, NewYork-Presbyterian Hospi-
tal, to a large community of Latino immigrants in Washington Heights Inwood.11 A
community health needs assessment, linked with an analysis of nancial, structural
and cognitive barriers guided the development of Patient Centered Medical Homes,
Information Technology communication strategies and cultural competence training
of ambulatory care sta.
Health Care Access Models
While many health care access barriers have been described in the literature, they have
generally not been incorporated into models that set access barriers as units of analysis;
classify barriers; and provide frameworks that facilitate measurement, analysis, and
reporting.12,13,14,15 We have not identied models in the literature that specically target
modiable health care access barriers. However, a few examples of analytic frameworks
tie health care access barriers to adverse health outcomes and disparities. DeVoe et al.
have presented a typology of barriers to health care access for low-income families
that includes no health insurance coverage, no access to care, and inability to aord
co-payments and other costs even if insured.16
Andersen’s Behavioral Model of Health Services Use is a well-known and frequently
applied model of access to care.17,18 is model sets the individual as the unit of analysis
and suggests that the individuals’ use of health services is a function of their need and
predisposition to use them.19 Andersen’s model serves as a framework for large scale
studies and incorporates a comprehensive and wide array of determinants. Determinants
include demographic factors (age and gender), social structure (education, occupa-
tion, ethnicity, and other factors measuring status in the community, as well as coping
and the health of the physical environment), and health beliefs (attitudes, values, and
knowledge that might inuence perceptions of need and use of health services). e
Model serves as a tool for the study of a broad set of determinants, both modiable
and not modiable. A number of variations of the Andersen model have evolved over
the years, but all subscribe to the same fundamental characteristics.17 e Andersen
model was built on the basis of quantitative national health surveys and oers a broad
framework for the analysis of data from large datasets.20
e Health Care Access Barriers Model
e Health Care Access Barriers (HCAB) Model facilitates the design of community
health interventions by targeting measurable and modiable determinants of health
status. is is dierent from the Andersen Model, which provides a broad framework of
modiable and non-modiable determinants and is ideal for large scale studies of health

564 Dening and targeting health care access barriers
services utilization. e HCAB is not a comprehensive model that attempts to include
all determinants; rather it targets modiable health care access barriers in order to serve
as a practical tool for root-cause analysis and community-based interventions.
e HCAB Model is summarized in Figure 1. e model provides a nomenclature
and framework for identifying, categorizing, and targeting health care access barri-
ers. It describes three categories of modiable health care access barriers (nancial,
structural, and cognitive). We will demonstrate that these three types of health care
access barriers are associated with decreased screening, late presentation to care, and
lack of treatment, which in turn result in poor health outcomes and health disparities.
By targeting those barriers that are measurable and modiable, the model facilitates
root-cause analysis and intervention design.
Over a number of years, the lead author and colleagues have developed a health
care access barriers model that is rooted in the social and cultural barriers that limit
doctor-patient interactions.21,22 Multiple health care access barriers facing Hispanics
were noted through interviews and focus group studies supported by the Robert Wood
Johnson Foundation in 2001.23 ese access barriers have been classied and sorted into
categories.24 In addition, a review of the literature yielded three intermediary variables
that link these access barriers with poor health outcomes.25 Here we articulate a model
oriented specically to health care access barriers that proposes mechanistic links
between three categories of access barriers and subsequent health disparities.
e fundamental characteristics of the HCAB model are classication of health care
access barriers; identication of barriers that are measurable, modiable, and identi-
ed using the best available evidence; and recognition of intermediary factors that link
barriers with health outcomes.
e HCAB model sets health care access barriers as the units of analysis and provides
an approach that focuses on the causal pathways between the access barriers and the
adverse health outcomes. is dierentiates HCAB model from the Andersen model,
which sets the individual as the unit of analysis.18 We propose a taxonomy that describes
three categories of health care access barriers: Financial—cost of care and health insur-
ance status barriers; Structural—including institutional and organizational barriers;
Cognitive—knowledge and communication barriers. e previously cited DeVoe model
addresses nancial and structural barriers, but it does not explore cognitive barriers,
which have also been shown to limit access.16,26,27,28 ese three categories of barriers
are reciprocally reinforcing and aect health care access individually and in concert.
For example, cognitive barriers may aggravate or compound nancial and structural
barriers. Similarly, nancial barriers may lead to structural or cognitive barriers.
e HCAB model also denes three intermediary variables (prevention, timely care,
treatment) that can serve as intermediary measures reecting the impact of access
barriers.
Financial, Structural, and Cognitive Health Care Access Barriers
Financial barriers to health care access arise in vulnerable populations when patients
are uninsured or underinsured.24 Research has demonstrated that the impact of being
uninsured and underinsured disproportionately aects Latinos and African Americans

565
J Carrillo, V Carrillo, Perez, Salas-Lopez, Natale-Pereira, and Byron
Figure 1. e health care access barriers (HCAB) model.
Health Outcomes
Disparities
Late Presentation Decreased
Prevention Decreased Care
Financial Barriers Cognitive Barriers
Structural Barriers
by limiting access to doctors when ill, going without a prescription for needed medi-
cations, or foregoing recommended tests or treatments.29 e uninsured population
includes many undocumented immigrants who are least likely to receive coverage from
federal and state health reform eorts. According to a 2002 study conducted by the
Commonwealth Fund, 34.1% of Hispanics and 21.6% of African Americans under age
65 in the United States are uninsured, compared with 12.5% for Whites.30
Individuals who are insured or who pay for their care by other means may never-
theless be subject to other access barriers that are not as tangible as insurance status.

566 Dening and targeting health care access barriers
Structural barriers are dened by the health care system’s availability. Such barriers may
be found within or outside of health care facilities. ese barriers act independently or
concurrently with nancial barriers already facing those without insurance. Structural
barriers may occur externally to the processes of care, as when people seek access to
health care services. ese barriers, as dened by recent studies, include but are not
limited to availability and proximity of facilities, transportation, child care, and structural
characteristics of care.31,32,33 Structural barriers are oen experienced within the health
care facility. Barriers such as excessive waiting times may aect care-seekers who are
have low incomes and live in neighborhoods of social and economic distress.14 Financial
and structural barriers may be further compounded by cognitive access barriers that
may, alone or in combination, adversely aect disease prevention and health care.
Box 1 provides examples of nancial, structural and cognitive barriers. Cogni-
tive barriers are rooted in the patient’s beliefs and knowledge of disease, prevention,
and treatment, as well as in the communication that occurs in the patient-provider
encounter.21,26–28,34,35 A patient’s lack of awareness of accessible health services may also
compound health barriers. Limited health literacy, as well as linguistic and cultural bar-
riers, may further prevent the patient from understanding and acquiring the necessary
knowledge to carry out therapeutic directions.36
Evidence-based Identication of
Barriers that are Measurable and Modiable
e HCAB model focuses on those health care access barriers that are associated with
adverse health care circumstances leading to health disparities. Many examples of such
discrete barriers can be found in the literature.12,13 ese barriers must be measurable in
order to facilitate quantitative analysis and evaluation. Furthermore, the model’s barriers
must be amenable to intervention, improvement, or correction: action can be taken to
eliminate, ameliorate, or prevent the barrier. For example, lack of health insurance has
been linked to health disparities and is readily measurable.29 Similarly, the structural
barriers and the cognitive barriers listed in Box 1 are all measurable and modiable.
Unlike HCAB, several of the components of the Andersen model, including demo-
graphic factors and social structure, have a low degree of mutability.19 e HCAB model
targets health care access barriers that are modiable and can be the subject of public
health and clinical interventions.
Recognition of Intermediary Factors that Link
Barriers with Health Outcomes
All three categories of health care barriers are associated with a number of intermedi-
ary factors that are known to result in poor health outcomes and disparities.16,35,37–39
Decreased use of preventive measures, delayed presentation and recognition of disease,
and lack of treatment or insucient treatment are all associated with poor health out-
comes.16,35,37–39 For example, in patients with low health literacy, there is a demonstrated
association with less use of preventive health services.40 Box 2 lists examples of associa-
tions between the three types of health care access barriers and the three intermediary

567
J Carrillo, V Carrillo, Perez, Salas-Lopez, Natale-Pereira, and Byron
Box 1.
EXAMPLES OF STRUCTURAL, FINANCIAL, AND
COGNITIVE BARRIERS TO HEALTH CARE ACCESS
Examples of Structural Barriers
Availability: Medical Home Waiting time
Transportation to health care facility Multiple locations for tests and specialists
Telephone access to providers Continuity of care
Lack of child care resources Multi-step care processes
Street safety Operating hours of health care facility
Examples of Financial Barriers
No health insurance
Underinsured
Examples of Cognitive Barriers
Knowledge Barriers Communication Barriers
Awareness of prevention facts Availability: interpreter services
Awareness of health resources Language concordance of signage
Health literacy Availability: cross-cultural communication
Understanding of diagnosis skills
Understanding of treatment Availability: translated materials
Racial/ethnic concordance of provider
Sources, as listed in the Notes at the end of this paper: 19, 21, 28, 29, 35, 37, 38, 39, 40, 42, 43,
44, 45, 46, 47, 48.
factors. ese three intermediary factors represent pathways that facilitate root-cause
analyses of episodes of health disparities and may aid in the design of local interven-
tions targeting disparities reduction.
Application of Health Care Access Barriers Model
e proposed HCAB model provides a nomenclature and taxonomy that facilitates the
discussion of health care access barriers. By dening categories and sub-categories of
health care access barriers, we establish a reference point and terminology for future
discussions. e taxonomy serves as a reminder of less evident barriers that might
otherwise be overlooked. For example, if one is focused on nancial barriers, reference
to the HCAB framework would lead to simultaneous considerations of the structural
and cognitive barriers.
e model is pragmatic, as it directs us to seek out those discrete and specic barriers
that are both measurable and modiable. Barriers that are not measurable or modi-
able should be noted and considered; however, for such barriers there is no point in
pursuing an analytic process that is directed toward solutions.

568 Dening and targeting health care access barriers
e HCAB model provides a systematic approach for conducting the root-cause
analyses of demonstrated disparities. By systematically identifying the presence of
nancial, structural and systemic, or cognitive barriers we can set up hypotheses that
can be tested. For example, an administrator may wonder what may be causing a dis-
Box 2.
EXAMPLES OF ASSOCIATED HEALTH OUTCOMES
Financial, Structural and
Cognitive Barriers
• Decreased Prevention
• Late Presentation
• Decreased Care
• Financial: No Insurance  Screening test
 Child immunization
Delayed HIV care
Delayed diagnosis (breast, melanoma,
colon, cervical cancer)
Delayed MI presentation
 Care (prenatal, child, adolescent)
 Diabetes care
• Structural: Continuity of care  Breast cancer screening
 Immunization
Delayed recognition of psychosocial
diagnosis
• Structural: Use of low performance
hospital Delayed percutaneous and thrombolytic
cardiac care
• Structural: No medical home  Preventive care reminders
• Structural: Excessive waiting times  Pediatric care
• Cognitive:  Breast Cancer
diagnostic and treatment knowledge Delayed breast cancer presentation
• Cognitive:  Literacy skill  Cancer screening
• Cognitive:  Health literacy  Breast and cervical cancer screening
 Flu vaccination
• Cognitive:  Interpreter Services  Colon cancer screening
•  Language Concordance  Asthma & ER use
•  Doctor-Patient Communication  HTN Care
Sources, as listed in the Notes at the end of this paper: 14, 29, 30, 31, 32, 33, 49, 50, 51, 52, 53,
54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65.

569
J Carrillo, V Carrillo, Perez, Salas-Lopez, Natale-Pereira, and Byron
parity noted in an oncology clinic. e administrator noted that 25% of all patients
found to have solitary lung nodules in routine screening chest x-ray (CXR) did not go
on to have denitive diagnosis and treatment. A systematic approach to this question
would spell out the various health care barriers that may have intervened between the
CXR nding and denitive treatment at the oncology center. e administrator might
use the HCAB model to evaluate the barriers faced by the adherent group and the
non-adherent group so as to nd the source of the problem.
Box 3 suggests the lines of inquiry that the administrator might pursue in this case.
With a thorough comparison of the barriers faced by the adherent group and the
non-adherent group the administrator would be well equipped to target the relevant
problem areas.
e HCAB model also facilitates the design of interventions addressing racial and
ethnic disparities by identifying those barriers that could arise for the target population.
ese barriers should be addressed by specic components of the intervention.
To illustrate how the HCAB model could bring about the development of interven-
tions, the following case scenario is provided. When establishing a community-based
intervention targeting type 2 diabetes mellitus, the planners would be aided by sys-
tematically addressing the three barrier categories that face the population in question.
Box 3.
IDENTIFICATION GUIDE FOR
HYPOTHETICAL ONCOLOGY SCENARIO
Financial Barriers—Health Insurance
What is insurance prole of a sample of patients who followed through with
evaluation?
What is the insurance prole of patients who did not complete evaluation?
What are the insurance requirements of diagnostic center?
Structural Barriers
Working telephone? Continuity of care?
Proximity to oncology center? Pre-authorization requirements?
Transportation? Signage?
Interpreters-sta access?
Working during hours of operation?
Cognitive Barriers
Knowledge
Evidence of patient understanding per chart review
Evidence of literacy per form completion
Communication
Language concordance?
Materials provided in patient’s language?

570 Dening and targeting health care access barriers
In this case, working with a health plan that provides governmental health insurance
access or with a local federally qualied health center might help address nancial
access barriers. Furthermore, given the presence of multiple structural barriers, the
introduction of patient navigators or community health workers might help overcome
structural barriers. Training the providers in skills-based cultural competence and
health literacy strategies might help reduce some cognitive barriers.
In the second case, the HCAB model provides an analytic framework that facilitates
research using factor analysis and regression analysis. e presence or absence of a
particular barrier can serve as the basic units of analysis for both qualitative and quan-
titative methods. e three intermediary variables (prevention, timely care, treatment)
can serve as outcome measures reecting the impact of access barriers. In this way
we may measure the impact of single barriers and multiple barriers. For example, we
can design a study of the impact of health access barriers on prevention and care for a
population of recent Mexican immigrants to a New York City neighborhood. A survey
instrument can be constructed using a set of nancial, structural, and cognitive barri-
ers and the results can be entered as variables along with routine socio-demographic
characteristics. Logistic regression analyses can help determine the impact of individual
barriers and various permutations of dierent types of barriers on preventive care
services, delay in initiation of care, and lack of necessary care.
e HCAB model may be tested by examining its usefulness in providing a nomen-
clature and framework for the classication, analysis, and reporting of modiable health
care access barriers. Early applications of the model by NewYork-Presbyterian Hospital
in Northern Manhattan have demonstrated such usefulness and practicality.11 e model
may also be tested by studying the impact of access barriers on three intermediary
measures (prevention, timely care, treatment) in interventions facilitated by HCAB.
Limitations
e HCAB model does not capture the overlap among multiple health care determi-
nants of disparities. e barriers dened by HCAB may occur simultaneously as well
as sequentially in real time. By postulating linear relationships in the HCAB model we
risk losing sight of the overlap and simultaneity of the complex web of determinants.
Furthermore, by concentrating the framework around access barriers to the exclusion
of other social and cultural determinants, we may not have encompassed the entirety of
causes of disparities. However, the identication of an evidence-based pathway between
measurable and modiable health care access barriers and health outcomes makes the
HCAB model a useful and practical tool for analysis and intervention.
Conclusion
As health care and public health professionals we have a special opportunity and respon-
sibility to target a particular determinant of disparities—health care access barriers.
Recognition, measurement, analysis and reporting of these barriers are prerequisites to
quality improvement and the design and evaluation of eective corrective interventions
to existing processes of care.

571
J Carrillo, V Carrillo, Perez, Salas-Lopez, Natale-Pereira, and Byron
Despite the fact that many types of health care access barriers have been widely
cited as root causes of poor health outcomes, we have lacked an eective taxonomy
and practical framework to help us measure, analyze and report modiable barriers.
We have articulated a methodology that denominates and classies health care access
barriers and provides a framework that allows us simultaneously to consider such dis-
parate variables as health insurance, transportation, and knowledge of risk factors. By
dening and targeting specic barriers that are measurable, modiable, and supported
by the evidence, we provide a formula that generates uniform standards and facilitates
the design of interventions. e adoption of a common set of descriptive terms and
uniform standards in the assessment of health care access barriers makes comparability
among studies possible. e use of a framework that provides for standardization and
comparability may also accelerate the pace of research in this area of critical need.
One can never capture a complex system with one model or taxonomy; much
depends on the questions one wants to ask.41 By capturing this slice of the complex
multifactorial interactions leading to adverse health outcomes we can answer certain
questions that may lead to practical and eective interventions.41 e more we learn
about the impact of these barriers, singly or combined, the more eective we will be
in reducing health disparities.
Our review of the literature substantiates and early applications of the model suggest,
that the Health Care Access Barriers Model provides a unique taxonomy and a practical
and eective framework for the classication, analysis, and reporting of modiable health
care access barriers. e model’s specic targeting of modiable barriers facilitates the
design of interventions that may lead to reduced disparities. is innovative categori-
zation format and practical analytic framework supports interventions that can help
reduce modiable health care access barriers faced by the poor and underserved.
Acknowledgments
is research project was supported by the Network for Multicultural Research on
Health and Healthcare, Department of Family Medicine—UCLA David Geen School
of Medicine, funded by the Robert Wood Johnson Foundation. Support was also pro-
vided by the Redes En Acción program of the National Cancer Institute. e authors
thank Marilyn Aguirre-Molina, EdD, Pamela S. Dickson, MBA, Joseph R. Betancourt,
MD, Alexander R. Green, MD, Michael Rodriguez, MD, and William A. Vega, PhD
for their multiple contributions.
Notes
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