The Health Care System: Operations Research and Improving Access

Paul M. Griffin, Martin Savelsbergh, Julie L. Swann

H. Milton Stewart School of Industrial and Systems Engineering Georgia Institute of Technology {pgriffin, mwps, jswann}@isye.gatech.edu

Abstract The health care system in the United States is facing a myriad of problems, such as growing costs, an aging population, a shortage of nurses and physicians, differences in quality of care, a significant population of uninsured persons, and disparities in health care outcomes. All of these challenges affect access to health care, which is our focus. We draw attention to the impact of lack of access to care, we highlight programs aimed at increasing access to care, we review (academic) literature concerning access to care, we introduce the key challenges to improving access to care, and, most importantly, we discuss key research questions that can, and should, be addressed by operations researchers.

1. Introduction According to the Organization for Economic Cooperation and Development (OECD), U.S. spending per capita on health care was $5,635 in 2003 (Anderson et al. 2006). This figure was two-and-a-half times the comparable median for OECD countries and 53% more than any other country. In addition, national health expenditures rose from $246 billion in 1980 to over $1.4 trillion in 2001 according to the National Health Statistics Group (Levit et al. 2003). It is estimated that as a country we will spend over $2 trillion in health expenditures in 2006, and that the main reason for these increases is simply higher prices, not higher utilization of resources (Heffler et al. 2006). This means that this increase in spending is not necessarily leading to the provision of additional or higher quality services. Rising costs, however, are only part of the problem. There are many people who do not have a main source of primary care. This may be due to a lack of insurance (46.6 million nationally in 2005 (DeNavas-Walt et al. 2005)), the fact that not all doctors take Medicaid patients, or because of a limited supply of primary care physicians where they live (over 20% of the U.S. population lives in rural areas while only 9% of physicians practice in such areas (Bureau of Health Professions 1992)). The uninsured are more likely to forgo or postpone care, which can in turn lead to an increase in health care expenses such as hospitalization for a health condition that could have been avoided. It is well known that having a source of primary care has many health benefits (Blumenthal 1995) including improvements in health status (Shi 1992; Shi and Starfield 2001), fewer hospitalizations (Freeman et al. 1982), more physician visits (Okada and Wan 1980), more control over treatable diseases (Lurie et al. 1984; Fihn and Wicher 1988), and fewer preventable hospitalizations (Deprez et al. 1987; O'Connor et al. 1990). A related issue is that by almost any measure, the disparities in health status and receipt of preventative care for the poor, minority, and elderly populations are growing. A further concern is that many people that are covered by safety nets such as Medicaid have at best limited access to care. According to the Health Resources and Services Administration, over one-fifth of the US population lives in areas designated as Health Professional Shortage Area (PSA) and over half of the population in the Southeast lives in Medically Underserved Areas (MUA) including poverty, shortages of physicians, or high infant mortality.

The Department of Health and Human Services published the document Healthy People 2010 (U.S. Department of Health and Human Services 2006) with a large consortium of organizations. One of the specific goals of this document is to Increase the proportion of persons who have a specific source of ongoing care, with a target of 96% by 2010 (the current percentage is 87%). A key issue then is determining effective ways of increasing access to basic health care for different segments of the population. We believe that there are enormous opportunities for operations researchers to contribute towards improving access to care, which is among the key challenges facing our national health care system. We hope that this article increases awareness of the issues surrounding access to care as well as the many opportunities for exciting, innovative, and valuable research. Access to health care is an area so vast that it is impossible to cover all it in a single paper. Therefore, we have had to make choices and have chosen to cover topics that illustrate current programs aimed at increasing access to care, provide examples of issues that have been addressed with operations research techniques, or highlight trends in health care delivery that offer new opportunities for the application of operations research. 2. How Should Access to Care be Measured? In order to determine if populations are receiving adequate health care access, appropriate (performance) measures must be developed and used. One reason is that measurement tends to drive behavior in the systems being observed, and so it is important that the correct measures are being used that leads to good outcomes. Since the publication of the Institutes of Medicines Crossing the Quality Chasm (Committee on Quality of Health Care in America 2001), a lot of effort has been focused on quality as a measure. Quality of care, however, has been shown to only have a small impact on disparities (e.g., racial) and so is not sufficient for access (Trivedi et al. 2006). Many researchers and organizations have developed standard measures for quality care and access to care. A good example is the National Healthcare Disparities Report (Agency for Healthcare Research and Quality 2005a, b) which tracks several measures of quality and access for disparities. Some have pointed out that one measure typically ignored, though growing in importance with recent demographic trends, are cultural-based ones (Tirado and Thom 2006). In the field of operations research, a common means of measuring performance is to use productivitybased measures that relate outputs to inputs. Data envelopment analysis (DEA) and stochastic frontier analysis (SFA) are two such popular approaches. These approaches estimate the efficiency of an organization (with respect to others) in using its portfolio of inputs to achieve a set of outputs. Thus it relates to health care access by identifying types of organizations that are efficient or ways to improve efficiency so that more patients can be served at a lower cost. DEA is a non-parametric approach developed by Charnes et al. (1978) that constructs a frontier from sample data and determines efficiency of a decision making unit. SFA, developed by Aigner et al. (1977), assumes a parametric form of the production function and employs a composed error model of inefficiency and random error. An SFA regression model is used to estimate efficiency. There are key differences between the approaches that we will not discuss here. Examples of the use of DEA in measuring health access include studying teaching hospitals (Grosskopf, Margaritis et al. 2004), health centers in rural areas (Kontodimopoulos et al. 2006), health maintenance organizations (Rosenman et al. 1997), hospitals in large metro areas (Wang et al. 1999), ownership of hospitals (Burgess and Wilson 1996), physicians within hospitals (Chilingerian 1995), and efficiencies in other parts of the world (Kirigia et al. 2004; Ramanathan 2005; Renner et al. 2005; Linna et al. 2006).

Others have examined the types of inputs (Ouellette and Vierstraete 2004) or outputs (Magnussen 1996), use of local aggregate measures (Ozcan 1995), or comparison to stochastic frontier regression (Chirikos and Sear 2000). The analysis has been used to analyze the impact of policy changes (Tambour 1997; Burgess and Wilson 1998), determine labor inefficiencies (Ozcan et al. 1996), or to set prices in health organizations (Rouse and Swales 2006). There are several important issues with regard to appropriate measures. First, there is no agreement about key terms such as access or equity. Equity in health services "implies that there are no differences in health services where health needs are equal (horizontal equity) or that enhanced health services are provided where greater health needs are present (vertical equity)" (Macinko and Starfield 2002). Access can be defined as the use of health care by individuals with a need (defined by self-reported morbidity) for care (Waters 2000). However, stated concerns are that individual-based measures of health inequalities may not address differences across populations and may not be valid since they are surveyed (Almeida et al. 2000). What is needed is a socially responsible view of fairness that is useful from a resource allocation perspective. Second, survey measures, albeit proxies for the truth, are what we are primarily going to have to use. Instead of worrying about perfect measures then, the focus should be on consistency (Knickman 1998). Third, surveys are getting increasingly expensive, and comparing the tradeoff of accuracy of information with quantity is important future survey design. Finally, a systems perspective of access is important, since delivery depends on several, at times confounding, components. 3. Existing Initiatives Aimed at Increasing Access to Care The Community Health Centers (CHCs) initiative is one type of program designed to improve access of primary care, especially for needy populations. These centers provide primary and preventive health care, outreach, dental care, some mental health and substance abuse treatments, and prenatal care, especially for people living in rural and urban medically underserved communities. Over 90% of CHC patients live with incomes below 200% of the federal poverty limits, and over 40% of CHC patients are uninsured. In 2002 the current administration announced a plan to expand the capabilities of the program with $2.2 billion, with a goal of reaching 6.1 million more patients (Office of the Press Secretary 2006). By many measures, CHCs are improving the health care of the community. Research has found that they reduced hospitalizations, reduced mortality, reduced usage of emergency rooms, and increased visits to physicians (Okada and Wan 1980; Dievler 1998, Stuart and Steinwachs 1993). It has also been found that their quality of service is comparable to other types of primary care (Stuart and Steinwachs 1993), and may be cost-effective for Medicaid patients as compared to some other sources of care (Dievler 1998). While 75% of uninsured persons in the United States report having a source of primary care, approximately 99% of CHC users do (Carlson et al. 2001). School-based health centers (SBCHs) emerged in the 1970s as a response to an increasing number of children and adolescents without access to health care and the recognition that children and adolescents need care that is age-sensitive, confidential, safe, and tailored to their unique needs (National Assembly on School-Based Health Care 2006). SBHCs operate in schools and provide a source of evaluation, diagnosis, and treatment of child and adolescent health needs. Most provide preventive care (including comprehensive health assessments), treatment of acute illnesses, screenings, immunizations, and counseling. The number of SBHCs has grown from a mere 120 in 1988 to nearly 1400 across 45 states in 2001. SBHCs are commonly sponsored by community health organizations, including hospitals, local health departments, community health centers, academic medical centers, and non-profit organizations. Only a relatively small percentage of SBHCs are sponsored by the school system. Studies have shown that SBHCs reduce inappropriate use of emergency rooms and increase appropriate use of medical and mental health services (Kaplan et al. 1998; Santelli et al. 1996; Anglin et al. 1996).

Moreover, SBCHs have been shown to positively impact the mental health of students and reduce hospitalizations rates for asthmatic children (Weist et al. 2006; Webber et al. 2003). Furthermore, there is some evidence that SBHCs also positively impact academic performance, in terms of attendance/absence indicators, drop out/graduation rates, standardized test scores, etc (Geierstanger et al. 2004). CHCs and SBCHs are examples of existing initiatives aimed at addressing lack of access to care. As mentioned above, these initiatives have been reasonable successful. However, many questions remain unanswered. Have they been as successful as they could have been? Should these programs be extended? If so, what is the most effective way to extend such programs? A thorough economic analysis of costs and long-term benefits is needed before policy makers at the state and national level will be willing to make funds available to significantly increase the number of CHCs and/or SBCHs. Are there alternative programs that could be even more effective? There are few studies that have explicitly considered access alternatives, particularly quantification of the targeting of specific populations or improvement of a particular health outcomes (such as access to a regular source of primary care), geographical demographic differences that affect health care need, or actual costs of persons under Medicaid. Different modes of access may also need to be compared on efficiency and equity. We believe that there are significant opportunities for operations researchers to help to answer these types of questions, and that there is a real need for rigorous mathematical/engineering approaches. 4. Issues in Access to Care 4.1. Where Should Health Care be Provided? One of the most important questions in improving health care access is where access should be provided, and this is also a natural area for operations researchers to contribute. Accessibility to a primary care physician, emergency room, or specialty needs clinic can help populations in meeting basic health care needs. Many problems in this area can be though of as variations on classical facility location problems (see Daskin (1995) for a review of the overall class of problems), where the goal is to locate a number of facilities across a geographical network so as to minimize an objective such as cost, subject to constraints on the system such as meeting demand or not exceeding capacity. A review of location models specifically applied to health care is found in Daskin and Dean (2004). Below, we focus primarily on papers specific to health care while there are many more that may be related in the general area of location modeling. Within health care, applications include locating hospitals (Sinuany-Stern et al. 1995), emergency medical services (Pirkul and Schilling 1988; Segall 2000), blood banks (Price and Turcotte 1986; Jacobs et al. 1996), and ambulance stations (Eaton et al. 1986; Carson and Batta 1990; McAleer and Naqvi 1994; AdensoDiaz and Rodriguez 1997) among others. Decisions might include the location of the facilities (Mehrez et al. 1996), the number of facilities to open (Schweikhart and Smithdaniels 1993), the services to provide at each facility (Griffin et al. 2006), the amount of equipment (Jayaraman and Srivastava 1995), or the level of capacities of the facilities (Berman et al. 1994; Segall 2000). Decisions could also include hierarchical location of multiple types of facilities in a network (Galvao et al. 1999; Galvao et al. 2006) or the simultaneous control of hospital operations with facility location decisions (Butler et al. 1992). In classic facility location problems, the objective function is often to minimize cost. While this may apply in some health care location decisions, there are also other types of objective functions with importance in the health industry. For instance, some include minimizing the travel distance of patients (Wang et al. 2003), maximizing the (possibly expected) demand covered (Revelle and Snyder 1995;

Gendreau et al. 2006), maximizing the number of new people with a primary care or preventative care location (Verter and LaPierre 2002; Griffin et al. 2006), or even maximizing the resulting health of the community based on the locations (Griffin et al. 2006). Malczewiski (1991) uses the dual criteria of accessibility and environmental quality of the location, and Schweikhart and Smithdaniels (1993) consider the multiple criteria of minimizing cost and maximizing market share of a managed health network. The focus in many of the health care location papers, especially the early ones, is on developing algorithms or heuristics to solve the formulated optimization problem in a reasonable amount of time. Approaches used include Lagrangian relaxation (Berman et al. 1994; Downs and Camm 1996; Haghani 1996), greedy adding and substitution algorithms (Eaton, Sanchez et al. 1986), heuristics based on decomposition into regions (McAleer and Naqvi 1994), and a center of gravity model (Price and Turcotte 1986). Modeling of decisions and constraints has become more sophisticated as the computational technologies have improved. Some recent research has considered stochastic elements in the network, including long or short-term changes in the system. For instance, this is particularly important when choosing where to locate emergency vehicles or ambulance stations (see Brotcorne et al. (2003) for a review of ambulance location models in operations research). Approaches can include stochastic programming (Berman et al. 1994; Beraldi et al. 2004), integer programming with reliability bounds (Ball and Lin 1993), and simulation (De Angelis et al. 2003; Harper et al. 2005). Papers in this area may also try to ensure that backup coverage is available when facilities are busy (Ball and Lin 1993; Marianov and Revelle 1994; Ball and Lin 1995), which is important in ambulance coverage or emergency room locations. Many of the research papers on locating health care facilities have had documented success in the industry (e.g., Price and Turcotte 1986; Carson and Batta 1990; Jacobs et al. 1996). Operations research models in health care have also been used to push the science of location modeling, giving both context and purpose behind some modeling decisions. However, there are many areas in which additional research in OR can contribute to health care access as it relates to facility location. As computational technology continues to improve, the runtime of the location algorithm is not likely to be the most important contribution in new OR research in this area. Even when the algorithm is an issue (such as in some cases with probabilistic scenarios), a continued challenge is in developing the data to populate the models, especially when such data does not exist directly in databases. Developing new models or methods for determining the data from multiple disparate sources is one area in which OR (and statistics) researchers are needed. Griffin et al. (2006) is one example of a paper using optimization of locations combined with model-based estimates of demand, but many such opportunities remain. There are many other areas in which operations research may also help including ones that relate to implementation, measurement, and informing public policy. Examples include answering questions such as the following: when counties collaborate to provide ambulatory services, how can the costs and services be shared in a way that is acceptable to all parties? How can equitability of health care access across a region be ensured and what are the appropriate measures of it? How much improvement can be gained from including future changes to the population in determining current site decisions? How should facilities be located when physicians or nurses are in short supply? How can new technologies affect the number and location of needed facilities? How does locating facilities in extremely rural or underdeveloped areas change the methods or decisions? How much does locating more health care facilities contribute to reducing disparities in health care access in the needy population, and how does it compare in cost and performance to other forms of increasing health care access? Important factors in answering these questions including obtaining an understanding of the health care system in question, determining appropriate objective functions or constraints that link the models with

issues in the real world, finding ways to populate the models with data that is meaningful, and using the models to answer questions that are not only operational but also ones that may have an impact on the health industry as a whole. 4.2. How Do We Fairly Allocate Scarce Resources? There are many components of providing for basic health care needs that may relate to resources that are limited. For instance, certain drugs may be desirable to treat health conditions but may be in short supply (or very expensive), or there may be a shortage of physicians. Below we briefly mention some of the areas in which operations research has had or could have an impact. In a pair of papers (Swaminathan 2003; Swaminathan et al. 2004), a team describes a decision support tool built to distribute drugs from 19 pharmaceutical firms to public safety net providers in California over a three-year period. An important component is that the authors tailored the optimization problems to health care, using objective functions such as efficiency (measured by drugs not distributed), effectiveness (delivering drugs to meet the needs as requested by the clinics), and equity (accounting for differences across clinics and requested drugs). Viswanathan and Bayney (2004) identify a project at Johnson & Johnson using statistical methods to improve design of proof-of-principle trials for new drugs, and Stonebraker (2002) describes decision analysis to determine which drugs to develop at Bayer Corporation. In Wilson et al. (2006), the authors study the epidemiological impact of geographical dispersion (urban or rural) of antiretroviral therapy on HIV transmission in South Africa, and discuss equity and efficiency outcomes. Vaccines are drugs that are particularly important for preventative health, e.g., children routinely receive vaccinations to prevent many once-common diseases. Optimization has been applied to determine how: physicians should select vaccines (Weniger et al. 1998), vaccines of different diseases can be combined to reduce cost to payors or society (Sewell et al. 2001), combination vaccines should be priced (Sewell and Jacobson 2003), vaccine wastage affects costs (Jacobson et al. 2004), costs are affected by a combination vaccine (Jacobson et al. 2003), or pediatric vaccines should be stockpiled to account for production interruptions (Jacobson et al. 2006). Becker and Starczak (1997) analyze how vaccines should be spread across households to prevent epidemics, and Wu et al. (2005) use stochastic dynamic programming to assess whether developing influenza vaccines based on past strains is reasonable. Vaccines for prevention of childhood disease or influenza epidemics still have many issues including production capacity, uncertainty, and incentives in the system, for which OR can make contributions. Another resource that is critical for some basic health care needs is blood, which may be used in surgeries, for treatments of some conditions, or to aid trauma victims. Blood is perishable, and demand is highly variable and uncertain. Brodheim et al. (1975) develop a class of inventory models for perishable commodities like blood, while Haijema et al. (2007) study inventory policies with two categories of blood platelets. Jagannathan and Sen (1991) analyze outdates and shortages when blood is pre-allocated to patients before surgery (or cross-matched) to improve inventory decisions. Brennan et al. (1992) focus on productivity of blood-mobiles and Bretthauer and Cote (1998) on bed capacity of blood clinics to improve overall donations. Wein and Zenios (1996) investigate the cost-effectiveness of using pooled screening for testing donated blood for viruses such as HIV. Hemmelmayr et al. (2006) study the costsaving potential of vendor managed inventory concepts at the Austrian blood bank. In many of these papers, researchers have found that complexities need to be included in the model that may prevent exact solutions, so they determine near-optimal policies for resource management. Organs for transplantation are another perishable resource in limited supply. Although most people will never need a transplant, the demand exceeds the supply and many people while waiting. As with many areas of health care access, one of the main trade-offs in organ allocation is efficiency (including system

measures of utility or cost) versus equity (fairness of allocations, which can be defined several ways). Sophisticated allocation rules are used to balance these outcomes across the system. Organ allocation is also a rich area for operations researchers, who have used models such as Markov decision processes or simulation to study the system with uncertainty; these papers also show several ways that equity can be included in mathematical models. Researchers have built simulation models to test specific organ allocation policies (Shabtai et al. 2003; Shechter et al. 2005), to study different kinds of equity criteria or objectives (Yuan et al. 1994), and to analyze how a patients health changes as a function of rationing rules and the supply/demand ratio (Howard 2001), in the last one finding that sickest-first is worse than first come first served but may be equitable. Zenios et al. (2000) study dynamic allocation of kidneys balancing utility maximization with minimization of two forms of inequity (likelihood of transplantation and differences in wait times). In several papers (Howard 2002; Alagoz et al. 2004; Alagoz et al. 2006), authors look at the stopping problem of whether or not to accept organs to maximize a function such as the patients utility. Other explicitly incorporate patient information: Ahn and Hornberger (1996) incorporate it by survey in organ allocation decisions, while Su and Zenios (2005) determine kidney allocation policies under the constraint that patients only accept offers maximizing their own personal reward, and Su and Zenios (2006) use mechanism design when there is information asymmetry in kidney allocation as to patient type, using fluid approximation of the transplant queues. The problem of optimizing the mix of direct and indirect exchanges of organs is studied in Zenios (2002), where the authors find an optimal dynamic exchange policy using Brownian approximations for the queueing model. Ozcan et al. (1999) apply DEA to evaluate organ procurement organizations, and Stahl et al. (2005) use an integer program to determine organ allocation regions where the objective is a weighted combination of efficiency and parity. Since health care access is in part determined by the financial resources available, the effective use of those resources can help to improve access to care, by improving the quality of the care received or by the overall quantity due to efficiencies gained. Several operations researchers have analyzed problems in this area including statistical studies in to estimate need for health care at local geographical areas in England that can be used to allocate resources correspondingly (Carrhill et al. 1994; CarrHill et al. 1997), DEA analysis of hospitals in Thailand to examine the impact that services to the poor have on the non-poor (Valdmanis et al. 2004), a study of five objectives to mathematically allocate resources in Tanzania (Flessa 2003), discussion of mathematical programming for budget allocation in pharmacology (Earnshaw and Dennett 2003), and financial planning for medical school in choosing the programs to fund (Brandeau et al. 1987). In addition to overall budget allocations, researchers have examined how to allocate resources to fight a particular disease, especially towards preventative programs. For example, optimization and heuristics for epidemics of infectious disease are considered in Zaric and Brandeau (2001b) and Brandeau et al. (2003), resources across interventions for diabetes are discussed in Earnsahw et al. (2002) and Zhang et al. (2004), and allocation across HIV prevention programs is addressed in Richter et al. (1999), Zaric and Brandeau (2001a), Wilson and Kahn (2003) and Harris (2006). Kim et al. (2006) use an integer program to identify a package of services to offer during screening for cervical cancer, and Tao et al. (2002) allocate financial resources to a set of programs at a particular clinic for Chlamydia. Zenios and Fuloria (2000) use multi-class fluid models to study dialysis and determine that use of the budget towards improvements in dialysis technology is likely to have more impact on life expectancy than an increase in reimbursement fees. Tools for budget allocations often include mathematical programming as well as the use of productionfunctions to measure impact. Researchers perform full optimization of the problem or may analyze ruleof-thumb heuristics for effectiveness; this may be especially important when they are commonly used in practice. Many of the above papers consider diseases that fall under basic health care needs, but even

when not they offer a set of tools that may be useful for analysis towards improving allocation of resources towards other diseases. However, there are many diseases or programs that have not yet been considered, so there are ample opportunities to work in this area, determining how allocations may be used to meet health care needs effectively. Queueing techniques have also been used to look at health organizations, such as to determine capacity or staffing. Research in this area includes study of emergency rooms (Green et al. 2006), intensive care units (McManus et al. 2004), emergency cardiac in-patients (de Bruin et al. 2005), overall hospital beds (Green and Nguyen 2001), and overall capacity across a state health care network (Green 2002). This type of analysis has shown that health organizations need to consider not only averages and expectation, but also the variability in their demand when planning. Further research in this area would also help organizations plan their use of scarce resources including limited labor supply, although it is important to recognize that the health industry faces different kinds of customer service constraints than those in many manufacturing industries. 4.3. What is the Impact of Medical Personnel Shortages? Supply of medical personnel plays a very large role in access to health care services. One key measure is simply the number of physicians and nurses per capita. Most studies argue that the US is currently facing a nursing shortage and that the problem is growing (Chagaturu and Vallabhaneni 2005; Department of Health and Human Services 2006). Whether there is an adequate supply of physicians has not always been clear, though most studies now argue that we are also facing a potential physician shortage (Cooper et al. 2002; Salsberg and Forte 2002; Merritt 2004). The Council on Graduate Medical Education has revised their projection of a physician surplus to one of shortage (Council on Graduate Medical Education 2005). Clearly medical personnel shortages are also a function of the type of services provided, the type of patient seen, geographic location, and venue. With regards to services provided, although there is an overall shortage projection of physicians, the US has a projected surplus of pediatricians (the number of pediatricians will jump 68% by 2020 while the number of children in the United States will increase only 9.3 percent (Shipman et al. 2004)). A physician may refuse to see a patient if they are not insured or are only covered by Medicare or Medicaid. For example, the percentage of pediatricians willing to accept new Medicaid patients in the US is 54.6% (Berman et al. 2002). This figure is higher than the other primary care specialists, since a higher proportion of children are covered by Medicaid than adults. Medical personnel shortages can vary by geographic location; particularly in rural areas where many argue that there are shortages compared to urban locations (Colwill and Cultice 2003; Whitcomb 2005; Reschovsky and Staiti 2005; Committee on the Future of Rural Health Care 2005). Attracting and retaining physicians becomes more difficult as the population decreases and the location becomes more remote (Rosenblatt 2004). The venue through which service is provided also matters. For example, in federally funded CHCs, workforce staffing shortages are higher than in equivalent hospitals (Rosenblatt et al. 2006), with rural CHCs facing greater shortages than urban ones. The important research questions with respect to medical personnel shortages include whether means can be developed to effectively increase the supply of medical personnel or to more efficiently use current personnel in way that reduces disparities between rural and urban populations and between the insured and uninsured. One way to increase supply is through incentives. Increasing wages (e.g. through increases in Medicare and/or Medicaid reimbursement) would be an example. This policy would only be effective if it shifts the supply curve out, otherwise physicians would simply pocket the increase. Past studies have not shown a strong correlation between Medicaid reimbursement levels and a corresponding increase in acceptance of Medicaid patients by physicians (Cunningham 2005). Providing health

insurance to those previously uninsured such as State Children's Health Insurance Program (SCHIP) is an equivalent approach (Szilagyi et al. 2004). Another example is a program such as Title VII that funds medical school costs and/or provides bonuses for working in rural areas. This program has been shown to increase physician supply in rural and low income areas (Rabinowitz et al. 1999; Meyer et al. 2002) (an absolute increase of 2% (Krist et al. 2005)), though the cost effectiveness of this program relative to other options has not been proven. Another means for increasing supply is through allowing other personnel to perform certain procedures by the relaxing of medical practice acts. Practice acts define who can perform which services and hence protect the public interest and safety of patients. However, in some cases they can raise the cost of services provided and additionally increase racial/ethnic disparities by restricting entry. For example, one study showed that in the oral health area, relaxing dental supervision for school-based sealant programs would increase public health delivery of sealants by over 23% (Griffin et al. 2007). Determining where relaxing these standards would be both safe and effective is key. Finally, improving the productivity of the delivery of services can raise the effective capacity of medical personnel. One way to do this is through technology, an example being the remote monitoring of patients. Another approach is to apply techniques common in manufacturing and logistics systems such as lean delivery, improved scheduling, sharing resources, and better capacity management. Several researchers have done work in this area using techniques such as simulation (Jun et al. 1999; Fone et al. 2003; Griffin et al. 2007). The important issue is that there are several ways to address potential medical personnel shortages, but to this point there has not been much work comparing the cost-effectiveness of these different approaches. This is complicated by the fact that modeling supply and demand of services is difficulty due to limited public data. 4.4. Who Should Get Screened and When? A significant component of preventive care is screening for disease. Perhaps the most important issue for screening is who should be screened for a disease; namely targeted populations or universal screening. A second issue is what frequency and timing should be used. One could employ one-time testing, intermittent testing, or routine testing. If intermittent testing is used, then the spacing of tests must also be determined. All of these factors can impact the cost-effectiveness. Screening can also help to determine disparities in care (Hambridge et al. 2007) or differences in prevalence (Freeman et al. 2005); higher rates often times being an indicator of health system concerns including access. There are several factors which influence whether screening will be cost-effective or not. These include i) prevalence of disease; as prevalence increases, fewer people need to be screened in order to detect a case, ii) cost and accuracy of the test; in addition to missing cases from false negatives, false positives can lead to costs such retesting or counseling, and iii) the perspective of analysis; a public health viewpoint will use social costs while a private insurer would only consider the costs brought on by the insured individual. One other very important factor is the nature of the disease. For example, infectious diseases have an externality in that it can be spread to others. In addition, for some diseases, behavioral changes can slow the progression in the individual. Screening may therefore be cost effective even if there is no cure. It is also important to consider potential coexisting chronic diseases (Gross et al. 2006). Expanding coverage for screening can also directly affect access to care (Morris 2006). Several researchers have looked at screening issues for different diseases. Most use Monte Carlo simulation (or simple Markov models) for disease progression. A population to be screened is selected based on risk characteristics and it is determined whether the screening is cost-effective or cost-savings.

Some examples include HIV screening (Sanders et al. 2005; Paltiel et al. 2005), Hepatitis C screening (Pereira and Sanz 2000; Singer and Younossi 2001; Stein et al. 2004), and colorectal cancer (Frazier et al. 2000; Brenner et al. 2006). Most of these papers, however, do not consider either the timing or frequency of the decision. There have been some past studies that have examined the impact of repeated screenings. Many of these (Michaelson et al. 1999; Vijan, Hofer et al. 2000; Chen et al. 2001) use simulation to examine policies and typically assume uniform intervals between screenings. Some exceptions include Kaplan and Satten (2000) who showed that the screening interval is a function of prevalence, and Diehl et al. (2006) who explicitly studied several policies and used frontier analysis to find the best policy. There are few papers that have developed techniques other than through simulation to study screening (an exception includes Faissol et al. (2006)). Analytical approaches would help to complement simulations by exploiting problem structure. In addition techniques which model the behavioral impact and explicit consideration of externalities, which are typically considered through simple expectations, are virtually non-existent. Due to patient preferences, it may also not be the case that screening is the appropriate choice even when it is cost-savings. Exploration of other studies of preventative care could also improve health care access overall. 5. Trends in Access to Care 5.1. Convenience Medical Clinics Around the country convenience medical clinics staffed by nurse practitioners are popping up and sharing space in supermarkets, discount retail stores, malls, corporate offices, and pharmacies (Woznicki 2005; Bell et al. 2006). These mini-clinics are designed to handle minor everyday ailments and offer an array of basic primary-care services from immunizations, to tests and treatments for common infections; they do not treat chronic conditions like hypertension, asthma, or diabetes. Minneapolis-based MinuteClinic, Inc. (www.minuteclinic.com) is one of the giants of the industry with mini-clinics in Target stores, Cub Foods stores, CVS pharmacies, and even in BestBuys corporate headquarters. Retail giant Wal-Mart recently entered the space when it announced a partnership with four convenience clinic providers: RediClinic, Quick Quality Care, Solantic, and Memorial Health. Unlike physicians offices, these convenience clinics keep their doors open as long as their landlords doors are open, often from 8 a.m. to 8 p.m. Furthermore, there is no need for an appointment; patients can walk in any time. Some mini-clinics post their services and the associated prices for all to see; others offer fixed prices, for example by charging a flat fee for all diagnostic tests. Some mini-clinics accept insurance; others do not. Many insurers have welcomed the mini-clinics because of the potential cost savings. Clinics also differ in the type of services they offer. Some clinics provide preventive screening, such as cholesterol and glucose checks; others do not. Medical practice acts limit the services that can be offered in mini-clinics. While nurse practitioners can prescribe antibiotics for sinus infections, they cannot prescribe medications for on-going conditions, such as birth control pills and cholesterol lowering drugs. Nurse practitioners often work together with area physicians in case they encounter problems or have questions. In some states it is even required for a nurse practitioner to have a supervisory relationship with a physician. The reactions to convenience medical clinics are mixed. Some physicians welcome them and see them as a chance to shift their focus from treating the common cold to more pressing concerns, such as difficult to treat blood pressure and chronic illnesses. On the other hand, concerns over the quality of care, safety, and oversight have been voiced.

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On a national scale, the number of convenience medical clinics is relatively small (although rapidly growing) and their role and value in the overall health care provision scheme is still being debated. Convenience medical clinics were the brainchild of an entrepreneur who realized that there had to be a better way to test and treat minor every-day ailments than having to wait for hours at an urgent care center. How can the nation benefit most from mini-clinics? Can mini-clinics increase access to care? What are the potential costs savings? What is the best way to set up a system of mini-clinics? Where should they be located? What services should be offered? Should the service offerings be the same everywhere? What prices should be charged for these services? When should the services be offered? Is it necessary to offer the services every day of the week? Would it be better to have a registered nurses operate different mini-clinics on different days? A thorough analysis of costs and long-term benefits is needed before policy makers at the state and national level will be willing to make funds available for such initiatives. Such an analysis should take into account geographic and demographic differences. There may be substantial differences between urban and rural areas. Mini-clinics may be especially valuable in rural areas with few other health care facilities. Beyond questions concerning the best way to set up and maintain a network of mini-clinics, we may investigate whether the concept is applicable beyond the offering of basic primary-care services. What about chronic illnesses? 5.2 Home Health Care According to Medicare home heath care includes skilled nursing care, as well as other skilled care services, like physical and occupational therapy, speech-language therapy, and medical social services (Centers for Medicare & Medicaid Services 2004). These services are given by a variety of skilled health care professionals at home. The need for home health care has grown for many reasons. Medical science and technology have improved. Many treatments that could once be done only in the hospital can now be done at home. Also, home health care is usually less expensive and can often be just as effective as care in a hospital or skilled nursing facility. And, just as important, most patients and their families prefer to stay at home rather than be in a hospital or a nursing home. The goal of short-term home health care is to provide treatment for an illness or injury. It helps to get better, regain independence, and become as self-sufficient as possible. The goal of long-term home health care (for chronically ill or disabled people) is to maintain the highest level of ability or health, and to help learn to live with the illness or disability. Beyond the home health care services supported by Medicare there are other home health care services. As individuals age, their need increases for assistance with activities of daily living, such as walking or dressing, and instrumental activities of daily living, such as grocery shopping and money management. At the very time that demand for long-term care services is increasing, the traditional supply of both paid caregivers and unpaid caregivers is shrinking. According to a 2002 report by the Joint Commission on Accreditation of Healthcare Organizations by 2020 there will be at least 400,000 fewer nurses available to provide care than will be needed (Super 2002) Home health care probably has the most obvious operations research opportunities. Since care givers have to visit the patients in their homes, vehicle routing technology can be deployed to increase the effectiveness of these services. A small number of papers specifically addressing routing applications in home health care have appeared in print (Begur et al. 1997; Cheng and Rich 1998; Bertels and Fahle 2006; Eveborn et al. 2006; Leff 2005). Some of the issues that are unique to home health care delivery

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are the matching of the skills of the nurses with patient requirements, the presence of part-time employees and full-time staff, and the need to allocate time for paper and lab work. 5.3 Remote health care monitoring Caring for patients with chronic illnesses is costly over a trillion dollars today and predicted to grow much larger. To address this trend, new technologies are being developed, most prominently remote monitoring devices (Blount et al. 2007; Yao and Warren 2005; www.ibm.com). By providing care givers with timely access to a patients health status, they can provide patients with appropriate preventive interventions, helping to avoid hospitalization and to improve the patients quality of care and quality of life. As such, remote health care has the promise of reducing health care costs by focusing on preventive measures and monitoring instead of emergency care and hospital admissions. As the risk for chronic diseases increases with age, the problems associated with chronic disease management will be exacerbated in the future as the population ages. (By 2040, one out of every five Americans will be over 65 and the number of people aged 85 and older will have tripled or quadrupled.) Remote monitoring involves collecting disease-specific metrics from biomedical devices used by patients in their homes or other settings outside a clinical facility. Remote monitoring systems typically collect patient readings and then transmit them to a remote server for storage and later examination by health care professionals. Once available on the server, the readings can be used in numerous ways by home health agencies, by physicians, and by informal care providers. Intel recently announced a consortium of 22 health care and technology companies that will set technology standards for home health care monitoring devices. The aim is to provide better preventive medical care and reduce unnecessary visits to the doctor and to the emergency room. The group plans to develop devices to serve several segments of the population: the 1 billion adults worldwide who are considered to be obese, the 860 million people with a chronic disease, and the growing elderly population. The goal is to feed data from weight scales, blood pressure monitoring devices, and, for the elderly, sensors in the home, to a network that will allow health care providers and family members to monitor a persons condition. Technological advances such as remote health care monitoring may provide a more cost-effective and less labor-intensive way to manage the care of patients with chronic illnesses. Is that true? Is it more costeffective? Is it less labor-intensive? How does it compare to other approaches? Who should pay for remote health care monitoring devices and services? Is it the patient? Is it the care provider? Is it the Health Maintenance Organization? And who provides the health care monitoring services? The manufacturer? Are these services outsourced to a third party? A different set of questions relates to what to do with the information that is gathered? There are huge opportunities for data mining; searching for patterns that may predict certain disease progressions. 6. Health Care in the Developing World Our focus and emphasis has been on issues and opportunities concerning access to care in the U.S. Of course, access to care may in fact be of even greater concern in developing countries, and there are many opportunities for operations research to offer improvement. Health care access may include a different focus or set of problems in the developing world, and it may be especially important to allocate scarce resources effectively. Datta (1993) describes several potential areas to aid the public sector in developing countries. Among the areas discussed are (a) Health Planning, (b) Disease Control, (c) Location/Allocation, (d) Health Administration, (e) Public Health, (f)

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Family Planning and (g) Nutrition Planning; Papageorgiou (1994) also discusses the use of OR in the public sector in developing areas. For instance, (Flessa 2003; Wilson, Kahn et al. 2006) are described previously and apply to areas (b) or (c). Harper and Shahani (2003) develop a simulation model that is especially focused on the needs of the developing world to predict patient progress and future needs/costs towards HIV transmission and treatment in India, falling in (b) or (e). Ferrelli, Serrano et al. (1997) describe several studies using continuous quality improvement to assess and improve delivery of health in Boliva, and they cite a lack of a culture of research and poor personnel training as issues. Other issues that may arise include limited infrastructure, lack of funds for advanced medical technology or sometimes basic supplies, a public that may not be educated on disease transmission, and lack of centralized management. Few papers in OR have considered topics that especially relate to the developing world though, so great attention is warranted in this area. 7. Conclusions Access to health care is an important societal problem. Health care costs are increasing without a corresponding increase in the quality of medical care, and many people are outside of the health care safety net. Providing access to basic health care is a stated goal of the government, but is difficult to achieve with limited resources. There are many problems that relate to health care access, including where and how care should be provided, how preventative care can be delivered to reduce overall health costs and how health care should be measured. There is a real need for rigorous mathematical/engineering approaches to addresses these problems. Operations research approaches have been used to address some problems in this arena, and there have been some successes in gaining improvements in the health care system. Yet, many challenges remain. Data mining and statistical techniques can be further developed for estimating data that populates optimization models. Policy analysis can be integrated with quantitative models for improved overall decision making. Issues of equity and fairness can be considered alongside efficiency in helping to determine how best to make decisions. Information asymmetries and incentives can be studied to further understand how payments and measurements should be determined. Many disparities in need and delivery also need to be addressed. The biggest impact will arise when operations researchers engage policymakers and public health officials in discussion, while learning as well as teaching. The United States may be at a crossroads in the quest to determine how to deliver health care to her people. The costs have never been so high, and the stakes are significant, with not only the health of the people to consider but also the competitiveness of industry in the global economy. In addition, there are significant demographic changes (such as an aging population) which will put significant burdens on health care provision. We hope that operations researchers will participate in helping to draw the map of how to effectively and equitably provide health care access. Acknowledgements This research has been supported in part by NSF-DMI-0348532. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the National Science Foundation or other sponsors. References

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