Adolescents : Access and Availability of Health Care

Gail B. Slap, M.D., LDI Senior Fellow, Associate Professor of Medicine and Pediatrics, School of Medicine, Director, Craig-Dalsimer Program in Adolescent Medicine, University of Pennsylvania Medical Center, and The Children's Hospital of Philadelphia

Volume 2, Number 3; May 1995

This Issue Brief examines adolescent health and barriers to care. Adolescent health care in the 1990's is fragmented and crisis-oriented. The reasons include financial disincentives to preventive care, adolescent discomfort with the health care system, and provider inexperience with adolescents.

Proposals to improve access to care for adolescents must address the needs, perceptions, and expectations of adolescents. Programs must provide comprehensive coordinated care. Whenever possible, this care should be available at a single site. When multiple sites are required, the adolescent patient should be taught how to navigate the system with increasing autonomy.

Health and Adolescence

The health care needs of adolescents differ from those of children and adults.
Adolescent care involves health promotion, illness and injury prevention, and the establishment of good health habits.
The major causes of adolescent mortality (injury, homicide, suicide) have a behavioral basis. Prevention requires education, skill, and foresight.

Access to health care is important to help modify adolescent risk behaviors and promote healthy habits.

Despite the perception that adolescence is a time of good health, the U.S. Congress' Office of Technology Assessment estimates that one in five adolescents suffers from at least one serious health problem.

- 5-10% of adolescents have a chronic disease or disability (e.g., asthma, heart disease, depression, vision impairment, or hearing loss).

Adolescents are at particularly high risk for unintentional pregnancy, sexually transmitted diseases (STD), injury, violence, suicidal behavior, and substance abuse.

- Among 15-24 year olds, injury causes 4 million person-years of lost work; this is the single most costly American health problem.

- Injury and violence cause 76% of deaths and account for a major share of chronic illness and disability in adolescents.

- Unintentional injury is the primary cause of death for individuals in this age group.

- Experimentation with alcohol is almost universal among adolescents; at least 90% of high school seniors in nation-wide surveys report some alcohol use. Alcohol use contributes to motor vehicle injury, and increases the likelihood of subsequent drug use, violence, and high-risk sexual behavior.

- An estimated 2.5 million adolescents contract an STD each year, and up to 25% of all adolescents will have had at least one STD before leaving high school.

- Pregnancy is the most common reason for adolescent girls to leave school. Nearly 1 million teens become pregnant each year.

Most adolescent mortality and morbidity is preventable, but attempts to intervene have met with limited success.

Adolescents see office-based physicians less often than any other age group, although they have higher rates of chronic medical illness and behavioral problems than do younger children.
Although most adolescent medicine specialists are pediatricians, only 23% of office visits by patients 10-18 years old are to pediatricians, with nearly 35% of visits to general or family practitioners.
The initial history and physical examination for a new adolescent patient are estimated to require 30-45 minutes. Only 4% of adolescent visits with a physician last 30 minutes or longer. Almost half (49%) of visits last 10 minutes or less.

Adolescent Access to Health Care

The goals of adolescent health care are to provide complete physical and psychosocial evaluation and treatment in an atmosphere of trust and confidentiality. However, adolescents face numerous barriers to receiving proper care and are inexperienced in utilizing the health care system.

Adolescents face significant financial barriers to health care.

The system may be an overwhelming experience that deters or delays care for adolescents first trying to use health services independently.

- Over half of all adolescent mothers receive inadequate prenatal care.

- Adolescents who received inadequate prenatal care are more likely to describe confusion about available services and medical coverage, have a negative opinion of physicians, and consider prenatal care as unimportant. They are also delayed in recognizing or acknowledging their pregnancy.

Poverty is the single most important factor affecting the health status of adolescents.

- Low physician participation in Medicaid limits service availability for poor minors.

- Competing priorities for other basic needs make it especially difficult for impoverished adolescents to receive health services or to utilize existing services.

- Adolescents living in rural areas are challenged with problems of transportation and a shortage of services.

Adolescents, age 15-19, are more likely than any other age group to be uninsured or underinsured.

- Youths comprise nearly one third of the 37 million Americans without insurance. Many insurance plans do not have coverage for preventive care, counseling, substance abuse, or other health related required services. In addition, out-of-pocket payments pose a major barrier to access for adolescents who seek care without parental knowledge.

Some adolescents face cultural barriers in accessing health care.

Some ethnic minorities are kept from using existing facilities because of the lack of culturally appropriate services and culturally sensitive providers.

- There is little information in the provider community about how racial and ethnic minorities experience adolescence. This makes it difficult for ethnic minority youth to receive appropriate services.

Adolescent perceptions of barriers to care differ from provider perceptions.

Adolescents identify factors related to site and provider cleanliness, infection control, provider competency and confidentiality as the principal barriers to seeking care.
Confidentiality is central to a trusting relationship between an adolescent and provider. Many providers are uncomfortable with the legal and ethical implications of independent care and decision making by adolescents.

- Evidence suggests that youths 14 years and older are able to make good decisions regarding their health, although most still benefit from parental involvement.

Physicians often overlook mental health problems in teenagers. Depression, hopelessness, and suicidal behavior are common, increasing, and increasingly undetected among adolescents.

Current Models of Health Care For Adolescents

Recent efforts to provide comprehensive, coordinated, accessible services for adolescents include: school based health clinics, independent multi-service centers, teen-specific public health clinics, and mobile vans.

One successful model for improving adolescent health care is the introduction of school based health clinics (SBHC).

- Existing clinics have high utilization rates by in-school adolescents. Some SBHC have recorded improved contraceptive use; decreased rates of pregnancy, substance use, and school dropout; and improved school attendance.

Independent multi-service centers are another approach to providing comprehensive adolescent health services.

- Multi-service centers integrate free services within a single site and are designed to attract homeless, runaway, and disenfranchised youth.

Public health clinics, which are available in most communities, are a common source of care for many youth.

- Most public health clinics provide both primary, preventive, and categorical services for specific conditions (i.e., prenatal care, STD treatments, and immunization).

- Public health clinics are not an option for all adolescents. They may require proof of Medicaid eligibility, limit confidentiality, and be unable to offer the provider the continuity that many adolescents need.

Policy Implications

The developmental characteristics and health behaviors of adolescents make the availability of health care services critically important to this population.

- Services that are particularly important for adolescents include: monitoring of growth and development, reproductive health care, diagnosis and treatment of sexually transmitted diseases, injury prevention, mental health care, and substance abuse management.

Services to adolescents need to be visible and available in many different health care settings, such as community centers, schools, physician offices, HMOs, and hospitals.
Development of guidelines, such as the American Medical AssociationŐs Guidelines for Adolescent Preventive Services, will increase the possibility that insurers will cover adolescent preventive services and that these services will become part of educational curriculae for health professionals.
The financing of health services for adolescents must be examined at the federal, state, and local levels.