Background
Barriers to accessing health and social care represent a key factor in causing health disparities. Regardless of their age, people with chronic conditions often face multiple and complex challenges when trying to identify the right patient pathways already at the onset of their illness or when the first signs of chronic disease appear [
1]. People with multiple long-term conditions have also been found to experience worse hospital care than all other patient groups [
2]. Further, an international study found that respondents with high morbidity scores report less positive experience with coordination of care compared to those with low morbidity scores, especially among patients with chronic lung, and mental health problems [
3]. According to the WHO [
4] “developing more integrated people-centred care systems has the potential to generate significant benefits to the health and health care of all people, including improved access to care, improved health and clinical outcomes, better health literacy and self-care, increased satisfaction with care, improved job satisfaction for health workers, improved efficiency of services, and reduced overall costs”. While the WHO’s framework on integrated, people-centred health services is highly valuable, existing frameworks on access to health care as well as studies evaluating integrated patient pathways often focus on care events as the basic unit of interest rather than on patient-centred integrated care across different stages of a patient’s illness [
4]. In other words, the integrated care discussion focuses on events rather than on the overall process from a patient’s perspective. Similarly, the WHO’s universal coverage framework focuses on what services are covered, aspects of cost sharing, and population coverage but does not capture inequalities in access at different care stages and/or in settings that are particularly relevant for patients with one or more chronic diseases [
5].
As a social health insurance (SHI) system, one of the key challenges in the organisation of the Austrian healthcare system is the fragmentation of organisational and financial structures [
6‐
9]. This applies particularly for people with multimorbidities and/or chronic conditions (ibid.), even if recent reforms have attempted to tackle fragmentation and to shift service provision away from the inpatient sector while expanding outpatient care in the context of target-based governance reforms [
7,
10]. In this context, the main stakeholders financing the system (nine provinces, federal level, SHI fund) agreed to continue addressing barriers to access in the reform period 2017–2021 (Table
1) [
18].
Table 1
Policy context: Austria
Austria is a developed welfare state with an SHI system covering around 99% of the population. The provision of health services in Austria is characterised by relatively unrestricted access to all levels of care including GPs, specialists, and hospitals, and there is no formal gatekeeping system in place [ 10]. However, in practice, the density of specialists with an SHI contract is low in some rural areas [ 11, 12], and the proportion of private providers, i.e., without an SHI contract, is rising. In fact, out-of-pocket payments at the point of service are higher in Austria than in other countries with similar levels of health expenditure (17.7% of health expenditure in 2019) [ 13, 14]. The proportion of people with voluntary health insurance (VHI) is growing [ 11, 12]. The latter also enjoy shorter waiting times for elective surgery [ 15] than patients without VHI. Despite high coverage with SHI and being continuously among the countries with the lowest levels of unmet needs in Europe, some authors have reported that a greater proportion of Austrian households are faced with health spending that exceeds their ability to pay than in most high-income countries in the EU [ 16]. While overall life expectancy is above the EU average (81.7 years in 2017) and rising, healthy life years at birth are substantially below the EU average, with approximately 57 years free of disability at birth versus 64 years in the EU as a whole [ 11, 12]. Regional variation is substantial, with shorter healthy life expectancy among people living in eastern parts of Austria compared to western parts [ 17]. |
Fragmentation is a major barrier identified in studies on people with chronic conditions in Austria: Patients with chronic conditions face difficulties identifying the right patient pathways, especially when in vulnerable situations, such as persons affected by homelessness [
19,
20]. People in lower socio-economic groups are not only at higher risk of being affected by chronic pain symptoms but also have more difficulties dealing with chronic symptoms due to lower health literacy [
21,
22]. Socio-cultural factors also contribute to difficulties managing chronic illness [
23‐
26]. Most studies have focused on specific groups, such as people affected by poverty or homelessness, while studies on chronic disease among children or in the general working age population are much rarer. Regarding mental health care or psychosocial care, the main barriers mentioned in the literature range from stigmatisation, information deficits, and waiting times among people with mental health problems (cf. [
27]) to barriers to accessing psychotherapy as well as psychiatric inpatient care and psychiatric care in hospital outpatient departments [
20,
27‐
36]. Previous studies have identified financial barriers to accessing psychotherapy, often in combination with other barriers such as long-term unemployment, risk of social exclusion, or language barriers [
29‐
32]. A main barrier includes the ability to navigate a fragmented system, with patients with mental health problems often facing a lack of coordination between care settings and care providers [
20,
30,
37]. The vast majority of studies investigating the accessibility of mental health care, however, focused on the working age population (or explicitly on dementia care) as well as on children and adolescents, while studies relating to chronic mental health conditions for the older population (except for long-term care and dementia) are rare (see, e.g., [
38] on older people with a substance use disorder in Vienna).
So far, few studies have systematically analysed barriers to accessing health care in the Austrian healthcare system for people with chronic conditions. This paper aims to fill this gap by highlighting such barriers at different stages of a patient’s illness in an SHI country setting in Europe. The study aims to identify barriers to access, with a special focus on patient pathways, in the Austrian context, using three case studies of people with chronic conditions and applying the barrier to access model developed by Levesque et al. [
39] as a conceptual framework. The research questions in this study are: What challenges in access do patients with chronic conditions face in the Austrian SHI system at different stages of their illness? How may barriers to access along a patient’s different stages of illness be conceptualised using Austria as an example of social health insurance countries?
Discussion
Beyond questions of who is covered, what services are covered, and what proportion of costs is covered, countries with almost universal coverage may still have barriers in their healthcare systems for people with chronic conditions. While studies on unmet needs suggest a very low level of barriers to accessing health care in the Austrian context [
13,
58], our study highlights potential ‘invisible’ barriers that go beyond structural factors such as universal coverage. Our study provides insights into existing inequalities and inequity when navigating the healthcare system and identifying the right patient pathways, using the examples of children with bronchial asthma, adults with non-specific chronic LBP, and older people with pre-existing mental illnesses. Its findings suggest that there are gaps and barriers to accessing health services for people with chronic conditions regardless of their age; as a result, they experience considerable challenges when trying to navigate the health system to access the services they need.
The case studies were chosen to reflect populations that are particularly susceptible to inequalities and inequity of access to healthcare services and which were previously under-researched; we thus aimed to cover a broad spectrum of barriers to areas of care for people with chronic illness. While the Levesque et al. [
39] framework was helpful in guiding our review of barriers to healthcare services and offered an insightful way of examining the case study populations included in this study, the importance of barriers in coordination among care providers was only partially captured by the framework, although this is particularly relevant for people with chronic conditions.
Our findings indicate the importance of an integrated approach in care, especially for people with chronic conditions. It is well known that people with chronic disease are often affected by more than one illness, which is why moving away from a single-disease framework towards a patient-centred model [
59] is recommended, or towards a function-oriented approach focusing on “whether a patient can function in a way that they find acceptable” rather than focusing on single parameters such as blood pressure reduction [
60]. The gradual introduction of a primary healthcare model in Austria is a first step towards such an approach as it often comprises multidisciplinary teams, including physicians, nurses, physiotherapists, social workers, and mental health staff [
61]. Primary care models are patient-centred, and collaboration between professionals as well as the distribution of their roles change according to patient needs [
62]. Further, innovative approaches such as the piloting of so-called social prescribing models in Austria may help patients with chronic conditions to benefit from non-medical referral options that can be delivered alongside existing primary care services [
63]. Embedded in the voluntary and community sectors, social prescribing can address complex health, psychological, and social issues presented in primary care, and there is increasing interest in its potential to reduce health inequalities and emergency department service demand [
64,
65].
A wide range of social determinants at individual and policy level create and influence access barriers, from the identification of healthcare needs to health consequences. Significant and recurring challenges to access reported by providers and patient advocates alike predominantly focused on patients’ ability to perceive a need and to subsequently seek and reach healthcare services. Across all case study populations, insufficient health literacy was identified by the providers as affecting patients’ perception of health needs and impeding individuals’ ability to navigate the health system. Further, communication issues affect the approachability of health services and adequate information exchange. In the cases highlighted by our study, a number of barriers were found to be unique to, or more prominent among, certain populations. For instance, while fear of stigmatisation and discrimination is highly prevalent among older people with mental illnesses and adults with non-specific chronic LBP, society generally has a non-judgmental and accepting attitude towards patients with bronchial asthma. It was highlighted that a lack of awareness of mental and/or somatic illnesses and insufficient consideration of comprehensive therapy approaches on the part of patients and providers alike often result in individuals avoiding or delaying seeking professional help for mental health problems. These results are in line with previous findings indicating that specific knowledge about treatment improves help-seeking and service use and that gaining knowledge about mental illnesses is one motivation to seek help [
66].
Limitations in the ability to seek and reach healthcare services become particularly evident as the demands on patients to orient within and navigate health care systems are increasing [
67]. In Austria, the context of this study, the fragmentation of the healthcare system as well as the social sector in relation to organisational and financial matters often poses a challenge and was described as complex, confusing, and difficult to navigate for patients. Such fragmentation across sectors is an additional complicating factor as social issues such as unemployment, low income, allowances, or care needs disproportionately affect people with multimorbidities and/or chronic conditions. Structural barriers such as a lack of infrastructure, inadequate public transport, long waiting times, and the limited (regional) availability of specialists with an SHI contract were frequently cited challenges for chronically ill patients. These findings are similar to those in a relevant study that found structural factors, such as access to transport or financial resources, to be a prerequisite for generating self-management capacity in patients with multimorbidity [
68]. Likewise, patients of low socioeconomic status face additional barriers to accessing care [
53]. Our findings suggest that system-based barriers disproportionally affect families and patients who experience challenges organising themselves and whose socioeconomic situation does not allow them to compensate for these potential disparities with financial or social resources. More drastically, patients with the greatest support needs, such as those with multimorbidities or chronic conditions, may often be left behind.
The results also reveal certain particularities for our case study populations. With regard to bronchial asthma, children’s health capital is dependent on their parents’ social situation and ability to utilise healthcare services. Still, according to our interviewees, asthma care pathways are usually better defined compared to non-specific chronic LBP or mental illnesses. Strict separation between school and other social settings and the healthcare system as well as disrupted continuity of care, especially in the transition phase from paediatric to adult medicine, were found to pose specific barriers for children’s health outcomes, however. The issue of transitioning asthma care from adolescents to adults is of major importance as the risk of respiratory morbidity increases in adulthood [
69]. A recent review also found that once patients are transferred to adult medicine, limited knowledge of their condition, limited understanding of how to manage related symptoms and comorbidities, and limited comprehension of medical indications often persist [
70]. Similarly, the burden of non-specific chronic LBP has implications for both ageing employees and employers. Many obstacles are faced by people with chronic pain when looking for employment or returning to work after a period of absence [
71‐
73]. If the cause of back pain is associated with workplace factors, a return to an unchanged workplace may not be successful and recovery may be impeded, regardless of appropriate treatment for the disorder [
74].
Our findings underline the role of necessary structures and conditions of health and social care systems. By examining the results along the dimensions based on Levesque et al.’s [
39] framework, we found that barriers involving coordination among care providers are strongly interlinked and that patient-centred communication is key if health outcomes are to be improved. Further, shortcomings in coordination, cooperation, and communication at the very beginning of patients’ treatment pathways are likely to impair the course of future treatment, leading to an exacerbation of existing barriers. The close interactions between poor communication, uncoordinated care pathways, and, ultimately, poorer health outcomes become particularly visible when addressing chronic conditions, confirming the importance of a holistic and patient-centred approach.
A particular strength of this study was the inclusion of four different perspectives. The heterogeneous sample consisting of health service providers, experts by experience (persons with one of the three conditions, their advocates or carers), researchers, and public health administration enabled a comprehensive, multidisciplinary assessment that gives an indication of the accessibility of the healthcare system in Austria for people with chronic conditions as well as a broader view of the changes required by stakeholders in the future. While we have captured some patients’ perspectives by proxy through provider interviews, we acknowledge that this gap may have significantly limited our insights into their unique experiences of access. Nevertheless, our interview partners demonstrated a high level of agreement concerning the key issues for people with chronic conditions. Although this article only concerns barriers to accessing the Austrian healthcare system, the results may also be useful in countries with similarly functioning systems, that is decentralised health and social care systems and other developed welfare states with a social health insurance system.
Our findings offer several implications for future research. Firstly, it would be important to expand this qualitative study to include more patient perspectives on barriers to obtain their views on how their needs and resources can be better supported. Secondly, future studies may investigate if and how ongoing reforms in health and social care systems (e.g., primary care units) address access barriers for people with chronic conditions identified by our study. Finally, further research will be helpful in conceptualising access along the different stages of a patient’s illness within a framework that is applied not only at the end of the care process but throughout. There is currently a gap in the evidence that would capture not only structural barriers to accessing health care but underpin indicators that are specific to the experience of people managing chronic conditions. This study contributes to the evidence by providing in-depth qualitative research – considering provider, expert, and researcher perspectives – on how patients with chronic conditions access care, including their barriers, and possible areas for improvement in health services to respond appropriately to patients’ specific needs.
Conclusion
Barriers to healthcare access particularly concern patients with chronic conditions, resulting in an urgent need to improve health services according to patients’ specific needs. Based on our findings, barriers are strongly interlinked. On the supply side, patterns of poor patient-provider communication, lack of a holistic therapeutic approach, an urban-rural divide, strict separation between social care and the healthcare system and limited consultation time were among the barriers identified. On the demand side, patients’ ability to perceive a need and to subsequently seek and reach healthcare services was an important barrier, closely linked to a patient’s socio-economic status, health literacy and ability to pay. For health services to be properly accessible to patients with chronic conditions, timely and integrated care independent of social and economic resources, continuity of care, and significant improvements in patient-centred communication and coordination of care are paramount. Further, shortcomings in coordination, cooperation, and communication at the very beginning of patients’ treatment pathways are likely to impede future courses of treatment, leading to an exacerbation of existing barriers. The close interactions between poor communication, uncoordinated care pathways, and, ultimately, poorer health outcomes become particularly visible when addressing chronic conditions and confirm the importance of a holistic and patient-centred approach.
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