Access, primary care, and the medical home: rights of passage.

Health Services Research, by now a mature field, has never developed precise terminology for most of the characteristics of health systems and services. Like Alice, its practitioners use terms to mean what they want them to mean, no more, no less. So it is with access. Everyone knows that, above all, people need "access" to health services to benefit from whatever health services have to offer. But what does "access" mean? Access, according to proper usage, is a noun meaning "a means of approaching or nearing a 'passage.'" People have access. "Accessible" is an adjective, meaning easily approached or entered; services can be said to be accessible if they have characteristics that make it possible for people to get to them. That is, places have varying degrees of accessibility, but people have varying degrees of access. So far, so good. What about "realized access," which is usually assumed to be synonymous with "utilization?" As characteristics other than access influence use, it confuses things to equate access with utilization. The paper by Jennifer DeVoe et al entitled, "A Usual Source of Care: Supplement or Substitute for Health Insurance Among Low-Income Children," deals with "access," but not only access.1 It builds on previous evidence in showing the importance of both health insurance (a measure of financial "access") and a source of primary care (which may vary in its accessibility) as policy strategies.2'3 Their paper attempts to tease out the relative advantages of each. The data indicate that, compared with children having both insurance and a regular source of care, insured children without a usual source of care had higher rates of unmet medical needs, no doctor visits in 12 months, and problems obtaining specialty care. On the other hand, having no health insurance but having a regular source of care predicted a higher likelihood of being unable to get timely urgent care, needed counseling, prescriptions, and having more problems obtaining dental treatment. Not all of the variables used to assess the impact of insurance and usual source of care are "access" variables. "Problem getting specialty care" would be expected to have more do to with having a usual source of care (and even MORE to do with the characteristics of that usual source) because of the need for referral in many health systems and specialty facilities. Similarly, "problem getting counseling" has more to do with the nature of the usual source of care than with "access." "Meeting needs" is certainly a characteristic of the quality of care received, undoubtedly at least as much as it is an "access" phenomenon. Dental services would not be expected to be related to usual source of care, as most "usual sources" do not provide it; it would be expected to be related to ability to pay (insurance). Insurance itself is an imprecise terms. In the United States, where most of 'insurance' is in the private market and there are innumerable variations in what insurance coverage and at what price, simply having insurance does not guarantee the ability to obtain needed care. Understanding the dynamics of these processes requires thinking about pathways. It has been almost 50 years since Avedis Donabedian suggested that it would be helpful to characterize phenomena in health services as structure, process, or outcome, and to examine the impact of structure on process and both on outcomes.4 It has been 35 years since the New England Journal of Medicine published a special article on the specific components of structure, process, and outcome, which showed how greater understanding