Technology-enabled health care supply chain for primary care: reducing disparities in the delivery of chronic care.

Abstract

Fundamental to health care supply chain management is the need to acknowledge that not everyone enjoys the same opportunities to access quality health care. Chronic conditions, which require ongoing access to primary care, are a leading cause of disparities in health. Ironically, even with major causes of chronic diseases well known and understood, vulnerability and impact are particularly associated with inadequate access to health care and treatment. This `gap' between the supply of and demand for quality health care demands major progress in preventing or delaying illness and death by crafting inexpensive and cost-effective interventions that take advantage of the scientific knowledge available. As an integral part of the health care supply chain, primary care not only helps prevent illness and death, but also serves as a point of first contact to reduce the difficulty in accessing needed health services. It is in the context of primary care where a large majority of health care needs and the management of health related problems can be addressed before they become acute enough to require hospitalization or emergency services. Yet, variation in primary care delivery associated with race, socioeconomic status, and other factors not attributable to clinical manifestations are prevalent which leads to inefficiencies and additional costs across the health care supply chain and further contributes to longstanding disparities in health status and outcomes. With the population of the United States continuing to grow and become increasingly diverse, both governmental and professional entities have taken special interest in identifying interventions that can help eliminate disparities in care. Health information technology has been regarded as a critical component in reducing disparities in care delivery by improving the awareness of both care-givers and patients through timely availability of information for the management of chronic disease conditions. The extant literature that addresses disparities due to socioeconomic class argues that care for socioeconomically disadvantaged patients is under-resourced and often lower in quality. Therefore, the unique characteristics of under-resourced settings due to both the patient population they serve as well as the communities where they operate should be considered when assessing the impact of health information technology on care delivery. The objective of the dissertation is to develop a framework that can begin to inform both academe and practice on how technology-enabled interventions in the supply chain for primary care can address the `gap' between the supply and demand of high quality and cost effective health care for chronic diseases. Using clinic level data of 400+ clinics from the Midwest, we develop and empirically test an actionable framework that considers various primary care and environmental characteristics that can enable the delivery of high quality care for chronic diseases, especially in regions with heterogeneous patient populations. The disease contexts for the dissertation, diabetes and depression, are disease conditions which afflict lower socioeconomic status and underserved patient populations and impose significant financial burden on a health care system. In the dissertation we describe the health care supply chain for chronic care and highlight issues of health disparities due to socioeconomic stratification. We then empirically examine the relationship between IT leveraging competence and disparities in high quality diabetes care due to differences in community and individual enabling resources in primary care settings. In particular, we highlight the promise and difficulties that information technology has on improving the quality of health care in primary care settings while at the same time addressing disparities in the delivery of care. Our results suggest that leveraging higher order IT capabilities may potentially increase disparities due to differences in resources that enable access to quality health care. Building on these results, we empirically examine the relationship between IT leveraging competence and affordable access to high quality care. We find that making care more affordable through the leveraging of IT can serve as an effective mechanism for reducing disparities by increasing access to high quality care for those who are more socioeconomically disadvantaged. Shifting our attention to behavioral health, we empirically evaluate behavioral health care for patients receiving treatment for depression through the supply chain for primary care. We place the health care supply chain in the broader community environment and center our attention on the impact of IT-enabled, evidence-based, and affordable primary care as mechanisms that can enable the integration of behavioral and physical care to improve behavioral health. Consistent with these arguments we find that improvements in short and long term depression outcomes are associated with primary care settings that leverage IT in conjunction with evidence-based practices. Further, we find that the effect of affordability becomes more prominent for the more socioeconomically disadvantaged communities. In addition, both physical and social characteristics of the community environment are associated with improvements in short and long term depression outcomes. By drawing from the established knowledge base in medical sociology, epidemiology, health policy, and health care management, the major contributions of this dissertation lie at the intersection of operations and supply chain management, quality management, and management of information systems by advancing the theory and practice of health care supply chain design for delivering high quality care for chronic diseases to a heterogeneous patient population. In particular, we highlight the significant challenges and complex problems in considering technology-enabled interventions in the supply chain for primary care in order to improve the quality of health care while at the same time addressing disparities in the delivery of care.