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Abstract

In recent years in Korea, healthcare utilization has been increasing due to aging of people with disability. However, accessibility to usual source of care (USCs) for people with disabilities remains unimproved. This study aimed to analyze current usage of USCs by people with disabilities in Korea in comparison with people without disabilities. This study utilized data of the 2018 Korean Health Panel Survey, a representative longitudinal survey of the entire nation that included 12 880 participants with or without disabilities in South Korea. People with disabilities were classified into Mobility Disorder, Communication Disorder, Mental Disorder, and Others. Logistic regression analysis was conducted to assess satisfaction with the utilization of USCs among people with or without disabilities. Analysis of Covariance (ANCOVA) was employed to examine difference in satisfaction between people with disabilities and those without. The proportion of people with disabilities utilizing USCs as their primary healthcare facility was only one-third of that of people without disabilities. In terms of overall satisfaction with USCs, respondents indicated insufficient consultation time and difficulty comprehending medical information during appointments. However, people with disabilities utilizing USCs as tertiary healthcare facilities reported higher satisfaction levels than people without disabilities, stating ease of understanding medical information, opportunities for asking questions, and ability to provide feedback. To enhance accessibility for people with disabilities to utilize USCs as their primary healthcare facility, it is necessary to strengthen accessibility through institutional mechanisms by providing disability-friendly physical facilities and auxiliary aids to facilitate communication with healthcare providers.

Keywords

disability usual source of care health care access health care utilization disability-friendly facilities

What do we already know about this topic?

Currently, the aging of South Korea’s disabled population is intensifying with a transition into an aged society. However, there is no discussion on policies or systems to address this demographic shift.

People with disabilities who have behavioral limitations require access to primary healthcare to ensure they receive appropriate treatment.

How does your research contribute to the field?

This research contributes to the field by addressing the critical issue of limited accessibility for people with disabilities to primary healthcare in South Korea. Efforts are needed to implement universal design principles and construct disability-friendly facilities in healthcare institutions, thereby enhancing accessibility and inclusivity for this marginalized population.

What are your research’s implications toward theory, practice, or policy?

This research highlights the importance of enhancing communication between individuals with disabilities and healthcare professionals. By improving communication, we can enhance satisfaction levels and ensure better access to primary healthcare for individuals with disabilities. This has significant implications for both practice and policy, emphasizing the need for inclusive healthcare services that cater to diverse needs of all individuals.

Introduction

The number of people with disabilities in South Korea has been increasing since 2016, reaching a total of 2.64 million in 2023. Among them, individuals with physical disabilities, hearing impairments, and visual impairments show the highest proportions.¹ Currently, aging of the disabled population is also intensifying. South Korea’s disabled population has entered an aged society. However, there is no discussion on policies or systems for this. In addition, people with disabilities are more likely to develop chronic diseases earlier than people without disabilities. Prevalence rates of chronic diseases such as hypertension (54.5%), diabetes (25.6%), and heart disease(17.3%) are also high.²

People with disabilities also have behavioral limitations. Thus, access to primary healthcare is important for them³ to receive appropriate treatment.³ People with disabilities have higher prevalence rates of chronic diseases than people without disabilities.⁴ Therefore, they have higher healthcare needs than people without disabilities. Because chronic diseases are treated over a long period of time, it is important to maintain continuity of care through usual source of care (USC). In addition, chronic disease management for people with disabilities is approached differently than for people without disabilities. Patients with disabilities have a strong preference for doctors who have specialized training in disability.⁵ Similarly, better access to primary healthcare naturally increases the number of hospital visits for people with disabilities.⁶ Thus, it is important to discuss ways to promote USC.

USCs are essential for chronic disease management because they can facilitate preventive healthcare access⁷ and provide a continuum of care for patients’ chronic conditions. Patients with chronic conditions are more likely to use USC.⁸ More frequent use of USC is associated with fewer specialist visits.⁹ When patients with USC and those without USC were compared, those with USC were found to be more likely to have adequate hypertension and hyperlipidemia management.¹⁰

Meanwhile, several studies^11
-15 have indicated that individuals with disabilities, despite the presence of USCs, tend to have lower satisfaction with the quality of medical care and physician services than people without disabilities for various reasons. In the United States, primary healthcare clinics lack disability-friendly facilities,¹¹ limiting the accessibility of individuals with disabilities. As the frequency of hospital visits by individuals with disabilities decreases, the rate of missed health check-ups in those with disabilities increases compared to that in those without disabilities.¹² Due to communication limitations, people with disabilities not only require assistance from medical staff during consultations, but also demand specialized aides to improve communication.¹³ When people with disabilities visit USCs, they expect communication challenges to be solved. However, in reality, hospitalization for preventable ambulatory care conditions (ACSCs) is higher for people with disabilities than for people without disabilities in South Korea, indicating that the primary healthcare service for people with disabilities is weak.¹⁴ Additionally, although disability-friendly healthcare screening centers do exist, they are insufficient, leading to a concentration of check-ups in tertiary hospitals.¹⁵

As shown in the above studies, people with disabilities might have more problems in accessing USCs than people without disabilities in terms of accessibility, need for preventive care, and improved communication. Notably, people with disabilities have a higher risk of falls than people without disabilities.¹⁶ They face challenges in the treatment of diabetes and respiratory diseases,¹⁷ experience unmet healthcare needs,¹⁸ and encounter communication issues, leading to misdiagnoses or incorrect prescriptions.¹⁹ However, there is limited research on issues in disability-friendly facilities in South Korea. While there have been fragmentary studies on people with disabilities in Korea, such as the number of emergency room visits²⁰ and the need for rehabilitation services,²¹ no studies have comprehensively examined the utilization of USCs by people with/without disabilities or factors that affect their satisfaction with the care they receive from USCs. In particular, no studies have matched people with disabilities and those without disabilities using a representative sample.

Thus, the present study aimed to analyze usage patterns and satisfaction of individuals with disabilities in USCs by comparing them using a representative sample. Initially, we examined whether individuals with disabilities used USCs more frequently than individuals without disabilities and analyzed which healthcare facilities were more concentrated in case of increased utilization. For patients with access to USCs, we explored differences in satisfaction with physicians and how satisfaction varied based on the type of USC. Given the scarcity of research results specific to Korea, we designed this study to reflect Korean healthcare utilization patterns and compared them with other existing studies with the aim of helping Korea’s healthcare policy for people with disabilities. Therefore, this study aimed to compare proportions of individuals with and without disabilities who had access to USCs and their satisfaction with USCs.

Methods

Data Source

This study utilized secondary data from the Korea Health Panel. The Korea Health Panel is managed by the Korea Institute for Health and Social Affairs (KIHASA) and the Korean National Health Survey. The panel survey selected general households residing in 16 administrative districts based on the 2005 Korea Census using a two-stage stratified cluster sampling method.²² Data collection for the Korea Health Panel has been conducted annually since 2008. Trained interviewers visited selected households to conduct Computer Assisted Personal Interviews (CAPI). Survey contents include general characteristics of respondents, inpatient and outpatient healthcare utilization, subjective health, and USC among others. Given that the survey includes information on the possession of USC and satisfaction with physician care, it is suitable for evaluating difficulties in using USCs among individuals with disabilities, which is the goal of this study. Ethical review and approval for this study were waived by the Institutional Review Board (IRB) of Samsung Medical Center (SMC) because it was secondary data analysis of an anonymous sample without any information to identify each person (IRB approval number: SMC202005065).

Sample Selection

The 2018 data used in this study consisted of 17 008 household members from 6379 households. Among them, individuals with missing responses on gender, age, residence, education level, health insurance, income level, subjective health, and outpatient care experience were excluded. Only those who responded that they had a USC and answered questions regarding outpatient care experience were included. Consequently, a final sample of 12 880 individuals was obtained. Within the dataset used for analysis, there were 920 individuals with disabilities and 11 960 individuals without disabilities. The analysis in this study was based on the 2018 data covering all regions of South Korea. People with disabilities were categorized into Mobility Disorder (Physical Disability, Brain Lesion), Communication Disorder (Visual Impairment, Hearing Impairment, Language Impairment), Mental Disorder (Intellectual Disability, Developmental Disability, Psychiatric Disorder), and Others (Renal Disorder, Heart Disorder, Respiratory Disorder, Liver Disorder, Facial Deformity, Urorrhea Disability, Ostomy, Epilepsy Disorder). This categorization followed Disability classification of Korea Ministry of Health and Welfare. Mobility Disorder included retardation and brain lesions. Communication Disorder included visual, hearing, and speech disorders. Mental Disorder included mental retardation, developmental disorders, and psychiatric disorders. Others included other disorders (kidney, heart, respiratory, liver, facial, urinary incontinence, and epilepsy).

To determine the prevalence of USCs, respondents were asked: “Is there a medical institution that you usually go to when you are sick or want to be examined or consulted for treatment?” Respondents answered “yes” if they had a USC. To assess satisfaction with medical care, the following 4 items were analyzed: (1) “Did you have enough time to talk to your doctor?” to assess whether patients were able to communicate well with their doctors, (2) “Did your doctor explain things in a way that you could understand?” to evaluate the clarity of medical explanations, (3) “Did your doctor give you a chance to talk about your questions or concerns about your treatment?” to assess whether patient concerns were addressed, and (4) “When making decisions about your treatment, did the doctor consider your opinions as much as you wanted?” to evaluate the extent to which patients were involved in treatment decisions.

Analysis

The analysis proceeded as follows. Logistic regression was employed to determine if individuals with disabilities would utilize USCs more frequently than those without disabilities. Additionally, the current status of healthcare institution utilization was analyzed to identify types of healthcare institutions utilized more heavily. For patients with a USC, this study also examined differences in satisfaction with physicians using logistic regression and assessed how satisfaction levels varied by the type of USC using analysis of covariance (ANCOVA). Given the paucity of research in this area in Korea, the study design was specifically crafted to reflect patterns of healthcare utilization in Korea. The goal was to contribute to the improvement of health care policies for individuals with disabilities in Korea by comparing these findings with existing research.

Descriptive analyses were performed using SAS (version 9.4) to identify patients’ demographic characteristics. Logistic regression analysis was conducted to examine satisfaction with healthcare utilization in USCs among people with and without disabilities. Independent variables in the logistic regression were tested for significance using univariate analysis (chi-square test). Individual characteristics such as gender, age, education level, residence, medical aid, household income and subjective health were used for control variables. For the age variable, those under 30 were grouped together because dividing them into 10-year intervals resulted in very small numbers, reducing statistical inference. Each variable was assessed for test power using Wald statistics. The Hosmer-Lemeshow chi-square test was used to verify the goodness of fit of the logistic regression model. To determine whether there was a difference in satisfaction by disability classification, a logistic analysis was conducted by classifying disability into Mobility Disorder, Communication Disorder, Mental Disorder, and Others. To further analyze how satisfaction with medical care differed among people with disabilities who had USC compared to those who did not have USC, a logistic analysis was performed. The same analysis was performed for people without disabilities. Finally, ANCOVA was used to evaluate satisfaction of people with disabilities and those without disabilities, as there might be differences in satisfaction at primary, secondary, and tertiary hospitals. For this analysis, we compared the mean of satisfaction on a continuous variable ranging from 1 to 5, with 1 being unsatisfied and 5 being satisfied. All analyses were performed using SAS 9.4, with significance set at P < .05.

Results

Supplemental Table 1 presents demographic characteristics of study participants. Regarding age groups, 72.3% of those with disabilities were in the age group of ≥60 years, which was twice the percentage for those without disabilities. In terms of education, 62.7% of those with disabilities and 24.9% of those without disabilities had less than a middle school education. The proportion of medical aid coverage among people with disabilities was 14.8%, approximately 7 times higher than that (2.3%) of those without disabilities. In terms of average annual income, 73.5% of people with disabilities and 40.0% of people without disabilities earned less than half of the national income. The proportion of people with disabilities who reported poor subjective health was 42.0%, about three times that of people without disabilities. Among people with disabilities, 62.1% reported having a commercial source of care, compared to 55.7% of those without disabilities.

Supplemental Table 2 summarizes types of USCs visited by people with disabilities. USCs were categorized into primary healthcare centers, secondary healthcare centers, and tertiary healthcare centers. The proportion of people with disabilities visiting primary healthcare centers as USC was about 10% lower than that of people without disabilities (59.96% for people with disabilities vs. 70.28% for people without disabilities). In particular, people with mental disabilities exhibited a significantly lower rate of using primary healthcare as USC at 38.71%. People with disabilities were more likely to use secondary or tertiary hospitals as their USC than people without disabilities. Regarding the use of secondary hospitals, 20.66% of people with mobility disabilities and 22.58% of people with mental disabilities used secondary hospitals as their USC, both higher than the 15.60% of people without disabilities. For the use of tertiary hospitals, 20.66% of people with mobility disabilities, 16.41% of people with communication disorders, and 38.71% of people with mental disorders used USC, all higher than the 14.12% of people without disabilities.

Table 1 summarizes results when patients with disabilities are categorized into Communication Disability, Mobility Disability, and Mental Disability and their satisfaction with care is compared with patients without disabilities. Patients with communication disability (aOR: 0.641, 95% CI: 0.474-0.868) and mental disability (aOR: 0.482, 95% CI: 0.259-0.895) were more likely to report insufficient conversation time. The same was true for ease of understanding [(communication disability aOR: 0.63, 95% CI: 0.46-0.864; mental disability aOR: 0.397, 95% CI: 0.205-0.769)]. In contrast, mobility disabilities did not show significant differences across all measures for satisfaction with care.

Table 1.

Adjusted Odd Ratios and 95% Confidence Intervals for Physician-Patients Communication According to Type of Disability.

		Enough time to talk			Easy to understand			Chance to question			Reflect opinion
Variables	Reference	AORs^a	95% CI^a		AORs	95% CI		AORs	95% CI		AORs	95% CI
Type of disability
People with disability	(not disabled)	0.766	0.651	0.902	0.827	0.694	0.986	0.843	0.712	0.998	0.936	0.782	1.119
Mobility disability	(not disabled)	0.819	0.671	1	0.924	0.744	1.147	0.923	0.751	1.134	1.01	0.813	1.255
Communication disability	(not disabled)	0.641	0.474	0.868	0.63	0.46	0.863	0.655	0.481	0.891	0.78	0.558	1.092
Mental disability	(not disabled)	0.482	0.259	0.895	0.397	0.205	0.769	0.556	0.286	1.082	0.615	0.283	1.335

Adjusted for sex, age, education, region, insurance type, income, self-rated health.

Bold values: p < 0.05.

Table 2 summarizes the extent to which people with disabilities and people without disabilities have trust in healthcare providers by the presence or absence of USC. People with disabilities were more likely to trust healthcare providers when they had USC. Specifically, people with disabilities were more likely to have enough time to talk to their healthcare provider (aOR: 1.674, 95% CI: 1.224-2.29), understand what they were being told (aOR: 1.528, 95% CI: 1.09-2.143), and have the opportunity to ask their healthcare provider questions (aOR: 1.626, 95% CI: 1.177-2.247). People without disabilities also reported higher levels of satisfaction with their care when they had USC [sufficient time to talk (aOR: 1.334, 95% CI: 1.213-1.468), understanding what was being told (aOR: 1.446, 95% CI: 1.299-1.61), being able to ask questions (aOR: 1.402, 95% CI: 1.27-1.547), and having their opinions taken into account (aOR: 1.188, 95% CI: 1.073-1.315)]. In addition, both people with disabilities and those without disabilities reported higher satisfaction with care if they rated their subjective health positively. People with disabilities reported that they had enough time to talk (aOR: 1.394, 95% CI: 1.015-1.913) and understood what they were told (aOR: 1.593, 95% CI: 1.135-2.237), while people without disabilities reported higher satisfaction with care across all items [enough time to talk (aOR: 1.529, 95% CI: 1.344-1.739), understanding of care (aOR: 1.627, 95% CI: 1.417-1.876), being able to ask and answer questions (aOR: 1.515, 95% CI: 1.328-1.727), and being listened to (aOR: 1.445, 95% CI: 1.261-1.655).

Table 2.

Adjusted Odd Ratios and 95% Confidence Intervals for Physician-Patients Communication According to Presence of a Clinic to Visit Mainly and Other Variables for People with Disability Compared to People Without Disability.

		Enough time to talk			Easy to understand			Chance to question			Reflect opinion
Variables	Reference	AORs^a	95% CI^a		AORs	95% CI		AORs	95% CI		AORs	95% CI
People with disability
Regular care	(None)	1.674	1.224	2.29	1.528	1.09	2.143	1.626	1.177	2.247	1.137	0.801	1.615
Sex (Female)	(Male)	1.353	0.986	1.855	1.391	0.991	1.952	1.226	0.885	1.698	1.43	1.009	2.026
Age (30-39)	(0-29)	0.656	0.207	2.083	0.672	0.174	2.592	1.233	0.321	4.736	2.943	0.364	23.824
Age (40-49)		1.032	0.387	2.747	0.969	0.311	3.024	1.273	0.449	3.61	0.723	0.264	1.986
Age (50-59)		0.666	0.359	1.234	0.684	0.337	1.388	0.854	0.445	1.64	0.727	0.36	1.469
Age (≥60)		0.707	0.455	1.098	0.714	0.442	1.154	0.981	0.613	1.57	1.238	0.731	2.096
Education (High school)	(Middle school or Lower)	0.678	0.389	1.182	0.463	0.244	0.877	0.71	0.399	1.263	0.547	0.292	1.026
Education (College or higher)		0.814	0.467	1.42	0.882	0.457	1.704	0.846	0.473	1.515	0.694	0.367	1.311
Region (Urban)	(Rural)	0.972	0.715	1.322	1.044	0.75	1.454	1.116	0.812	1.535	1.103	0.785	1.55
Insurance (Medicaid)	(Non-Medicaid)	1.182	0.759	1.843	1.287	0.802	2.067	1.446	0.892	2.344	1.332	0.794	2.235
Income (Above 50%)	(Below 50%)	1.18	0.817	1.704	1.485	0.982	2.245	1.346	0.919	1.973	1.228	0.824	1.831
Self-rated Health (Not bad)	(Bad)	1.394	1.015	1.913	1.593	1.135	2.237	1.081	0.779	1.5	1.199	0.845	1.702
People without disability
Regular care	(None)	1.334	1.213	1.468	1.446	1.299	1.61	1.402	1.27	1.547	1.188	1.073	1.315
Sex (Female)	(Male)	1.093	0.994	1.201	1.058	0.951	1.177	1.082	0.981	1.193	1.081	0.977	1.197
Age (30-39)	(0-29)	0.867	0.719	1.045	0.904	0.731	1.119	0.847	0.697	1.03	0.958	0.781	1.176
Age (40-49)		0.882	0.731	1.064	0.924	0.746	1.145	0.896	0.736	1.09	0.942	0.769	1.153
Age (50-59)		0.848	0.725	0.993	1.04	0.867	1.247	0.953	0.808	1.125	1.062	0.895	1.26
Age (≥60)		0.986	0.851	1.142	1.051	0.891	1.239	1.002	0.861	1.166	0.935	0.802	1.089
Education (High school)	(Middle school or lower)	1.109	0.942	1.306	0.839	0.699	1.007	0.861	0.727	1.019	0.911	0.766	1.083
Education (College or higher)		1.034	0.917	1.165	0.973	0.846	1.12	0.913	0.805	1.037	0.902	0.791	1.028
Region (Urban)	(Rural)	0.997	0.905	1.098	1.002	0.899	1.117	0.991	0.897	1.095	0.92	0.83	1.019
Insurance (Medicaid)	(Non-Medicaid)	1.108	0.816	1.505	1.131	0.815	1.569	1.101	0.807	1.502	0.894	0.658	1.215
Income (Above 50%)	(Below 50%)	1.022	0.919	1.137	1.226	1.089	1.381	1.063	0.952	1.187	1.101	0.983	1.234
Self-rated Health (Not bad)	(Bad)	1.529	1.344	1.739	1.627	1.417	1.867	1.515	1.328	1.727	1.445	1.261	1.655

Adjusted odd ratios and 95% confidential interval by multiple logistic regression.

Bold values: p < 0.05.

Table 3 shows results of an ANCOVA comparing ratings of satisfaction with USCs by people with disabilities and those without disabilities with USC. In primary healthcare institutions, both people with disabilities and those without disabilities reported having sufficient time for conversation and finding medical content more understandable. For each item, primary healthcare institutions received slightly higher satisfaction ratings from people without disabilities than from people with disabilities. On the other hand, for tertiary hospitals, people with disabilities expressed higher satisfaction than people without disabilities for items related to ease of understanding medical content, having opportunity to ask questions, and ability to reflect their opinions.

Table 3.

Adjusted Odd Ratios and 95% Confidence Intervals for Physician-Patients Communication According to Type of a Clinic to Visit Mainly for People with Disability Compared to People Without Disability.

	Enough time to talk*				Easy to understand*				Chance to question*				Reflect opinion*
Variables	Mean	95% CI^a		P > F	Mean	95% CI		P > F	Mean	95% CI		P > F	Mean	95% CI		P < F
Primary clinic
Non-disabled	3.886	3.825	3.947	.027	3.983	3.930	4.036	.038	3.957	3.900	4.015	.272	3.830	3.768	3.893	.282
Disabled	3.856	3.766	3.946	.027	3.921	3.843	4.000	.038	3.910	3.825	3.994	.272	3.786	3.692	3.880	.282
Hospital
Non-disabled	3.793	3.665	3.921	.005	3.844	3.733	3.955	.000	3.722	3.595	3.848	.000	3.862	3.718	4.006	.331
Disabled	3.785	3.617	3.952	.005	3.805	3.661	3.950	.000	3.678	3.512	3.843	.000	3.791	3.598	3.985	.331
Tertiary Hospital
Non-disabled	3.794	3.653	3.935	.865	3.917	3.799	4.036	.015	3.871	3.747	3.995	.055	3.717	3.583	3.851	.004
Disabled	3.799	3.627	3.970	.865	4.036	3.891	4.180	.015	4.024	3.872	4.175	.055	3.925	3.761	4.089	.004

Adjusted for sex, age, education, region, insurance type, income, and self-rated health.

1: Unknown, 2: Not at all, 3: Sometimes, 4: In general, 5: Always.

Bold values: p < 0.05.

Discussion

To summarize results of this study, people with disabilities are more likely to use tertiary hospitals as USC than people without disabilities. In contrast, only one-third of people with mental disabilities used primary care as USC compared to half of people without disabilities. When it comes to satisfaction with USCs, people with communication disorders and mental disorders are particularly dissatisfied, reporting insufficient time to talk during appointments and difficulty understanding what is being said. Both people with disabilities and those without disabilities were more likely to be satisfied with their care at USCs. However, the lower their subjective health, the less satisfied they were with their care. Finally, when satisfaction ratings of people with disabilities and those without disabilities with commercial treatment centers were compared, people with disabilities were more satisfied than people without disabilities when visiting tertiary hospitals for categories of easy to understand medical treatment, opportunity to ask questions, and ability to reflect their opinions.

This study found that people with disabilities were more likely to have USC than people without disabilities. People with disabilities have to take into account special circumstances of their disability in their medical care. Thus, if they visit a doctor who can address their communication limitations, they are more likely to return to the doctor, which naturally leads to frequent visits. A study by Horner-Johnson and Dobbertin²³ has similarly found that people with disabilities have a higher rate of USCs. The rate of USCs varies by type of disability because different types of disabilities have different ways of communicating with medical staff.²⁴ People with disabilities are at a higher risk of developing complications or secondary conditions due to their disability than people without disabilities.²⁵ The prevalence of chronic diseases such as hypertension and diabetes is also higher in people with disabilities than in people without disabilities,^26,27 which naturally increases their healthcare needs. In other words, people with disabilities are more likely to use USCs that can maintain convenience and continuity of care.

This study found that people with disabilities were more likely to visit secondary or tertiary hospitals as USC. In general, tertiary hospitals treat severe illnesses, while primary healthcare treats mild chronic illnesses. Therefore, access to primary healthcare is necessary for treating chronic illnesses. However, currently in Korea, people with disabilities do not have easy access to primary healthcare. Thus, they are more likely to visit tertiary hospitals. Tertiary hospitals are more accessible to people with disabilities because they are equipped with disability-friendly facilities such as parking lots and facilities for people with disabilities. On the other hand, primary healthcare centers are only half as accessible as hospital-level healthcare centers,²¹ which means that fewer people with disabilities will use primary healthcare centers as USC. Improving accessibility in primary healthcare will be essential for people with disabilities to use primary healthcare as USC.

In addition, this study confirmed that people with mental disabilities had a higher preference for tertiary hospitals than those with other types of disabilities. Unlike those with other disabilities, people with mental disabilities need to be hospitalized when their symptoms become severe. For this reason, people with mental disabilities prefer tertiary hospitals where it is relatively easy for them to be hospitalized.²⁸ They also prefer medical centers that are spatially close to them.²⁹ However, tertiary medical centers are not evenly distributed by region.³⁰ Thus, accessibility to tertiary medical centers is limited. On the other hand, if tertiary medical centers are used as USCs, accessibility will be limited, making it challenging not only for treating mental health, but also for managing chronic conditions.

In this study, the retention of USCs was high among people with mental disabilities. However, overall healthcare satisfaction was low. In Korea, it is believed that negative experiences during hospitalization in psychiatric institutions could lead to a lack of trust in medical staff. Human rights of people with mental disabilities have only been discussed in South Korea since the 2000s. Prior to that time, people with mental disabilities could be forcibly hospitalized without their consent. A study by Park and Kang³¹ has found that hospitalized people with mental disabilities are more satisfied with services that provide them with adequate living conditions, ensure their right to self-determination, and are free from abuse and violence. Therefore, it is important for medical institutions and medical staff to build trust with people having mental disabilities.

In this study, both people with disabilities and those without disabilities reported higher satisfaction with care when they had USC, with the magnitude of satisfaction being higher for people with disabilities than for people without disabilities. In other words, people with disabilities were more likely to benefit from having a USC than people without disabilities. However, the lower the subjective health, the lower the healthcare satisfaction of people with disabilities. In general, lower subjective health is associated with greater health needs. However, if a person with a communication disability has a limited amount of time to explain his or her condition to the doctor, his/her satisfaction level will be low. On average, people with disabilities take longer to visit a doctor than people without disabilities.³² South Korea has the last to second lowest number of doctors per capita among OECD countries at 2.51.³³ Thus, the time spent for each patient is short due to patient overcrowding.³⁴ It is speculated that people with disabilities who have low health levels need more time and that their needs are not being met, which may explain the decrease in satisfaction with doctor consultations.

Finally, people with disabilities were more satisfied with medical staff at tertiary hospitals than people without disabilities when they visited USCs, while people with disabilities were less satisfied with medical staff at primary and secondary hospitals. Medical staff at tertiary hospitals are composed of specialists. They possess better understanding of their medical specialties and more knowledge of people with disabilities. In addition, tertiary hospitals often have assistants who can help people with communication disabilities communicate, making it easier for them to receive care. In fact, studies have shown that people with disabilities prefer healthcare providers who have specialized knowledge about their disability.⁵ Therefore, it is understandable that people with disabilities would prefer tertiary care providers who understand their disability and make it easier to communicate with. Thus, they would be more satisfied with their care.

Based on findings of this study, the following policy recommendations can be made. First, there is a need to improve accessibility for people with disabilities. In terms of physical accessibility, it is necessary to implement Universal design and establish facilities for the convenience of people with disabilities at primary healthcare institutions, making it easier for them to access medical facilities. For visually impaired individuals, facilities such as tactile blocks should be installed to facilitate movement. Mandating features such as providing elevators and eliminating thresholds in healthcare facilities are also imperative. In terms of communication accessibility, efforts are needed to facilitate communication between people with disabilities and healthcare professionals. Some individuals with disabilities require assistance from interpreters. However, even large hospitals employ only 1 or 2 interpreters, making it difficult for them to communicate during hospital visits. Additionally, the appropriateness of using tertiary healthcare institutions as USC needs to be enhanced. Disabled patients tend to visit tertiary healthcare institutions more often as USC than visiting primary and secondary healthcare institutions. Healthcare management at healthcare institutions is divided into main disability management and general healthcare management. However, tertiary healthcare institutions are inappropriate for general healthcare management. To prevent complications and secondary conditions through chronic disease management, it is necessary to increase medical accessibility and trust in medical professionals so that people with disabilities can use primary healthcare institutions as usual sources of care.

Limitations

This study has some limitations. First, not all disabilities were analyzed due to data limitations. In addition, this study was a single-year analysis. It did not look at changes over time, making it difficult to determine how disability affected access to and satisfaction with commercial care before and after it occurred. Since we only adjusted for demographic characteristics of people with and without disabilities, we could not consider other direct causes of disability. Nevertheless, this study was meaningful in that it comprehensively examined the usage and satisfaction of USCs by matching people with disabilities and those without disabilities using a representative sample. It also examined differences in satisfaction by disability status/type and type of USC. Future studies should clearly identify causes of disability, the point in time when disability occurs, and changes that occur as disability develops.

Conclusions

This study analyzed patterns of use and satisfaction with usual sources of care (USCs) among individuals with and without disabilities in South Korea using data of the 2018 Korean Health Panel Survey. It was found that individuals with disabilities utilized tertiary hospitals as USCs at a higher rate than those without disabilities, especially individuals with mental disorders. Tertiary hospitals were preferred as USCs due to their disability-friendly facilities and the ease of admission during treatment. Additionally, satisfaction with USC utilization at tertiary hospitals was found to be high. Tertiary hospitals are equipped with appropriate aids to assist individuals with communication or mobility restrictions due to disabilities, which are less available in primary clinics. However, for individuals with disabilities, primary clinics were preferred due to their proximity, facilitating continuity of care. Therefore, to promote the use of primary clinics as USCs for individuals with disabilities, improvements in physical and communication accessibility are necessary.

Supplemental Material

sj-docx-1-inq-10.1177_00469580241273110 – Supplemental material for Cross-Sectional Analysis of Difficulties Using Usual Source of Care for People with Disability

Supplemental material, sj-docx-1-inq-10.1177_00469580241273110 for Cross-Sectional Analysis of Difficulties Using Usual Source of Care for People with Disability by Jane Ko and Jae-Hyun Park in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-2-inq-10.1177_00469580241273110 – Supplemental material for Cross-Sectional Analysis of Difficulties Using Usual Source of Care for People with Disability

Supplemental material, sj-docx-2-inq-10.1177_00469580241273110 for Cross-Sectional Analysis of Difficulties Using Usual Source of Care for People with Disability by Jane Ko and Jae-Hyun Park in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Author Contributions

All authors take full responsibility for the research concept, methods, and results.

Data Availability

The Korea Health Panel data is managed by the Korea Institute for Health and Social Affairs and the National Health Insurance Service. The data can be received by requesting via email from the person in charge of the Korea Health Panel site (khp.re.kr).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant (grant number: HI20C1073) of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) funded by the Ministry of Health & Welfare, Republic of Korea.

Ethical Consideration

Ethical review and approval were waived for this study by the Samsung Medical Center Institutional Review Board because it was a secondary data analysis of an anonymous sample that did not include any information to identify survey participants (SMC202005065).

ORCID iD

Jane Ko

Supplemental Material

Supplemental material for this article is available online.

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