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Background: The 2014 Veterans Choice Act and subsequent 2018 Veteran's Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans. Objective: To understand Veterans' experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans. Design: Qualitative descriptive design. Participants: United States (US) Veterans in Northwestern states engaged in VA and/or community care. Approach: Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis. Key Results: We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women's healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation. Conclusions: Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans—especially those with medical complexities, those living far from healthcare services, or those seeking women's healthcare. [ABSTRACT FROM AUTHOR]

Purpose: Telemedicine care dramatically expanded during the COVID-19 pandemic. We characterized facilitators and barriers to telemedicine implementation among safety-net primary care clinics serving patients with limited English proficiency (LEP). Methods: We collected data on telemedicine volume and patient demographics among safety-net clinics participating in a telemedicine learning collaborative. Data on various metrics were reported to the collaborative from February 2019 through August 2021. We conducted semi-structured interviews with clinical and quality leaders, purposively sampling clinics serving high proportions of patients with LEP. We analyzed interviews with a mixed inductive-deductive approach applying the Consolidated Framework for Implementation Research. Results: By September 2020, the 23 sites served 121,589 unique patients with in-person and 120,338 with telephone visits; 47% of these patients had LEP. Of 10,897 unique patients served by video visits, 38% had LEP. As a proportion of total visits, telemedicine (telephone and video) visits increased from 0–17% in October 2019–March 2020 to 10–98% in March–August 2020. We conducted 14 interviews at 11 sites. Themes included (1) existing telemedicine platforms and interpreter services were not optimized to support patients with LEP; (2) clinics invested significant labor iterating workflows; (3) sites with technological infrastructure and language-concordant staff were best suited to serve patients; (4) patients speaking less-represented languages or experiencing intersecting literacy barriers were underserved with telemedicine. Interviewees recommended innovations in telemedicine platforms and community-based access. Conclusions: Safety-net sites relied on existing resources to accommodate patients with LEP, but struggled providing access for the most marginalized. Proactive, data-driven strategies to address patient and community barriers as well as optimize clinical workflows with high-quality, certified medical interpreters are needed to ensure equitable access. [ABSTRACT FROM AUTHOR]

Background/Objective: Optimizing patients' access to primary care is critically important but challenging. In a national survey, we asked primary care providers and staff to rate specific care processes as access management challenges and assessed whether clinics with more of these challenges had worse access outcomes. Methods: Study design: Cross sectional. National Primary Care Personnel Survey (NPCPS) (2018) participants included 6210 primary care providers (PCPs) and staff in 813 clinics (19% response rate) and 158,645 of their patients. We linked PCP and staff ratings of access management challenges to veterans' perceived access from 2018–2019 Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (SHEP-PCMH) surveys (35.6% response rate). Main measures: The NPCPS queried PCPs and staff about access management challenges. The mean overall access challenge score was 28.6, SD 6.0. The SHEP-PCMH access composite asked how often veterans reported always obtaining urgent appointments same/next day; routine appointments when desired and having medical questions answered during office hours. Analytic approach: We aggregated PCP and staff responses to clinic level, and use multi-level, multivariate logistic regressions to assess associations between clinic-level access management challenges and patient perceptions of access. We controlled for veteran-, facility-, and area-level characteristics. Key Results: Veterans at clinics with more access management challenges (> 75th percentile) had a lower likelihood of reporting always receiving timely urgent care appointments (AOR:.86, 95% CI:.78–.95); always receiving routine appointments (AOR:.74, 95% CI:.67–.82); and always reporting same- or next-day answers to telephone questions (AOR:.79, 95% CI:.70–.90) compared to veterans receiving care at clinics with fewer (< 25th percentile) challenges. Discussion/Conclusion: Findings show a strong relationship between higher levels of access management challenges and worse patient perceptions of access. Addressing access management challenges, particularly those associated with call center communication, may be an actionable path for improved patient experience. [ABSTRACT FROM AUTHOR]

Background: Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions. We synthesized evidence on implementation strategies to increase EBP access and use. Methods: We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for articles on EBP implementation within integrated health systems to treat chronic pain or chronic mental health conditions. Reviewers independently screened articles, extracted results, coded qualitative findings, and rated quality using modified criteria from Newcastle–Ottawa (quantitative results) or Critical Appraisal Skills Programme (qualitative results). We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework and classified outcomes using RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, Maintenance). Results: Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems. No studies evaluated MBSR implementation. Eight articles evaluated strategies within VHA. Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback. CBT and ACT implementation demonstrated moderate to large improvements in patient symptoms and quality of life. Trainings increased mental health provider self-efficacy in delivering EBPs, improved provider EBP perceptions, and increased provider EBP use during programs, but had unclear impacts on Reach. It was unclear whether external facilitation added benefit. Provider EBP maintenance was modest; barriers included competing professional time demands and patient barriers. Discussion: Multi-faceted CBT and ACT implementation programs increased provider EBP Adoption but had unclear impacts on Reach. Future implementation efforts should further evaluate Reach, Adoption, and Maintenance; assess the added value of external facilitation; and consider strategies targeting patient barriers. Future work should use implementation frameworks to guide evaluations of barriers and facilitators, processes of change, and outcomes. Registration: PROSPERO registration number CRD42021252038. [ABSTRACT FROM AUTHOR]

Background: Unmet need for medical care is common among Medicare beneficiaries, but less is known whether unmet need differs between those with high and low levels of need. Objective: To examine unmet need for medical care among fee-for-service (FFS) Medicare beneficiaries by level of care need. Design, Setting, and Participants: We included 29,123 FFS Medicare beneficiaries from the 2010–2016 Medicare Current Beneficiary Survey. Main Measures: Our outcomes included three measures of unmet need for medical care. We also examined the reasons for not obtaining needed medical care. Our primary independent variable was a categorization of groups by levels of care need: those with low need (the relatively healthy and those with simple chronic conditions) and those with high need (those with minor complex chronic conditions, those with major complex chronic conditions, the frail, and the non-elderly disabled). Results: The rates of reporting unmet need for medical care were highest among the non-elderly disabled (23.5% [95% CI: 19.8–27.3] for not seeing a doctor despite medical need, 23.8% [95% CI: 20.0–27.6] for experiencing delayed care, and 12.9% [95% CI: 10.2–15.6] for experiencing trouble in getting needed care). However, the rates of reporting unmet need were relatively low among the other groups (ranging from 3.1 to 9.9% for not seeing a doctor despite medical need, from 3.4 to 5.9% for experiencing delayed care, and from 1.9 to 2.9% for experiencing trouble in getting needed care). The most common reason for not seeing a doctor despite medical need was concerns about high costs for the non-elderly disabled (24%), but perception that the issue was not too serious was the most common reason for the other groups. Conclusions and Relevance: Our findings suggest the need for targeted policy interventions to address unmet need for non-elderly disabled FFS Medicare beneficiaries, especially for improving affordability of care. [ABSTRACT FROM AUTHOR]

Background: Primary care providers (PCPs) are essential to increasing access to office-based buprenorphine medication treatment for opioid use disorder (B-MOUD). Barriers to B-MOUD prescribing are well-documented, but there is little information regarding incentives to overcome these barriers. Objective: To identify optimal incentives for PCPs to promote B-MOUD prescribing and compare incentive preferences across provider and practice characteristics. Design: We surveyed PCPs using best-worst scaling (BWS) to prioritize seven potential incentives for B-MOUD prescribing (monetary compensation, paid vacation, protected time, professional development, reduced workload, service recognition, clinical resources). We then used a direct elicitation approach to determine preferred incentive levels (e.g., monetary thresholds) and types (e.g., specific clinical resources). Participants: Primary care physicians and advanced practice providers (APPs) at a large Department of Veterans Affairs healthcare system. Main Measures: B-MOUD prescribing incentive preferences and relative preference levels using descriptive statistics and conditional logistic regression with relative importance scale transformation (coefficients sum to 100, higher coefficient=greater importance). Key Results: Fifty-three PCPs responded (73% response), including 47% APPs and 36% from community-based clinics. Reduced workload (relative importance score=26.8), protected time (18.7), and clinical resources (16.8) were significantly more preferred (Ps < 0.001) than professional development (10.5), paid vacation (10.3), or service recognition (1.5). Relative importance of monetary compensation varied between physicians (12.6) and APPs (17.5) and between PCPs located at a medical center (11.4) versus community clinic (22.3). APPs were more responsive than physicians to compensation increases of $5000 and $12,000 but less responsive to $25,000; trends were similar for medical center versus community clinic PCPs. The most frequently requested clinical resource was on-demand consult access to an addiction specialist. Conclusions: Interventions promoting workload reductions, protected time, and clinical resources could increase access to B-MOUD in primary care. Monetary incentives may be additionally needed to improve B-MOUD prescribing among APPs and within community clinics. [ABSTRACT FROM AUTHOR]

Background/Objective: The VA MISSION Act aimed to increase Veterans' access to care by allowing eligible Veterans to use VA-paid care from non-VA providers ("VA-purchased care"). We interviewed Veterans who were eligible for both VA-delivered and VA-purchased care to examine factors they consider when making decisions about whether to use VA-delivered or VA-purchased care. Methods: We conducted semi-structured interviews with 28 Veterans across the USA who were eligible for VA-delivered and VA-purchased care, using deductive and inductive analysis to develop themes. Participants were recruited from a survey about healthcare access and decision-making. More than half of participants lived in rural areas, 21 were men, and 25 were > 50 years old. Key Results: Veteran participants identified (1) high-quality relationships with providers based on mutual trust, empathy, authenticity, and continuity of care, and (2) a positive environment or "eco-system of care" characterized by supportive interactions with staff and other Veterans, and exemplary customer service as integral to their decisions about where to receive care. These preferences influenced their engagement with VA and non-VA providers. We discovered corresponding findings related to Veterans' information needs. When making decisions around where to receive care, participants said they would like more information about VA and non-VA providers and services, and about coordination of care and referrals, including understanding processes and implications of utilizing VA-purchased care. Discussion/Conclusion: Current VA-purchased care eligibility determinations focus on common access metrics (e.g., wait times, distance to care). Yet, Veterans discussed other important factors for navigating care decisions, including patient-provider relationship quality and the larger healthcare environment (e.g., interactions with staff and other Veterans). Our findings point to the need for health systems to collect and provide information on these aspects of care to ensure care decisions reflect what is important to Veterans when navigating where to receive care. [ABSTRACT FROM AUTHOR]

Background: There are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing. Objective: Investigate associations between LEP and access to care in adults. Design: Cross-sectional nationally representative survey. Participants: Adults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014–2018 Medical Expenditure Panel Survey Main Measures: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18–64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening. Key Results: Adults aged 18–64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27–2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89–2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79–2.23), cholesterol check (aOR = 1.22; CI = 1.03–1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37–1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years. Conclusions: Adults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care. [ABSTRACT FROM AUTHOR]

Background: Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations. Objective: To compare young people's perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity. Design: Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used. Participants: 1,414 individuals assigned female at birth aged 18–28. Main Measures: Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception. Key Results: Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62–2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13–2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic. Conclusions: Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care. Trial Registration: ClinicalTrials.gov Identifier: NCT03519685 [ABSTRACT FROM AUTHOR]

Background: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.Objectives: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.Design: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.Participants: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.Main Measures: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.Results: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.Conclusion: Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability.To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability.We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65.Our analysis included 19,876 individuals (aged 59–71) without functional disability and 8376 individuals with functional disability from the 2014–2021 Medical Expenditure Panel Survey.We assessed health insurance coverage, financial burden of care, and access to care.Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by − 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (− $578 vs. − $344 for out-of-pocket spending, − 3.7 vs. − 4.9 percentage points for cost-sharing, and − 2.5 vs. − 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (− 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care).Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability. [ABSTRACT FROM AUTHOR]

Background: The number of Californians covered by Medi-Cal increased more than 50% between 2013 and 2018, largely due to expansion under the Affordable Care Act (ACA). This rapid expansion of Medicaid rolls prompted concerns that Medi-Cal enrollees would face greater difficulty accessing health care. Objective: Examine whether gaps in access to care between Medi-Cal and employer-sponsored insurance (ESI) present in 2013 (prior to ACA implementation) had changed by 2018 (several years post implementation). Design: Secondary analysis of data from the 2013 and 2018 California Health Interview Survey. The sample included adults of ages 18–64 insured all year and covered by ESI or Medi-Cal at time of interview. Logistic regressions were used to examine variation across years in the association between access to care and insurance type. Main Measures: Five access to care outcomes were assessed: no usual source of care, not accepted as new patient in past year, insurance not accepted in past year, delayed medical care in past year, and difficulty getting timely appointment. The main predictors of interest were type of insurance (Medi-Cal or ESI) and survey year (2013 or 2018). Key Results: The association between insurance type and access to care changed significantly over time for three outcomes: not accepted as new patient in past year (OR = 0.55, 95% CI = 0.32–0.97), delayed medical care in past year (OR = 1.55, 95% CI = 1.06–2.25), and difficulty getting timely appointment (OR = 0.41, 95% CI = 0.23–0.74). Predicted probabilities indicate gaps between Medi-Cal and ESI narrowed for not accepted as new patient in past year and difficulty getting timely appointment, but widened for delayed medical care. Conclusions: Despite the rapid expansion in the number of Californians covered by Medi-Cal, most gaps in access to care between Medi-Cal and ESI enrollees improved or did not significantly change between 2013 and 2018. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care.Objective: Compare gynecologist supply in veterans' county of residence versus at their VA site.Design: We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences.Participants: All women veteran FY2017 VA primary care users nationally.Main Measures: Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists.Key Results: Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist.Conclusions: Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity. [ABSTRACT FROM AUTHOR]

Background: There are concerns about the capacity of rural primary care due to potential workforce shortages and patients with disproportionately more clinical and socioeconomic risks. Little research examines the configuration and delivery of primary care along the spectrum of rurality. Objective: Compare structure, capabilities, and payment reform participation of isolated, small town, micropolitan, and metropolitan physician practices, and the characteristics and utilization of their Medicare beneficiaries. Design: Observational study of practices defined using IQVIA OneKey, 2017 Medicare claims, and, for a subset, the National Survey of Healthcare Organizations and Systems (response rate=47%). Participants: A total of 27,716,967 beneficiaries with qualifying visits who were assigned to practices. Main Measures: We characterized practices' structure, capabilities, and payment reform participation and measured beneficiary utilization by rurality. Key Results: Rural practices were smaller, more primary care dominant, and system-owned, and had more beneficiaries per practice. Beneficiaries in rural practices were more likely to be from high-poverty areas and disabled. There were few differences in patterns of outpatient utilization and practices' care delivery capabilities. Isolated and micropolitan practices reported less engagement in quality-focused payment programs than metropolitan practices. Beneficiaries cared for in more rural settings received fewer recommended mammograms and had higher overall and condition-specific readmissions. Fewer beneficiaries with diabetes in rural practices had an eye exam. Most isolated rural beneficiaries traveled to more urban communities for care. Conclusions: While most isolated Medicare beneficiaries traveled to more urban practices for outpatient care, those receiving care in rural practices had similar outpatient and inpatient utilization to urban counterparts except for readmissions and quality metrics that rely on services outside of primary care. Rural practices reported similar care capabilities to urban practices, suggesting that despite differences in workforce and demographics, rural patterns of primary care delivery are comparable to urban. [ABSTRACT FROM AUTHOR]

Background: We previously found that a 6-month multidimensional diabetes program, TIME (Telehealth-Supported, Integrated Community Health Workers, Medication-Access) resulted in improved clinical outcomes. Objective: To follow TIME participant clinical outcomes for 24 months Participants: Low-income Latino(a)s with type 2 diabetes Design and Intervention: We collected post-intervention clinical data for five cohorts (n = 101, mean n = 20/cohort) who participated in TIME programs from 2018 to 2020 in Houston, Texas. Main Measures: We gathered HbA1c (primary outcome), weight, body mass index (BMI), and blood pressure data at baseline, 6 months (intervention end), and semiannually thereafter until 24 months after baseline to assess sustainability. We also evaluated participant loss to follow-up until 24 months. Key Results: Participants decreased HbA1c levels during the intervention (p < 0.0001) and maintained these improvements at each timepoint from baseline to 24 months (p range: < 0.0001 to 0.015). Participants reduced blood pressure levels during TIME and maintained these changes at each timepoint from baseline until 18 months (systolic p range < 0.0001 to 0.0005, diastolic p range: < 0.0001 to 0.008) but not at 24 months (systolic: p = 0.065; diastolic: p = 0.85). There were no significant weight changes during TIME or post-intervention: weight (p range = 0.07 to 0.77), BMI (p range = 0.11 to 0.71). Attrition rates (loss to follow-up during the post-intervention period) were 5.9% (6 months), 24.8% (12 months), 35.6% (18 months), and 41.8% (24 months). Conclusions: It is possible for vulnerable populations to maintain long-term glycemic and blood pressure improvements using a multiple dimensional intervention. Attrition rates rose over time but show promise given the majority of post-intervention timepoints occurred during the COVID-19 pandemic when low-income populations were most susceptible to suboptimal healthcare access. Future studies are needed to evaluate longitudinal outcomes of diabetes interventions conducted by local clinics rather than research teams. [ABSTRACT FROM AUTHOR]

Importance: Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood.To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood.Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System.Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs).After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95% confidence interval (CI): 1.11–1.28), any access to care problems (AOR: 1.26, 95% CI: 1.12–1.42), and any functional limitations (AOR: 1.18, 95% CI: 1.10–1.28); adults aged ≥ 65 with FMI reported higher likelihood of reporting any smoking or unhealthy drinking behaviors (AOR: 1.23, 95% CI: 1.05–1.43) and impaired functional status (AOR: 1.30, 95% CI: 1.10–1.54). Associations were attenuated after additional adjustment for socioeconomic measures, especially educational attainment, but remained statically significant for multiple outcomes.FMI during childhood was associated with adverse health-related outcomes for adults of all ages. Developing programs to improve access to education and economic opportunities for adults with FMI may help mitigate the disparities.Objective: Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood.To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood.Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System.Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs).After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95% confidence interval (CI): 1.11–1.28), any access to care problems (AOR: 1.26, 95% CI: 1.12–1.42), and any functional limitations (AOR: 1.18, 95% CI: 1.10–1.28); adults aged ≥ 65 with FMI reported higher likelihood of reporting any smoking or unhealthy drinking behaviors (AOR: 1.23, 95% CI: 1.05–1.43) and impaired functional status (AOR: 1.30, 95% CI: 1.10–1.54). Associations were attenuated after additional adjustment for socioeconomic measures, especially educational attainment, but remained statically significant for multiple outcomes.FMI during childhood was associated with adverse health-related outcomes for adults of all ages. Developing programs to improve access to education and economic opportunities for adults with FMI may help mitigate the disparities.Design and Participants: Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood.To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood.Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System.Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs).After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95% confidence interval (CI): 1.11–1.28), any access to care problems (AOR: 1.26, 95% CI: 1.12–1.42), and any functional limitations (AOR: 1.18, 95% CI: 1.10–1.28); adults aged ≥ 65 with FMI reported higher likelihood of reporting any smoking or unhealthy drinking behaviors (AOR: 1.23, 95% CI: 1.05–1.43) and impaired functional status (AOR: 1.30, 95% CI: 1.10–1.54). Associations were attenuated after additional adjustment for socioeconomic measures, especially educational attainment, but remained statically significant for multiple outcomes.FMI during childhood was associated with adverse health-related outcomes for adults of all ages. Developing programs to improve access to education and economic opportunities for adults with FMI may help mitigate the disparities.Main Measures: Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood.To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood.Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System.Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs).After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95% confidence interval (CI): 1.11–1.28), any access to care problems (AOR: 1.26, 95% CI: 1.12–1.42), and any functional limitations (AOR: 1.18, 95% CI: 1.10–1.28); adults aged ≥ 65 with FMI reported higher likelihood of reporting any smoking or unhealthy drinking behaviors (AOR: 1.23, 95% CI: 1.05–1.43) and impaired functional status (AOR: 1.30, 95% CI: 1.10–1.54). Associations were attenuated after additional adjustment for socioeconomic measures, especially educational attainment, but remained statically significant for multiple outcomes.FMI during childhood was associated with adverse health-related outcomes for adults of all ages. Developing programs to improve access to education and economic opportunities for adults with FMI may help mitigate the disparities.Key Results: Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood.To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood.Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System.Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs).After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95% confidence interval (CI): 1.11–1.28), any access to care problems (AOR: 1.26, 95% CI: 1.12–1.42), and any functional limitations (AOR: 1.18, 95% CI: 1.10–1.28); adults aged ≥ 65 with FMI reported higher likelihood of reporting any smoking or unhealthy drinking behaviors (AOR: 1.23, 95% CI: 1.05–1.43) and impaired functional status (AOR: 1.30, 95% CI: 1.10–1.54). Associations were attenuated after additional adjustment for socioeconomic measures, especially educational attainment, but remained statically significant for multiple outcomes.FMI during childhood was associated with adverse health-related outcomes for adults of all ages. Developing programs to improve access to education and economic opportunities for adults with FMI may help mitigate the disparities.Conclusions: Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood.To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood.Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System.Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs).After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95% confidence interval (CI): 1.11–1.28), any access to care problems (AOR: 1.26, 95% CI: 1.12–1.42), and any functional limitations (AOR: 1.18, 95% CI: 1.10–1.28); adults aged ≥ 65 with FMI reported higher likelihood of reporting any smoking or unhealthy drinking behaviors (AOR: 1.23, 95% CI: 1.05–1.43) and impaired functional status (AOR: 1.30, 95% CI: 1.10–1.54). Associations were attenuated after additional adjustment for socioeconomic measures, especially educational attainment, but remained statically significant for multiple outcomes.FMI during childhood was associated with adverse health-related outcomes for adults of all ages. Developing programs to improve access to education and economic opportunities for adults with FMI may help mitigate the disparities. [ABSTRACT FROM AUTHOR]

Discussion Similar to the geographic inaccessibility of clinical trials for other diseases,[4] the opportunity to enroll in biomedical therapeutic trials throughout the first 8 months of the COVID-19 pandemic was not equitably available across the US. Clinical trials, Rural health, Coronavirus disease 2019 (COVID-19), Health disparities, Access to care Keywords: Coronavirus disease 2019 (COVID-19); Clinical trials; Rural health; Health disparities; Access to care EN Coronavirus disease 2019 (COVID-19) Clinical trials Rural health Health disparities Access to care 3650 3653 4 11/23/21 20211101 NES 211101 Prior Presentations An abstract version of this study was presented as a poster at the AcademyHealth Annual Research Meeting (June 14-17, 2021) and received the Best Student Poster Award. [Extracted from the article]

Background: Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices.Objective: To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients.Design: We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018.Participants: A total of 2190 medical practices with at least three adult primary care physicians.Main Measures: Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not.Key Results: FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001).Conclusion: FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities. [ABSTRACT FROM AUTHOR]

Background: Stable, affordable housing is an established determinant of health. As affordable housing shortages across the USA threaten to displace people from their homes, it is important to understand the implications of cost-related residential moves for healthcare access.Objective: To examine the relationship between cost-related moves and unmet medical needs.Design: We performed a cross-sectional analysis of 7 waves (2011-2017) of the California Health Interview Survey.Participants: We included all respondents ages 18 and older.Main Measures: The primary predictor variable was residential move history in the past 5 years (cost-related move, non-cost-related move, or no move). The primary outcome was unmet medical needs in the past year (necessary medications and/or medical care that were delayed or not received).Key Results: Our sample included 146,417 adults (42-47% response rate), representing a weighted population of 28,518,590. Overall, 20.3% of the sample reported unmet medical needs in the past year, and 4.9% reported a cost-related move in the past 5 years. In multivariable logistic regression models, adjusted risk of unmet medical needs increased for adults with both cost-related moves (aOR 1.38; 95% CI 1.19-1.59) and non-cost-related moves (aOR 1.17; 95% CI 1.09-1.26) compared to those with no moves. Among people who had moved, those with cost-related moves were more likely to report unmet medical needs compared to people with non-cost-related moves (p = 0.03).Conclusions: People who have moved due to unaffordable housing represent a population at increased risk for unmet medical needs. Policy makers seeking to improve population health should consider strategies to limit cost-related moves and to mitigate their adverse effects on healthcare access. [ABSTRACT FROM AUTHOR]

Background: No-shows are a persistent and costly problem in all healthcare systems. Because forgetting is a common cause of no-shows, appointment reminders are widely used. However, qualitative research examining appointment reminders and how to improve them is lacking. Objective: To understand how patients experience appointment reminders as part of intervention development for a pragmatic trial of enhanced appointment reminders. Design: Qualitative content analysis Participants: Twenty-seven patients at a single Department of Veterans Affairs hospital and its satellite clinics Approach: We conducted five waves of interviews using rapid qualitative analysis, in each wave continuing to ask veterans about their experience of reminders. We double-coded all interviews, used deductive and inductive content analysis to identify themes, and selected quotations that exemplified three themes (limitations, strategies, recommendations). Key Results: Interviews showed four limitations on the usability of current appointment reminders which may contribute to no-shows: (1) excessive information within reminders; (2) frustrating telephone systems when calling in response to an appointment reminder; (3) missing or cryptic information about clinic logistics; and (4) reminder fatigue. Patients who were successful at keeping appointments often used specific strategies to optimize the usability of reminders, including (1) using a calendar; (2) heightening visibility; (3) piggybacking; and (4) combining strategies. Our recommendations to enhance reminders are as follows: (1) mix up their content and format; (2) keep them short and simple; (3) add a personal touch; (4) include specifics on clinic location and contact information; (5) time reminders based on the mode of delivery; and (6) hand over control of reminders to patients. Conclusions: Appointment reminders are vital to prevent no-shows, but their usability is not optimized for patients. There is potential for healthcare systems to modify several aspects of the content, timing, and delivery of appointment reminders to be more effective and patient-centered. [ABSTRACT FROM AUTHOR]

Background: eConsult programs have been instituted to increase access to specialty expertise. Opt-in choice eConsult programs maintain primary care physician (PCP) autonomy to decide whether to utilize eConsults versus traditional specialty referrals, but little is known about how this intervention may impact PCP eConsult adoption and traditional referral demand. Objective: We assessed the feasibility of implementing an opt-in choice eConsult program and examined whether this intervention reduces demand for in-person visits for primary care patients requiring specialty expertise. Design: Stepped-wedge, cluster randomized trial conducted from July 2018 to June 2019. Participants: Sixteen primary care practices in a large, urban academic health care system. Intervention: Our intervention was an opt-in choice eConsult available in addition to traditional specialty referral; our implementation strategy included in-person training, audit and feedback, and incentive payments. Main measures: Our implementation outcome measure was the eConsult rate: weekly proportion of eConsults per PCP visit at each site. Our intervention outcome measure was traditional referral rate: weekly proportion of referrals per PCP visit at each site. We also assessed PCP experiences with questionnaires. Key results: Of 305,915 in-person PCP visits, there were 31,510 traditional referrals to specialties participating in the eConsult program, and 679 eConsults. All but one primary care site utilized the opt-in choice eConsult program, with a weekly rate of 0.05 eConsults per 100 PCP visits by the end of the study period. The weekly rate of traditional referrals was 11 per 100 PCP visits at the end of the study period; this represents a significant increase in traditional referral rate after implementation of eConsults. PCPs were generally satisfied with the eConsult program and valued prompt provider-to-provider communication. Conclusions: Implementation of an opt-in choice eConsult program resulted in widespread PCP adoption; however, this did not decrease the demand for traditional referrals. Future studies should evaluate different strategies to incentivize and increase eConsult utilization while maintaining PCP choice. [ABSTRACT FROM AUTHOR]

As the COVID-19 pandemic continues to unfold, payers across the USA have stepped up to alleviate patients' financial burden by waiving cost-sharing for COVID-19 testing and treatment. However, there has been no substantive discussion of potential long-term effects of COVID-19 on patient health or their financial and policy implications. After recovery, patients remain at risk for lung disease, heart disease, frailty, and mental health disorders. There may also be long-term sequelae of adverse events that develop in the course of COVID-19 and its treatment. These complications are likely to place additional medical, psychological, and economic burdens on all patients, with lower-income individuals, the uninsured and underinsured, and individuals experiencing homelessness being most vulnerable. Thus, there needs to be a comprehensive plan for preventing and managing post-COVID-19 complications to quell their clinical, economic, and public health consequences and to support patients experiencing delayed morbidity and disability as a result. [ABSTRACT FROM AUTHOR]

Background: Health care operations managers need to balance scheduling frequent follow-ups for patients with chronic conditions and fitting in patients requiring care for new complaints.Objective: We quantify how frequency of follow-up visits corresponds with access to care for patients receiving care from the Department of Veterans Affairs (VA).Design: We use patient data collected between October 2013 and June 2016 by the Survey of Healthcare Experiences of Patients (SHEP). Our sample is comprised of 94,496 patients. We estimate logistic models with 1-month lagged facility-level predictors.Main Measures: We calculate monthly measures characterizing facility-level service provision, including the average time between successive primary care visits, the average primary care visit length, the percentage of primary care appointments that are overbooked, the percent of visits that are unscheduled (i.e., walk-ins), and the ratio of patients to providers. We control for economic factors that are associated with health care supply and demand, including median household income, veteran priority status, the Zillow Housing Price Index, and veteran unemployment rates. We also control for patient demographics.Patients: We restrict the data to patients with at least one in-person primary care visit who have provided information on their ability to access urgent and routine care.Key Results: We find that shorter average follow-up times are associated with better access for patients needing urgent or routine care. A 1-month increase in the average time between successive primary care visits is associated with 10% (p < 0.001) lower odds of reporting being able to access urgent care within 1 day and 13% (p < 0.001) lower odds of reporting usually or always being able to access routine care when needed.Conclusion: Facilities with higher average follow-up times are more likely to have patients report that they are unable to quickly access urgent or routine primary care. [ABSTRACT FROM AUTHOR]

Background: Insurance-based denials are common barriers for transgender and non-binary individuals in accessing medically necessary gender-affirming care. Little is known about how experiences of transgender-related insurance denials may vary by insurance type.Objective: This study investigates the association between transgender and non-binary individuals' experiences of different forms of transgender-related insurance denials and insurance type.Design and Participants: The 2015 United States Transgender Survey was conducted by the National Center for Transgender Equality to ascertain US transgender and non-binary experiences across multiple life experiences, including individual health status, health services access and utilization, and experiences with denials.Main Measures: Multivariate logistic regressions were conducted, and adjusted risk ratios were calculated, to analyze the likelihood of experiencing eight different forms of denials by insurance type, including private, Medicare, Medicaid, and military-related, and having multiple types of insurance coverage.Key Results: Models revealed significant relationships between transgender-related insurance denials and insurance type for 11,320 transgender and non-binary adults. Compared with those with private insurance, Medicaid coverage was associated with an increased likelihood of experiencing denials for hormone therapy (adjusted risk ratio (ARR) = 1.22; CI = 1.05-1.42; p = 0.02); having no in-network surgery providers was associated with Medicare (ARR = 1.84; CI = 1.29-2.62; p = 0.009) or Medicaid (ARR = 1.54; CI = 1.20-1.98; p = 0.003); and military-based insurance was associated with transition-related surgery denials (ARR = 1.53; CI = 1.36-1.72; p < 0.001).Conclusions: Researchers and practitioners must consider the link between type of insurance coverage and experiences with different forms of transgender-related insurance denial. These results provide continuing support for broad non-discrimination policy efforts, but also direct our attention to targeted insurance policy interventions by form of denial, which can promote equitable access for transgender and non-binary people across all healthcare needs. [ABSTRACT FROM AUTHOR]

Background: In the USA, people with limited English proficiency (LEP) disproportionately experience gaps in health insurance coverage and access to care. The Patient Protection and Affordable Care Act (ACA) of 2010 included reforms that could improve these outcomes.Objective: To describe changes in insurance coverage and access to health care by English language proficiency over 2006-2016.Design: We used regression models to estimate changes in coverage and access after 2010 for adults with high vs. limited English proficiency, adjusting for socio-economic status, demographic characteristics, and health care needs. We used difference-in-differences models to assess adjusted changes in disparities by English proficiency after 2010. Supplemental analyses used nearest-neighbor propensity score matching to balance the characteristics of respondents.Participants: Respondents aged 18-64 in the Medical Expenditure Panel Survey over 2006-2016, with high (n = 174,214) or limited (n = 16,484) English language proficiency.Main Measures: Insurance coverage was a binary variable indicating any health insurance coverage during the past 12 months. Access to care was measured using binary variables indicating whether the respondent had a usual source of care and received necessary medical, dental, and preventive care.Key Results: Gains in health insurance coverage after 2010 were significant for adults with high English proficiency (1.7 percentage points, p < 0.001) and adults with limited English proficiency (4.6 percentage points, p = 0.007); gains did not significantly vary by English proficiency. Adults with LEP showed larger improvements than adults with high English proficiency in having a usual source of care (5 percentage points, p = 0.007) and receiving needed medical care and dental care (1.4 percentage points, p = 0.013, and 2.8 percentage points, p = 0.009, respectively). Findings remained similar when matching was used to balance the measured characteristics of respondents with high vs. limited English proficiency.Conclusions: Disparities in health care access by English proficiency narrowed after 2010, the year of passage of the ACA. [ABSTRACT FROM AUTHOR]

Background: There have been no large-scale studies to date of patients' experiences with electronic consultation (eConsult) between primary and specialty care.Objective: Compare experiences with eConsult and referral for in-person specialist consultation.Design: Online survey 2-6 weeks following eConsult or referral at 9 US academic medical centers.Participants: Adult patients with no more than one eConsult or referral order from a primary care provider (PCP) in the prior month. Over 9 months, 29,291 email invitations were sent (88% referral; 12% eConsult).Main Measures: Trust in and satisfaction with PCP; consult type awareness; agreement with decision to seek specialist input; timeliness of care; mode of PCP-patient eConsult communication; satisfaction with specialist's recommendations; future preference for eConsult or referral.Key Results: A 27.6% response rate yielded 8087 respondents (88.4% referral; 11.6% eConsult). Many did not know that their PCP had placed a referral (32.8% unaware) or eConsult (52.9%), and eConsult awareness was significantly higher among patients reporting better health (OR 1.62, 95% CI 1.18-2.23). Most (81.4% eConsult; 82.0% referral) were satisfied with the specialist's recommendations. Those who had a good primary care experience were more likely to be satisfied (eConsult: OR 10.63, 95% CI 2.95-38.32; referral: OR 2.87, 95% CI 1.86-4.44). For a similar problem in the future, 78% of eConsult and 32% percent of referral patients preferred eConsult.Conclusions: This multisite study demonstrates that many patients find virtual consultation to be an acceptable strategy for the management of their medical condition and that trust and confidence in one's PCP are crucial ingredients for a satisfying eConsult experience. The lack of awareness of eConsult among many patients who were beneficiaries of the service warrants an increased effort to include patients in eConsult decision-making and communication. Further research is needed to assess eConsult acceptability and satisfaction in more diverse patient populations. [ABSTRACT FROM AUTHOR]

Background: Evidence is limited and mixed as to how the Patient Protection and Affordable Care Act (ACA) Medicaid expansions affected the utilization of primary care physicians (PCPs) and emergency departments (EDs) at the national level.Objective: To examine the association between the ACA Medicaid expansions and changes in the utilization of PCP and ED visits at the national level during the first 3 years (2014-2016) of the implementation.Design: A difference-in-differences analysis to compare outcomes between individuals in 32 states that expanded Medicaid versus individuals in 19 non-expansion states.Participants: A nationally representative sample of US-born individuals 26-64 years old with family incomes lower than 138% of the federal poverty level from the 2010-2016 Medical Expenditure Panel Survey.Intervention: ACA Medicaid expansions MAIN MEASURES: We examined PCP-related outcomes ((i) whether a participant had any PCP visit during a year and (ii) the annual number of PCP visits per person) and ED-related outcomes ((i) whether a participant had any ED visit during a year and (ii) the annual number of ED visits per person).Key Results: A total of 17,803 participants were included in our analysis. We found that the proportion of individuals with any PCP visit during a year marginally increased (difference-in-differences estimate, + 3.6 percentage points [pp]; 95% CI, - 0.4 pp to + 7.6 pp; P = 0.08) following the Medicaid expansions, without any change in the annual number of PCP visits per person. We found no evidence that ED utilization (both the proportion of individuals with any ED visit during a year and the annual number of ED visits per person) changed meaningfully after the Medicaid expansions.Conclusion: Using the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in access to PCPs without an increase in ED use. [ABSTRACT FROM AUTHOR]

Objective: To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon.Design: Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology).Participants: 420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015.Outcome: Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions.Results: Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers.Conclusions: This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations. [ABSTRACT FROM AUTHOR]

Background: Though Asian Americans made gains in coverage following the Affordable Care Act (ACA), substantial variations in access to care remain across different ethnic subgroups. Several states are considering adoption of policies to collect health data for Asian Americans that is disaggregated by ethnic subgroup, which may identify disparities in access to care.Objective: We examined coverage and access to care between non-Hispanic White and Asian American adults following the ACA in California. We first compared outcomes in non-Hispanic White adults with all Asian Americans in our sample, and then evaluated whether we detect disparities when data is disaggregated into five of the most populous ethnic subgroups (Chinese, Korean, Filipino, Vietnamese, and Japanese).Design: Cross-sectional California Health Interview Survey data were collected between January 2014 and December 2016.Participants: Our sample included 19,201 non-Hispanic White and 3077 Asian American non-elderly adults age 18 to 64 living in California.Main Measures: Our outcomes were (1) being uninsured, (2) having a usual source of care, (3) delaying necessary medical care, and (4) delaying necessary prescription medications. Using multivariable logistic regression models, we examined our outcomes, adjusting for predisposing, enabling, need, and acculturation factors.Key Results: Compared with non-Hispanic Whites, some subgroups of Asian Americans reported significantly worse access to care: disaggregated, adjusted analyses revealed that Koreans were significantly less likely to report a usual source of care (adjusted odds ratio [AOR] = 0.31, p < 0.01) relative to non-Hispanic Whites. Chinese (AOR = 0.42, p < 0.01) and Vietnamese (AOR = 0.34, p < 0.01) adults were significantly less likely to delay necessary care.Conclusions: Disaggregated analyses identified differences in access to care for Asian American subgroups following the ACA. State policies to collect disaggregated health data for Asian Americans may reveal heterogeneity in experiences of care and inform specific policies to reduce disparities in access to care. [ABSTRACT FROM AUTHOR]

Background: Concerns exist about availability and access to psychiatric services in the USA. For Medicare beneficiaries, one impediment to psychiatric services is the extent to which psychiatrists have opted out of the Medicare program.Objective: This study describes geographic variation in rates that psychiatrists opt out of Medicare, and assesses physician-level and geographic-level predictors of opt-out.Design: Retrospective cross-sectional analysis of data describing psychiatrists' opt-out status as of March 2017 linked to data on psychiatrist location, psychiatrist characteristics (obtained from a comprehensive US physician database), and market area-level characteristics.Participants: 27,838 psychiatrists in the USA MAIN MEASURES: Whether a psychiatrist had opted out of Medicare as of March 2017.Key Results: Overall, 7.0% of psychiatrists (1940/27,838) opted out of Medicare as of March 2017. Opt-out rates varied substantially across states and within states. Physician-level factors independently associated with opt-out included: older age (psychiatrists > 65 years were 2.6 percentage points more likely to opt vs. psychiatrists < 35 years old, p = 0.03), greater years of experience, female gender (female psychiatrists were 2.6 percentage points more likely to opt out than male psychiatrists, p < 0.001), graduation from a top-20 ranked medical school (1.7 percentage points more likely to opt out of Medicare, p < 0.001), and domestic medical graduate (domestic graduates were 7.3 percentage points more likely to opt out of Medicare vs. foreign graduates, p < 0.001). Adjusting for other individual- and geographic-level factors, psychiatrists who practiced in areas with more psychiatrists per Medicare beneficiary were less likely to opt out (p < 0.001).Conclusions: The overall likelihood that psychiatrists opt out of Medicare is significant and varies considerably across regions and by characteristics of psychiatrists. [ABSTRACT FROM AUTHOR]

Background: To enhance the acute care delivery system, a comprehensive understanding of the patient's perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary.Methods: We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses.Results: Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: "it's urgent because it hurts," and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: "my doctor said he was booked up and he instructed me to go to the ED." The third domain was related to multiple advantages associated with ED care: "my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support." In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers.Conclusions: In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED. [ABSTRACT FROM AUTHOR]

Background: To address concerns about Veterans' access to care at US Department of Veterans Affairs (VA) healthcare facilities, the Veterans Access, Choice, and Accountability Act was enacted to facilitate Veterans' access to care in non-VA settings, resulting in the "Veterans Choice Program" (VCP).Objectives: To assess the characteristics of Veterans who used or planned to use the VCP, reasons for using or planning to use the VCP, and experiences with the VCP.Design: Mixed-methods.Subjects: After sampling Veterans in the Midwest census region receiving care at VA healthcare facilities, we included 4521 Veterans in the analyses. Of these, 60 Veterans participated in semi-structured qualitative interviews.Approach: Quantitative data were derived from VA's administrative and clinical data and a survey of Veterans including Veteran characteristics and self-reported use of VCP. Associations between Veterans' characteristics and use or planned use of the VCP were assessed using logistic regression analysis. Interview data were analyzed using thematic analysis.Key Results: Veterans with a higher odds of reporting use or intended use of the VCP were women, lived further distances from VA facilities, or had worse health status than other Veterans (P ≤ 0.01). Key themes included positive experiences with the VCP (timeliness of care, location of care, access to services, scheduling improvements, and coverage of services), and negative experiences with the VCP (complicated scheduling processes, inconveniently located appointments, delays securing appointments, billing confusion, and communication breakdowns).Discussion: Our findings suggest that Veterans value access to care close to their home and care that addresses the needs of women and Veterans with poor health status. The Mission Act was passed in June 2018 to restructure the VCP and consolidate community care into a single program, continuing VA's commitment to support access to community care into the future. [ABSTRACT FROM AUTHOR]

Background: Changing Medicaid fees is a common approach for states to address budget fluctuations, and many currently set Medicaid physician fees at levels lower than Medicare and private insurers. The Affordable Care Act included a temporary Medicaid fee bump for primary care providers (PCPs) in 2013-2014 that recently led to both an increase and then subsequent decrease in PCP fees in many states.Objective: To conduct a systematic literature review on the effects of changing Medicaid fees on provider participation and enrollees' access to care and service use.Methods: We searched PubMed/Medline and JSTOR and identified 18 studies that assessed the longitudinal impact of provider fee changes in Medicaid on the outcomes of interest. We summarized information on study design, methods, and findings.Results: Seven studies examined the impact of fee changes on provider participation in Medicaid. Of these, three studies found that fee increases were associated with positive effects on providers' likelihood of accepting Medicaid patients or on their Medicaid caseloads. Five studies that examined the impact of fee changes on Medicaid enrollees' access to care found a positive association with one or more access measure, such as having a usual source of care or appointment availability. Lastly, eight of 14 studies that examined service use found positive associations between fee changes and at least one measure of use, such as changes in the probability of enrollees having any visit, the number of visits, and shifts in the site of care toward office-based care; others largely did not find significant associations.Conclusions: There is mixed evidence on the impact of changing Medicaid fees on provider participation and enrollees' service use; however, increasing fees appears to have more consistent positive effects on access to care. Whether these improvements in access translate into better health outcomes or downstream cost savings are critical questions. [ABSTRACT FROM AUTHOR]

Primary care is the foundation of the health care system and the basis for new payment and delivery reforms in the USA. Yet since 2008, primary care visit rates dropped by 6-25% across a range of populations in five sources of national survey and administrative data. We hypothesize three likely mechanisms behind the decline: decreases in patients' ability, need, or desire to seek primary care; changes in primary care practice such as greater use of teams and non-face-to-face care; and replacement of in-person primary care visits with alternatives such as specialist, retail clinic, and commercial telemedicine visits. These mechanisms require further investigation. In the meantime, the trend prompts us to optimize the primary care visit and embrace the growth of alternatives while preserving the fundamental benefits of primary care. [ABSTRACT FROM AUTHOR]

Background: Discontinuous Medicaid insurance erodes access to care, increases administrative costs, and exposes enrollees to substantial out-of-pocket spending.Objective: To assess the impact of Medicaid expansion under the Affordable Care Act on continuity of Medicaid coverage among those enrolled prior to expansion.Design: Using a difference-in-differences framework, we compared Colorado, a state that expanded Medicaid, to Utah, a nonexpansion state, before and after Medicaid expansion implementation.Participants: Adults ages 18-62 who were enrolled in Medicaid coverage in Colorado and Utah prior to expansion, from the Utah and Colorado All Payer Claims Databases, 2013-2015.Main Measures: The primary outcomes were the duration of Medicaid enrollment and rates of disrupted coverage.Key Results: Following Medicaid expansion, enrollees in Colorado gained an additional 2 months of coverage over two years of follow-up and were 16 percentage points less likely to experience a coverage disruption in a given year relative to enrollees in Utah.Conclusions: Increasing Medicaid eligibility levels under the Affordable Care Act appears to be an effective strategy to reduce churning in the Medicaid program, with important implications for other states that are considering Medicaid expansion. [ABSTRACT FROM AUTHOR]

In January 2018, the Center for Medicare and Medicaid Services (CMS) released guidance that encouraged states to submit Section 1115 waivers that impose work requirements on some Medicaid beneficiaries. To evaluate the potential impact of a policy, we need to accurately predict both how far a policy will spread and how durable it will prove over time. This commentary draws upon recent political science scholarship to describe potential constraints that changes in state-level partisan control can impose on CMS's current waiver strategy, as well as how state-level constraints might interact with judicial review to further limit the policy's spread. [ABSTRACT FROM AUTHOR]

Background: The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.Objective: To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).Design: Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects.Participants: A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.Main Measures: Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.Key Results: Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.Conclusions: Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services. [ABSTRACT FROM AUTHOR]

Background: High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.Objective: To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.Design and Participants: We identified adults aged 18-64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015-2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18-64 years and ≥ 65 years.Main Measures: Prevalence of material, psychological, and behavioral hardship and hardship intensity.Key Results: Approximately 137.1 million (95% CI 132.7-141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18-64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).Conclusions: Medical financial hardship is common in the USA, especially in adults aged 18-64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future. [ABSTRACT FROM AUTHOR]

Background: Persons with speech, language, and/or voice disabilities (collectively referred to as communication disabilities (CD)) represent 10% of the US population, yet their healthcare outcomes have not been described. Generally, research shows that persons with disabilities have poorer health and healthcare outcomes than their non-disabled peers.Objectives: To examine the health and healthcare outcomes of persons with CD compared to persons without CD.Design: Retrospective cohort study of the 2012 National Health Interview Survey, which contained the first supplemental questions on CD. We compared proportional differences in outcomes; logistic and ordered logistic regression assessed the outcome measures across CD categories, controlling for demographics, non-communication disabilities, and chronic conditions. Findings are weighted to permit national inferences.Participants: Adults (≥ 18 years old) were divided into 4 mutually exclusive groups: people with voice disabilities only; speech/language disabilities only; speech/language and voice disabilities; and people without CD.Main Measures: Chronic health conditions; self-rated health; access to care; unmet needs for care; healthcare utilization.Key Results: Adults with CD more frequently had ≥ 1 chronic condition (voice 67.9%, speech/language 68.6%, speech/language and voice 79.9%, no CD 50.1%, p < 0.001) and reported fair/poor health (voice 19.5%, speech/language 32.5%, speech/language and voice 48.3%, no CD 11.2%, p < 0.001) compared to those without CD. Adults with CD more frequently utilized healthcare compared to those without CD. However, persons with CD endorsed greater difficulties accessing care than those without CD, including identifying a usual source of care, trouble finding a physician, and delaying or foregoing care (e.g., delayed due to availability of care: voice 26.1%, speech/language 37.2%, speech/language and voice 30.8% no CD 16.1%, p < 0.001).Conclusions: Persons with CD are medically complex and experience greater challenges accessing healthcare than persons without CD. Healthcare providers need support and tools to provide equitable care that addresses the medical needs of persons with CD. [ABSTRACT FROM AUTHOR]

Coverage, Affordability, and Care for Low-Income People with Diabetes: 4 Years after the Affordable Care Act's Medicaid Expansions Keywords: diabetes; Medicaid expansions; access to care; disparities EN diabetes Medicaid expansions access to care disparities 2222 2224 3 07/13/20 20200701 NES 200701 INTRODUCTION Diabetes is one of the most common and expensive diseases in the USA. Although the positive impact of the Affordable Care Act (ACA)'s Medicaid expansions on insurance coverage, access, and health have been extensively studied in the general population,[1], [2] the extent to which the ACA Medicaid expansions affect people with diabetes is unclear. [Extracted from the article]

Background: Medically underserved or low socioeconomic status (SES) patients face significant vulnerability and a high risk of adverse events following hospital discharge. The environmental, social, and economic factors, otherwise known as social determinants, that compound this risk have been ineffectually described in this population. As the underserved comprise 30% of patients discharged from the hospital, improving transitional care and preventing readmission in this group has profound quality of care and financial implications.Method: EMBASE and MEDLINE searches were conducted to examine specific barriers to care transitions in underserved patients following an episode of acute care. Articles were reviewed for barriers and categorized within the context of five general themes.Results: This review yielded 17 peer-reviewed articles. Common factors affecting care transitions were cost of medications, access to care, housing instability, and transportation. When categorized within themes, social fragility and access failures, as well as therapeutic misalignment, disease behavior, and issues with accountability were noted.Discussion: Providers and health systems caring for medically underserved patients may benefit through dedicating increased resources and broadening collaboration with community partners in order to expand health care access and enhance coordination of social services within this population. Future studies are needed to identify potential interventions targeting underserved patients to improve their post-hospital care. [ABSTRACT FROM AUTHOR]

Background: The Veterans Choice Program (VCP) was implemented to improve healthcare access by expanding healthcare options for Veterans Health Administration (VHA) enrollees.Objectives: To understand Veterans' experience accessing VCP care.Design: Qualitative content analysis.Subjects: Forty-seven veterans from three medical centers in three of the five VA geographical regions.Approach: We used semi-structured telephone interviews designed to elicit descriptions of Veterans' experiences. Data was analyzed using iterative, inductive, and deductive content analysis. Broad themes were identified based on representative interview responses.Key Results: We identified six themes: general impressions (concept and frustration); preferred source of care (institution, specialty, and individual provider); facilitators (VA staff facilitation and proactive Veterans); barriers (complexity, lack of responsiveness, lack of local providers, and poor coordination); perceived sources of VCP problems (learning curve, leadership and staff, and politics); and unintended negative impact (responsibility for costs of care and discontinued access to community care).Discussion: Most Veterans who had received care through the VCP felt that it improved their access to care. However, accessing care through the VCP is a complex process that requires proactive Veterans and active support from the VA, third-party administrators, and availability of participating community providers. Veterans' abilities to navigate this process and the level of support provided varied widely. Even patients who did receive care through VCP found the process challenging. Greater support is needed for some Veterans to successfully access VCP care because Veterans who need care the most may be the least able to access it. [ABSTRACT FROM AUTHOR]

Background: Transgender people, those whose gender identity does not match their sex assigned at birth, face barriers to receiving health care. These include discrimination, prohibitive cost, and difficulty finding transgender-inclusive providers. As transgender identities are not typically recognized in public health research, the ability to compare the health of the transgender population to the overall population is limited.Objective: The Colorado Transgender Health Survey sought to explore current disparities and their effects on the health of transgender people in Colorado.Design and Participants: The Colorado Transgender Health Survey, based on the Behavioral Risk Factor Surveillance System (BRFSS), was developed by the Colorado Department of Public Health and Environment, transgender advocates, and transgender community members. Outreach was targeted to transgender-inclusive events and organizations.Main Measures: Responses to the 2014 Colorado Transgender Health Survey were compared side by side to Colorado 2014 BRFSS data.Results: Results from 406 transgender or gender-nonconforming adults who live in Colorado were included in the analysis. Forty percent of respondents report delaying medical care due to cost, inadequate insurance, and/or fear of discrimination. Respondents report significant mental health concerns, with 43% reporting depression, 36% reporting suicidal thoughts, and 10% attempting suicide in the past year. Respondents with a transgender-inclusive provider were more likely to receive wellness exams (76 versus 48%), less likely to delay care due to discrimination (24 versus 42%), less depressed (38 versus 54%), and less likely to attempt suicide (7 versus 15%) than those without.Conclusions: The transgender community in Colorado faces significant disparities, especially around mental health. However, a transgender-inclusive provider is associated with improved mental and physical health and health behaviors. Further population-level research and provider education on transgender health should to be incorporated into national efforts to eliminate health disparities. [ABSTRACT FROM AUTHOR]

Background: Transportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative.Objective: To evaluate the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments.Design: In one of two similar practices, all eligible Medicaid patients were offered rideshare-based transportation ("rideshare practice"). A difference-in-difference analytical approach using logistic regression with robust standard errors was employed to compare show rate changes between the rideshare practice and the practice where rideshare was not offered ("control practice").Participants: Our study population included residents of West Philadelphia who were insured by Medicaid and were established patients at two academic general internal medicine practices located in the same building.Intervention: We designed a rideshare-based transportation pilot intervention. Patients were offered the service during their reminder call 2 days before the appointment, and rides were prescheduled by research staff. Patients then called research staff to schedule their return trip home.Main Measures: We assessed the effect of offering rideshare-based transportation on appointment show rates by comparing the change in the average show rate for the rideshare practice, from the baseline period to the intervention period, with the change at the control practice.Key Results: At the control practice, the show rate declined from 60% (146/245) to 51% (34/67). At the rideshare practice, the show rate improved from 54% (72/134) to 68% (41/60). In the adjusted model, controlling for patient demographics and provider type, the odds of showing up for an appointment before and after the intervention increased 2.57 (1.10-6.00) times more in the rideshare practice than in the control practice.Conclusions: Results of this pilot program suggest that offering a rideshare-based transportation service can increase show rates to primary care for Medicaid patients. [ABSTRACT FROM AUTHOR]

Purpose: Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as "closing the referral loop." As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative.Objective/design: To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016.Main Measures: The primary metric was documented specialist appointment completion rate. Explanatory analyses included documented appointment scheduling rate, individual clinic differences, appointment wait times, and geographic distance to appointments.Key Results: Of the 103,737 analyzed referral scheduling attempts, only 36,072 (34.8%) resulted in documented complete appointments. Low documented appointment scheduling rates (38.9% of scheduling attempts lacked appointment dates), individual clinic differences in closing the referral loop, and significant differences in wait times and distances to specialists between complete and incomplete appointments drove this gap. Other notable findings include high variation in wait times among specialties and correlation between high wait times and low documented appointment completion rates.Conclusions: The rate of closing the referral loop in this health system is low. Low appointment scheduling rates, individual clinic differences, and patient access issues of wait times and geographic proximity explain much of the gap. This problem is likely common among large health systems with complex provider networks and referral scheduling. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve rates of closing the referral loop. More research is necessary to determine the impact of these changes and other potential driving factors. [ABSTRACT FROM AUTHOR]

Background: Accessible diagnostic equipment, including height-adjustable examination tables, is necessary to accommodate patients with disabilities. Studies demonstrate that only a minority of clinics provide accessible equipment. For clinics with this equipment, no studies have examined the use of such equipment in routine clinical care.Objective: In primary care clinics with and without height-adjustable examination tables, we compared the frequency and variation in physical evaluations on examination tables and patients' perceptions of quality care.Design: Survey administered to patients at two primary care clinics in Rochester, MN, in 2015. One clinic had height-adjustable examination tables in every exam room; the other clinic had none.Patients: A total of 399 English-speaking adult primary care patients (61% participation).Main Measures: Participants were asked whether they were physically evaluated on a table during their clinical encounter. In addition, they completed two subscales of the Patient Perception of Quality of Care survey: Perceptions of Provider's Bedside Manner and Perceptions of Provider's Work.Key Results: Overall, there were no differences between clinics in the likelihood of patients being examined on an exam table or in their perceptions of quality of care. Across both clinics, patients who reported a disability were 27% less likely to be examined on a table, were less likely to rate their provider's bedside manner favorably (74% vs. 59%) and to have positive perceptions of their provider's work (46% vs. 32%) than patients without disabilities.Conclusions: The presence of accessible medical equipment was not associated with care delivered to patients. While this might not be meaningful for most patients, it could be problematic for patients with disabilities, who are less likely to be examined. Therefore, accessible equipment alone may not be sufficient to reduce disparities in the care experience. Provider- and organization-level factors must thus be considered in efforts to provide equitable care to patients with disabilities. [ABSTRACT FROM AUTHOR]

Background: No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients.Objective: To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates.Design: Single-center randomized controlled trial.Participants: A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15 % risk) for their appointment in 7 days.Intervention: Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care).Main Measures: Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue.Key Results: The no-show rate in the intervention arm (22.8 %) was significantly lower (absolute risk difference -6.4 %, p < 0.01, 95 % CI [-9.8 to -3.0 %]) than that in the control arm (29.2 %). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35 days; 95 % CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly.Conclusions: A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of no-show. The use of targeted interventions may be of interest to practices taking on increased accountability for population health. [ABSTRACT FROM AUTHOR]

The article offers a report on the study of access to treatment for alcohol use disorder ( AUD) at U.S. health centers as of 2014 health center patient survey. Topics discussed include treatment rates for AUD remain low despite the existence of evidence based behavioral and pharmacologic treatment approaches; description of three-stage sampling design in the survey method; and views on limitations of study.

Background: Veterans with evidence of homelessness have high rates of mental health and substance abuse disorders, but chronic medical conditions such as diabetes are also prevalent.Objective: We aimed to determine the impact of homelessness on glycemic control in patients with type 2 diabetes mellitus.Design: Longitudinal analysis of a retrospective cohort.Subjects: A national cohort of 1,263,906 Veterans with type 2 diabetes. Subjects with evidence of homelessness were identified using a combination of diagnostic and administrative codes.Main Measures: Odds for poor glycemic control using hemoglobin A1C (HbA1C) cutoff values of 8 % and 9 %. Homeless defined as a score based on the number of indicator variables for homelessness within a veterans chart.Key Results: Veterans with evidence of homelessness had a significantly greater annual mean HbA1C ≥ 8 (32.6 % vs. 20.43 %) and HbA1C ≥ 9 (21.4 % vs. 9.9 %), tended to be younger (58 vs. 67 years), were more likely to be non-Hispanic black (39.1 %), divorced (43 %) or never married (34 %), to be urban dwelling (88.8 %), and to have comorbid substance abuse (46.7 %), depression (42.3 %), psychoses (39.7 %), liver disease (18.8 %), and fluid/electrolyte disorders (20.4 %), relative to non-homeless veterans (all p < 0.0001). Homelessness was modeled as an ordinal variable that scored the number of times a homelessness indicator was found in the Veterans medical record. We observed a significant interaction between homelessness and race/ethnicity on the odds of poor glycemic control. Homelessness, across all racial-ethnic groups, was associated with increased odds of uncontrolled diabetes at a cut-point of 8 % and 9 % for hemoglobin A1C ; however, the magnitude of the association was greater in non-Hispanic whites [8 %, OR 1.55 (1.47;1.63)] and Hispanics [8 %, OR 2.11 (1.78;2.51)] than in non-Hispanic blacks [8 %, OR 1.22 (1.15;1.28)].Conclusions: Homelessness is a significant risk factor for uncontrolled diabetes in Veterans, especially among non-Hispanic white and Hispanic patients. While efforts to engage homeless patients in primary care services have had some success in recent years, these data suggest that broader efforts targeting management of diabetes and other chronic medical conditions remain warranted. [ABSTRACT FROM AUTHOR]

Background: One-quarter of U.S. patients do not have a primary care provider or do not have complete access to one. Work and personal responsibilities also compete with finding convenient, accessible care. Telehealth services facilitate patients' access to care, but whether patients are satisfied with telehealth is unclear.Objective: We assessed patients' satisfaction with and preference for telehealth visits in a telehealth program at CVS MinuteClinics.Design: Cross-sectional patient satisfaction survey.Participants: Patients were aged ≥18 years, presented at a MinuteClinic offering telehealth in January-September 2014, had symptoms suitable for telehealth consultation, and agreed to a telehealth visit when the on-site practitioner was busy.Main Measures: Patients reported their age, gender, and whether they had health insurance and/or a primary care provider. Patients rated their satisfaction with seeing diagnostic images, hearing and seeing the remote practitioner, the assisting on-site nurse's capability, quality of care, convenience, and overall understanding. Patients ranked telehealth visits compared to traditional ones: better (defined as preferring telehealth), just as good (defined as liking telehealth), or worse. Predictors of preferring or liking telehealth were assessed via multivariate logistic regression.Key Results: In total, 1734 (54 %) of 3303 patients completed the survey: 70 % were women, and 41 % had no usual place of care. Between 94 and 99 % reported being "very satisfied" with all telehealth attributes. One-third preferred a telehealth visit to a traditional in-person visit. An additional 57 % liked telehealth. Lack of medical insurance increased the odds of preferring telehealth (OR = 0.83, 95 % CI, 0.72-0.97). Predictors of liking telehealth were female gender (OR = 1.68, 1.04-2.72) and being very satisfied with their overall understanding of telehealth (OR = 2.76, 1.84-4.15), quality of care received (OR = 2.34, 1.42-3.87), and telehealth's convenience (OR = 2.87, 1.09-7.94) CONCLUSIONS: Patients reported high satisfaction with their telehealth experience. Convenience and perceived quality of care were important to patients, suggesting that telehealth may facilitate access to care. [ABSTRACT FROM AUTHOR]

Background: Little is known about the factors that influence physicians' admission decisions, especially among lower acuity patients. For the purpose of our study, non-medical refers to all of the factors-other than the patient's clinical condition-that could potentially influence admission decisions.Objective: To describe the influence of non-medical factors on physicians' decisions to admit non-critically ill patients presenting to the ED.Design: Cross-sectional study of hospital admissions at a single academic medical center.Participants: Non-critically ill adult patients admitted to the hospital (n = 297) and the admitting emergency medicine physicians (n = 34).Main Measures: A patient survey assessed non-medical factors, including primary care access and utilization. A physician survey assessed clinical and non-medical factors influencing the decision to admit. Based on physician responses, admissions were characterized as "strongly acuity-driven," "moderately acuity-driven," or "weakly acuity-driven." Among these admission types, we compared length of stay, cost, and readmission within 30 days to the hospital or ED.Key Results: Based on the admitting physician's assessment, we categorized the motivation for admission as strongly acuity-driven in 185 (62 %) admissions, moderately acuity-driven in 92 (31 %), and weakly acuity-driven in 20 (7 %). Per the physician surveys, 51 % of hospitalizations were strongly or moderately influenced by one or more non-medical factors, including lack of information about baseline conditions (23 %); inadequate access to outpatient specialty care (14 %); need for a diagnostic testing or procedure (12 %); a recent ED visit (11 %); and inadequate access to primary care (10 %). Compared with strongly-acuity driven admissions, admissions that were moderately or weakly acuity-driven were shorter and less costly but were associated with similar rates of ED (35 %) and hospital (27 %) readmission.Conclusions: Non-medical factors are influential in the admission decisions for many patients presenting to the emergency department. Moderately and weakly acuity-driven admissions may represent a feasible target for alternative care pathways. [ABSTRACT FROM AUTHOR]