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Safety net organizations in rural regions face structural barriers to providing services. Organizations that serve rural Latino communities may face additional barriers related to restrictive immigration policies and anti‐immigrant climates. This study examines the impacts of restrictive immigration policies on safety net organizations that provide critical services to Latinos in rural areas to elucidate the mechanisms by which immigration policies influence Latino health. We conducted a qualitative analysis of 20 in‐depth interviews with safety net organizations providing legal, nutritional, healthcare, labor, educational, and advocacy services to Latinos in rural California. Rural Latino‐serving safety net organizations face immigration‐related funding restrictions and anti‐immigrant climates. Under restrictive immigration policies, rural safety net organizations are forced to extend beyond their organizational missions to circumvent immigration‐related funding restrictions and address anti‐immigrant climates to deliver their services. Staff working in these organizations are at the frontlines of anti‐immigrant climates and experienced an emotional toll from their work. States should address anti‐immigrant climates and increase funding to support organizations who serve Latinos in rural regions. To ensure that rural safety net organizations meet their mission, immigration‐related eligibility requirements from safety net services should be removed. In addition, funders should allocate resources towards mental health services to address the impacts of anti‐immigrant climates on staff who serve in rural Latino communities. [ABSTRACT FROM AUTHOR]

The document "National Social Risk Factor Screening Rates Among Federally Qualified Health Center Patients" presents the first national estimates of social risk factor screening rates among patients at federally qualified health centers (FQHCs) in the US. The study found that 62.0% of FQHCs currently collect social risk data using a standardized screener. Among FQHCs that screened for social risk factors, 25.5% of patients had documentation of being screened, but there was significant variation among FQHCs, with some screening over 80% of their patients and others screening fewer than 20%. The document highlights challenges such as staff training, workflow integration, and limited funding that may contribute to low screening rates. Supporting FQHCs in their efforts to address social risk factors is crucial for providing equitable care to patients. [Extracted from the article]

Objective: To investigate Covid‐19 vaccination as a potential secondary public health benefit of case management for Medicaid beneficiaries with health and social needs. Data Sources and Study Setting: The CommunityConnect case management program for Medicaid beneficiaries is run by Contra Costa Health, a county safety net health system in California. Program enrollment data were merged with comprehensive county vaccination records. Study Design: Individuals with elevated risk of hospital and emergency department use were randomized each month to a case management intervention or usual care. Interdisciplinary case managers offered coaching, community referrals, healthcare connections, and other support based on enrollee interest and need. Using survival analysis with intent‐to‐treat assignment, we assessed rates of first‐dose Covid‐19 vaccination from December 2020 to September 2021. In exploratory sub‐analyses we also examined effect heterogeneity by gender, race/ethnicity, age, and primary language. Data Collection and Extraction Methods: Data were extracted from county and program records as of September 2021, totaling 12,866 interventions and 25,761 control enrollments. Principal Findings: Approximately 58% of enrollees were female and 41% were under age 35. Enrollees were 23% White, 12% Asian/Pacific Islander, 20% Black/African American, and 36% Hispanic/Latino, and 10% other/unknown. Approximately 35% of the intervention group engaged with their case manager. Approximately 56% of all intervention and control enrollees were vaccinated after 9 months of analysis time. Intervention enrollees had a higher vaccination rate compared to control enrollees (adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 1.02–1.10). In sub‐analyses, the intervention was associated with stronger likelihood of vaccination among males and individuals under age 35. Conclusions: Case management infrastructure modestly improved Covid‐19 vaccine uptake in a population of Medicaid beneficiaries that over‐represents social groups with barriers to early Covid‐19 vaccination. Amidst mixed evidence on vaccination‐specific incentives, leveraging trusted case managers and existing case management programs may be a valuable prevention strategy. [ABSTRACT FROM AUTHOR]

The article titled "Should We Bury HbA1c?" explores the use of glycated hemoglobin (HbA1c) in diabetes care. It acknowledges that while HbA1c is commonly used and cost-effective, it has limitations due to various factors such as red blood cell turnover, certain diseases, and race/ethnicity. The article suggests the need to consider these limitations and explore alternative methods for managing diabetes. It also discusses the use of continuous glucose monitoring (CGM) as a real-time tool for monitoring glucose levels, but highlights the limited availability and accessibility of CGM, leading to healthcare disparities. The article emphasizes the importance of policy changes to improve CGM access and recognizes HbA1c as a complementary metric to CGM for predicting diabetes complications. [Extracted from the article]

Healthcare providers (HP) work in high-stress situations, interacting with patients and families who are often in crisis. HPs who work in safety net clinics, which provide care to uninsured, Medicaid recipients and other vulnerable populations, interact with patients who are frequently frustrated by long wait times, extensive paperwork, short appointments, and have generally lower health literacy. Many patients have chronic conditions and substance use disorders which has been associated with higher likelihood to be perceived as verbally aggressive and/or perpetrate workplace violence (WPV). Using interviews with 26 HPs at safety net clinics, we investigated how HPs manage interactions with aggressive patients and avoid burnout. Findings are based on emotional labor constructs describing why and how workers use emotion management strategies to smooth communication and relationships with clients/patients. According to our participants, HPs perform emotional labor to de-escalate interactions, prevent WPV, and to develop relationships with patients who might become regular clinic patients. We found that HPs perceive an influence of the clinic context on patient aggression management, hold initial perceptions that shape engagement with aggressive patients, and report emotional labor and burnout that came from interacting with aggressive patients to prevent WPV. We offer implications that extend research on emotional labor and burnout, provide guidance to healthcare organizations, and offer directions for future theory and research. [ABSTRACT FROM AUTHOR]

We explored the association between the use of a hospital-based food pantry and subsequent emergency department (ED) utilization among Medicaid patients with diabetes in a large safety-net health system. Leveraging 2015-2019 electronic health record data, we used a staggered difference-in-differences approach to measure changes in ED use before vs after food pantry use. Food pantry use was associated with a 7.3 percentage point decrease per patient per quarter (95% confidence interval, -13.8 to -0.8) in the probability of subsequent ED utilization (P = .03). Addressing food insecurity through hospital-based food pantries may be one mechanism for reducing ED use among low-income patients with diabetes. [ABSTRACT FROM AUTHOR]

To examine the associations between food insecurity and health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic and examine whether the associations were less pronounced among adults with safety nets. We conducted a retrospective longitudinal cohort study using the 2020–2021 Medical Expenditure Panel Survey. Linear probability models were used to assess the associations between food insecurity in one year and the outcomes of interest in the following year while adjusting for baseline characteristics. We performed the analyses for the entire population and then conducted stratified analyses for adults with and without Supplemental Nutrition Assistance Program (SNAP) benefits or Medicaid coverage. Compared with food-secure adults, food-insecure adults were 9.1 percentage points less likely to report life satisfaction and 9.9, 10.2, and 13.2 percentage points more likely to experience delays in getting medical care, postpone or forgo medical care because of cost, and struggle with paying medical bills. Food-insecure adults were 30.4, 27.2, and 23.5 percentage points more likely to face challenges in affording necessities, paying utility bills, and meeting rent or mortgage payments on time than food-secure adults. Notably, the strengths of these associations were attenuated among adults with SNAP benefits or Medicaid coverage. Food insecurity was associated with poor health, limited access to and affordability of care, and a greater financial burden of care among US adults during the pandemic. Nevertheless, safety net programs can play a critical role in alleviating adverse consequences. [ABSTRACT FROM AUTHOR]

Objective. To determine the impact of adverse social and behavioral determinants of health (SBDH) on health care use in a safety-net community hospital (SNCH) heart failure (HF) population. Methods. We performed a retrospective analysis of HF patients at a single SNCH between 2018–2019 (N= 4594). Results. At least one adverse SBDH was present in 21% of the study population. Patients with at least one adverse SBDH were younger (57 vs. 68 years), more likely to identify as Black (50% vs. 36%), be male (68% vs. 53%), and have Medicaid insurance (48% vs. 22%), p<.001. Presence of at least one adverse SBDH (homelessness, substance use, or incarceration) correlated with increased hospitalizations (2.3 vs 1.4/patient) and ED visits (5.1 vs 2.1/patient), p<.0001. Adverse SBDH were independent predictors of HF readmissions. Prescribing of guideline-directed medical therapy was similar among all patients. Conclusions. In a SNCH HF cohort, adverse SBDH predominantly afflict younger Black men on Medicaid and are associated with increased utilization. [ABSTRACT FROM AUTHOR]

Community Mental Health Centers (CMHCs) and Federally Qualified Health Centers (FQHCs) are critical access points for families with adolescents needing mental health care, especially those enrolled in Medicaid. However, barriers exist which may reduce their accessibility. This study aims to describe the availability and accessibility of outpatient mental health services for children and adolescents at safety-net health centers in a large metropolitan county. Approximately one year after the COVID-19 pandemic began in the U.S., a comprehensive sample of 117 CMHCs and 117 FQHCs were called and administered a 5-minute survey. Approximately 10% of health centers were closed, and 20% (28.2% of FQHCs and 7.7% of CMHCs) reported not offering outpatient mental health services. Despite CMHCs having 5.4 more clinicians on staff on average, reported wait times were longer at CMHCs than FQHCs. These findings indicate that online directories intended to be a comprehensive and accessible resource, such as the SAMHSA Treatment Locator, are often inaccurate or out-of-date. [ABSTRACT FROM AUTHOR]

Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis. [ABSTRACT FROM AUTHOR]

The article presents the results of a study published in "JAMA Health Forum," which showed that the Medicare's new health equity adjustment (HEA) in the hospital value-based purchasing (HVBP) program will substantially benefit safety net hospitals and those mainly serving African American patients. The HEA will be implemented in 2026. Also cited is the program's aim to improve equity in healthcare.

Background: Release from prison is characterized by discontinuity of healthcare services and results in poor health outcomes, including an increase in mortality. Institutions capable of addressing this gap in care seldom collaborate in comprehensive, data-driven transition of care planning. This study harnesses information from a data exchange between correctional facilities and community-based healthcare agencies in Colorado to model a care continuum after release from prison. Methods: We merged records from Denver Health (DH), an urban safety-net healthcare system, and the Colorado Department of Corrections (CDOC), for people released from January 1 to June 30, 2021. The study population was either (a) released to the Denver metro area (Denver and its five neighboring counties), or (b) assigned to the DH Regional Accountable Entity, or (c) assigned to the DH medical home based on Colorado Department of Healthcare Policy and Financing attribution methods. Outcomes explored were outpatient, acute care, and inpatient utilization in the first 180 days after release. We used Pearson's chi-squared tests or Fisher exact for univariate comparisons and logistic regression for multivariable analysis. Results: The care continuum describes the healthcare utilization at DH by people released from CDOC. From January 1, 2021, to June 30, 2021, 3242 people were released from CDOC and 2848 were included in the data exchange. 905 individuals of the 2848 were released to the Denver metro area or attributed to DH. In the study population of 905, 78.1% had a chronic medical or psychological condition. Within 180 days of release, 31.1% utilized any health service, 24.5% utilized at least one outpatient service, and 17.1% utilized outpatient services two or more times. 10.1% utilized outpatient services within the first 30 days of release. Conclusions: This care continuum highlights drop offs in accessing healthcare. It can be used by governmental, correctional, community-based, and healthcare agencies to design and evaluate interventions aimed at improving the health of a population at considerable risk for poor health outcomes and death. [ABSTRACT FROM AUTHOR]

Safety-net hospitals (SNHs) provide health care services to individuals regardless of their ability to pay. These hospitals serve Medicaid recipients, the uninsured, and people with limited access to health care due to their socioeconomic status, race, or ethnicity. In addition to providing health care to the most vulnerable, SNHs are crucial in training the next generation of clinicians. Hospitals serving Medicaid patients and the uninsured have low operating margins because of a dated State Medicaid financial model, and as a result, many now face closure. This review provides historical context for the financial challenges facing SNHs in Brooklyn, New York. In addition, it examines how New York State's Medicaid reimbursement methodology threatens the viability of hospitals that serve low-income communities. Finally, the article suggests a solution to the health care crisis in Brooklyn, capitalizing on structural payment reform successes in other states. [ABSTRACT FROM AUTHOR]

Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease—including end-stage manifestations of cirrhosis and liver cancer—is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings. [ABSTRACT FROM AUTHOR]

Purpose Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison–patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role. Methods We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program. Results Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non–English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support. Conclusion Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital. [ABSTRACT FROM AUTHOR]

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative aimed at improving access to diabetes specialty care for patients within a safety-net health system in Dallas County, TX, through the implementation of electronic consultations. [ABSTRACT FROM AUTHOR]

The article discusses that in 2023, California and Washington state received waivers allowing Medicaid to cover healthcare for incarcerated individuals, aiming to improve post-release healthcare. U.S. Centers for Medicare & Medicaid Services (CMS) guidance outlines key goals and required benefits, emphasizing coordination and continuity of care. To modernize carceral healthcare, independent financing and oversight are crucial, following the example of other high-income countries like England.

Objective: When prescribed with opioids, sedative-hypnotics substantially increase the risk of overdose. The objective of this paper was to describe characteristics and trends in opioid sedative-hypnotic co-prescribing in a network of safety-net clinics serving low-income, publicly insured, and uninsured individuals. Methods: This retrospective longitudinal analysis of prescription orders examined opioid sedative-hypnotic co-prescribing rates between 2009 and 2018 in the OCHIN network of safety-net community health centers. Sedative-hypnotics included benzodiazepine and non-benzodiazepine sedatives (eg, zolpidem). Co-prescribing patterns were assessed overall and across patient demographic and co-morbidity characteristics. Results: From 2009 to 2018, 240 587 patients had ≥1 opioid prescriptions. Most were White (65%), female (59%), and had Medicaid insurance (43%). One in 4 were chronic opioid users (25%). During this period, 55 332 (23%) were co-prescribed a sedative-hypnotic. The prevalence of co-prescribing was highest for females (26% vs 19% for males), non-Hispanic Whites (28% vs 13% for Hispanic to 20% for unknown), those over 44 years of age (25% vs 20% for <44 years), Medicare insurance (30% vs 21% for uninsured to 22% for other/unknown), and among those on chronic opioid therapy (40%). Co-prescribing peaked in 2010 (32%) and declined steadily through 2018 (20%). Trends were similar across demographic subgroups. Co-prescribed sedative-hypnotics remained elevated for those with chronic opioid use (27%), non-Hispanic Whites (24%), females (23%), and those with Medicare (23%) or commercial insurance (22%). Conclusions: Co-prescribed sedative-hypnotic use has declined steadily since 2010 across all demographic subgroups in the OCHIN population. Concurrent use remains elevated in several population subgroups. [ABSTRACT FROM AUTHOR]

Objectives: The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion to the Provider Relief Fund, allowing for direct payments to health care providers due to COVID‐19. Few studies have evaluated participation in the Provider Relief Fund (PRF), and none have specifically looked at dental providers in the safety net. Methods: We conducted a retrospective, secondary data analysis using a quasi‐experimental cohort design of South Carolina dentists who received PRF payments, comparing those who did and did not participate in the safety net. Safety net practice was operationalized as those participating in Medicaid, and whether they provided care in dental health professional shortage areas, or rural communities. Results: Of the 628 dental providers in South Carolina who received PRF payments, 34% were identified as Medicaid providers while 66% did not participate in Medicaid; we found no statistical difference between payments to Medicaid versus non‐Medicaid dental providers. Of PRF payments to dental providers participating in South Carolina's Medicaid program, we found no difference between payments to rural and urban providers but did find that practices offering services in dental care shortage areas received less than providers practicing in counties not designated as a shortage area. Conclusions: The PRF achieved its goal of distributing financial support to providers affected by the COVID‐19 pandemic. But without policy imperatives linked to need‐based allocations or incentives for PRF recipients to serve safety net populations, we may later learn this was a missed opportunity for PRF. [ABSTRACT FROM AUTHOR]

The Medicaid Delivery System Reform Incentive Payment (DSRIP) program has been among the most widely adopted value-based payment strategies to drive improved population health management among safety net populations. Using comprehensive claims data from New Jersey and difference-in-differences modeling, the authors examine the impact of DSRIP pay-for-performance disease management programs on outcomes related to targeted chronic conditions. The authors find DSRIP reduced asthma hospitalizations and emergency department visits, pneumonia readmissions, and improved alcohol and drug treatment. Positive program-specific findings are encouraging for future DSRIP-like initiatives and demonstrate provider ability to successfully adapt to payment reforms. [ABSTRACT FROM AUTHOR]

Purpose: Lung cancer screening (LCS) results in earlier detection of malignancy and decreases mortality but requires access to care to benefit. We assessed factors associated with timing of lung cancer diagnosis in the absence of systematic LCS in an urban safety net hospital. Patients and Methods: Retrospective chart review was performed of patients with pathologic diagnosis and/or staging of lung cancer at our institution between 2015 and 2018. Patient socio-demographics, disease characteristics, factors associated with access to medical care, and time point and process by which the patient accessed care were collected and analyzed. Results: In total, 223 patients were identified with median age of 63 years and 57.8% male predominance. Racial distribution was 22.9%, 20.2%, 17.1%, and 9.4% for Black, White, Asian, and Hispanic, respectively. Stage at diagnosis was 8.1%, 4.5%, 17.0%, and 60.5% for stages I, II, III, and IV, respectively. Medicaid (59.6%) and Medicare/Medicaid (17.1%) were the most common insurance types, while 16.1% had no insurance. A majority (54.3%) had no established primary care provider (PCP), and only 17.9% had an in-network PCP. Patients without PCPs were more likely to have diagnostic evaluation initiated from Emergency Department or Urgent Care settings (95.0% vs 50.1%, P <.01) and present with later stage disease (92.7% vs 77.8%, P <.01). Of the 83 patients that met age and smoking history LCS criteria, only 33.7% (12.6% of total) also had an in-network PCP. Conclusion: Absence of established PCPs is associated with later stage presentation of lung cancer and may limit system- level benefits of LCS implementation. [ABSTRACT FROM AUTHOR]

To assess the relative contributions of individual insurance status and hospital payer mix (safety net status) to quality of care and survival for patients with cervical cancer. We used the National Cancer Database to identify patients with cervical cancer diagnosed from 2004 to 2017. Patients were classified by insurance (uninsured/Medicaid/private/Medicare/other) and hospitals were grouped into quartiles based on the proportion of uninsured/Medicaid patients (payer mix) (top quartile defined as safety-net hospital (SNHs) and lowest as Q1 hospitals). Quality-of-care was assessed by adherence to evidence-based metrics. Individual contributions of insurance status and payer mix to survival was assessed with a proportional hazards Cox model. A total of 124,339 patients including 11,338 uninsured (9.1%) and 27,281 Medicaid (21.9%) recipients treated at 1156 hospitals were identified. Quality-of-care was not significantly different across hospital quartiles. Adjusting for patients' clinical/demographic characteristics, treatment at a SNH was associated with a 14% higher mortality (HR = 1.14; 95% CL, 1.08–1.20) than at Q1 hospitals. Testing for individual insurance, uninsured patients had 32% increased mortality (HR = 1.32; 95% CI,1.26–1.38) and Medicaid recipients 40% increased (HR = 1.40; 95%CI,1.35–1.44) compared to privately insured patients. Examining both payer mix and insurance, only individual insurance retained a significant impact on mortality. Individual insurance may be a more important predictor of survival than site-of-care and hospital payer mix for women with cervical cancer. There is substantial variation in outcomes within hospitals based on individual insurance, regardless of hospital payer mix. • Among patients with cervical cancer, treatment at a safety-net hospital is associated with a 14% increased mortality. • When testing for individual insurance, uninsured patients had 32% increased mortality. • Examining for both payer mix and insurance status, only individual insurance retained a significant impact on mortality. [ABSTRACT FROM AUTHOR]

BACKGROUND: Restrictive state and payer policies may be effective in reducing opioid prescribing by surgeons, but their impact has not been well studied. In 2017, Washington Medicaid implemented an opioid prescribing limit of 42 pills, prompting a large regional safety-net hospital to implement a decision support intervention in response. We aimed to evaluate the effects on surgeons’ prescribing. STUDY DESIGN: We retrospectively studied postoperative opioid prescribing (quantity of pills prescribed at discharge) to opioid-naïve surgical patients at a regional safety-net hospital from 2016 to 2020. We investigated associations between the policy and opioid prescribing by using interrupted time series analysis, adjusting for clinical and sociodemographic factors. RESULTS: A total of 12,799 surgical encounters involving opioid-naïve patients (59% male, mean age 52) were analyzed. Opioids were prescribed for 75%. From 2016 to 2020, the mean prescribed opioid quantity decreased from 36 pills to 17 pills. In interrupted time series analysis, the Medicaid policy implementation was associated with an immediate change of –8.4 pills (95% CI –12 to –4.7; p < 0.001) per prescription and a subsequent rate of decrease similar to that prepolicy. In a comparison of changes between patients insured through Medicaid vs Medicare, Medicaid patients had an immediate change of –9.8 pills (95% CI –19 to –0.76; p = 0.03) after policy implementation and continued decreases similar to those prepolicy. No immediate or subsequent policy-related changes were observed among Medicare patients. CONCLUSION: In a large regional safety-net institution, postoperative opioid prescriptions decreased in size over time, with immediate changes associated with a state Medicaid policy and corresponding decision support intervention. These findings pose implications for surgeons, hospital leaders, and payers seeking to address opioid use via judicious prescribing. [ABSTRACT FROM AUTHOR]

Introduction: Studies have shown mixed findings regarding the impact of immigration policy changes on immigrants' utilization of primary care. Methods: We used a difference-in-differences analysis to compare changes in missed primary care appointments over time across two groups: patients who received care in Spanish, Portuguese, or Haitian Creole, and non-Hispanic, white patients who received care in English. Results: After adjustment for age, sex, race, insurance, hospital system, and presence of chronic conditions, immigration policy changes were associated with an absolute increase in the missed appointment prevalence of 0.74 percentage points (95% confidence interval: 0.34, 1.15) among Spanish, Portuguese and Haitian-Creole speakers. We estimated that missed appointments due to immigration policy changes resulted in lost revenue of over $185,000. Conclusions: We conclude that immigration policy changes were associated with a significant increase in missed appointments among patients who receive medical care in languages other than English. [ABSTRACT FROM AUTHOR]

To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid. We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12 weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12 weeks postpartum. We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9 years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p <.01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12 weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p =.46). Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12 weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity. [ABSTRACT FROM AUTHOR]

In contrast to fee-for-service payment arrangements where healthcare providers are paid based on services provided, value-based contracting focuses payment based on agreed upon patient health outcomes and goals to improve population health and efficient use of the healthcare system. Primary Care Payment Reform to Change Care Delivery and Improve Value The success of payment reform is maximized when the changes in payment mechanism are able to change provider and health system behavior in a manner that improves overall population health. Importantly, for capitation to be most effective in changing on-the-ground care delivery, payment mechanisms across Medicaid, commercial payors, Medicare, and dual payment plans such as integrated Medicare-Medicaid plans will need to be aligned. [Extracted from the article]

Rhode Island has been selected as one of 10 states for a federal demonstration program called Certified Community Behavioral Health Clinic (CCBHC). This program aims to transition the state to a new system of behavioral healthcare that provides care for people of all ages, regardless of their ability to pay. The grant allows Rhode Island to receive higher Medicaid reimbursements for services provided at CCBHCs, reducing costs for the state. The state estimates receiving approximately $15 million in additional federal funding for the fiscal year 2024 and $26 million for 2025. The funding will support the opening of eight CCBHC sites on October 1, 2024, with plans for additional sites in the following year. [Extracted from the article]

Long-term care has been defined as a continuation of medical services, social services, and housing for patients with chronic health conditions, which have limited their abilities to partake in everyday activities. In the United States, the Affordable Care Act (ACA) was enacted to expand coverage for Medicaid and to improve the quality and cost of healthcare. The purpose of this study was to evaluate the impact of the ACA on long-term care to determine if it has increased Medicaid payments. The methodology for this investigation utilized a literature review following a systematic approach utilizing 48 references and complemented with a semi-structured interview. It was found that the ACA has increased Medicaid payments, and the number of uninsured patients has decreased. With the implementation of the ACA, nursing homes and lifelong care facilities have been required through the ACA to meet new requirements that have made it easier to file complaints about the quality of care. This study also suggested a decrease in readmission rates with Medicaid and the ACA in long-term settings. The ACA implementation has increased Medicaid payments, and quality of care has been improved through a decrease of readmissions, ulcers, and falls in long-term care facilities. [ABSTRACT FROM AUTHOR]

We examined health care utilization among federally qualified health center (FQHCs) users from a Medicaid managed care organization based on 2016 administrative claims data (n = 8,402). FQHC users had fewer primary care visits (Adjusted Incidence Rate Ratios (aIRR): 0.82; 95% CI: 0.76–0.88) compared with non-FQHC users. Statistically significant differences were not observed in emergency department visits (aIRR: 1.19; 95% CI: 0.98–1.46) and hospitalizations (aIRR: 1.03; 95% CI: 0.80–1.34). FQHCs provide comprehensive primary care to Medicaid managed care beneficiaries with diabetes in fewer PCP visits. Results provide evidence to health policy experts and MCOs to increase provider network contracting with FQHCs. [ABSTRACT FROM AUTHOR]

The radiation oncology alternative payment model (RO-APM) was developed by the Center for Medicare and Medicaid Innovation, a part of the Centers for Medicare & Medicaid Services, as a vehicle to optimize value for patients undergoing radiation therapy. By shifting reimbursement away from fee-for-service and toward a prospective bundled payment system, the RO-APM is intended to bend the cost curve in radiation oncology while preserving or even enhancing outcomes. As with prior large-scale policy initiatives, the nature and magnitude of the RO-APM's impact on care delivery will vary substantially depending on a host of local factors, including practice setting. Urban academic centers play a key role in radiation oncology by spearheading innovation, managing the most complicated cases, training the next generation of radiation oncologists, and often caring for vulnerable patient populations. Thus, to protect patients' access to this high-quality cancer care, it will be crucial to characterize the RO-APM's projected impact on large urban academic institutions before its implementation, including possible unintended adverse consequences. Here, we provide an overview of this seismic change in radiation oncology reimbursement and discuss its unique potential implications for large urban academic institutions as a means to facilitate necessary preparations and inform future revisions to the model. [ABSTRACT FROM AUTHOR]

Objectives. To compare the severity of inpatient hospitalizations between undocumented immigrants and Medi-Cal patients in a large safety-net hospital in Los Angeles, California. Methods. We conducted a retrospective analysis of all 2019 inpatient stays at a Los Angeles hospital (n = 22 480), including patients of all races/ethnicities. We examined 3 measures by using insurance status to approximate immigration status: illness severity, length of hospital stay, and repeat hospitalizations. We calculated group differences between undocumented and Medi-Cal patients by using inverse probability weighted regression adjustment separately for patients aged 18 to 64 years and those aged 65 years and older. Results. Younger undocumented patients had less severe illness and shorter lengths of stay than their Medi-Cal counterparts. Older undocumented immigrants also had less severe illness, but had similar lengths of stay and were more likely to have repeated hospitalizations. Conclusions. While existing work suggests that undocumented immigrants could have more severe health care needs on account of their poorer access to medical care, we did not see clear health disadvantages among hospitalized undocumented immigrants, especially younger patients. There were fewer differences between undocumented and Medi-Cal patients who were older. (Am J Public Health. 2021;111(11):2019–2026. https://doi.org/10.2105/AJPH.2021.306485) [ABSTRACT FROM AUTHOR]

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]

Medicaid state dental programs have experienced changes related to provider practice settings with the increased growth of dental support organizations (DSOs). The authors conducted this study to assess the impact of state Medicaid reform on the dental practice environment by examining provider activity and practice setting. This was a retrospective cohort study of more than 13 million dental claims in the Virginia Medicaid program. It included children and dental care providers in the Virginia dental Medicaid program at some time during a 9-year period (fiscal years 2003-2011). The independent variable was the provider practice setting: private practice, DSO, and safety-net practice. The outcomes included annual measures of claims, patients, and payments per provider. The outcomes were examined over 3 phases of the study period: prereform (2003-2005), implementation phase (2006-2008), and postreform maturation (2009-2011). Provider activity increased after dental program reform, with private-practice providers delivering most of the dental care in the Medicaid program. There was a significant penetration of DSO providers in number of providers, claims per provider, and patients per provider (P <.001). Regression results found that providers in DSO settings had an increased number of patients and claims compared with private-practice providers. Medicaid reform has resulted in a significant increase in provider participation and growth of DSO-affiliated providers. Areas of the state with more dense population had a higher penetrance of dentists practicing in DSO settings providing dental services to children enrolled in Medicaid. [ABSTRACT FROM AUTHOR]

The article focuses on the Texas Dental Association's (TDA) advocacy for Medicaid and CHIP, emphasizing the importance of maintaining and strengthening the dental public health safety net. Topics include TDA's efforts to prevent funding reductions, review Medicaid preventive dental policy, and ensure dentist concerns are addressed in various programs and committees to enhance dental care access and quality for Medicaid and CHIP participants.

Rationale, aims and objectives: Missed appointments are a persistent problem across healthcare settings, and result in negative outcomes for providers and patients. We aimed to review and evaluate the effectiveness of interventions designed to reduce missed appointments in safety net settings. Methods: We conducted a systematic review of interventions reported in three electronic databases. Data extraction and quality assessment were conducted according to PRISMA guidelines. Eligible studies were analyzed qualitatively to describe intervention types. A random effects model was used to measure the pooled relative risk of appointment adherence across interventions in the meta‐analysis. Results: Thirty‐four studies met inclusion criteria for the qualitative synthesis, and 21 studies reported sufficient outcome data for inclusion in the meta‐analysis. Qualitative analysis classified nine types of interventions used to increase attendance; however, application of each intervention type varied widely between studies. Across all study types (N = 12 000), RR was 1.08, (95% CI 1.03, 1.13) for any intervention used to increase appointment attendance. No single intervention was clearly effective: facilitated appointment scheduling [RR = 3.31 (95% CI: 0.30, 37.13)], financial incentives [RR = 1.88 (0.73, 4.82)] case management/patient navigator [RR = 1.09, (0.96, 1.24)], text messages [RR = 1.02 (0.96, 1.08)], transportation, [RR = 1.05 (0.98, 1.13)], telephone reminder calls [RR 1.12, (0.87, 1.45)], in‐person referrals, [RR = 1.01 (0.90, 1.13)], patient contracts [RR = 0.87 (0.52, 1.46)] or combined strategies, [RR = 1.16 (1.03, 1.32)]. No strategy was clearly superior to others, p interaction =.50. Conclusions: Strategies to improve appointment adherence in safety net hospitals varied widely and were only modestly effective. Further research harmonizing intervention delivery within each strategy and comparing strategies with the most potential for success is needed. [ABSTRACT FROM AUTHOR]

Background: Extreme disparities in access, experience, and outcomes highlight the need to transform how pregnancy care is designed and delivered in the United States, especially for low-income individuals and people of color.Methods: We used human-centered design (HCD) to understand the challenges facing Medicaid-insured pregnant people and design interventions to address these challenges. The HCD method has three phases: Inspiration, Ideation, and Implementation. This study focused on the first and second. In the Inspiration phase we conducted semi-structured interviews with a purposeful sample of stakeholders who had either received or participated in the care of Medicaid-insured pregnant people within our community, with a specific emphasis on representation from marginalized communities. Using a general inductive approach to thematic analysis, we identified themes, which were then framed into design opportunities. In the Ideation phase, we conducted structured brainstorming sessions to generate potential prototypes of solutions, which were tested and iterated upon through a series of community events and engagement with a diverse community advisory group.Results: We engaged a total of 171 stakeholders across both phases of the HCD methodology. In the Inspiration phase, interviews with 23 community members and an eight-person focus group revealed seven insights centered around two main themes: (1) racism and discrimination create major barriers to access, experience, and the ability to deliver high-value pregnancy care; (2) pregnancy care is overmedicalized and does not treat the pregnant person as an equal and informed partner. In the Ideation phase, 162 ideas were produced and translated into eight solution prototypes. Community scoring and feedback events with 140 stakeholders led to the progressive refinement and selection of three final prototypes: (1) implementing telemedicine (video visits) within the safety-net system, (2) integrating community-based peer support workers into healthcare teams, and (3) delivering co-located pregnancy-related care and services into high-need neighborhoods as a one-stop shop.Conclusions: Using HCD methodology and a collaborative community-health system approach, we identified gaps, opportunities, and solutions to address perinatal care inequities within our urban community. Given the urgent need for implementable and effective solutions, the design process was particularly well-suited because it focuses on understanding and centering the needs and values of stakeholders, is multi-disciplinary through all phases, and results in prototyping and iteration of real-world solutions. [ABSTRACT FROM AUTHOR]

Background: Despite the frequency and cost of hospitalizations for acute respiratory failure (ARF), the literature regarding the impact of hospital safety net burden on outcomes of these hospitalizations is sparse.Research Question: How does safety net burden impact outcomes of ARF hospitalizations such as mortality, tracheostomy, and resource use?Study Design and Methods: This was a retrospective cohort study using the National Inpatient Sample 2007-2017. All patients hospitalized with a primary diagnosis of ARF were tabulated using the International Classification of Diseases 9th and 10th Revision codes, and safety net burden was calculated using previously published methodology. High- and low-burden hospitals were generated from proportions of Medicaid and uninsured patients. Trends were analyzed using a nonparametric rank-based test, whereas multivariate logistic and linear regression models were used to establish associations of safety net burden with key clinical outcomes.Results: Of an estimated 8,941,334 hospitalizations with a primary diagnosis of ARF, 33.9% were categorized as occurring at low-burden hospitals (LBHs) and 31.6% were categorized as occurring at high-burden hospitals (HBHs). In-hospital mortality significantly decreased at HBHs (22.8%-12.6%; nonparametric trend [nptrend] < .001) and LBHs (22.0%-10.9%; nptrend < .001) over the study period, as did tracheostomy placement (HBH, 5.6%-1.3%; LBH, 3.5%-0.8%; all nptrend <.001). After adjustment for patient and hospital factors, an HBH was associated with increased odds of mortality (adjusted OR [AOR], 1.11; 95% CI, 1.10-1.12) and tracheostomy use (AOR, 1.33; 95% CI, 1.29-1.37), as well as greater hospitalization costs (β coefficient, +$1,083; 95% CI, $882-$1,294) and longer lengths of stay (β coefficient, +3.3 days; 95% CI, 3.2-3.3 days).Interpretation: After accounting for differences between patient cohorts, high safety net burden was associated independently with inferior clinical outcomes and increased costs after ARF hospitalizations. These findings emphasize the need for health care reform to ameliorate disparities within these safety net centers, which treat our most vulnerable populations. [ABSTRACT FROM AUTHOR]

The article explores barriers to trauma-informed care for youths in publicly funded clinics. Topics include disparities in mental health outcomes related to adverse childhood events (ACEs), the impact of the Covid-19 pandemic on mental health, and difficulties in accessing trauma-informed care, especially for racial and ethnic minorities. Researchers found that Black and Latinx callers were more likely to be denied appointments, exacerbating existing mental health treatment disparities.

In South Carolina, a state that has foregone Medicaid expansion, working poor residents often rely on safety net clinics for medical care. This care often occurs far from major hospitals, in different, inferior, spaces where limited services are provided in lesser circumstances. The temporary and conditional aid provided in these clinics is meant as a last resort, but often serves as the only source of care for many working poor patients, who must manage the effects of sustained precarity and protracted immiseration with conditional aid provided by volunteers. Here I explore the function that volunteering plays in regulating patients' utilization, and ability to contest, the quality of safety net care. Using ethnographic examples and interview data I show how the needs of patients—referred to in the clinics as "clients"—are managed and contained by a moral economy of volunteer care. These reciprocal obligations of debt and duty preclude working poor patients from making demands of, or lodging complaints against, the free clinics' staff, due to their capacity as volunteers, and leaves the state's safety net effectively unassailable to accusations of inefficacy or neglect. Consequently, patients must defer care, ignore episodes of maltreatment, and ration and share prescription medications, lest they be considered recusant or deemed not sufficiently appreciative of the volunteer staff dedicating their time to them. As a result of this moral economy, the plight of the state's uninsured working poor residents goes under-recognized as the safety net absorbs their cases, hiding the attritional nature of the ostensibly free care they receive and ration. • In the U.S., working poor residents must often rely on safety net clinics for medical care. • US safety net clinics are often underfunded and overwhelmed. • The immense need for safety net care is contained by a moral economy of volunteerism. • In this moral economy, patients must be appreciative in the face of substandard care. [ABSTRACT FROM AUTHOR]

This study investigated the association between the implementation of the Affordable Care Act (ACA) and Latinxs' use of behavioral health services in the US. Organizational responses from the 2010, 2014, and 2016 National Mental Health Service Survey were used to examine the number and proportion of outpatient Latinx admissions over time, as well as the role of Medicaid expansion and health safety net funding on Latinxs' admissions. Findings showed that there was an increase in Latinx admissions post-ACA (2014). However, 2 years post-implementation (2016), Latinx admissions were at levels lower than prior to the healthcare reform. Despite this overall decrease, behavioral health safety net organizations, particularly those located in states that adopted the expansion of Medicaid, served more Latinxs than behavioral health service organizations outside the safety net. Policy and practice implications to strengthen behavioral safety net organizations that serve Latinxs are discussed. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent to which patterns could be identified in the use of empirical definitions of SNHs.Methods: We conducted a PRISMA guided systematic review of studies published between 2009 and 2018 and analyzed 22 articles that met the inclusion criteria of hospital-level analyses with a clear SNH definition.Results: Eleven unique SNH definitions were identified, and there were no obvious patterns in the use of a definition category (Medicaid caseload, DSH payment status, uncompensated care, facility characteristics, patient care mix) by the journal type where the article appeared, dataset used, or the year of publication.Conclusions: Overall, there is broad variability in the conceptualization of, and variables used to define, SNHs. Our work advances the field toward the development of standards in measuring, operationalizing, and conceptualizing SNHs across research and policy questions. [ABSTRACT FROM AUTHOR]

States' decisions to expand Medicaid may have important implications for their hospitals' financial ability to weather the Coronavirus disease 2019 (COVID-19) pandemic. This study estimated the effects of the Affordable Care Act (ACA) Medicaid expansion on hospital finances in 2017 to update earlier findings. The analysis also explored how the ACA Medicaid expansion affects different types of hospitals by size, ownership, rurality, and safety-net status. We found that the early positive financial impact of Medicaid expansion was sustained in fiscal years 2016 and 2017 as hospitals in expansion states continued to experience decreased uncompensated care costs and increased Medicaid revenue and financial margins. The magnitude of these impacts varied by hospital type. As COVID-19 has brought hospitals to a time of great need, findings from this study provide important information on what hospitals in states that have yet to expand Medicaid could gain through expansion and what is at risk should any reversal of Medicaid expansions occur. [ABSTRACT FROM AUTHOR]

The article explores how Medicaid and the Children's Health Insurance Program (CHIP) insure of all U.S. children depends public benefits or stake in the debate over the role of a strong public insurance system in achieving greater health equity. Topics include federal Medicaid funding is tied to state spending in the U.S. health system; and federally mandated eligibility expansions for infants and other children have helped Medicaid evolutions.

PURPOSE Little is known about the provision of oncologic services by Project Access safety net care coordination programs. MATERIALS AND METHODS Information on safety net care coordination program locations, health services, and patient eligibility was obtained via program Web sites and calls. For programs not offering oncologic care, program directors were interviewed to identify oncologic care barriers. RESULTS Web sites of 29 safety net care coordination programs in 22 states were identified; 62% (n 5 18) offered oncologic services. Programs were in 65% (n 5 11) of states that did not expand Medicaid. Of those offering oncologic services, 83% (n 5 15) offered free chemotherapy, and 93% (n 5 27) of all programs offered oncologic imaging. Program director interviews revealed costs, longitudinal care, and multiple-physician buy-in as barriers limiting oncologic care. CONCLUSION Third-party care coordination centers provide a novel and potentially unrecognized approach to increasing oncology service access. Further research should identify strategies to overcome the relative lack of oncologic care offerings. [ABSTRACT FROM AUTHOR]