Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program

BACKGROUND

Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists.

METHODS

The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3-7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics.

RESULTS

According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that "UMPH made me more likely to practice primary care" and 59% agreed "UMPH should target residents pursuing subpecialty careers."

CONCLUSIONS

A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers.

Patients' and Caregivers' Experiences with the Multi-Payer Advanced Primary Care Practice Demonstration

BACKGROUND

The patient-centered medical home (PCMH) model aims to improve primary health care using a patient-centered approach. Little qualitative research has investigated how the PCMH model affects patient experience with care.

OBJECTIVE

To understand Medicaid and Medicare patient and caregiver experiences with PCMHs participating in the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration.

DESIGN

Qualitative study.

PARTICIPANTS

Medicare, Medicaid, and dually eligible patients who were patients in primary care practices participating in the MAPCP Demonstration and caregivers of such patients (N = 490).

APPROACH

From July through November 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the MAPCP Demonstration. Separate groups were held for Medicare high-risk, Medicare low-risk, Medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of Medicaid children (or, in Vermont, with patients participating in the Support and Services at Home program), in two different geographical areas in each state. Focus group discussions were recorded, transcribed, and analyzed using NVivo qualitative data analysis software.

RESULTS

Participants' experiences with care were generally consistent with the expectations of a PCMH, although some exceptions were noted. Medicaid only and dually eligible beneficiaries generally had less-positive experiences than Medicare beneficiaries. Most participants said their practices had not solicited feedback from them about their experiences with care. Few participants knew what the term "medical home" meant or were aware that their practices were working to become PCMHs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records.

CONCLUSIONS

Most participants had positive experiences with their care. Opportunities exist, however, to improve care for Medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in PCMH practice transformation.

Does Primary Care Provider Supply Influence Medicaid Acceptability?

BACKGROUND

Following the Affordable Care Act's Medicaid expansions, access to care improved through elevated coverage rates among the low-income population. In Michigan, a major factor contributing to improved access among low-income patients was increased Medicaid acceptance in primary care settings.

OBJECTIVES

Prior evidence shows substantial geographic variation preacceptance and postacceptance of Medicaid. In this study, we determine whether physician's willingness to accept new Medicaid patients is moderated by the availability of other providers in close proximity.

METHODS

The study uses Michigan simulated patient (ie, "secret shopper") data collected during 2014 and 2015, and applies a difference-in-differences styled event-study regression approach comparing trends in Medicaid acceptability and appointment scheduling between areas in Michigan with higher densities of primary care providers against those with lower densities of providers that could arguably be classified a health professional shortage areas.

RESULTS

Through one year after Michigan's Medicaid expansion, practices in low-supply areas appeared no more likely (P>0.10) to turn away a newly insured Medicaid patient than a practice in a supply-rich area. The wait times for patients in a low-supply area were about a day longer (P<0.05) than for patients in supply-rich areas through 4 months after the expansion, though this difference dissipated through 8 and 12 months after the expansion.

CONCLUSIONS

These results indicate that newly insured Medicaid patients are gaining access to care in settings with limited health care supply.

Most Primary Care Physicians Provide Appointments, But Affordability Remains A Barrier For The Uninsured

The US uninsurance rate has nearly been cut in half under the Affordable Care Act, and access to care has improved for the newly insured, but less is known about how the remaining uninsured have fared. In 2012-13 and again in 2016 we conducted an experiment in which trained auditors called primary care offices, including federally qualified health centers, in ten states. The auditors portrayed uninsured patients seeking appointments and information on the cost of care and payment arrangements. In both time periods, about 80 percent of uninsured callers received appointments, provided they could pay the full cash amount. However, fewer than one in seven callers in both time periods received appointments for which they could make a payment arrangement to bring less than the full amount to the visit. Visit prices in both time periods averaged about $160. Trends were largely similar across states, despite their varying changes in the uninsurance rate. Federally qualified health centers provided the highest rates of primary care appointment availability and discounts for uninsured low-income patients.

The impact of public performance reporting on health plan selection and switching: A systematic review and meta-analysis

The dissemination of public performance reporting (PPR) cards aims to increase utilisation of information on quality of care by consumers when making health plan choices. However, evaluations of PPR cards show that they have little impact on consumer choices. The aim of this study is to undertake a systematic review and meta-analysis of the impact of PPR cards in promoting health plan selection and switching between health plans by consumers. We searched five online databases and eight previous reviews for studies reporting findings on PPR and health plans. We extracted data and conducted quality assessment, systematic critical synthesis and meta-analyses on the included studies. We identified eight relevant health plan articles related to selection (n = 2), switching (n = 4), selection/switching (n = 2). Meta-analyses showed that PPR was associated with an improvement in health plan selection and a very small deterioration in switching health plans though these changes were not statistically significant. Differences were observed between employer-sponsored health insurance and Medicare/Medicaid insurance. Given the small number of studies included in the review, further research examining the impact of PPR on health plan selection and switching in a range of insurance markets is required.

State Variation in Medicaid Reimbursements for Orthopaedic Surgery

BACKGROUND

Medicaid reimbursements are determined by each state and are subject to variability. We sought to quantify this variation for commonly performed inpatient orthopaedic procedures.

METHODS

The 10 most commonly performed inpatient orthopaedic procedures, as ranked by the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, were identified for study. Medicaid reimbursement amounts for those procedures were benchmarked to state Medicare reimbursement amounts in 3 ways: (1) ratio, (2) dollar difference, and (3) dollar difference divided by the relative value unit (RVU) amount. Variability was quantified by determining the range and coefficient of variation for those reimbursement amounts.

RESULTS

The range of variability of Medicaid reimbursements among states exceeded $1,500 for all 10 procedures. The coefficients of variation ranged from 0.32 (hip hemiarthroplasty) to 0.57 (posterior or posterolateral lumbar interbody arthrodesis) (a higher coefficient indicates greater variability), compared with 0.07 for Medicare reimbursements for all 10 procedures. Adjusted as a dollar difference between Medicaid and Medicare per RVU, the median values ranged from -$8/RVU (total knee arthroplasty) to -$17/RVU (open reduction and internal fixation of the femur).

CONCLUSIONS

Variability of Medicaid reimbursement for inpatient orthopaedic procedures among states is substantial. This variation becomes especially remarkable given recent policy shifts toward focusing reimbursements on value.

Physicians' Perceptions of Volunteer Service at Safety-Net Clinics

BACKGROUND

Volunteer physicians are crucial for the operation of safety-net clinics, which provide medical care for uninsured and underinsured populations. Thus, identifying ways to maximize the number of physicians volunteering at such clinics is an important goal.

OBJECTIVE

To investigate the perceptions, motivations, functions, and barriers associated with physician volunteering in four safety-net clinics in San Bernardino County, Southern California, a location of great medical need with many barriers to care.

METHODS

The study participants are physicians belonging to the Southern California Permanente Medical Group who use a combination of discretionary time (during regular work hours) and personal time in evening and weekend hours to volunteer their services. The experimental design incorporates a mixed methodology: an online survey of 31 physicians and follow-up interviews with 8 of them.

RESULTS

Physicians conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective "escape hatch" from the pressures of the physicians' regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients' social, transportation, and financial challenges.

CONCLUSION

The results suggest that appealing to physicians' values and faith, and highlighting the burnout-prevention qualities of volunteering, may be key to recruitment and retention of volunteer physicians who serve underserved and underinsured populations in community clinics.

Effects of state-level medicaid policies and patient characteristics on time to breast cancer surgery among medicaid beneficiaries

Medicaid beneficiaries with cancer are less likely to receive timely and high-quality care. This study examined whether differences in state-level Medicaid policies affect delays in time to surgery (TTS) among women diagnosed with breast cancer. Using 2006-2008 Medicaid data, we identified women aged 18-64 enrolled in Medicaid diagnosed with breast cancer. Analyses examined associations of state-specific Medicaid surgery reimbursements, Medicaid eligibility recertification period (annually vs. shorter) and required patient copayment on time from breast cancer diagnosis to receipt of breast surgery. Patients receiving neoadjuvant therapy were excluded. Separate multivariable regression analyses controlling for patient demographic characteristics and clustering by state were performed for breast conserving surgery (BCS), inpatient mastectomy, and outpatient mastectomy. The study included 7542 Medicaid beneficiaries with breast cancer: 3272 received BCS, 2156 outpatient mastectomy, and 2115 inpatient mastectomy. Higher Medicaid reimbursements for BCS were associated with decreased time from diagnosis to surgery. A 12-month (vs. <12 month) Medicaid eligibility recertification period was associated with decreased TTS for BCS and outpatient mastectomy. Black Medicaid beneficiaries (compared with non-Hispanic White beneficiaries) were more likely to experience delays for all three types of surgery, while Hispanic beneficiaries were more likely to experience delays only for outpatient mastectomy. State-level Medicaid policies and patient characteristics can affect receipt of timely surgery among Medicaid beneficiaries with breast cancer. As delays in surgery can increase morbidity and mortality, changes to state Medicaid policies and health system programs are needed to improve access to care for this vulnerable population.

The Effect of Medicaid Expansion on Delivery of Finger and Thumb Replantation Care to Medicaid Beneficiaries and the Uninsured

BACKGROUND

Despite advances in replantation, over 80 percent of finger and thumb amputation injuries in the United States result in revision amputation. Although numerous factors contribute to this, disparities in access and delivery of replantation care play a substantial role. With ongoing Medicaid expansion under the Affordable Care Act, it is prudent to understand whether expansion of coverage changes use of replantation care.

METHODS

The authors used the 2001 Medicaid expansion in New York State to evaluate changes in replantation for Medicaid beneficiaries and the uninsured. Data for patients having undergone replantation between 1998 and 2006 were obtained from the New York State Inpatient Database. The authors used an interrupted time series to evaluate the effect of Medicaid expansion on the probability that Medicaid beneficiaries or uninsured patients underwent replantation. Census data were used for population-adjusted case volume analysis.

RESULTS

After expansion, the likelihood of Medicaid as the primary payer for replantation increased 0.0059 percent per quarter, reaching a 1.7 percent increase 5 years after expansion. With population-based analysis, this indicates that Medicaid covered 12 additional replantation cases in New York State annually. After expansion, 11 fewer of the replantation cases in New York State each year were provided to patients without health care coverage.

CONCLUSIONS

Medicaid expansion resulted in a modest but significant increase in replantation for Medicaid beneficiaries. In addition, fewer patients that underwent replantation remained uninsured. Considering the substantial cost and effort burden of replantation, these findings support the benefits of Medicaid expansion on delivery and payer coverage of replantation.

Measuring Medicaid Physician Participation Rates and Implications for Policy

Policy makers continue to debate Medicaid expansion under the Affordable Care Act, and concerns remain about low provider participation in the program. However, there has been little research on how various measures of physician participation may reflect different elements of capacity for care within the Medicaid program and how these distinct measures correlate with one another across states. Our objectives were to describe several alternative measures of provider participation in Medicaid using recently publicly available data, to compare state rankings across these different metrics, and to discuss potential advantages and disadvantages of each measure for research and policy purposes. Overall, we find that Medicaid participation as measured by raw percentages of physicians taking new Medicaid patients is only weakly correlated with population-based measures that account for both participation rates and the numbers of physicians per capita or physicians per Medicaid beneficiary. Participation rates for all physicians versus primary care physicians also offer different information about state-level provider capacity. Policy makers should consider multiple dimensions of provider access in assessing policy options in Medicaid, and further research is needed to evaluate the linkages between these provider-based measures and beneficiaries' perceptions of access to care in the program.

Testing the Validity of Primary Care Physicians' Self-Reported Acceptance of New Patients by Insurance Status

OBJECTIVE

To compare physicians' self-reported willingness to provide new patient appointments with the experience of research assistants posing as either a Medicaid beneficiary or privately insured person seeking a new patient appointment.

DATA SOURCES/STUDY SETTING

Survey administered to California physicians and telephone calls placed to a subsample of respondents.

STUDY DESIGN

Cross-sectional comparison.

DATA COLLECTION/EXTRACTION METHODS

All physicians whose California licenses were due for renewal in June or July 2013 were mailed a survey, which included questions about acceptance of new Medicaid and new privately insured patients. Subsequently, research assistants using a script called the practices of a stratified random sample of 209 primary care physician respondents in an attempt to obtain a new patient appointment. By design, half of the physicians selected for the telephone validation reported on the survey that they accepted new Medicaid patients and half indicated that they did not.

PRINCIPAL FINDINGS

The percentage of callers posing as Medicaid patients who could schedule new patient appointments was 18 percentage points lower than the percentage of physicians who self-reported on the survey that they accept new Medicaid patients. Callers were also less likely to obtain appointments when they posed as patients with private insurance.

CONCLUSIONS

Physicians overestimate the extent to which their practices are accepting new patients, regardless of insurance status.

Changes in use of autologous and prosthetic postmastectomy reconstruction after medicaid expansion in New York state

BACKGROUND

With Medicaid expansion beginning in 2014, it is important to understand the effects of access to reconstructive services for new beneficiaries. The authors assessed changes in use of breast cancer reconstruction for Medicaid beneficiaries after expansion in New York State in 2001.

METHODS

The authors used the State Inpatient Database for New York (1998 to 2006) for all patients aged 19 to 64 years who underwent breast reconstruction. An interrupted time series design with linear regression modeling evaluated the effect of Medicaid expansion on the proportion of breast reconstruction patients that were Medicaid beneficiaries.

RESULTS

The proportion of breast reconstructions provided to Medicaid beneficiaries increased by 0.28 percent per quarter after expansion (p < 0.001), resulting in a 5.5 percent increase above predicted trajectory without expansion. This corresponds to a population-adjusted increase of 1.8 Medicaid cases per 1 million population per quarter. On subgroup analysis, there was no significant increase in the proportion of autologous reconstructions (p = 0.4); however, the proportion of prosthetic reconstructions for Medicaid beneficiaries had a significant increase of 0.41 percent per quarter (p < 0.001), resulting in a 7.5 percent cumulative increase. This indicates that 135 additional prosthetic reconstruction operations were provided to Medicaid beneficiaries within 5 years of expansion.

CONCLUSIONS

Surgeons increased the volume of breast reconstructions provided to Medicaid beneficiaries after expansion. However, there are disparities between autologous and prosthetic reconstruction. If Medicaid expansion is to provide comprehensive care, with adequate access to all reconstructive options, these disparities must be addressed.

Finding medical care for colorectal cancer symptoms: experiences among those facing financial barriers

Financial barriers can substantially delay medical care seeking. Using patient narratives provided by 252 colorectal cancer patients, we explored the experience of financial barriers to care seeking. Of the 252 patients interviewed, 84 identified financial barriers as a significant hurdle to obtaining health care for their colorectal cancer symptoms. Using verbatim transcripts of the narratives collected from patients between 2008 and 2010, three themes were identified: insurance status as a barrier (discussed by n = 84; 100% of subsample), finding medical care (discussed by n = 30; 36% of subsample) and, insurance companies as barriers (discussed by n = 7; 8% of subsample). Our analysis revealed that insurance status is more nuanced than the categories insured/uninsured and differentially affects how patients attempt to secure health care. While barriers to medical care for the uninsured have been well documented, the experiences of those who are underinsured are less well understood. To improve outcomes in these patients it is critical to understand how financial barriers to medical care are manifested. Even with anticipated changes of the Affordable Care Act, it remains important to understand how perceived financial barriers may be influencing patient behaviors, particularly those who have limited health care options due to insufficient health insurance coverage.

The effect of pre-Affordable Care Act (ACA) Medicaid eligibility expansion in New York State on access to specialty surgical care

BACKGROUND

Critics argue that expanding health insurance coverage through Medicaid may not result in improved access to care. The Affordable Care Act provides reimbursement incentives aimed at improving access to primary care services for new Medicaid beneficiaries; however, there are no such incentives for specialty services. Using the natural experiment of Medicaid expansion in New York (NY) State in October 2001, we examined whether Medicaid expansion increased access to common musculoskeletal procedures for Medicaid beneficiaries.

METHODS

From the State Inpatient Database for NY State, we identified 19- to 64-year-old patients who underwent lower extremity large joint replacement, spine procedures, and upper/lower extremity fracture/dislocation repair from January 1998 to December 2006. We used interrupted time series analysis to evaluate the association between Medicaid expansion and trends in the relative and absolute number of Medicaid beneficiaries who underwent these musculoskeletal procedures.

RESULTS

Before Medicaid expansion, we observed a slight but steady temporal decline in the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries. After expansion, this trend reversed, and by 5 years after Medicaid expansion, the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries was 4.7 percentage points [95% confidence interval, 3.9-5.5] higher than expected, based on the preexpansion time trend.

CONCLUSION

Medicaid expansion in NY State significantly improved access to common musculoskeletal procedures for Medicaid beneficiaries.

Impact of state-specific Medicaid reimbursement and eligibility policies on receipt of cancer screening

BACKGROUND

Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries.

METHODS

Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal.

RESULTS

Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined.

CONCLUSIONS

Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population.

The effect of medicaid expansion in new york state on use of subspecialty surgical procedures by medicaid beneficiaries and the uninsured

BACKGROUND

Understanding the benefits of Medicaid is crucial as states decide whether to expand Medicaid under the Patient Protection and Affordable Care Act. We used the 2001 Medicaid expansion in New York to evaluate changes in use by Medicaid beneficiaries and the uninsured of breast cancer reconstruction, panniculectomy, and lower-extremity trauma management.

METHODS

Data for all patients 19 to 64 years old having undergone the selected procedures between 1998 and 2006 were obtained from the State Inpatient Database. We used an interrupted time series using variance weighted least squares regression to evaluate the effect of Medicaid expansion on the probability that Medicaid beneficiaries or uninsured patients received the procedures. We also determined the predicted use had there been no expansion. New York Census data were used for population-adjusted case-volume calculations.

RESULTS

Likelihood of Medicaid as the primary payer increased significantly after expansion, 0.34% per quarter (95% CI, 0.28-0.40), without a decrease in uninsured patients receiving these procedures. This resulted in a 7.2% increase in the proportion of Medicaid beneficiaries receiving these procedures, an additional 1.9 Medicaid cases per quarter per 100,000 New York residents. In subgroup analysis, the proportion of Medicaid beneficiaries increased for breast reconstruction (0.28% per quarter; 95% CI, 0.21-0.35) and panniculectomy (0.19% per quarter; 95% CI, 0.1-0.28) without a decrease for the uninsured. Lower-extremity trauma procedures had a decreasing trend in use by uninsured patients with a slight increase for Medicaid beneficiaries (not significant).

CONCLUSIONS

Subspecialty surgeons responded to expansion by increasing volume of procedures for Medicaid beneficiaries. This occurred without decline in care for the uninsured, suggesting that Medicaid expansion resulted in increased access for underserved patients. Although more patients received needed care once they had coverage, subgroup analysis identified persistence of additional barriers to use of certain surgical services.

Exploration of Charity toward Busking (Street Performance) as a Function of Religion

To examine conceptions of religion and charity in a new venue—busking (street performance)—103 undergraduate students at a regional universityin the southeastern U.S. completed a battery of surveys regarding religion, and attitudes and behaviors toward busking. For those 85 participants who had previously encountered a busker, stepwise regression was used to predict increased frequency of giving to buskers. The best predictive model of giving to buskers consisted of three variables including less experienced irritation toward buskers, prior experience with giving to the homeless, and lower religious fundamentalism.

The impact of insurance coverage in diminishing racial and ethnic disparities in behavioral health services

OBJECTIVE

To estimate whether racial/ethnic behavioral health service disparities are likely to be reduced through insurance expansion coverage expected through the Affordable Health Care Act.

DATA SOURCES

Pooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001-2003).

STUDY DESIGN

We employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage.

DATA COLLECTION

Access to care was assessed by whether any behavioral health treatment was received in the past year. Need was determined by presence of prior year psychiatric disorder, psychiatric diagnoses, physical comorbidities, gender, and age.

PRINCIPAL FINDINGS

Improving patient education and availability of community clinics, combined with insurance coverage reduces service disparities across racial/ethnic groups.However, even with expanded insurance coverage, approximately 10 percent fewer African Americans with need for behavioral health services are likely to receive services compared to non-Latino whites while Latinos show no measurable disparity.

CONCLUSIONS

Expansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.

Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures?

BACKGROUND

Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs.

OBJECTIVE

To examine the association between PO location and P4P performance.

DESIGN

Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S.

PARTICIPANTS

160 POs participating in 2009.

MAIN MEASURES

We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use.

KEY RESULTS

The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001).

CONCLUSIONS

Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.

Residents' attitudes and behaviors regarding care for underserved patients: a multi-institutional survey

BACKGROUND

Resident physicians often encounter underprivileged patients before other providers, yet little is known about residents' attitudes and behaviors regarding these patients.

OBJECTIVE

To measure US resident physician attitudes regarding topics relevant to medically underserved patients, their behaviors (volunteerism) with underserved patients, and the association between attitudes and behaviors.

METHODS

In 2007 and 2008, 956 surveys on resident attitudes and behaviors about underserved patients were distributed to 18 residency programs in the United States. Survey content was based on existing literature and an expert needs assessment. The attitude assessment had 15 items with 3-point scales (range 0-1). The behavior assessment evaluated volunteering for underserved patients in the past, present, and future.

RESULTS

A total of 498 surveys (response rate  =  52%) were completed. Attitudes regarding underserved patients were generally positive and more favorable for women than men (overall attitude score 0.83 versus 0.74; P  =  < .001). Rates of volunteering for underserved patients were high in medical school (N  =  375, 76%) and anticipated future practice (N  =  409, 84%), yet low during residency (N  =  95, 19%). Respondents who volunteered regularly had more favorable attitudes than those who did not volunteer (overall average attitude score of 0.81 versus 0.73; P  =  <.001). Relationships between hours volunteered per-week and favorable attitudes about topics related to the underserved were significant across all 15 items in medical school and anticipated future practice (P value range of .035 to <.0001).

CONCLUSIONS

This survey revealed that US residents' attitudes towards topics regarding medically underserved populations are generally favorable. Rates of volunteerism for underserved patients were higher in medical school than during residency, and resident's anticipated rates of volunteerism in future practice volunteerism were approximately the same as rates of volunteerism in medical school. Resident attitudes are strongly correlated with volunteerism.

Auditing access to specialty care for children with public insurance

BACKGROUND

Health care reform has expanded eligibility to public insurance without fully addressing concerns about access. We measured children's access to outpatient specialty care to identify disparities in providers' acceptance of Medicaid and the Children's Health Insurance Program (CHIP) versus private insurance.

METHODS

Between January and May 2010, research assistants called a stratified, random sample of clinics representing eight specialties in Cook County, Illinois, which has a high proportion of specialists. Callers posed as mothers of pediatric patients with common health conditions requiring outpatient specialty care. Two calls, separated by 1 month, were placed to each clinic by the same person with the use of a standardized clinical script that differed by insurance status.

RESULTS

We completed 546 paired calls to 273 specialty clinics and found significant disparities in provider acceptance of Medicaid-CHIP versus private insurance across all tested specialties. Overall, 66% of Medicaid-CHIP callers (179 of 273) were denied an appointment as compared with 11% of privately insured callers (29 of 273) (relative risk, 6.2; 95% confidence interval [CI], 4.3 to 8.8; P<0.001). Among 89 clinics that accepted both insurance types, the average wait time for Medicaid-CHIP enrollees was 22 days longer than that for privately insured children (95% CI, 6.8 to 37.5; P=0.005).

CONCLUSIONS

We found a disparity in access to outpatient specialty care between children with public insurance and those with private insurance. Policy interventions that encourage providers to accept patients with public insurance are needed to improve access to care.

Erosion in the Healthcare Safety Net: Impacts on Different Population Groups

Safety net hospitals (SNHs) have played a critical role in the U.S. health system providing access to health care for vulnerable populations, in particular the Medicaid and uninsured populations. However, little research has examined how access for these populations changes when contraction of the safety net occurs. Institutional policies, such as hospital closure or ownership conversion, could affect the supply of minority health care providers, thus exacerbating disparities in outcomes. We use multilevel logistic modeling of person-level hospital discharge data to examine the effects of contractions in the California safety net over the period of 1990-2000 on access to care as measured by changes in ambulatory care sensitive condition (ACSC) admissions, using geographic methods to characterize proximity to a contraction event. We found that presence of a contraction event was associated with a statistically significant increase in the predicted probability of impeded access, with an increase of about 1% for Medicaid-insured populations and about 4-5% for the uninsured. The Medicaid-insured group also maintained the highest rates of ACSC admissions over time, suggesting persistent access problems for this vulnerable group. This research is timely given continued budget problems in many states, where rising unemployment has increased the number of Medicaid enrollees by 6 million and uninsured individuals by 1.5 million, increasing pressure on remaining SNHs.

Time is money: opportunity cost and physicians' provision of charity care 1996-2005

OBJECTIVE

To test whether physicians' provision of charity care depends on their hourly wage.

DATA SOURCES

Secondary data from four rounds of the Community Tracking Study (CTS) Physician Survey (1996-2005). Data are nationally representative of nonfederal office- and hospital-based physicians spending at least 20 hours per week on patient care.

STUDY DESIGN

A two-part model with site-level fixed effects, time trend variables, and site-year interactions is used to model the relationship between physicians' hourly wage and both their decision to provide any charity care and the amount of charity care provided. Salaried and nonsalaried physicians are modeled separately.

DATA COLLECTION/EXTRACTION METHODS

Data from each round of the CTS were merged into a single cross-sectional file with 38,087 physician-year observations.

PRINCIPAL FINDINGS

The association between physician's hourly wage and the likelihood of providing charity care is positive for salaried physicians and negative for nonsalaried physicians. Among physicians providing any charity care, hourly wage is positively associated with the amount of charity care provided regardless of salaried status. Practice characteristics are also significant.

CONCLUSIONS

The financial considerations of salaried physicians differ significantly from those of nonsalaried physicians in the decision to provide charity care, but factor similarly into the amount of charity care provided.

Unhealthy competition: consequences of health plan choice in California Medicaid

OBJECTIVES

We compared the quality of care received by managed care Medicaid beneficiaries in counties with a choice of health plans and counties with no choice.

METHODS

This cross-sectional study among California Medicaid beneficiaries was conducted during 2002. We used a multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care-sensitive conditions by duration of plan enrollment.

RESULTS

Among beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%; P < .001). Annual ambulatory care-sensitive admission rates adjusted for age, gender, and race/ethnicity were significantly higher among beneficiaries living in counties with a choice of plans (6.58 admissions per 1000 beneficiaries; 95% confidence interval [CI] = 6.57, 6.58) than among those in counties with no choice (6.27 per 1000; 95% CI = 6.27, 6.28).

CONCLUSIONS

Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.

Beyond insurance coverage: usual source of care in the treatment of hypertension and hypercholesterolemia. Data from the 2003-2006 National Health and Nutrition Examination Survey

BACKGROUND

Expanding insurance coverage, while necessary, may not be sufficient to ensure high-quality care for adults with cardiovascular disease. We sought to examine the association between having a usual source of care (USOC) and receiving medication treatment of hypertension and hypercholesterolemia.

METHODS

Using the 2003-2006 National Health and Nutrition Examination Survey, we categorized USOC (a place to go when sick or need medical advice) and insurance status in adults >or=35 years old with an indication for medication treatment of hypertension (n = 3,142) and hypercholesterolemia (n = 1,134), determined using the Joint National Committee 7 and Adult Treatment Panel III recommendations, respectively. Multivariable logistic regression modeling was used to determine the independent effect of USOC on receiving treatment of hypertension and hypercholesterolemia, controlling for age, sex, race/ethnicity, insurance status, and comorbidities. Separate multivariable models were examined stratified by insurance status.

RESULTS

Among subjects with an indication for treatment of hypertension and hypercholesterolemia, 32.4% and 42.0% were untreated, respectively. When compared with adults with a USOC, adults without a USOC were more likely to be untreated for hypertension (adjusted prevalence ratio [aPR] 2.43, 95% CI 1.88-2.85) and hypercholesterolemia (aPR 1.79, 95% CI 1.31-2.13). In stratified analyses among subjects with insurance, no USOC remained associated with being untreated (hypertension, aPR 2.58, 95% CI 1.88-3.08; hypercholesterolemia, aPR 1.65, 95% CI 0.97-2.18).

CONCLUSIONS

Absence of a USOC was associated with being untreated for hypertension and hypercholesterolemia, even among individuals with insurance, suggesting that efforts to improve chronic disease management should also facilitate access to a regular source of care.

Medicaid funding for abortion: providers' experiences with cases involving rape, incest and life endangerment

CONTEXT

The Hyde Amendment bans federal Medicaid funding for abortion in the United States except if a pregnancy resulted from rape or incest or endangers the life of the woman. Some evidence suggests that providers do not always receive Medicaid reimbursement for abortions that should qualify for funding.

METHODS

From October 2007 to February 2008, semistructured in-depth interviews about experiences with Medicaid reimbursement for qualifying abortions were conducted with 25 respondents representing abortion providers in six states. A thematic analysis approach was used to explore respondents' knowledge of and experiences seeking Medicaid reimbursement for qualifying abortions, as well as individual, clinical and structural influences on reimbursement. The numbers of qualifying cases that were and were not reimbursed were assessed.

RESULTS

More than half of Medicaid-eligible cases reported by respondents in the past year were not reimbursed. Respondents reported that filing for reimbursement takes excessive staff time and is hampered by bureaucratic claims procedures and ill-informed Medicaid staff, and that reimbursements are small. Many had stopped seeking Medicaid reimbursement and relied on nonprofit abortion funds to cover procedure costs. Respondents reporting receiving reimbursement said that streamlined forms, a statewide education intervention and a legal intervention to ensure that Medicaid reimbursed claims facilitated the process.

CONCLUSIONS

The policy governing federal funding of abortion is inconsistently implemented. Eliminating administrative burdens, educating providers about women's rights to obtain Medicaid reimbursement for abortion in certain circumstances and holding Medicaid accountable for reimbursing qualifying cases are among the steps that may facilitate Medicaid reimbursement for qualifying abortions.

Do reimbursement delays discourage Medicaid participation by physicians?

Policymakers have focused primarily on increasing Medicaid reimbursement rates to increase physicians' participation in Medicaid, although physicians often complain of payment delays and other administrative burdens associated with Medicaid. Linking state-level data on average reimbursement times to the 2004-05 Community Tracking Study Physician Survey, this study examines how Medicaid reimbursement time affects physicians' willingness to accept Medicaid patients. Delays in reimbursement can offset the effects of high Medicaid fees, thereby lowering participation to levels that are closer to those in states with relatively low rates. Increasing these rates may be insufficient to increase physicians' participation unless accompanied by reductions in administrative burden.