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Sommers BD, Tipirneni R. Reconsidering and Measuring Patient Access in Medicaid. JAMA HEALTH FORUM 2024; 5:e241399. [PMID: 38662351 DOI: 10.1001/jamahealthforum.2024.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
This JAMA Forum discusses the ways that policymakers can use different metrics that are more meaningful to patients when measuring patient access to treatment in the Medicaid program.
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Affiliation(s)
- Benjamin D Sommers
- Department of Health Policy and Management, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Renuka Tipirneni
- Division of General Medicine, Institute for Healthcare Policy and Innovation and University of Michigan Medical School, Ann Arbor
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2
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Volerman A, Carlson B, Wan W, Murugesan M, Asfour N, Bolton J, Chin MH, Sripipatana A, Nocon RS. Utilization, quality, and spending for pediatric Medicaid enrollees with primary care in health centers vs non-health centers. BMC Pediatr 2024; 24:100. [PMID: 38331758 PMCID: PMC10851548 DOI: 10.1186/s12887-024-04547-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Limited research has explored the performance of health centers (HCs) compared to other primary care settings among children in the United States. We evaluated utilization, quality, and expenditures for pediatric Medicaid enrollees receiving care in HCs versus non-HCs. METHODS This national cross-sectional study utilized 2012 Medicaid Analytic eXtract (MAX) claims to examine children 0-17 years with a primary care visit, stratified by whether majority (> 50%) of primary care visits were at HCs or non-HCs. Outcome measures include utilization (primary care visits, non-primary care outpatient visits, prescription claims, Emergency Department (ED) visits, hospitalizations) and quality (well-child visits, avoidable ED visits, avoidable hospitalizations). For children enrolled in fee-for-service Medicaid, we also measured expenditures. Propensity score-based overlap weighting was used to balance covariates. RESULTS A total of 2,383,270 Medicaid-enrolled children received the majority of their primary care at HCs, while 18,540,743 did at non-HCs. In adjusted analyses, HC patients had 20% more primary care visits, 15% less non-primary care outpatient visits, and 21% less prescription claims than non-HC patients. ED visits were similar across the two groups, while HC patients had 7% lower chance of hospitalization than non-HC. Quality of care outcomes favored HC patients in main analyses, but results were less robust when excluding managed care beneficiaries. Total expenditures among the fee-for-service subpopulation were lower by $239 (8%) for HC patients. CONCLUSIONS In this study of nationwide claims data to evaluate healthcare utilization, quality, and spending among Medicaid-enrolled children who receive primary care at HCs versus non-HCs, findings suggest primary care delivery in HCs may be associated with a more cost-effective model of healthcare for children.
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Affiliation(s)
- Anna Volerman
- Departments of Medicine and Pediatrics, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - Bradley Carlson
- University of Chicago Pritzker School of Medicine, 924 E 57th St, Chicago, IL, 60637, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Manoradhan Murugesan
- Department of Public Health Sciences, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Nour Asfour
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Joshua Bolton
- Health Resources and Services Administration (Affiliation at Time Research Conducted), 5600 Fishers Lane, Rockville, MD, 20857, USA
| | - Marshall H Chin
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Alek Sripipatana
- Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD, 20857, USA
| | - Robert S Nocon
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA, 91101, USA
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Jones JC, Golafshar MA, Coston TW, Rao R, Wysokinska E, Johnson E, Esplin ED, Nussbaum RL, Heald B, Klint M, Barrus K, Uson PL, Nguyen CC, Colon-Otero G, Bekaii-Saab TS, Dronca R, Kunze KL, Samadder NJ. Universal Genetic Testing vs. Guideline-Directed Testing for Hereditary Cancer Syndromes Among Traditionally Underrepresented Patients in a Community Oncology Program. Cureus 2023; 15:e37428. [PMID: 37181954 PMCID: PMC10173369 DOI: 10.7759/cureus.37428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Background Detection of pathogenic germline variants (PGVs) has implications for cancer screening, prognosis, treatment selection, clinical trial enrollment, and family testing. Published guidelines provide indications for PGV testing, determined by clinical and demographic factors, but their applicability in an ethnically and racially diverse community hospital population is unknown. This study describes the diagnostic and incremental yield of universal multi-gene panel testing in a diverse population in a community cancer practice. Methods We completed a prospective study of proactive germline genetic sequencing among patients with solid tumor malignancies at a community-based oncology practice in downtown Jacksonville, FL, between June 2020 and September 2021. The patients were unselected for cancer type, stage, family history, race/ethnicity, and age. PGVs identified using an 84-gene next-generation sequencing (NGS) tumor genomic testing platform were stratified by penetrance. National Comprehensive Cancer Networks (NCCN) guidelines determined incremental PGV rates. Results Two hundred twenty-three patients were enrolled, with a median age of 63 years, 78.5% female. 32.7% were Black/African American, and 5.4% were Hispanic. 39.9% of patients were commercially insured, Medicare/Medicaid insured 52.5%, and 2.7% were uninsured. The most common cancers in this cohort were breast (61.9%), lung (10.3%), and colorectal (7.2%). Twenty-three patients (10.3%) carried one or more PGVs, and 50.2% carried a variant of uncertain significance (VUS). Though there was no significant difference in the rate of PGVs based on race/ethnicity, African Americans were numerically more likely to have a VUS reported than whites (P=0.059). Eighteen (8.1%) patients had incremental clinically actionable findings that practice guidelines would not have detected, which was higher in non-whites. Conclusions In this racially/ethnically and socioeconomically diverse cohort, universal multi-gene panel testing (MGPT) increased diagnostic yield over targeted guideline-informed testing. Rates of VUS and incremental PGV were higher in non-white populations.
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Affiliation(s)
| | | | | | - Rohit Rao
- Hematology & Oncology, Mayo Clinic, Jacksonville, USA
| | | | | | | | | | - Brandie Heald
- Medical Affairs, Invitae Corporation, San Francisco, USA
| | | | | | - Pedro L Uson
- Hematology & Oncology, Mayo Clinic, Phoenix, USA
| | | | | | | | - Roxana Dronca
- Hematology & Oncology, Mayo Clinic, Jacksonville, USA
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Jung OS, Cummings JR. Employee Engagement in Quality Improvement and Patient Sociodemographic Characteristics in Federally Qualified Health Centers. Med Care Res Rev 2023; 80:43-52. [PMID: 36000499 PMCID: PMC9806475 DOI: 10.1177/10775587221118157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Quality improvement (QI) work is critical, particularly in federally qualified health centers (FQHCs) that treat underserved populations. In a national sample of 45 FQHCs, we examined how patients' sociodemographic characteristics were associated with employee engagement in QI, via innovation contests that solicited ideas for improving care and offered opportunities to vote on ideas. We posited that patients' sociodemographic characteristics influence the complexity and intensity of clinical work and thus employees' capacity to engage in QI. Regression results indicated that the percentage of patients living in poverty was negatively associated with employee participation in idea submission and voting. Moreover, the percentage of Hispanic patients was negatively associated with participation in voting. The percentage of Black patients, however, was not associated with either outcome. FQHCs that serve a higher share of low income and/or Hispanic patients may face resource and personnel constraints that reduce employees' capacity to contribute to QI efforts.
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Affiliation(s)
- Olivia S. Jung
- Emory University, Atlanta, GA,
USA,Harvard University, Allston, MA,
USA,Massachusetts General Hospital, Boston,
USA,Olivia S. Jung, Department of Health Policy
and Management, Rollins School of Public Health, Emory University, 1518 Clifton
Road, Atlanta, GA 30322, USA.
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Barnes PA, Barouhas I, Staab EM, Benitez A, Li J, Campbell A, Schaefer CT, Quinn M, Baig AA. Assessing the effectiveness of a diabetes group visit training for health center staff: a pilot study of five Midwestern community health centers. BMC Health Serv Res 2022; 22:747. [PMID: 35659672 PMCID: PMC9167554 DOI: 10.1186/s12913-022-08108-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 05/16/2022] [Indexed: 11/11/2022] Open
Abstract
Background Diabetes group visits are shared appointments that include diabetes education in a group setting and individual visits with a medical provider. An 18-month pilot study was designed to evaluate organizational capacity and staff preparedness in implementing and sustaining diabetes group visits. Results Data were collected and analyzed from pre-post assessments and key informant interviews with community health center (CHC) staff (N = 26) from teams across five Midwestern states. Overall, participants demonstrated high baseline knowledge and awareness about diabetes group visit implementation. Changes in attitudes and practices did occur pertaining to familiarity with billing and increased awareness about potential barriers to diabetes group visit implementation. Key assets to diabetes group visit implementation were access to pre-designed resources and materials, a highly motivated team, and supportive leadership. Key obstacles were socioeconomic challenges experienced by patients, constraints on staff time dedicated to group visit implementation, and staff turnover. Conclusions Results of the study provide a framework for implementation of diabetes group visit trainings for CHC staff. Future research is needed to assess the training program in a larger sample of CHCs.
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Antecedents of geographical expansion: The case of federally qualified health centers. Health Care Manage Rev 2022; 47:E32-E40. [PMID: 35019863 DOI: 10.1097/hmr.0000000000000327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Federally qualified health centers (FQHCs) are pivotal safety net primary care providers for the medically underserved. FQHCs have complex organizational designs, with many FQHCs providing care at multiple physical locations ("sites"). The number of sites, however, varies considerably between FQHCs, which can have important implications for differential access that may perpetuate disparities in quality of care. PURPOSE The objective of this study is to explore the organizational and environmental antecedents of the number of sites operated by each FQHC. The findings of this study contribute to a better understanding of FQHCs' expansion that has vital implications for cost and access outcomes. METHODOLOGY/APPROACH The study is based on data between the years 2012 and 2018. Using multivariate growth curve modeling, we analyzed the final sample, consisting of 5,482 FQHC-years. RESULTS The level of competition, measured as the number of FQHC sites in the Primary Care Service Area (PCSA) and the number of primary care physicians per 1,000 PCSA residents, was positively associated with the number of FQHC sites. The number of patients, the level of federal grant, and the year were also positively associated with the number of FQHC sites, whereas percentage of Medicaid patients; workforce supply, measured as primary care physician assistants per 1,000 PCSA residents; Medicaid expansion; and state/local funding available for FQHCs were not. CONCLUSION Findings of this study indicate that competition, especially between peer FQHCs, is significantly associated with FQHC expansion. PRACTICE IMPLICATIONS This result suggests that FQHC managers and policymakers may closely monitor cost, access, and quality implications of competition and FQHC expansion.
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Dehlendorf C, Fox E, Silverstein IA, Hoffman A, Campora Pérez MP, Holt K, Reed R, Hessler D. Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale. Contraception 2021; 103:310-315. [PMID: 33508252 DOI: 10.1016/j.contraception.2021.01.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Person-centeredness is a critical component of quality in family planning. We previously validated an 11-item Interpersonal Quality of Family Planning (IQFP) scale. We sought to create a parsimonious version of the scale in preparation for testing its appropriateness as a patient-reported outcome performance measure. STUDY DESIGN To explore clarity and importance of each of the 11 items, we conducted English and Spanish cognitive interviews with patients who received contraceptive counseling (n = 33) at 3 publicly funded California clinics. We triangulated these results with psychometric analysis of previously collected IQFP data (n = 1097) to assess validity and reliability of selected item combinations. RESULTS The 11-item IQFP scale was reduced to a 4-item scale (the Person-Centered Contraceptive Counseling scale, or PCCC) that includes items evaluating provider performance regarding respect for patients, information provision, and eliciting and honoring patient preferences for birth control. Interview participants deemed the items included in the 4-item PCCC important and clear in both English and Spanish versions of the instrument. The 4-item PCCC retained the 11-item IQFP's psychometric properties, including internal consistency (Cronbach's alpha = 0.92 vs 0.97 for the PCCC and IQFP, respectively) and a consistent single factor analysis solution (factor loadings = 0.86-0.92 and 0.81-0.91). The 4-item PCCC additionally retained the construct and predictive validity of the IQFP. CONCLUSIONS The 4-item PCCC is a valid and reliable as a measure of person-centered contraceptive counseling that reflects patients' perspectives on contraceptive counseling. IMPLICATIONS Person-centered measures such as the 4-item PCCC can help inform efforts to improve health care quality. Future work will investigate the validity and reliability of the 4-item PCCC as a performance measure to determine the appropriateness of its use in the quality improvement context.
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Affiliation(s)
- Christine Dehlendorf
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, United States.
| | - Edith Fox
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Ilana A Silverstein
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Alexis Hoffman
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - María Paula Campora Pérez
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Kelsey Holt
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Reiley Reed
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Danielle Hessler
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
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Ben Zayed S, Gani AB, Bin Othman MK. Conclusion. OPERATIONAL MANAGEMENT IN EMERGENCY HEALTHCARE 2021:103-108. [DOI: 10.1007/978-3-030-53832-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Melas M, Subbiah S, Saadat S, Rajurkar S, McDonnell KJ. The Community Oncology and Academic Medical Center Alliance in the Age of Precision Medicine: Cancer Genetics and Genomics Considerations. J Clin Med 2020; 9:E2125. [PMID: 32640668 PMCID: PMC7408957 DOI: 10.3390/jcm9072125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 12/15/2022] Open
Abstract
Recent public policy, governmental regulatory and economic trends have motivated the establishment and deepening of community health and academic medical center alliances. Accordingly, community oncology practices now deliver a significant portion of their oncology care in association with academic cancer centers. In the age of precision medicine, this alliance has acquired critical importance; novel advances in nucleic acid sequencing, the generation and analysis of immense data sets, the changing clinical landscape of hereditary cancer predisposition and ongoing discovery of novel, targeted therapies challenge community-based oncologists to deliver molecularly-informed health care. The active engagement of community oncology practices with academic partners helps with meeting these challenges; community/academic alliances result in improved cancer patient care and provider efficacy. Here, we review the community oncology and academic medical center alliance. We examine how practitioners may leverage academic center precision medicine-based cancer genetics and genomics programs to advance their patients' needs. We highlight a number of project initiatives at the City of Hope Comprehensive Cancer Center that seek to optimize community oncology and academic cancer center precision medicine interactions.
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Affiliation(s)
- Marilena Melas
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA;
| | - Shanmuga Subbiah
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Glendora, CA 91741, USA;
| | - Siamak Saadat
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Colton, CA 92324, USA;
| | - Swapnil Rajurkar
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Upland, CA 91786, USA;
| | - Kevin J. McDonnell
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center and Beckman Research Institute, Duarte, CA 91010, USA
- Center for Precision Medicine, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
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Choi S, Weech-Maldonado R, Powers T. The context, strategy and performance of the American safety net primary care providers: a systematic review. J Health Organ Manag 2020; 22:529-550. [PMID: 32681633 DOI: 10.1108/jhom-11-2019-0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided. DESIGN/METHODOLOGY/APPROACH A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases. FINDINGS 28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance. ORIGINALITY/VALUE Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context-strategy-performance relationships in the context of FQHCs.
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Affiliation(s)
- Seongwon Choi
- Department of Health Care Administration, Trinity University, San Antonio, Texas, USA
| | - Robert Weech-Maldonado
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Powers
- Department of Marketing, Industrial Distribution and Economics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Darney BG, Biel FM, Rodriguez MI, Jacob RL, Cottrell EK, DeVoe JE. Payment for Contraceptive Services in Safety Net Clinics: Roles of Affordable Care Act, Title X, and State Programs. Med Care 2020; 58:453-460. [PMID: 32049877 PMCID: PMC7148195 DOI: 10.1097/mlr.0000000000001309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs. METHODS Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities. RESULTS We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states. CONCLUSIONS Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.
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Affiliation(s)
- Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
- National Institute of Public Health, Population Research Center (INSP/CISP), Cuernavaca, Morelos, Mexico
- OHSU-PSU School of Public Health
| | - Frances M Biel
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | | | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, OR
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Barnes PA, Staab EM, Campbell A, Schaefer C, Quinn MT, Baig AA. Organizational Factors Influencing the Early Implementation Process of Diabetes Group Visits by Five Midwestern Community Health Centers: A Multisite Case Study Analysis. Popul Health Manag 2019; 23:297-304. [PMID: 31692409 DOI: 10.1089/pop.2019.0110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective was to identify facilitators and challenges of implementing diabetes group visits in 5 Midwestern community health center (CHC) settings that care for diverse patient populations. Interview data were collected from July to August 2015. An interview guide was developed to explore health center teams' initial experiences with diabetes group visit implementation. Interviews were conducted with 14 individuals who participated in a training prior to diabetes group visit implementation. Four levels of coding (open, in vivo, categorical, and thematic) were used to identify characteristics of group visit implementation in 5 CHCs. A semi-structured model encouraged interprofessional teamwork across all CHC teams. Self-appointed or chosen team champions were the "pulse" or central driving force of implementation. A designated time in the clinic for patients to receive education and psychosocial support enhanced engagement in diabetes self-management. Early buy-in from upper leadership was critical to securing fiscal and human resources as unexpected needs emerged during group visit implementation. Time commitment of clinic staff and providers for ongoing operations, socioeconomic challenges of patients, staff turnover, and billing were reported as challenges in the initial implementation process. This study acknowledges the influence of administrative and sociocultural factors on successful implementation of diabetes group visits. Future research should further explore how these factors influence successful adoption of diabetes group visits in health centers across the United States and the impact of group visit implementation on staff and patient outcomes.
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Affiliation(s)
- Priscilla A Barnes
- Department of Applied Health Science, Indiana University School of Public Health, Bloomington, Indiana, USA
| | - Erin M Staab
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Amanda Campbell
- MidWest Clinicians' Network, Inc., East Lansing, Michigan, USA
| | - Cindy Schaefer
- Dunigan Family School of Nursing, University of Evansville, Evansville, Indiana, USA
| | - Michael T Quinn
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Arshiya A Baig
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA
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Shukor AR, Edelman S, Brown D, Rivard C. Developing Community-Based Primary Health Care for Complex and Vulnerable Populations in the Vancouver Coastal Health Region: HealthConnection Clinic. Perm J 2019; 22:18-010. [PMID: 30227907 DOI: 10.7812/tpp/18-010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Designing, delivering, and evaluating high-performing primary health care services for complex and vulnerable subpopulations are challenging endeavors. However, there is a relative paucity of research evidence available to support such work. OBJECTIVE To provide a case study using HealthConnection Clinic, a public primary care center located in Metropolitan Vancouver's North Shore. METHODS Developmental evaluation approach operationalizing the 10 Building Blocks of High-Performing Primary Care framework using qualitative and quantitative methods. RESULTS The clinic provided valuable insights to policymakers and researchers related to development of the Building Blocks' foundational elements, particularly engaged leadership, empanelment, and data-driven improvement. The study highlighted the key enablers, achievements, challenges, and barriers related to operationalizing each Building Block. The Building Blocks were a useful heuristic that enabled the development and evaluation of primary care for complex subpopulations. Particularly salient from a Canadian policy perspective was the demonstration that system integration was possible when highly engaged leaders from a Regional Health Authority and a Division of Family Practice shared a common vision and purpose. HealthConnection Clinic's entrepreneurial spirit has enabled the development of innovative, evidence-based tools such as the AMPS complexity assessment tool (attachment, medical conditions, psychological/mental health/addictions challenges, and socioeconomic status), designed to identify and assess biopsychosocial complexity and needs. The study also highlighted the importance of incorporating community orientation and equity into developmental work. CONCLUSION The study demonstrates how the Building Blocks approach can be adapted to operationalize high-performing primary care standards in settings serving complex and vulnerable populations.
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Affiliation(s)
- Ali Rafik Shukor
- Regional Primary Care Evaluator for the Vancouver Coastal Health Authority in Vancouver, British Columbia, Canada
| | - Sandra Edelman
- Manager of Public Health and Chronic Disease Services for the North Shore Division of Community Family Health in Vancouver, British Columbia, Canada
| | - Dean Brown
- Medical Director of the North Shore Division of Community Family Health in Vancouver, British Columbia, Canada
| | - Cheryl Rivard
- Project Manager for the Vancouver Coast Health Authority in Vancouver, British Columbia, Canada
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Sommers BD, McMURTRY CL, Blendon RJ, Benson JM, Sayde JM. Beyond Health Insurance: Remaining Disparities in US Health Care in the Post-ACA Era. Milbank Q 2018; 95:43-69. [PMID: 28266070 DOI: 10.1111/1468-0009.12245] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Benjamin D Sommers
- Harvard T.H. Chan School of Public Health.,Harvard Medical School.,Brigham & Women's Hospital
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Cole MB, Galárraga O, Wilson IB, Wright B, Trivedi AN. At Federally Funded Health Centers, Medicaid Expansion Was Associated With Improved Quality Of Care. Health Aff (Millwood) 2018; 36:40-48. [PMID: 28069845 DOI: 10.1377/hlthaff.2016.0804] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2014 many uninsured, low-income nonelderly adults gained access to health insurance in states that expanded Medicaid eligibility under the Affordable Care Act. Federally funded community health centers were likely to be particularly affected by this expansion because many of their patients were uninsured and low income. We used a difference-in-differences approach to compare changes among 1,057 such centers in expansion versus nonexpansion states from 2011 to 2014, in terms of their patients' insurance coverage, the number of patients they served, and the quality of care they provided. Medicaid expansion was associated with large increases (12 percentage points) in Medicaid coverage and corresponding declines (11 percentage points) in uninsurance rates. The numbers of patients served increased in both expansion and nonexpansion states, and the magnitude of increase did not differ significantly between the groups of states. Medicaid expansion was associated with improved quality on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control. This analysis suggests that states' decisions about Medicaid expansion have important consequences for health center patients, with expansion improving treatment and outcomes of chronic disease and bolstering the use of recommended preventive services.
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Affiliation(s)
- Megan B Cole
- Megan B. Cole is a PhD candidate in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Omar Galárraga
- Omar Galárraga is an assistant professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Ira B Wilson
- Ira B. Wilson is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Brad Wright
- Brad Wright is an assistant professor in the Department of Health Management and Policy at the University of Iowa College of Public Health, in Iowa City
| | - Amal N Trivedi
- Amal N. Trivedi is an associate professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
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Rieselbach RE, Epperly T, Friedman A, Keahey D, McConnell E, Nichols K, Nycz G, Roberts J, Schmader K, Shin P, Shtasel D. A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:406-413. [PMID: 28930763 DOI: 10.1097/acm.0000000000001901] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.
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Affiliation(s)
- Richard E Rieselbach
- R.E. Rieselbach is professor emeritus of medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, and past president, Association of Program Directors in Internal Medicine. T. Epperly is president and chief executive officer, Family Medicine Residency of Idaho, clinical professor of family medicine, University of Washington School of Medicine, Seattle, Washington, and past president and board chair, American Academy of Family Physicians. A. Friedman is professor emeritus of pediatrics, past vice president, Health Sciences, and former dean, University of Minnesota Medical School, Minneapolis, Minnesota, and former board chair, American Board of Pediatrics. D. Keahey is chief advocacy and research officer, Physician Assistant Education Association, and adjunct associate professor, University of Utah School of Medicine, Utah Physician Assistant Program, Salt Lake City, Utah; ORCID: http://orcid.org/0000-0003-3107-3678. E. McConnell is associate professor, Duke University School of Nursing, clinical nurse specialist and nurse scientist, Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Durham, North Carolina, director, Center of Excellence in Geriatric Nursing Education, and codirector, Health Resources and Services Administration-funded Duke Geriatric Workforce Enhancement Program; ORCID: http://orcid.org/0000-0002-2896-8596. K. Nichols is professor of internal medicine and dean, Chicago College of Medicine, Downers Grove, Illinois, past president, American Osteopathic Association, and president, Institute of Medicine of Chicago; ORCID: http://orcid.org/0000-0002-4960-4118. G. Nycz is executive director, Family Health Center of Marshfield, Inc., Marshfield, Wisconsin; ORCID: http://orcid.org/0000-0001-6151-0336. J. Roberts is professor and former dean, School of Pharmacy, and director, Center for Interprofessional Practice and Education, University of Wisconsin-Madison, Madison, Wisconsin; ORCID: http://orcid.org/0000-0002-2309-7621. K. Schmader is professor of medicine and chief, Division of Geriatrics, Department of Medicine, Duke University Medical Center, director, Geriatric Research, Education and Clinical Center, and associate chief of staff, Geriatrics and Extended Care, Department of Veterans Affairs Medical Center, Durham, North Carolina. P. Shin is associate professor, Health Policy and Management, George Washington University, Washington, DC, and director, Geiger Gibson Program in Community Health, RCHN Community Health Foundation. D. Shtasel is founding director, Kraft Family National Center for Leadership and Training in Community Health, Massachusetts General Hospital Michele and Howard J. Kessler Chair in Public and Community Psychiatry, and associate professor of psychiatry, Harvard Medical School, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-8932-8066
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Huguet N, Hoopes MJ, Angier H, Marino M, Holderness H, DeVoe JE. Medicaid Expansion Produces Long-Term Impact on Insurance Coverage Rates in Community Health Centers. J Prim Care Community Health 2017; 8:206-212. [PMID: 28513249 PMCID: PMC5665709 DOI: 10.1177/2150131917709403] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND It is crucial to understand the impact of the Affordable Care Act (ACA). This study assesses changes in insurance status of patients visiting community health centers (CHCs) comparing states that expanded Medicaid to those that did not. METHODS Electronic health record data on 875,571 patients aged 19 to 64 years with ≥ 1 visit between 2012 and 2015 in 412 primary care CHCs in 9 expansion and 4 nonexpansion states. We assessed changes in rates of total, uninsured, Medicaid-insured, and privately insured primary care and preventive care visits; immunizations administered, and medications ordered. RESULTS Rates of uninsured visits decreased pre- to post-ACA, with greater drops in expansion (-57%) versus nonexpansion (-20%) states. Medicaid-insured visits increased 60% in expansion states while remaining unchanged in nonexpansion states. Privately insured visits were 2.7 times higher post-ACA in nonexpansion states with no increase in expansion states. Comparing 2015 with 2014: Uninsured visit rates continued to decrease in expansion (-28%) and nonexpansion states (-19%), Medicaid-insured rates did not significantly increase, and privately insured visits increased in nonexpansion states but did not change in expansion states. CONCLUSIONS Medicaid expansion and subsidies to purchase private coverage likely increased the accessibility of health insurance for patients who had previously not been able to access coverage.
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Affiliation(s)
| | | | | | - Miguel Marino
- Oregon Health & Science University, Portland, OR, USA
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Federally Qualified Health Center Substitution of Local Health Department Services. Am J Prev Med 2017; 53:405-411. [PMID: 28751056 DOI: 10.1016/j.amepre.2017.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 05/16/2017] [Accepted: 06/05/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013. METHODS Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013. RESULTS There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume. CONCLUSIONS LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission-and LHDs may be strategically placed to continue to deliver these services.
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Angier H, Hoopes M, Marino M, Huguet N, Jacobs EA, Heintzman J, Holderness H, Hood CM, DeVoe JE. Uninsured Primary Care Visit Disparities Under the Affordable Care Act. Ann Fam Med 2017; 15:434-442. [PMID: 28893813 PMCID: PMC5593726 DOI: 10.1370/afm.2125] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/24/2017] [Accepted: 07/03/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Health insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity. METHODS We undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured). RESULTS After the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78). CONCLUSION The lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
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Affiliation(s)
| | | | - Miguel Marino
- Oregon Health & Science University, Portland, Oregon
| | | | - Elizabeth A Jacobs
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Health Care Utilization Rates After Oregon's 2008 Medicaid Expansion: Within-Group and Between-Group Differences Over Time Among New, Returning, and Continuously Insured Enrollees. Med Care 2017; 54:984-991. [PMID: 27547943 DOI: 10.1097/mlr.0000000000000600] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status. OBJECTIVES (1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization. METHODS Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region. RESULTS PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period. CONCLUSIONS Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.
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The Importance of Partnerships in Local Health Department Practice Among Communities With Exceptional Maternal and Child Health Outcomes. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2016; 22:542-9. [DOI: 10.1097/phh.0000000000000402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Turning Back the Clock on Women's Health in Medically Underserved Communities. Womens Health Issues 2015; 25:601-3. [DOI: 10.1016/j.whi.2015.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/15/2015] [Indexed: 11/18/2022]
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