Inter-clinician eConsults without programmatic incentives or requirements: a qualitative study of primary care provider perspectives.

BACKGROUND: Inter-clinician electronic consultation (eConsult) programmes are becoming more widespread in the USA as health care systems seek innovative ways of improving specialty access. Existing studies examine models with programmatic incentives or requirements for primary care providers (PCPs) to participate. OBJECTIVE: We aimed to examine PCP perspectives on eConsults in a system with no programmatic incentive or requirement for PCPs to use eConsults. METHODS: We conducted seven focus groups with 41 PCPs at a safety-net community teaching health care system in Eastern Massachusetts, USA. RESULTS: Focus groups revealed that eConsults improved PCP experience by enabling patient-centred care and enhanced PCP education. However, increased workload and variations in communication patterns added challenges for PCPs. Patients were perceived as receiving timelier and more convenient care. Timelier care combined with direct documentation in the patient record was perceived as improving patient safety. Although cost implications were less clear, PCPs perceived costs as being lowered through fewer unnecessary visits and laboratories. CONCLUSIONS: Our findings suggest that eConsult systems with no programmatic incentives or requirements for PCPs have the potential to improve care.

Unauthorized Immigrants Prolong the Life of Medicare's Trust Fund.

BACKGROUND AND OBJECTIVE: Unauthorized immigrants seldom have access to public health insurance programs such as Medicare Part A, which pays hospitals and other health facilities and is funded through the Medicare Trust Fund. DESIGN AND MAIN MEASURES: We tabulated annual and total Trust Fund contributions and withdrawals by unauthorized immigrants (i.e., outlays on their behalf) from 2000 to 2011 using the Current Population Survey and Medical Expenditure Panel Surveys. We estimated when the Trust Fund would be depleted if unauthorized immigrants had neither contributed to it nor withdrawn from it. We estimated Trust Fund surpluses by unauthorized immigrants if 10 % were to become authorized annually over the subsequent 7 years. KEY RESULTS: From 2000 to 2011, unauthorized immigrants contributed $2.2 to $3.8 billion more than they withdrew annually (a total surplus of $35.1 billion). Had unauthorized immigrants neither contributed to nor withdrawn from the Trust Fund during those 11 years, it would become insolvent in 2029-1 year earlier than currently predicted. If 10 % of unauthorized immigrants became authorized annually for the subsequent 7 years, Trust Fund surpluses contributed by unauthorized immigrants would total $45.7 billion. CONCLUSIONS: Unauthorized immigrants have prolonged the life of the Medicare Trust Fund. Policies that curtail the influx of unauthorized immigrants may accelerate the Trust Fund's depletion.

Experiences applying for and understanding health insurance under Massachusetts health care reform.

BACKGROUND: The Affordable Care Act was modeled on the Massachusetts Health Reform of 2006, which reduced the number of uninsured largely through a Medicaid expansion and the provision of publicly subsidized insurance obtained through a Health Benefits Exchange. METHODS: We surveyed a convenience sample of 780 patients seeking care in a safety-net system who obtained Medicaid or publicly subsidized insurance after the Massachusetts reform, as well as a group of employed patients with private insurance. RESULTS: We found that although most patients with Medicaid or publicly subsidized exchange-based plans were able to obtain assistance with applying for and choosing an insurance plan, substantial proportions of respondents experienced difficulties with the application process and with understanding coverage and cost features of plans. CONCLUSIONS: Under the Affordable Care Act, efforts to simplify the application process and reduce the complexity of plans may be warranted, particularly for vulnerable patient populations cared for by the medical safety net.

Support for National Health Insurance Seven Years Into Massachusetts Healthcare Reform: Views of Populations Targeted by the Reform.

Before the Affordable Care Act (ACA), many surveys showed majority support for national health insurance (NHI), also known as single payer; however, little is currently known about views of the ACA's targeted population. Massachusetts residents have had seven years of experience with state health care reform that became the model for the ACA. We surveyed 1,151 adults visiting safety-net emergency departments in Massachusetts in late 2013 on their preference for NHI or the Massachusetts reform and on their experiences with insurance. Most of the patients surveyed were low-income and non-white. The majority of patients (72.0%) preferred NHI to the Massachusetts reform. Support for NHI among those with public insurance, commercial insurance, and no insurance was 68.9%, 70.3%, and 86.3%, respectively (p < .001). Support for NHI was higher among patients dissatisfied with their insurance plan (83.3% vs. 68.9%, p = .014), who delayed medical care (81.2% vs. 69.6%, p < .001) or avoided purchasing medications due to cost (87.3% vs. 71.4%; p = .01). Majority support for NHI was observed in every demographic subgroup. Given the strong support for NHI among disadvantaged Massachusetts patients seven years after state health reform, a reappraisal of the ACA's ability to meet the needs of underserved patients is warranted.

Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts health reform.

INTRODUCTION: Under the Massachusetts health reform, low income residents (those with incomes below 150 % of the Federal Poverty Level [FPL]) were eligible for Medicaid and health insurance exchange-based plans with minimal cost-sharing and no premiums. Those with slightly higher incomes (150 %-300 % FPL) were eligible for exchange-based plans that required cost-sharing and premium payments. METHODS: We conducted face to face surveys in four languages with a convenience sample of 976 patients seeking care at three hospital emergency departments five years after Massachusetts reform. We compared perceived affordability of insurance, financial burden, and satisfaction among low cost sharing plan recipients (recipients of Medicaid and insurance exchange-based plans with minimal cost-sharing and no premiums), high cost sharing plan recipients (recipients of exchange-based plans that required cost-sharing and premium payments) and the commercially insured. RESULTS: We found that despite having higher incomes, higher cost-sharing plan recipients were less satisfied with their insurance plans and perceived more difficulty affording their insurance than those with low cost-sharing plans. Higher cost-sharing plan recipients also reported more difficulty affording medical and non-medical health care as well as insurance premiums than those with commercial insurance. In contrast, patients with low cost-sharing public plans reported higher plan satisfaction and less financial concern than the commercially insured. CONCLUSIONS: Policy makers with responsibility for the benefit design of public insurance available under health care reforms in the U.S. should calibrate cost-sharing to income level so as to minimize difficulty affording care and financial burdens.

Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients.

INTRODUCTION: The Affordable Care Act (ACA) and the 2006 Massachusetts (MA) health reform law, on which the ACA was based, aimed to improve the affordability of care largely by expanding publicly sponsored insurances. Both laws also aimed to promote consumer understanding of how to acquire, maintain and use these public plans. A prior study found an association between the level of cost-sharing required in these plans and the affordability of care. Preparatory to a quantitative study we conducted this qualitative study that aimed to examine (1) whether cost sharing levels built into the public insurance types that formed the backbone of the MA health reform led to unaffordability of care and if so, (2) how insurances with higher cost sharing levels led to unaffordability of care in this context. METHODS: We interviewed 12 consumers obtaining the most commonly obtained insurances under MA health reform (Medicaid and Commonwealth Care) at a safety net hospital emergency department. We purposefully interviewed a stratified sample of higher and low cost sharing recipients. We used a combination of inductive and deductive codes to analyze the data according to degree of cost-sharing required by different insurance types. RESULTS: We found that higher cost sharing plans led to unaffordability of care, as evidenced by unmet medical needs, difficulty affording basic non-medical needs due to expenditures on medical care, and reliance on non-insurance resources to pay for care. Participants described two principal mechanisms by which higher cost sharing led to unaffordability of care: (1) cost sharing above what their incomes allowed and (2) poor understanding of how to effectively acquire, maintain and utilize insurance new public plans. CONCLUSIONS: Further efforts to investigate the relationship between perceived affordability of care and understanding of insurance for the insurance types obtained under MA health reform may be warranted. A potential focus for further work may be quantitative investigation of how the level of calibration of cost-sharing to income and understanding of insurances under the MA reform was associated with perceived affordability of care.

Strategies for Aligning Physicians to System Redesign Goals at Eight Safety-Net Systems.

BACKGROUND: Facing recent economic and regulatory pressures, safety-net systems (SNSs) are redesigning their organizations to improve care delivery, remain financially viable, and maintain competitive positions. Aligning physicians with redesign goals is a priority, particularly as many SNSs shift toward patient-centered, population health-focused models. No previous work has examined efforts to align physicians to safety net redesign efforts. METHODS: This qualitative study, conducted at eight SNSs, examined challenges faced in a changing health care environment, as well as strategies and resources to address them. RESULTS: Strategies clustered in two categories: physician role definition and organizational infrastructure. Physician role definition strategies were (1) changing payment and employment arrangements, (2) changing clinical roles, (3) increasing physician involvement in quality improvement, and (4) strengthening physician leadership in clinical and quality roles. Organizational infrastructure strategies were (1) ensuring medical center leadership support and integration, (2) utilizing data to drive physician behavior, and (3) addressing competing allegiances with academia. All sites reported multifaceted approaches but differed in specific strategies employed, facilitators noted, and challenges encountered. DISCUSSION: The findings highlight the need to implement multiple strategies to align physicians in redesign efforts. They suggest that all health systems, whether SNSs or not, can capitalize on qualities of physicians and existing infrastructural and leadership elements to achieve physician alignment. However, they must contend with and address challenges of competing allegiance (for example, academic, physician organization, hospital), as well as resistance to changing clinical roles and payment structures.

Computed tomography associated cancers and cancer deaths following visits to U.S. emergency departments.

We estimated the number of future cancers and cancer deaths following computed tomography scans (CTs) performed in U.S. emergency departments annually and determined whether increases in the proportion of visits resulting in CTs over the past decade were accompanied by changes in markers of severity of illness or primary reason for visit. We applied national estimates of effective dose to adult emergency department visits in the 2008 National Hospital Ambulatory Medical Care Survey. We utilized the Biologic Effects of Ionizing Radiation Model VII to estimate the number of future cancers and cancer deaths caused by CTs performed in U.S. emergency departments. We calculated the proportion of visits resulting in CTs from 1998 to 2008. In 2008, 16,406,921 CTs were performed nationally on adults, which will cause an estimated 3,750 cancers and 1,994 cancer deaths. The increasing proportion of emergency department visits resulting in CTs was not accompanied by proportional increases in markers of severity of illness or primary reason for visit. The substantial number of future cancers and cancer deaths attributable to CTs and increases in CTs without accompanying increases in markers of severity or changes in primary reason for visit highlight the importance of examining the benefits of CTs.

Immigrant Essential Workers Likely Avoided Medicaid And SNAP Because Of A Change To The Public Charge Rule.

During the COVID-19 pandemic in the US, essential workers have provided health care, food, and other necessities, often incurring considerable risk. At the pandemic's start, the federal government was in the process of tightening the "public charge" rule by adding nutrition and health benefits to the cash benefits that, if drawn, could subject immigrants to sanctions (for example, green card denial). Census Bureau data indicate that immigrants accounted for 13.6 percent of the population but 17.8 percent of essential workers in 2019. About 20.0 million immigrants held essential jobs, and more than one-third of these immigrants resided in US states bordering Mexico. Nationwide, 12.3 million essential workers and 18.9 million of their household members were at risk because of the new sanctions. The rule change (which was subsequently revoked) likely caused 2.1 million essential workers and household members to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance on the eve of the pandemic, highlighting the potential of immigration policy changes to exacerbate health risks.

Do Medical Scribes Help Primary Care Providers Respond More Quickly to Out-of-Visit Tasks?

PURPOSE: Medical scribes are charged with decreasing documentation burden associated with patient visits. Reducing time spent on documentation may afford providers the opportunity to respond to out-of-visit inbox tasks faster. METHODS: We compare changes in the time taken to address patient portal messages, prescription requests, and test results from before to after scribe implementation among scribed primary care providers (PCPs), compared with nonscribed PCPs during the same time period. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, and adjusted for provider and patient characteristics. RESULTS: We examined 472,411 tasks, including 27,645 tasks for 5 scribed PCPs and 444,766 tasks of 74 nonscribed PCPs. In unadjusted analyses, we found no change in time to completion for prescription refill requests, results and patient portal messages; the change in time to completion from pre to post intervention among scribed PCPs was 1.02 times that of nonscribed providers (P = .585) for prescription refill requests, 1.06 times that of nonscribed providers (P = .516) for patient portal messages, and 1.02 times that of nonscribed providers (P = .787) for results. Adjustment for provider and patient characteristics did not change these findings. CONCLUSIONS: Our study suggests that scribes are not associated with improved time to completion of inbox messages for PCPs. While scribes seem to have many benefits, our study suggests they may not improve time to completion of out-of-visit tasks. Reducing the time to completion for these tasks likely requires other interventions targeted to achieve those outcomes.

Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999-2018.

One in seven people in the US speak Spanish at home, and twenty-five million people in the US have limited English proficiency. Using nationally representative data from the Medical Expenditure Panel Survey, we compare health care spending for and health care use by Hispanics adults with limited English proficiency with spending for and use by English-proficient Hispanic and non-Hispanic adults. During 2014-18 mean annual per capita expenditures were $1,463 (35 percent) lower for Hispanic adults with limited English proficiency than for Hispanic adults who were English proficient, after adjustment for respondents' characteristics. Hispanic adults with limited English proficiency also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient. Health care spending gaps between Hispanic adults with limited English proficiency and non-Hispanic adults with English proficiency widened between 1999 and 2018. These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency.

The financial advantages of medical scribes extend beyond increased visits.

Employing medical scribes can boost revenue for a practice, the authors show, well beyond being an opportunity to expand patient volume.

Quality of US primary care delivered by resident and staff physicians.

BACKGROUND: Few population-based data are available on the quality of outpatient care provided by resident physicians in the US. OBJECTIVE: To assess the quality of outpatient care delivered by resident and staff physicians. DESIGN: Cross-sectional analysis. We used chi-square tests to compare resident and staff physician performance on 19 quality indicators. Using multivariable logistic regression, we controlled for sex, age, race/ethnicity, insurance, and metropolitan status. PARTICIPANTS: 33,900 hospital-based outpatient visits from the 1997-2004 National Hospital Ambulatory Medical Care Survey (NHAMCS). MEASUREMENTS: Resident and staff physician performance on 19 quality indicators. RESULTS: Resident physicians were more likely to care for younger, non-white, female, urban, and Medicaid-insured patients. In both adjusted and unadjusted analyses, residents outperformed staff on four of 19 measures including angiotensin converting enzyme inhibitor use for congestive heart failure (57.0% vs. 27.6%; p=<0.001), diuretic use for hypertension (57.8% vs. 44.0%; p=<0.001), statin use for hyperlipidemia (56.3% vs. 40.4%; p=0.001), and routine blood pressure screening (85.3% vs. 79.6%; p=0.02). Residents and staff performed at similar levels for counseling (range 15.7 to 32.0%). Residents and staff performed similarly well on measures capturing inappropriate prescribing or overuse of diagnostic testing (range 48.6 to 100%). Residents and staff performed similarly on measures of appropriate prescribing (range from 30.9% to 69.2%). CONCLUSIONS: Primary care provided by resident physicians is of similar or higher quality than that provided by staff physicians. Significant opportunity remains to improve quality of outpatient care provided by all physicians. Residency training programs should devote attention to improving outpatient quality of care delivered by residents.

Comparison of Use of Health Care Services and Spending for Unauthorized Immigrants vs Authorized Immigrants or US Citizens Using a Machine Learning Model.

Importance: Knowledge about use of health care services (health care utilization) and expenditures among unauthorized immigrant populations is uncertain because of limitations in ascertaining legal status in population data. Objective: To examine health care utilization and expenditures that are attributable to unauthorized and authorized immigrants vs US-born individuals. Design, Setting, and Participants: This cross-sectional study used the data on documentation status from the Los Angeles Family and Neighborhood Survey (LAFANS) to develop a random forest classifier machine learning model. K-fold cross-validation was used to test model performance. The LAFANS is a randomized, multilevel, in-person survey of households residing in Los Angeles County, California, consisting of 2 waves. Wave 1 began in April 2000 and ended in January 2002, and wave 2 began in August 2006 and ended in December 2008. The machine learning model was then applied to a nationally representative database, the 2016-2017 Medical Expenditure Panel Survey (MEPS), to predict health care expenditures and utilization among unauthorized and authorized immigrants and US-born individuals. A generalized linear model analyzed health care expenditures. Logistic regression modeling estimated dichotomous use of emergency department (ED), inpatient, outpatient, and office-based physician visits by immigrant groups with adjusting for confounding factors. Data were analyzed from May 1, 2019, to October 14, 2020. Exposures: Self-reported immigration status (US-born, authorized, and unauthorized status). Main Outcomes and Measures: Annual health care expenditures per capita and use of ED, outpatient, inpatient, and office-based physician care. Results: Of 47 199 MEPS respondents with nonmissing data, 35 079 (74.3%) were US born, 10 816 (22.9%) were authorized immigrants, and 1304 (2.8%) were unauthorized immigrants (51.7% female; mean age, 47.6 [95% CI, 47.4-47.8] years). Compared with authorized immigrants and US-born individuals, unauthorized immigrants were more likely to be aged 18 to 44 years (80.8%), Latino (96.3%), and Spanish speaking (95.2%) and to have less than 12 years of education (53.7%). Half of unauthorized immigrants (47.1%) were uninsured compared with 15.9% of authorized immigrants and 6.0% of US-born individuals. Mean annual health care expenditures per person were $1629 (95% CI, $1330-$1928) for unauthorized immigrants, $3795 (95% CI, $3555-$4035) for authorized immigrants, and $6088 (95% CI, $5935-$6242) for US-born individuals. Conclusions and Relevance: Contrary to much political discourse in the US, this cross-sectional study found no evidence that unauthorized immigrants are a substantial economic burden on safety net facilities such as EDs. This study illustrates the value of machine learning in the study of unauthorized immigrants using large-scale, secondary databases.

Association Between Provider Engagement, Staff Engagement, and Culture of Safety.

As healthcare organizations seek to improve patient experience, quality, and safety, employee engagement and perceptions of patient safety (POPS) have increasingly become foci of attention. Yet, the relationship between these constructs is poorly understood. We examined the correlation between provider and staff engagement (collectively, "employee engagement"), and between employee engagement and POPS in ambulatory and hospital environments. We found significant correlations between staff engagement and POPS, and between provider engagement and POPS in ambulatory and hospital environments. We also found significant correlation between provider and staff engagement. Although all correlations were weak (correlation coefficients of 0.17-0.47), there were significant increases in POPS with increases in employee engagement (in both ambulatory and hospital environments) and increases in provider engagement with increases in staff engagement. These increases range from 4% to 11% for every 17% increase in staff engagement. These findings suggest that healthcare systems seeking to improve provider engagement, staff engagement, and POPS may find synergistic effects between these efforts in ambulatory and hospital settings.

Primary Care Behavioral Health Integration for Anxiety Management in a Safety-Net Health Care System.

This report describes the implementation of a primary care behavioral health integration program for anxiety management at Cambridge Health Alliance (CHA), a safety-net health care system. Using a staged implementation process, CHA built upon existing capacities to create a comprehensive infrastructure for managing behavioral health conditions in primary care.

Impact of Social Factors on Hospital Readmissions at Massachusetts' Two Largest Safety Net Hospitals After State Health Reform.

Little is known about whether social factors are related to readmissions among non-elderly adults admitted to safety-net hospitals (SNHs), particularly after health reform that lowered barriers to obtaining post-discharge medical care through insurance expansion. We conducted a prospective cohort study of 713 non-elderly adults at two of Massachusetts' largest SNHs eight years after Massachusetts' health reforms. Social factors were assessed through in-person interviews and electronic health record data. After adjustment for clinical variables, public insurance, White race/ethnicity, being unemployed, being unstably housed, having an alcohol-related index admission, and having a substance use-related index admission remained associated with readmissions at 90 days. At 30 days, public insurance, worry about safety or condition of housing, and having an alcohol-related index admission remained associated with readmissions. Unadjusted models were consistent with these findings. Accounting for social factors in readmission adjustment schemes used by payers may be important for ensuring payment equity.

Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care.

IMPORTANCE: In October 2018, the Trump administration published a proposed rule change that would increase the chance of an immigrant being deemed a "public charge" and thereby denied legal permanent residency or entry to the United States. The proposed changes are expected to cause many immigrant parents to disenroll their families from safety-net programs, in large part because of fear and confusion about the rule, even among families to whom the rule does not technically apply. OBJECTIVE: To simulate the potential harms of the rule change by estimating the number, medical conditions, and care needs of children who are at risk of losing their current benefits, including Medicaid and Children's Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP). DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study used nationally representative data from 4007 children 17 years of age or younger who participated in the 2015 Medical Expenditure Panel Survey to assess their potential risk of losing benefits because they live with a noncitizen adult. Statistical analysis was conducted from January 3 to April 8, 2019. MAIN OUTCOMES AND MEASURES: The number of children at risk of losing benefits; the number of children with medical need, defined as having a potentially serious medical diagnosis; being disabled (or functionally limited); or having received any specific treatment in the past year. The numbers of children who would be disenrolled under likely disenrollment scenarios drawn from research on immigrants before and after the 1996 welfare reform were estimated. RESULTS: A total of 8.3 million children who are currently enrolled in Medicaid and CHIP or receiving SNAP benefits are potentially at risk of disenrollment, of whom 5.5 million have specific medical needs, including 615 842 children with asthma, 53 728 children with epilepsy, 3658 children with cancer, and 583 700 children with disabilities or functional limitations. Nonetheless, among the population potentially at risk of disenrollment, medical need was less common than among other children receiving Medicaid and CHIP or SNAP (64.5%; 95% CI, 61.5%-67.4%; vs 76.0%; 95% CI, 73.9%-78.4%; P < .001). The proposed rule is likely to cause parents to disenroll between 0.8 million and 1.9 million children with specific medical needs from health and nutrition benefits. CONCLUSIONS AND RELEVANCE: The proposed public charge rule would likely cause millions of children to lose health and nutrition benefits, including many with specific medical needs that, if left untreated, may contribute to child deaths and future disability.

Care For America's Elderly And Disabled People Relies On Immigrant Labor.

As the US wrestles with immigration policy and caring for an aging population, data on immigrants' role as health care and long-term care workers can inform both debates. Previous studies have examined immigrants' role as health care and direct care workers (nursing, home health, and personal care aides) but not that of immigrants hired by private households or nonmedical facilities such as senior housing to assist elderly and disabled people or unauthorized immigrants' role in providing these services. Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans.