Projecting Informal Care Demand among Older Koreans between 2020 and 2067.

BACKGROUND: The number of Korean older people receiving informal care is expected to rise sharply due to aging population. This study makes projections of demand for informal care in community-dwelling older people aged 65 and over in Korea until 2067. METHOD: The study drew on data collected from waves 4-6 of the Korean Longitudinal Study of Aging (2012-2016, n = 12,975). Population data published by Statistics Korea and data from the Long-term Care Insurance Statistical Yearbook for Korea were also used. A macro-simulation model was built to make the projections. RESULTS: The number of older people receiving informal care will increase from 0.71 million in 2020 to 2.2 million in 2067. Demand for informal care from adult children or relatives is projected to rise by 257%, much faster than the increase in demand for spousal care (164%). The estimates are sensitive to alternative assumptions about future mortality rates, fertility rates, patterns of migration, and the prevalence of functional disabilities in the population. CONCLUSION: Demand for informal care in Korea will rise substantially in the coming decades, and the increase will be uneven for different groups of care users. Our analyses are not only relevant to the long-term care system for the general older population but also have profound implications for intensive users of long-term care in Korea. The findings highlight the importance of accurate identification of unmet needs in the population and timely delivery of government support to older people and their informal caregivers.

Community Health Centers: a Key Partner to Achieve Medicaid Expansion.

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.

Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception.

CONTEXT: Long-acting reversible contraception (LARC) is the most effective reversible method to prevent unplanned pregnancies. Variability in state-level policies and the high cost of LARC could create substantial inconsistencies in Medicaid coverage, despite federal guidance aimed at enhancing broad access. This study surveyed state Medicaid payment policies and outreach activities related to LARC to explore the scope of services covered. METHODS: Using publicly available information, we performed a content analysis of state Medicaid family planning and LARC payment policies. Purposeful sampling led to a selection of nine states with diverse geographic locations, political climates, Medicaid expansion status, and the number of women covered by Medicaid. RESULTS: All nine states' Medicaid programs covered some aspects of LARC. However, only a single state's payment structure incorporated all core aspects of high-quality LARC service delivery, including counseling, device, insertion, removal, and follow-up care. Most states did not explicitly address counseling, device removal, or follow-up care. Some states had strategies to enhance access, including policies to increase device reimbursement, stocking and delivery programs to remove cost barriers, and covering devices and insertion after an abortion. CONCLUSIONS: Although Medicaid policy encourages LARC methods, state payment policies frequently fail to address key aspects of care, including counseling, follow-up care, and removal, resulting in highly variable state-level practices. Although some states include payment policy innovations to support LARC access, significant opportunities remain.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center.

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.

Development of high resolution 3D hyperpolarized carbon-13 MR molecular imaging techniques.

The goal of this project was to develop and apply techniques for T2 mapping and 3D high resolution (1.5mm isotropic; 0.003cm3) 13C imaging of hyperpolarized (HP) probes [1-13C]lactate, [1-13C]pyruvate, [2-13C]pyruvate, and [13C,15N2]urea in vivo. A specialized 2D bSSFP sequence was implemented on a clinical 3T scanner and used to obtain the first high resolution T2 maps of these different hyperpolarized compounds in both rats and tumor-bearing mice. These maps were first used to optimize timings for highest SNR for single time-point 3D bSSFP acquisitions with a 1.5mm isotropic spatial resolution of normal rats. This 3D acquisition approach was extended to serial dynamic imaging with 2-fold compressed sensing acceleration without changing spatial resolution. The T2 mapping experiments yielded measurements of T2 values of >1s for all compounds within rat kidneys/vasculature and TRAMP tumors, except for [2-13C]pyruvate which was ~730ms and ~320ms, respectively. The high resolution 3D imaging enabled visualization the biodistribution of [1-13C]lactate, [1-13C]pyruvate, and [2-13C]pyruvate within different kidney compartments as well as in the vasculature. While the mouse anatomy is smaller, the resolution was also sufficient to image the distribution of all compounds within kidney, vasculature, and tumor. The development of the specialized 3D sequence with compressed sensing provided improved structural and functional assessments at a high (0.003cm3) spatial and 2s temporal resolution in vivo utilizing HP 13C substrates by exploiting their long T2 values. This 1.5mm isotropic resolution is comparable to 1H imaging and application of this approach could be extended to future studies of uptake, metabolism, and perfusion in cancer and other disease models and may ultimately be of value for clinical imaging.

Privacy and Confidentiality Practices In Adolescent Family Planning Care At Federally Qualified Health Centers.

CONTEXT: The confidentiality of family planning services remains a high priority to adolescents, but barriers to implementing confidentiality and privacy practices exist in settings designed for teenagers who are medically underserved, including federally qualified health centers (FQHCs). METHODS: A sample of 423 FQHCs surveyed in 2011 provided information on their use of five selected privacy and confidentiality practices, which were examined separately and combined into an index. Regression modeling was used to assess whether various state policies and organizational characteristics were associated with FQHCs' scores on the index. In-depth case studies of six FQHCs were conducted to provide additional contextual information. RESULTS: Among FQHCs reporting on confidentiality, most reported providing written or verbal information regarding adolescents' rights to confidential care (81%) and limiting access to family planning and medical records to protect adolescents' confidentiality (84%). Far fewer reported maintaining separate medical records for family planning (10%), using a security block on electronic medical records to prevent disclosures (43%) or using separate contact information for communications regarding family planning services (50%). Index scores were higher among FQHCs that received Title X funding than among those that did not (coefficient, 0.70) and among FQHCs with the largest patient volumes than among those with the smallest caseloads (0.43). Case studies highlighted how a lack of guidelines and providers' confusion over relevant laws present a challenge in offering confidential care to adolescents. CONCLUSIONS: The organizational practices used to ensure adolescent family planning confidentiality in FQHCs are varied across organizations.

After the Affordable Care Act: Health Reform and the Safety Net.

Two major safety net providers - community health centers and public hospitals - continue to play a key role in the health care system even in the wake of coverage reform. This article examines the gains and threats they face under the Affordable Care Act.

Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States.

OBJECTIVE: To examine variations in the quality and cost of care provided to patients with diabetes mellitus by Community Health Centers (CHCs) compared to other primary care settings. RESEARCH DESIGN AND METHODS: We used data from the 2005-2008 Medical Expenditure Panel Survey (N = 2,108). We used two dependent variables: quality of care and ambulatory care expenditures. Our primary independent variable was whether the respondent received care in a Community Health Centers (CHCs) or not. We estimated logistic regression models to determine the probability of quality of care, and used generalized linear models with log link and gamma distribution to predict expenditures for CHC users compared to non-users of CHCs, conditional on patients with positive expenditures. RESULTS: Results showed that variations of quality between CHC users and non-CHC users were not statistically significant. Patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared to non-users of CHCs. CONCLUSIONS: These findings suggest an opportunity for policymakers to control costs for diabetes mellitus patients without having a negative impact on quality of care.

Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation.

Community health centers reach their fiftieth anniversary in 2015, along with Medicaid. Health policy makers have understood the programs' symbiotic connection from the earliest days of their implementation. Medicaid's expansion and growth have made the modern community health center program possible, while health centers represent one of the principal sources of primary care for the nation's Medicaid population. With their shared mission and high level of interdependence, Medicaid and community health centers are essential for continued health system transformation in medically underserved communities nationwide--for example, by implementing delivery system reforms aimed at increasing clinical integration and improving efficiencies and by becoming medical homes for high-risk patients. Achieving this transformation will depend on the ability of community health centers and Medicaid to understand and respond to the challenges that each faces, while fully deploying the strengths that each has to offer.

The Role of Federally Qualified Health Centers in Delivering Family Planning Services to Adolescents.

PURPOSE: The purpose of this article was to examine the role of community health centers (CHCs) in providing comprehensive family planning services to adolescents, looking at the range of services offered and factors associated with provision of these services. METHODS: This study employed a mixed methods approach comprising a national survey of CHCs and six in-depth case studies of health centers to examine the organization and delivery of family planning services. We developed an adolescent family planning index comprising nine family planning services specifically tailored to adolescents. We analyzed the influence of state-level family planning policies, funding for adolescents, and organizational characteristics on the provision of these services in CHCs. The case studies identified barriers to the provision of family planning to adolescent patients. RESULTS: The survey found substantial variation in the provision of family planning services at CHCs, with a mean of 6.33 out of a maximum score of 13 on the family planning adolescent services index. Title X funding and location within a favorable state policy environment were significantly associated with higher scores on the family planning adolescent services index (p value < .001 and .002, respectively). Case studies revealed barriers to adolescent family planning, including lack of funding, lack of knowledge, and limitations on school-based clinical services. CONCLUSIONS: CHCs have the opportunity to play a significant role in providing high-quality family planning to low-income, medically underserved adolescents. Additional funding, resources, and a favorable policy climate would further improve CHCs' ability to serve the family planning needs of this special patient population.

Food insecurity, food assistance and health status in the U.S. community health center population.

OBJECTIVES: This study explored the relationship between food insecurity, food assistance, and self-reported health status among community health center (CHC) clients. METHODS: Using data from the 2009 Community Health Center Patient Survey (n = 4,562), representing Federally Qualified Health Center clients, we conducted logistic regression analyses to identify the association between food insecurity and fair/poor health status, controlling for food assistance and sociodemographic factors. RESULTS: Approximately 1/3 of the sample (31.9%) reported fair/poor health status, 10.9% reported food insecurity, and 52.6% reported public food assistance. Multivariate analyses revealed that, among women, those with food insecurity had significantly higher odds of reporting fair/poor health status (AOR = 2.14, 95% CI 1.20-3.82). CONCLUSIONS: Expansion of financial access to health care via the Patient Protection and Affordable Care Act coupled with recent funding cuts to the Supplemental Nutrition Assistance Program means that CHCs play an increasingly important role in addressing food insecurity.

Identifying key patient demographics and organizational factors that contribute to health center participation in research.

Federally Qualified Health Centers are well positioned for translational research given their diverse patient population, unique characteristics, and community knowledge. This was the first national survey that assessed their research activities. Those with research experience were more likely to be urban and Health Care for the Homeless grantees and had more patients, minority patients, and physicians relative to nonphysician providers, enabling services providers, Medicaid revenues per Medicaid patient, and total revenues per patient than health centers with no experience and no future interest in research. Only enabling services providers to patient ratios and total patients remained significant after controlling for other factors.

Engaging Community Health Centers (CHCs) in research partnerships: the role of prior research experience on perceived needs and challenges.

Despite community health centers' substantial role in local communities and in the broader safety-net healthcare system, very limited research has been conducted on community health center research experience, infrastructure, or needs from a national perspective. A national survey of 386 community health centers was conducted in 2011 and 2012 to assess research engagement among community health centers and their perceived needs, barriers, challenges, and facilitators with respect to their involvement in public health and health services research. This paper analyzes the differences between health centers that currently conduct or participate in research and health centers that have no prior research experience to determine whether prior research experience is indicative of different perceived challenges and research needs in community health center settings.

No evidence that primary care physicians offer less care to Medicaid, community health center, or uninsured patients.

The Affordable Care Act increases US investment in Medicaid and community health centers, yet many people believe that care in such safety-net programs is substandard. Using data from more than 31,000 visits to primary care physicians in the period 2006-10, we examined whether the length or content of a visit was different for safety-net patients-those insured by Medicaid, those who are uninsured, and those seen in a community health center-compared to patients with private insurance. We found no significant differences in the average length of a primary care visit or in the likelihood of a patient's receiving preventive health counseling. Medicaid patients received more diagnostic and treatment services, and uninsured patients received fewer services, compared to privately insured patients, but the differences were small. This analysis indicates that length and content of primary care visits are comparable for safety-net and other patients. The main factors that contribute to differences in visit length and content are patients' health needs and the type of visit involved.

The role of community health centers in providing behavioral health care.

The prevalence of behavioral health problems is higher for low-income individuals, yet this population is less likely to receive behavioral health treatment. Community health centers have their advantages as behavioral health-care providers because they serve a majority low-income population and are located in medically underserved areas. Their role in providing behavioral health care is expected to expand under health reform as they are expected to double their patient capacity, and due to increased insurance coverage for individuals with behavioral health problems. However, the ability of community health centers to provide behavioral health care is compromised by provider shortages and funding shortfalls.

Cost savings associated with the use of community health centers.

This study assesses the potential cost savings associated with the use of community health centers, based on econometric analyses of the 2006 Medical Expenditure Panel Survey. After controlling for health status, health insurance coverage, income, age, and other factors, this study finds that patients who receive a majority of their ambulatory care at community health centers have significantly lower annual overall medical expenditures (24%) and ambulatory expenditures (25%) than those who do not. These results are consistent with other studies indicating that, by providing good quality primary care, community health centers can reduce the utilization of other medical services.

Safety-net providers after health care reform: lessons from Massachusetts.

BACKGROUND: National health reform is designed to reduce the number of uninsured adults. Currently, many uninsured individuals receive care at safety-net health care providers such as community health centers (CHCs) or safety-net hospitals. This project examined data from Massachusetts to assess how the demand for ambulatory and inpatient care and use changed for safety-net providers after the state's health care reform law was enacted in 2006, which dramatically reduced the number of individuals without health insurance coverage. METHODS: Multiple methods were used, including analyses of administrative data reported by CHCs and hospitals, case study interviews, and analyses of data from the 2009 Massachusetts Health Reform Survey, a state-representative telephone survey of adults. RESULTS: Between calendar years 2005 and 2009, the number of patients receiving care at Massachusetts CHCs increased by 31.0%, and the share of CHC patients who were uninsured fell from 35.5% to 19.9%. Nonemergency ambulatory care visits to clinics of safety-net hospitals grew twice as fast as visits to non-safety-net hospitals from 2006 to 2009. The number of inpatient admissions was comparable for safety-net and non-safety-net hospitals. Most safety-net patients reported that they used these facilities because they were convenient (79.3%) and affordable (73.8%); only 25.2% reported having had problems getting appointments elsewhere. CONCLUSIONS: Despite the significant reduction in uninsurance levels in Massachusetts that occurred with health care reform, the demand for care at safety-net facilities continues to rise. Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after health care reform programs are established.