Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study.

BACKGROUND: Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce. OBJECTIVE: To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making. DESIGN: We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022. PARTICIPANTS: Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling. APPROACH: Semi-structured interviews were conducted with healthcare workers across Michigan. KEY RESULTS: Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging. CONCLUSIONS: A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.

Trust and distrust in low-income Michigan residents during the early COVID-19 pandemic: A qualitative study.

BACKGROUND: Trust and distrust have shaped health behaviour during the COVID-19 pandemic. Since the start of the pandemic, misinformation and polarization eroded trust across the United States. In states like Michigan, pandemic restrictions led to significant unrest. Michiganders also faced disproportionate morbidity and mortality from COVID-19 during this period. OBJECTIVE: The objective of this qualitative study was to understand the individual experiences of trust in low-income Michiganders during the early COVID-19 pandemic. PARTICIPANTS: Twenty-four participants at or below 200% of the federal poverty line who resided in Michigan were recruited for this study. APPROACH: Interviews were conducted during the winter of 2020 using a formal interview guide that addressed sources of information, perceptions of risk and exposure, protective behaviours and impacts of the pandemic at home, work and in receiving healthcare. RESULTS: Thematic analysis showed that themes of trust and distrust emerged in multiple facets of our participants' experiences, including in the context of information sources, the behaviours of others, health, financial security, employment and overall safety. Trust and distrust in low-income communities often stemmed from significant financial and economic vulnerabilities and instability in access to healthcare that was exacerbated in the pandemic. Furthermore, participant trust was shaped by internal (e.g., relationships with others) and external (e.g., source of information, social inequity) factors that influenced their perceptions and experiences during the pandemic. CONCLUSION: Trust has played an important role in many aspects of the experiences of low-income communities during the COVID-19 pandemic. This is important for clinicians to consider as COVID-19 becomes endemic, and trust continues to impact patients' approaches to vaccines, testing and treatment options. PATIENT OR PUBLIC CONTRIBUTION: This study was designed and conducted with the assistance and input of the members of the DECIDERS Steering Committee, a diverse statewide network of community members in Michigan. The DECIDERS team allows community members to have a voice in the design and conduct of health research, and collaborates with researchers to improve health across the state of Michigan.

Inclusionary Trials: A Review of Lessons Not Learned.

The COVID-19 pandemic revealed weaknesses in the public health infrastructure of the United States, including persistent barriers to engaging marginalized communities toward inclusion in clinical research, including trials. Inclusive participation in clinical trials is crucial for promoting vaccine confidence, public trust, and addressing disparate health outcomes. A long-standing body of literature describes the value of community-based participatory research in increasing marginalized community participation in research. Community-based participatory research emphasizes shared leadership with community members in all phases of the research process, including in the planning and implementation, interpretation, and dissemination. Shared leadership between academic and industry with marginalized communities can assist with inclusive participation in vaccine trials and increase public trust in the development of the vaccines and other therapies used during public emergencies. Nevertheless, epidemiologic and clinical research do not yet have a strong culture of community partnership in the scientific process, which takes time to build and therefore may be difficult to develop and rapidly scale to respond to the pandemic. We outline practices that contribute to a lack of inclusive participation and suggest steps that trialists and other researchers can take to increase marginalized communities' participation in research. Practices include planning for community engagement during the planning and recruitment phases, having regular dialogues with communities about their priorities, supporting them throughout a study, and navigating complex structural determinants of health. Additionally, we discuss how research institutions can support inclusive practices by reexamining their policies to increase participation in clinical trials and instilling institutional trustworthiness.

Operationalizing a patient engagement plan for health research: Sharing a codesigned planning template from a national clinical trial.

INTRODUCTION: Engaging with patients about their lived experience of health and illness and their experience within the healthcare system can help inform the provision of care, health policies and health research. In the context of health research, however, operationalizing the levels of patient engagement is not straightforward. We suggest that a key challenge to the routine inclusion of patients as partners in health research is a lack of tangible guidance regarding how this can be accomplished. METHODS: In this article, we provide guidance on how to codesign and operationalize a concrete patient engagement plan for any health research project. RESULTS: We illustrate a seven-step approach using the example of a national clinical trial in Canada and provide a patient engagement planning template for use in any health research project. CONCLUSION: Such concrete guidance should improve the design and reporting of patient engagement in health research. PATIENT OR PUBLIC CONTRIBUTION: The De-Implementing Wisely Research group is informed by a national 9-member patient partner council (PPC). The research team includes three lead patient partners who are coinvestigators on the grant that funds the program of research. Members of the council advise on all aspects of the study design and implementation. The ideas presented in this paper were informed by regular communication and planning with the PPC; specific contributions of lead patient partner authors are outlined as follows: Brian Johnston, Susan Goold and Vanessa Francis are patient partners with a wide breadth of experience in the healthcare system and health research projects. The guidance in this article draws on their lived and professional expertise. All patient partner authors contributed to the planning of the manuscript, participated in meetings to develop content and provided critical manuscript edits and comments on drafts.

Longitudinal trends in enrollees' employment and student status after Medicaid expansion.

BACKGROUND: Medicaid community engagement requirements previously received federal approval in 12 states, despite limited data on their impact on enrollees' employment-related activities. Our objective was to assess longitudinal changes in enrollees' employment and student status after implementation of Michigan's Medicaid expansion. METHODS: Longitudinal telephone survey of Michigan Medicaid expansion enrollees in 2016 (response rate [RR] = 53.7%), 2017 (RR = 83.4%), and 2018 (N = 2,608, RR = 89.4%) serially assessing self-reported employment or student status. Survey responses were benchmarked against statewide changes in assessed similar low-income adults in the U.S. Census Bureau Current Population Survey. We used mixed models with individual random effects to assess changes in the proportion of enrollees who were employed or students by year. RESULTS: Most respondents had incomes < 100% FPL (61.7% with 0-35% of the federal poverty level [FPL], 22.9% with 36-99% FPL, and 15.4% with 100-133% FPL), 89.3% had at least a high school diploma/equivalent, and they ranged in age (39.6% age 19-34, 34.5% age 35-50, 25.9% age 51-64). Employment or student status increased significantly among Michigan Medicaid expansion respondents, from 54.5% in 2016 to 61.4% in 2018 (P < 0.001), including among those with a chronic condition (47.8% to 53.8%, P < 0.001) or mental health/substance use disorder (48.5% to 56.0%, P < 0.001). In contrast, the statewide proportion of low-income non-elderly adults who were employed or students did not change significantly (from 42.7% in 2016 to 46.0% in 2018, P = 0.57). CONCLUSIONS: Medicaid expansion, absent a community engagement requirement, was associated with increased employment and related activities. The role of Medicaid in providing safety-net coverage to individuals during times of economic stress is likely to grow.

Engagement with Health Risk Assessments and Commitment to Healthy Behaviors in Michigan's Medicaid Expansion Program.

BACKGROUND: Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees' health. OBJECTIVE: To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program. DESIGN: Telephone survey conducted in Michigan January-October 2016. PARTICIPANTS: A random sample of HMP enrollees aged 19-64 with ≥ 12 months of enrollment, stratified by income and geographic region. MAIN MEASURES: Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior. KEY RESULTS: Among respondents (N = 4090), 49.3% (95% CI 47.3-51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5-86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6-92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5-52.8% vs. 36.2%, 95% CI 31.7-41.1%; p < 0.01). Among enrollees completing an HRA, nearly half said they did it because their PCP suggested it (45.9%, 95% CI 43.2-48.7%), and most reported it helped their PCP understand their health needs (89.7%). Awareness of financial incentives was limited (28.1%, 95% CI 26.3-30.0%), and very few reported it as the primary reason for HRA completion (2.5%, 95% CI 1.8-3.4%). Most committed to a healthy behavior (80.7%, 95% CI 78.5-82.8%), and common behaviors chosen were nutrition/diet (57.2%, 95% CI 54.2-60.2%) and exercise/activity (52.6%, 95% CI 49.5-55.7%). CONCLUSIONS: In the Healthy Michigan Plan, PCPs appeared influential in enrollees' completion of HRAs and healthy behavior engagement, while knowledge of financial incentives was limited. Additional study is needed to understand the relative importance of financial incentives and PCP engagement in impacting healthy behaviors in state Medicaid programs.

Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey.

BACKGROUND: Physicians play a key role in mitigating and managing costs in healthcare which are rising. OBJECTIVE: Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs. PARTICIPANTS: Random sample of 1200 US physicians from the AMA Masterfile. MEASURES: Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. KEY RESULTS: Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. CONCLUSIONS AND RELEVANCE: US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.

Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion.

BACKGROUND: Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services. OBJECTIVE: Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services. DESIGN: Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment. PARTICIPANTS: 4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims. KEY RESULTS: In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services. CONCLUSIONS: After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians.

BACKGROUND: Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care. OBJECTIVE: To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care. DESIGN: Cross-sectional survey of ACO clinicians in 2018. PARTICIPANTS: 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%. MAIN MEASURES: Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care. RESULTS: Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation. CONCLUSIONS: Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

How Would Low-Income Communities Prioritize Medicaid Spending?

CONTEXT: Medicaid plays a critical role in low-income, minority, and medically underserved communities, particularly in states that have expanded Medicaid under the Affordable Care Act. Yet, the voices of underresourced communities are often unheard in decisions about how to allocate Medicaid's scarce resources, and traditional methods of public engagement are poorly suited to gathering such input. We argue that deliberative public engagement can be a useful tool for involving communities in setting Medicaid priorities. METHOD: We engaged 209 residents of low-income, medically underserved Michigan communities in discussions about Medicaid spending priorities using an exercise in informed deliberation: CHAT (CHoosing All Together). Participants learned about Medicaid, deliberated in small groups, and set priorities both individually and collectively. FINDINGS: Participants prioritized broad eligibility consistent with the ACA expansion, accepted some cost sharing, and prioritized spending in areas-including mental health-that are historically underfunded. Participants allocated less funding beyond benefit coverage, such as spending on healthy communities. Participants perceived the deliberative process as fair and informative, and they supported using it in the policy-making process. CONCLUSION: The choices of participants from low-income, medically underserved communities reflect a unique set of priorities and suggest that engaging low-income communities more deeply in Medicaid policy making might result in different prioritization decisions.

Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study.

BACKGROUND: It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions. OBJECTIVE: Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being. DESIGN: Mixed-methods study including a telephone survey and semi-structured interviews. SETTING: Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP). PARTICIPANTS: 4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment. MAIN MEASURES: Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status. KEY RESULTS: Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health. CONCLUSIONS: Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.

BACKGROUND: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy. OBJECTIVE: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities. CONCLUSIONS: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

Evaluating community deliberations about health research priorities.

CONTEXT: Engaging underrepresented communities in health research priority setting could make the scientific agenda more equitable and more responsive to their needs. OBJECTIVE: Evaluate democratic deliberations engaging minority and underserved communities in setting health research priorities. METHODS: Participants from underrepresented communities throughout Michigan (47 groups, n = 519) engaged in structured deliberations about health research priorities in professionally facilitated groups. We evaluated some aspects of the structure, process, and outcomes of deliberations, including representation, equality of participation, participants' views of deliberations, and the impact of group deliberations on individual participants' knowledge, attitudes, and points of view. Follow-up interviews elicited richer descriptions of these and also explored later effects on deliberators. RESULTS: Deliberators (age 18-88 years) overrepresented minority groups. Participation in discussions was well distributed. Deliberators improved their knowledge about disparities, but not about health research. Participants, on average, supported using their group's decision to inform decision makers and would trust a process like this to inform funding decisions. Views of deliberations were the strongest predictor of these outcomes. Follow-up interviews revealed deliberators were particularly struck by their experience hearing and understanding other points of view, sometimes surprised at the group's ability to reach agreement, and occasionally activated to volunteer or advocate. CONCLUSIONS: Deliberations using a structured group exercise to engage minority and underserved community members in setting health research priorities met some important criteria for a fair, credible process that could inform policy. Deliberations appeared to change some opinions, improved some knowledge, and were judged by participants worth using to inform policymakers.

Primary Care Clinicians' Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study.

BACKGROUND: Michigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs). OBJECTIVE: Assess PCPs' perspectives about the impact of HMP on their patients and practices. DESIGN: In 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs. SETTING: Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail. PARTICIPANTS: Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104). MEASUREMENTS: PCPs' experiences with HMP patients and recent changes in their practices. RESULTS: Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened. LIMITATIONS: PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias. CONCLUSIONS: PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.

Members of Minority and Underserved Communities Set Priorities for Health Research.

Policy Points Engaging and involving underrepresented communities when setting research priorities could make the scientific research agenda more equitable, more just, and more responsive to their needs and values. Groups and individuals from minority and underserved communities strongly prioritized child health and mental health research, often choosing to invest at the highest possible level. Groups consisting of predominantly Native American or Arab American participants invested in culture and beliefs research at the highest level, while many groups did not select it at all. The priority given to culture and beliefs research by these groups illustrates the importance of paying special attention to unique preferences, and not just commonly held views, when getting public input on spending priorities for research. CONTEXT: A major contributor to health disparities is the relative lack of resources-including resources for science-allocated to address the health problems of those with disproportionately greater needs. Engaging and involving underrepresented communities in setting research priorities could make the scientific research agenda more equitable, more just, and more responsive to their needs and values. We engaged minority and underserved communities in informed deliberations and report here their priorities for health research. METHODS: Academic-community partnerships adapted the simulation exercise CHAT for setting health research priorities. We had participants from minority and medically underserved communities (47 groups, n = 519) throughout Michigan deliberate about health research priorities, and we used surveys and CHAT software to collect the demographic characteristics and priorities selected by individuals and groups. FINDINGS: The participants ranged in age (18 to 88), included more women than men, and were overrepresented by minority groups. Nearly all the deliberating groups selected child health and mental health research (93.6% and 95.7%), and most invested at the highest level. Aging, access, promote health, healthy environment, and what causes disease were also prioritized by groups. Research on mental health and child health were high priorities for individuals both before and after group deliberations. Access was the only category more likely to be selected by individuals after group deliberation (77.0 vs 84.0%, OR = 1.63, p = .005), while improve research, health policy, and culture and beliefs were less likely to be selected after group deliberations (all, p < .001). However, the level of investment in many categories changed after the group deliberations. Participants identifying as Black/African American were less likely to prioritize mental health research, and those of Other race were more likely to prioritize culture and beliefs research. CONCLUSIONS: Minority and medically underserved communities overwhelmingly prioritized mental health and child health research in informed deliberations about spending priorities.

Solidarity and cost management: Swiss citizens' reasons for priorities regarding health insurance coverage.

CONTEXT: Approaches to priority-setting for scarce resources have shifted to public deliberation as trade-offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health-care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care. METHODS: We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health-care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio-economic backgrounds in the three language regions. FINDINGS: Participants developed strategic arguments based on the importance of basic coverage for all, and of cost-benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable. CONCLUSION: The Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade-offs and setting priorities for complex health issues.

Attitudes toward cost-conscious care among U.S. physicians and medical students: analysis of national cross-sectional survey data by age and stage of training.

BACKGROUND: The success of initiatives intended to increase the value of health care depends, in part, on the degree to which cost-conscious care is endorsed by current and future physicians. This study aimed to first analyze attitudes of U.S. physicians by age and then compare the attitudes of physicians and medical students. METHODS: A paper survey was mailed in mid-2012 to 3897 practicing physicians randomly selected from the American Medical Association Masterfile. An electronic survey was sent in early 2015 to all 5,992 students at 10 U.S. medical schools. Survey items measured attitudes toward cost-conscious care and perceived responsibility for reducing healthcare costs. Physician responses were first compared across age groups (30-40 years, 41-50 years, 51-60 years, and > 60 years) and then compared to student responses using Chi square tests and logistic regression analyses (controlling for sex). RESULTS: A total of 2,556 physicians (65%) and 3395 students (57%) responded. Physician attitudes generally did not differ by age, but differed significantly from those of students. Specifically, students were more likely than physicians to agree that cost to society should be important in treatment decisions (p < 0.001) and that physicians should sometimes deny beneficial but costly services (p < 0.001). Students were less likely to agree that it is unfair to ask physicians to be cost-conscious while prioritizing patient welfare (p < 0.001). Compared to physicians, students assigned more responsibility for reducing healthcare costs to hospitals and health systems (p < 0.001) and less responsibility to lawyers (p < 0.001) and patients (p < 0.001). Nearly all significant differences persisted after controlling for sex and when only the youngest physicians were compared to students. CONCLUSIONS: Physician attitudes toward cost-conscious care are similar across age groups. However, physician attitudes differ significantly from medical students, even among the youngest physicians most proximate to students in age. Medical student responses suggest they are more accepting of cost-conscious care than physicians and attribute more responsibility for reducing costs to organizations and systems rather than individuals. This may be due to the combined effects of generational differences, new medical school curricula, students' relative inexperience providing cost-conscious care within complex healthcare systems, and the rapidly evolving U.S. healthcare system.

Self-Reported Rationing Behavior Among US Physicians: A National Survey.

BACKGROUND: Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic. OBJECTIVE: To describe rationing behavior and associated factors among US physicians. DESIGN: Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior. SETTING: US physicians across a full spectrum of practice settings. PARTICIPANTS: A total of 2541 respondents, representing 65.6 % of the original mailing list of 3872 US addresses. INTERVENTIONS: The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word "ration" on perceived responsibility. MAIN OUTCOME MEASURES: Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing. KEY RESULTS: In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9-0.9] and 0.5 [0.4-0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 [0.2-0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6-0.9]) than those self-reporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing. CONCLUSIONS: More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior.

Health Insurance Trends and Access to Behavioral Healthcare Among Justice-Involved Individuals-United States, 2008-2014.

BACKGROUND: A large proportion of justice-involved individuals have mental health issues and substance use disorders (SUD) that are often untreated due to high rates of uninsurance. However, roughly half of justice-involved individuals were estimated to be newly eligible for health insurance through the Affordable Care Act (ACA). OBJECTIVE: We aimed to assess health insurance trends among justice-involved individuals before and after implementation of the ACA's key provisions, the dependent coverage mandate and Medicaid expansion, and to examine the relationship between health insurance and treatment for behavioral health conditions. DESIGN: Repeated and pooled cross-sectional analyses of data from the National Survey on Drug Use and Health (NSDUH). PARTICIPANTS: Nationally representative sample of 15,899 adults age 19-64 years between 2008 and 2014 with a history of justice involvement during the prior 12 months. MAIN MEASURES: Uninsurance rates between 2008 and 2014 are reported. Additional outcomes include adjusted treatment rates for depression, serious mental illness, and SUD by insurance status. KEY RESULTS: The dependent coverage mandate was associated with a 13.0 percentage point decline in uninsurance among justice-involved individuals age 19-25 years (p < 0.001). Following Medicaid expansion, uninsurance declined among justice involved individuals of all ages by 9.7 percentage points (p < 0.001), but remained 16.3 percentage points higher than uninsurance rates for individuals without justice involvement (p < 0.001). In pooled analyses, Medicaid, relative to uninsurance and private insurance, was associated with significantly higher treatment rates for illicit drug abuse/dependence and depression. CONCLUSION: Given the high prevalence of mental illness and substance use disorders among justice-involved populations, persistently elevated rates of uninsurance and other barriers to care remain a significant public health concern. Sustained outreach is required to reduce health insurance disparities between individuals with and without justice involvement. Public insurance appears to be associated with higher treatment rates, relative to uninsurance and private insurance, among justice-involved individuals.