Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act.

BACKGROUND: Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. OBJECTIVE: To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA. DESIGN: Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending. PARTICIPANTS: Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey. INTERVENTION: ACA implementation, January 1, 2014. MAIN MEASURES: Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income. KEY RESULTS: Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care. CONCLUSIONS: ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.

Community-based organizations' perspectives on improving health and social service integration.

BACKGROUND: Collaborations between health systems and community-based organizations (CBOs) are increasingly common mechanisms to address the unmet health-related social needs of high-risk populations. However, there is limited evidence on how to develop, manage, and sustain these partnerships, and implementation rarely incorporates perspectives of community social service organizations. To address these gaps, we elicited CBOs' perspectives on service delivery for clients, the impact of the Whole Person Care-Los Angeles (WPC-LA) initiative to integrate health and social care, and their suggestions for improving health system partnerships. METHODS: Using stakeholder engaged principles and a qualitative Rapid Assessment Process, we conducted brief surveys and in-depth semi-structured interviews with 65 key informants from 36 CBOs working with WPC-LA. RESULTS: Major themes identified by CBOs included: 1) the importance of a holistic, client-centered, continuously engaged approach that is reliant on regional partnerships; 2) benefits of WPC-LA expanding capacity and networks; 3) concerns about communication and redundancy hindering WPC-LA; and 4) a need for more equitable partnerships incorporating their approaches. CONCLUSIONS: CBOs value opportunities for integration with health systems, bring critical expertise to these partnerships, and seek to strengthen cross-sector collaborations. Early, equitable, and inclusive participation in the development and implementation of these partnerships may enhance their effectiveness, but requires policy that prioritizes and incentivizes sustainable and mutually beneficial partnerships.

Unlocking HIV Pre-Exposure Prophylaxis Delivery: Examining the Role of HIV Providers in Pre-Exposure Prophylaxis Care.

Despite being a promising prevention strategy for populations at risk for HIV acquisition, there has not been rapid uptake of HIV antiretroviral pre-exposure prophylaxis (PrEP). Yet, HIV clinics within the Mount Sinai Health System in New York City have successfully incorporated PrEP. HIV care providers (n = 18), who practice in these clinics and were early PrEP adopters, participated in a survey and semistructured interview. Qualitative thematic analysis revealed that barriers and facilitators to PrEP uptake were identified on multiple levels from broader systemic to provider-and-patient-level concerns. The following themes were identified: (1) to reach a greater proportion of patients at risk for HIV and address racial/ethnic and gender disparities, PrEP should be available in a variety of settings and provided by different types of providers within proximity to affected populations; (2) financial support is needed beyond addressing medication cost; and (3) multidisciplinary teams and population-specific clinic protocols can assist providers in conducting high-quality visits and addressing these barriers to PrEP.

Assessing the hidden curriculum for the care of patients with limited english proficiency: An instrument development.

Background: Patients with limited English proficiency (LEP) are a growing population in the United States at risk for disparities in quality and safety of care. Medical student competency to care for patients with LEP is impacted by a hidden curriculum (HC) that undermines the learning experience; yet to date, there is no way to measure it. Thus, we designed an instrument to assess this HC. Methods: Based on findings from previous qualitative work and input from medical students and experts in LEP and psychometrics, we developed a 23-item survey with four domains. We e-mailed this to 3rd and 4th year students from two medical schools in the US. We conducted principal axis factoring to determine the instrument's construct validity. Only items with a factor loading ≥0.50 were retained. Results: We obtained 111 complete responses. Twenty-two of the 23 original items were retained. Four factors/components emerged, which did not support the original proposed domains. Three factors loaded on a mix of role modeling, and learning environment, structural, and organizational variables, while the fourth factor retained two role modeling items. Based on the factor extraction solution, we restructured the instrument into three domains: role modeling, demonstration of effective systems, and consequences of structural barriers for patients with LEP (Cronbach's alpha: 0.81-0.95, total variance accounted for 53.7%). Discussion: The results led us to reassess the domain structure to create an instrument representing students' perceptions and context. Our instrument, the LEP-HC, will allow medical educators to investigate a specific and important HC and improve teaching about care of patients with LEP.

Through the Veil of Language: Exploring the Hidden Curriculum for the Care of Patients With Limited English Proficiency.

PURPOSE: Patients with limited English proficiency (LEP) experience lower-quality health care and are at higher risk of experiencing adverse events than fluent English speakers. Despite some formal training for health professions students on caring for patients with LEP, the hidden curriculum may have a greater influence on learning. The authors designed this study to characterize the hidden curriculum that medical and nursing students experience regarding the care of patients with LEP. METHOD: In 2014, the authors invited students from one medical school and one nursing school, who had completed an interprofessional pilot curriculum on caring for patients with LEP 6 to 10 months earlier, to participate in semistructured interviews about their clinical training experiences with LEP patients. The authors independently coded the interview transcripts, compared them for agreement, and performed content analysis to identify major themes. RESULTS: Thirteen students (7 medical and 6 nursing students) participated. Four major themes emerged: role modeling, systems factors, learning environment, and organizational culture. All 13 students described negative role modeling experiences, and most described role modeling that the authors coded as "indifferent." Students felt that the current system and learning environment did not support or emphasize high-quality care for patients with LEP. CONCLUSIONS: The hidden curriculum that health professional students experience regarding the care of patients with LEP is influenced by systems limitations and a learning environment and organizational culture that value efficiency over effective communication. Role modeling seems strongly linked to these factors as supervisors struggle with these same challenges.

Differences between nurse practitioner and physician care providers on rates of secondary cancer screening and discussion of lifestyle changes among breast cancer survivors.

PURPOSE: Breast cancer survivorship care is provided by surgical and medical oncologists, primary care physicians (PCPs), and nurse practitioner survivorship specialists (NPs). The study objective was to identify whether frequency of cancer screening and discussion of healthy lifestyles differed across these provider types. We also determined differences by provider in survivor reported follow through with lifestyle recommendations. METHODS: Breast cancer survivors completed surveys regarding the type of health-care provider they most recently saw, cancer screening, discussion, and self-reported lifestyle change since their breast cancer diagnosis. RESULTS: Seven hundred fifty-nine breast cancer survivors (78.7 % of those invited) completed the survey; 51.8 % indicated that their last visit was with a medical oncologist. There was no difference in rates of cancer screening (colon, cervical, and breast) among types of providers. A significantly larger proportion of patients who last saw an NP reported that they had discussed physical activity (78.6 %) as compared to medical oncologist 54.4 %, surgeon 43.1 %, radiation oncologist 64.1 %, and PCP 61.3 % (p < 0.001). Similar observations were observed for discussion of nutrition and weight (NP 70.0 %, medical oncologist 36.5 %, surgeon 25.7 %, radiation oncologist 48.7 %, PCP 35.5 %; p < 0.001). There was no significant difference across provider type in self-reported implementation of change in physical activity or diet. CONCLUSIONS: Our data indicate that a visit to the NP was related to comparable screening rates, but despite that NPs are more often discussing lifestyle modification, self-reported change in nutrition and physical exercise did not differ across provider type. IMPLICATIONS FOR CANCER SURVIVORS: NPs perform favorably with respect to lifestyle recommendations. Given the reported lack of lifestyle change, it is important to triage to providers who specialize in lifestyle modification and, if plausible, learn and provide actual evidence-based approaches to achieve positive outcomes in this area.