Medicaid Patients Have Greater Difficulty Scheduling Health Care Appointments Compared With Private Insurance Patients: A Meta-Analysis

Disparities in Treatment for Alcohol Use Disorder Among All of Us Participants

OBJECTIVE

The authors examined racial/ethnic and socioeconomic disparities in receiving treatment for alcohol use disorder (AUD).

METHODS

A retrospective cohort study was conducted that included adults (≥18 years) with AUD from the All of Us Controlled Tier database v7. Outcomes were lifetime receipt of FDA-approved medications (disulfiram, acamprosate, and naltrexone), psychotherapy (individual, family, and group-based session), and combination treatment (medication and psychotherapy). The study examined treatment receipt by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), insurance (private, Medicare, Medicare and Medicaid, Medicaid, Veteran Affairs [VA], none), income (<$10K, $10-<$50K, $50-$100K, >$100K), and area deprivation index (ADI) quintiles. Multivariable logistic and multinomial logistic regressions were used to assess the association between patient characteristics and treatment receipt.

RESULTS

The cohort consisted of 18,692 patients (mean age=57.1 years; 60.7% were male; 47.1% were non-Hispanic White). Almost 70% received no treatment, 11.4% received medication, 24.0% received psychotherapy, and 4.9% received combination treatment. In adjusted analysis, non-Hispanic Black (aOR=0.78, 95% CI=0.69-0.89) and Hispanic (aOR=0.75, 95% CI=0.64-0.88) individuals were less likely to receive medication than non-Hispanic White counterparts. There was no association between race/ethnicity and receipt of psychotherapy or combination treatment. Compared with private insurance, dual eligibility was associated with less use of medication, Medicare and Medicaid with less use of medication and combination treatment, and VA and no insurance with more use of psychotherapy and combination treatment. Higher income and lower ADI were positively associated with all treatment types.

CONCLUSIONS

There are disparities in AUD treatment by race/ethnicity, socioeconomic status, and insurance. Systematic approaches are required to improve equitable access to effective treatment.

Impact of sociodemographic status and sex on chronic rhinosinusitis and olfaction in people with cystic fibrosis

BACKGROUND

Sociodemographic status (SDS) including race/ethnicity and socioeconomic status as approximated by education, income, and insurance status impact pulmonary disease in people with cystic fibrosis (PwCF). The relationship between SDS and chronic rhinosinusitis (CRS) remains understudied.

METHODS

In a prospective, multi-institutional study, adult PwCF completed the 22-Question SinoNasal Outcome Test (SNOT-22), Smell Identification Test (SIT), Questionnaire of Olfactory Disorder Negative Statements (QOD-NS), and Cystic Fibrosis Questionnaire-Revised (CFQ-R). Lund-Kennedy scores, sinus computed tomography, and clinical data were collected. Data were analyzed across race/ethnicity, sex, and socioeconomic factors using multivariate regression.

RESULTS

Seventy-three PwCF participated with a mean age of 34.7 ± 10.9 years and 49 (67.1%) were female. Linear regression identified that elexacaftor/tezacaftor/ivacaftor (ETI) use (β = ‒4.09, 95% confidence interval [CI] [‒6.08, ‒2.11], p < 0.001), female sex (β = ‒2.14, 95% CI [‒4.11, ‒0.17], p = 0.034), and increasing age (β = ‒0.14, 95% CI [‒0.22, ‒0.05], p = 0.003) were associated with lower/better endoscopy scores. Private health insurance (β = 17.76, 95% CI [5.20, 30.32], p = 0.006) and >16 educational years (β = 13.50, 95% CI [2.21, 24.80], p = 0.020) were associated with higher baseline percent predicted forced expiratory volume in one second (ppFEV1). Medicaid/Medicare insurance was associated with worse endoscopy scores, CFQ-R respiratory scores, and ppFEV1 (all p < 0.017), and Hispanic/Latino ethnicity was associated with worse SNOT-22 scores (p = 0.047), prior to adjustment for other cofactors. No other SDS factors were associated with SNOT-22, QOD-NS, or SIT scores.

CONCLUSIONS

Differences in objective measures of CRS severity exist among PwCF related to sex, age, and ETI use. Variant status and race did not influence patient-reported CRS severity measures or olfaction in this study. Understanding how these factors impact response to treatment may improve care disparities among PwCF.

CLINICAL TRIALS

NCT04469439.

Eye Care in Federally Qualified Health Centers

PURPOSE

To assess changes in vision care availability at Federally Qualified Health Centers (FQHCs) between 2017 and 2021 and whether neighborhood-level demographic social risk factors (SRFs) associated with eye care services provided by FQHCs.

DESIGN

Secondary data analysis of the Health Resources and Services Administration (HRSA) data and 2017-2021 American Community Survey (ACS).

PARTICIPANTS

Federally Qualified Health Centers.

METHODS

Patient and neighborhood characteristics for SRFs were summarized. Differences in FQHCs providing and not providing vision care were compared via Wilcoxon-Mann-Whitney tests for continuous measures and chi-square tests for categorical measures. Logistic regression models were used to test the associations between neighborhood measures and FQHCs providing vision care, adjusted for patient characteristics.

MAIN OUTCOME MEASURES

Odds ratios (ORs) with 95% confidence intervals (CIs) for neighborhood-level predictors of FQHCs providing vision care services.

RESULTS

Overall, 28.5% of FQHCs (n = 375/1318) provided vision care in 2017 versus 32% (n = 435/1362) in 2021 with some increases and decreases in both the number of FQHCs and those with and without vision services. Only 2.6% of people who accessed FQHC services received eye care in 2021. Among the 435 FQHCs that provided vision care in 2021, 27.1% (n = 118) had added vision services between 2017 and 2021, 71.5% (n = 311) had been offering vision services since at least 2017, and 1.4% (n = 6) were newly established. FQHCs providing vision care in 2021 were more likely to be in neighborhoods with a higher percentage of Hispanic/Latino individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0094), Medicaid-insured individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0120), and no car households (OR, 1.07, 95% CI, 1.01-1.13, P = 0.0142). However, FQHCs with vision care, compared to FQHCs without vision care, served a lower percentage of Hispanic/Latino individuals (27.2% vs. 33.9%, P = 0.0007), Medicaid-insured patients (42.8% vs. 46.8%, P < 0.0001), and patients living at or below 100% of the federal poverty line (61.3% vs. 66.3%, P < 0.0001).

CONCLUSIONS

Vision care services are available at a few FQHCs, localized to a few states. Expanding eye care access at FQHCs would meet patients where they seek care to mitigate vision loss to underserved communities.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

The Impact of Living in a Low Food Access/Low Income Area on Obstructive Sleep Apnea

OBJECTIVE

To assess differences in obstructive sleep apnea (OSA)-related health parameters between residents of low income/low access (LILA) census tracts-food deserts-and non-LILA residents STUDY DESIGN: Retrospective review.

SETTING

Single institution serving a large region in Southern California from 2017 to 2023.

METHODS

Census tracts are defined as LILA if a significant proportion of residents live below the poverty threshold and far from healthy food vendors. Adults newly diagnosed with OSA on polysomnography were included. Food access status was determined by searching patient addresses in the US Department of Agriculture Food Access Research Atlas. Baseline and 1-year follow-up body mass index (BMI) and vitals were collected and compared based on food access and other demographic variables.

RESULTS

A total of 379 patients in the LILA+ group and 2281 patients in the LILA- group met inclusion criteria. BMI was higher in the LILA group (36.6 ± 9.4 vs 35.2 ± 8.9; P = .006). The effect of food access was most significant in certain demographic groups: patients aged < 65, males, Asian/Pacific Islanders, Hispanics, and patients with Medicaid coverage all had a higher BMI when in the LILA+ group compared to the LILA- group. When considering insurance, LILA+ patients with Medicaid coverage had a significantly higher BMI than LILA- patients with non-Medicaid coverage (40.4 ± 10.3 vs 34.2 ± 8.4, P < .001. Blood pressure, heart rate, and apnea-hypopnea index were also significantly higher in LILA+/Medicaid group. BMI change across all demographic groups was minimal at 1-year follow-up.

CONCLUSION

Living in a LILA census tract may result in worse OSA-related health parameters. When accounting for insurance status, the effects are even more profound. Intensive counseling on the importance of weight management should begin at the diagnosis of OSA.

Insurance Status, Language, and Access to Care for Pediatric Anterior Cruciate Ligament Injury

Background

Patients with public insurance (PUBs) face more difficulty obtaining orthopaedic appointments and have longer wait times than privately insured patients (PVTs). These delays are associated with greater injury severity at the time of surgery, which affects sports injuries such as anterior cruciate ligament tears where early surgical stabilization leads to better outcomes. Additionally, previous evidence showed that patients with limited English proficiency often must rely on informal translation services, such as family members or friends, to communicate with their orthopaedic surgeons, which may represent a disparity in the care provided.

Hypothesis

It was hypothesized that PUBs would be less likely to obtain an appointment compared with PVTs and that most providers would not offer professional translation services to Spanish-speaking patients.

Study Design

Cross-sectional study.

Methods

The authors called 50 randomly selected orthopaedic surgeons' offices in California specializing in sports medicine to request an appointment. Each office was called 4 times in random order for the hypothetical patient having either private or public insurance and speaking either Spanish or English.

Results

The hypothetical PUB had significantly decreased access to an appointment (19% of offices offered an appointment) when compared to the PVT (73.8% offered an appointment). Independent private practice (IPP) offices were less likely to accept public insurance (13.3%) compared with offices at academic medical centers (57.1%). There was no difference in access to an appointment for the Spanish- versus English-speaking patient. Translation services were offered at 73.8% of the orthopaedic offices.

Conclusion

Overall, the data illustrated disparities in access to pediatric orthopaedic care for PUBs compared to those with private insurance. Disparities were most prominent in IPP settings, which were less likely than academic offices to accept public insurance. Additionally, it was found that 73.8% of the offices the authors contacted offered Spanish translation services. Interventions should focus on increasing acceptance of public insurance and translation services in IPP settings. Future studies should expand this analysis to other languages and investigate the potential impacts of language on the quality of care provided.

Factors influencing treatment and time spent with physicians in patients with uveitis compared to other ophthalmology subspecialties in the National Ambulatory Medical Care Survey

BACKGROUND

Cases of uveitis can necessitate long-term treatment resulting in recurrent follow-up appointments. Analysing the demographic distribution and patient factors influencing treatment and time spent with physicians in this population compared to other subspecialties of ophthalmology using the National Ambulatory Medical Care Survey (NAMCS) has not previously been studied.

METHODS

Data were extracted from the NAMCS database, a large, nationally representative survey of office-based specialists, entered between 2012-2016 and 2018. Demographics, time with physician, and payor types were compared between patients with a uveitis-related diagnosis codes versus all other ophthalmic subspecialty diagnoses.

RESULTS

Overall, 12,870 ophthalmic patients were included of which 300 had uveitis-related diagnosis codes. Uveitis patients were more likely to be non-Caucasian (p < 0.0001 to p = 0.022), visiting the physician's office due to flare of or treatment for a chronic medical problem (p < 0.0001 to p = 0.022). Adjusted for age, sex, race, and ethnicity, uveitis patients spent a significantly longer time (mean 27.5 min) compared to comprehensive ophthalmology patients (mean 25.5 min) with their physician (p = 0.0041). Among the uveitis patient population, African American patients (p = 0.0053), Hispanic or Latino (p = 0.034), and Medicaid (p = 0.035) patients had increased office visit times.

CONCLUSIONS

Those with uveitis spent more time with the physician than comprehensive patients. Race, ethnicity, payor type, and the major reason for the visit all significantly impacted uveitis office visit times. In order to manage their schedules, providers should be aware of the additional support and time needed by these patients during office visits.

Patient Preferences for Immediate Compared With Delayed Postpartum Intrauterine Device Placement

OBJECTIVE

To use choice-based conjoint survey methodology to evaluate patient values and decision making regarding immediate compared with delayed placement of postpartum intrauterine devices (IUDs).

METHODS

We conducted a cross-sectional study in which we surveyed 200 nonpregnant, parous patients. Participants chose between hypothetical postpartum IUDs varying in multiple attributes (hormonal or nonhormonal IUD type, placement timing, 1-year efficacy, expulsion risk, risk of lost strings, and malposition risk). The primary outcome was preference for immediate compared with delayed postpartum IUD placement and importance of placement timing relative to other attributes. Secondarily, we evaluated whether demographic and neighborhood characteristics were associated with timing preference and attribute importance.

RESULTS

We included 190 participants for analysis. Most participants (62.6%) preferred delayed placement. There was no significant difference in timing preference by race ( P =.28) or block-level Area Deprivation Index score ( P =.27). Patients who preferred immediate placement were more likely to have public insurance than private insurance (70.4% vs 29.6%, P =.04); however, the majority of patients (55.1%) with public insurance still preferred delayed placement. Attributes of IUD type, malposition risk, 1-year efficacy, and expulsion risk all had greater effects on patient decision making than placement timing. There was no difference in attribute importance by race ( P =.30), Area Deprivation Index score ( P =.88), or insurance type ( P =.22).

CONCLUSION

Patients preferred the higher efficacy and lower complication rates of delayed postpartum IUD placement over the convenience of immediate placement. Insurance considerations may affect these timing preferences. There was no difference in attribute importance between demographic groups or based on neighborhood-level factors, indicating that, although both immediate and delayed postpartum IUD placement should be offered, counseling should not vary according to individual demographic characteristics.

Cultural considerations in gastroenterology: barriers to care and a call for humility and action

Culture is a broadly defined term and patients' cultural identity may show up in the medical setting in visible and invisible ways. In this paper, we aim to discuss cultural considerations in gastrointestinal (GI) care. Our definition of "culture" reflects the commonly ascribed race and ethnicity and will also discuss other minority groups such as sexual and gender minorities (SGMs). We will review what is known about rates of GI conditions across various cultural groups, acknowledging that our data reflect inequity in representation. While the healthcare system has overall shown an increased awareness of the role that systemic and institutional racism plays in affecting patient care, this has not been widely studied in the context of GI though has a profound impact. Multiple factors affect the interaction between patients' cultural identities and engagement in and quality of GI care. Stigma related to cultural factors or cultural intersection has the capacity to shape if, when, and how medical care is approached, received and applied. Conditions and symptoms in GI are often complicated; health literacy (HL) is the ease with which patients can navigate getting from diagnosis to treatment and engage in self-management and also interacts with cultural context. Some aspects of a patient's experience, background and skill are imperceptible and require the healthcare provider to attend to treatment with humility, respect and self-reflection if they wish to effectively engage. We introduce the concept of cultural humility to GI and offer practical suggestions for those providing clinical care. We also call for future investment in a diverse healthcare delivery system and continued legislation to promote social equity.

Wait times for scheduling appointments with hospital affiliated dermatologists in New York City

Patients' experience accessing dermatologic care is understudied. The purpose of this cross-sectional study was to examine current wait times for new patients to receive dermatological care in NYC. Websites at 58 accredited private and public hospitals in the five boroughs of NYC were reviewed to identify dermatology practices. Office telephone numbers listed on each website were called to collect information pertaining to whether the physician was accepting new patients, type of insurance accepted (public, private, both, or none), and the number of days until a new patient could be seen for an appointment. Data pertaining to the time kept on hold and availability of web-based booking were also collected. Mean waiting time for an appointment was 50 days [standard deviation, SD 66] - nearly 2 months, but the distribution was considerably skewed. The median waiting time was 19.5 days [Interquartile range, IQR 4-60]. The time kept on hold to make the appointment was negligible at about 1 min (63 s, SD = 77) but could take up to ~ 7 min. Two-thirds of dermatologists accepted private, Medicare, and Medicaid insurance (n = 228, 66%); a small number accepted only private insurance (n = 12, 4%) or no insurance at all (n = 16, 5%). The median waiting time for an appointment for the 228 providers that accepted Medicaid was 30.5 days (IQR = 5.0-73.25) while for providers who did not accept Medicaid (n = 116) the median wait time for an appointment was 13.0 days (IQR = 3.0-38.0). Just over half (56%) of the dermatologists allowed for appointments to be booked on their website (n = 193). This research highlights the necessity of incorporating new strategies into routine dermatology appointments in order to increase treatment availability and decrease healthcare inequality.

Trends and Patterns in Emergency Department Visits: A Comprehensive Analysis of Adult Data From the National Center for Health Statistics (NCHS) Database

Background Emergency department (ED) visits among adults have increased in recent years, with the United States reporting 140 million ED visits in 2021, equating to an overall rate of 43 visits per 100 people. This trend underscores challenges in accessing primary care and addressing underlying health conditions. Understanding the trends and patterns in ED utilization is essential for informing healthcare policy and practice. Objective This study aims to comprehensively analyze trends and patterns in ED visits among adults using data from the National Center for Health Statistics (NCHS) database. Methods We conducted a retrospective analysis of ED visit data from 1999 to 2019, focusing on adults aged 18 and over. The prevalence rates of ED visits were examined across demographic, socioeconomic, and geographic groups using datasets retrieved from the NCHS database. Statistical analysis included one-way ANOVA and chi-square tests to assess variations in ED visit rates. Results This study's findings revealed a consistent increase in overall ED visits among adults, from 17.2 ± 0.3% in 1999 to 21.7 ± 0.3% in 2019. Disparities in ED utilization were evident across demographic and socioeconomic groups. Females had slightly higher visit rates, and significant racial disparities were noted, with American Indian or Alaska Native and Black or African American individuals showing the highest visit rates. Age-specific variations were observed, with young adults (18-24 years) and older adults (65 years and above) exhibiting higher visit rates. Socioeconomic status and health insurance coverage emerged as significant determinants, highlighting disparities in healthcare access. Conclusion This study provides valuable insights into the trends and patterns of ED visits among adults, emphasizing the need for targeted interventions to address healthcare disparities and improve access to primary care services.

Sociodemographic Factors Associated with Delayed Presentation in Craniosynostosis Surgery at a Tertiary Children's Hospital

Background

Craniosynostosis is a common diagnosis requiring early referral to a pediatric plastic surgeon; however, disparities in healthcare may influence presentation timing and affect treatment options and outcomes. This study aimed to explore sociodemographic factors contributing to delay in craniosynostosis surgical consultation.

Methods

A retrospective cohort study of 694 California-based craniosynostosis patients at a tertiary children's hospital was performed from 2006 to 2023. State-specific Area Deprivation Index (ADI) and distance to the hospital were calculated using ZIP codes. Multivariate linear and logistic regressions considered race, insurance type, syndromic status, suture type, and ZIP code-based socioeconomic factors.

Results

Median age of presentation was 4.5 [interquartile range: 2.6-7.6] months with racial/ethnic breakdown of Hispanic/Latinx (41.2%), White (23.6%), Asian (3.7%), Black/African American (2.0%), or other/unreported (29.5%) with 58.4% having public insurance and an average distance to the hospital of 48.3 km. Median ADI was 5.4 [interquartile range: 4.0-7.1]. By linear regression, public insurance (P < 0.001) and higher ADI decile (P < 0.001) independently contributed to an older age of presentation. Patients with public insurance (odds ratio 1.90; P = 0.002) were more likely to present after 4 months of age.

Conclusions

Patients who had public insurance or resided in more disadvantaged areas presented later for craniosynostosis surgical consultation. Eliminating disparities in these populations ensures more equitable access to surgical options and can improve patient outcomes.

Variation in dentist participation between dental medicaid managed care organizations

OBJECTIVES

Dentists' Medicaid participation is a critical factor affecting dental care access for Medicaid beneficiaries. An important gap in existing literature is the variation in participation across Medicaid dental Managed Care Organizations (MCOs) in states with more than one. This study examined the variation in participation overall and in predictors of dentist participation between two MCOs in Iowa's Dental Medicaid program.

METHODS

Data were obtained from a survey of Iowa private practice dentists (n = 1256). Responding general dentists (n = 497) were included in the final analytic sample. Univariate, bivariate, and multivariable logistic regression analyses were conducted to examine demographic and practice characteristics associated with dentist participation (acceptance of new Medicaid patients) between MCOs and by age category.

RESULTS

Among respondents, the proportions accepting new adults with Medicaid were 26% (MCO 1) and 7% (MCO 2); for children, they were 40% (MCO 1) and 11% (MCO 2). For adults, dentists who were too busy (MCO1) and solo practice dentists (MCO2) were positively significantly associated with the acceptance of new patients. For children, group and rural practice dentists, as well as dentists who worked <32 h/week were positively significantly associated with acceptance of new patients with MCO1.

CONCLUSIONS

There was considerable variation in dentist-reported acceptance of new adult and child Medicaid patients, and in the factors affecting acceptance of new patients between MCOs in Iowa dental Medicaid. Future studies of Medicaid participation should consider variations by MCO in states with more than one dental MCO so as not to miss important factors affecting Medicaid participation.

Differences in Person-Centered Care in Fetal Care Centers: Results from the U.S. Pilot Study of the PCC-FCC Scale

OBJECTIVE

We report findings from a U.S. mixed-methods pilot study of the Person-Centered Care in Fetal Care Centers (PCC-FCC) Scale.

METHODS

Participants, who received care at a U.S. Fetal Care Center (FCC) between 2017 and 2021, completed an online questionnaire providing sociodemographic details, specifics about the care received, qualitative experiences, and scores from the PCC-FCC Scale.

RESULTS

Participants' (n = 247) PCC-FCC scores and qualitative feedback indicate high perceived person-centered care (PCC), particularly in areas of care coordination, respectful care, and patient education. However, 8% scored below the midpoint, and 38% of comments were negative, especially regarding expectation setting, preparation for post-intervention maternal health, and psychosocial support. Public insurance was associated with higher total PCC-FCC (p = 0.03) and Factor 2 scores (p = 0.02) compared to those with private insurance. The qualitative themes trust, clarity, comprehensive care, compassion, and belonging further elucidate the concept of PCC in FCCs.

CONCLUSION

The PCC-FCC Scale pilot study revealed strong overall PCC in FCCs, yet variability in patient experiences suggests areas needing improvement, including expectation setting, preparation for post-intervention maternal health, and psychosocial support. Future research must prioritize diverse samples and continued mixed methodologies to better understand the role of insurance and identify other potential disparities, ensuring comprehensive representation of the FCC patient population.

Effect of core preventative screening on kidney stone surgical patterns

PURPOSE

In the surgical treatment of kidney stones, decreased access to healthcare has been shown to exacerbate stone burden, often requiring more invasive and extensive procedures. The objective of this study is to evaluate the effects of preventative health screening on kidney stone surgical treatment patterns.

METHODS

We performed a retrospective analysis of data from the Healthcare Cost and Utilization Project (HCUP) Florida state-wide dataset and the PLACES Local Data for Better Health dataset from the Centers of Disease Control and Prevention (CDC). ZIP Code Tabulation Areas (ZCTAs) identified from the PLACES data were merged with the HCUP dataset to create a single dataset of community-level stone outcomes and community health measures. We included adult patients 18 years or older who underwent at least one urologic stone procedure from 2016 to 2020.

RESULTS

128,038 patients from 885 communities were included in the study. Patients underwent an average of 1.42 surgeries (Median = 1.39, SD = 0.16). Increased core preventative screening was associated with increased surgical frequency (Estimate: 0.51, P < 0.001). The low core preventative screening group had a higher prevalence of PNL than SWL while the high core preventative screening group had a low PNL prevalence compared to SWL.

CONCLUSION

Increased core preventative screenings are associated with less invasive kidney stone surgeries, suggesting that preventative screenings detect stones at an earlier stage.

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Orthotic Helmet Therapy for Deformational Plagiocephaly: Stratifying Outcomes by Insurance

OBJECTIVE

Deformational Plagiocephaly (DP) is commonly treated with cranial orthosis, or helmet therapy. A large, national study on the impact of insurance status on helmet outcomes is lacking. We assessed treatment outcomes for helmet therapy based on insurance status.

DESIGN

This was a retrospective data analysis of patients referred to Cranial Technologies, Inc for helmet therapy between 2014-2020 across 21 states.

PATIENTS, PARTICIPANTS

There were a total of 211,417 patients referred for helmeting, of whom 141,513 received helmet therapy.

MAIN OUTCOMES MEASURES

Multivariate regression was used to assess the relationship of insurance status with post-treatment residual flattening, measured by cephalic index (CI) and cranial vault asymmetry index (CVAI), and treating provider rating of success.

RESULTS

Patients with Medicaid were more likely to complete treatment with residual flattening measured by CI and CVAI when compared to patients with private insurance (OR: 1.58, CI: 1.51-1.65, p < 0.001 and OR: 1.21, CI: 1.15-1.28, p < 0.001, respectively). Providers of patients with Medicaid were more likely to give a low rating of success following treatment (OR: 3.25, CI: 2.70-3.92, p < 0.001).

CONCLUSIONS

Our study investigating the impact of insurance status on helmet therapy across 21 states found that patients with Medicaid were more likely to experience residual flattening and have lower provider-rated outcomes compared to those with commercial insurance. Given significant caregiver burden posed by helmet therapy, which requires frequent visits and consistent helmet use, caregivers of patients with Medicaid may require greater support to reduce outcome disparities observed here.

Access to Sudden Sensorineural Hearing Loss Care at Private Equity-Owned Otolaryngology Clinics

OBJECTIVE

Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models.

STUDY DESIGN

Cross-sectional prospective review.

SETTING

Private practice otolaryngology clinics.

METHODS

We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type.

RESULTS

Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004).

CONCLUSIONS

Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options.

Comparing Socio-Demographics and HIV Testing and Prevention Outcomes Between Low-Income HIV-Negative Heterosexually Active Black Women and Men with Health Insurance

OBJECTIVE

This study is to compare socio-demographic, HIV testing, and prevention factors experienced by insured low-income heterosexual Black women and men.

METHODS

We examined cross-sectional data from Black women and men (n = 5837) recruited in 23 U.S. cities for National HIV Behavioral Surveillance June-December 2019. We compared socio-demographic and behavioral factors between groups using log-linked Poisson regression models, producing adjusted prevalence ratios and 95% confidence intervals.

RESULTS

Black women were less likely than Black men to have private insurance (aPR 0.61, 95% CI 0.50-0.74, p < 0.0001). Black women were more likely than Black men to have incomes at or below the poverty line (aPR 1.04, 95% CI 1.01-1.07, p = 0.02), be aware of PrEP (aPR 1.20, 95% CI 1.12-1.28, p < 0.0001), and have been recently tested for HIV (aPR 1.12, 95% CI 1.04, 1.20, p < 0.01).

CONCLUSIONS

Despite insured status, many Black women and men experienced suboptimal access to and utilization of HIV testing and prevention services. Understanding how social conditions produce differential access to care may help inform HIV prevention interventions.

Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association

Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.

Disparities in Access to Deep Brain Stimulation for Parkinson's Disease and Proposed Interventions: A Literature Review

BACKGROUND

Deep brain stimulation (DBS) is an effective therapy for Parkinson's disease (PD), but disparities exist in access to DBS along gender, racial, and socioeconomic lines.

SUMMARY

Women are underrepresented in clinical trials and less likely to undergo DBS compared to their male counterparts. Racial and ethnic minorities are also less likely to undergo DBS procedures, even when controlling for disease severity and other demographic factors. These disparities can have significant impacts on patients' access to care, quality of life, and ability to manage their debilitating movement disorders.

KEY MESSAGES

Addressing these disparities requires increasing patient awareness and education, minimizing barriers to equitable access, and implementing diversity and inclusion initiatives within the healthcare system. In this systematic review, we first review literature discussing gender, racial, and socioeconomic disparities in DBS access and then propose several patient, provider, community, and national-level interventions to improve DBS access for all populations.

Medicaid Expansion Increases Access for Rural and Impoverished Patients with Pancreatic Ductal Adenocarcinoma in Southern States

INTRODUCTION

Medicaid expansion (ME) impacted patients when assessed at a national level. However, of the 32 states in which Medicaid expansion occurred, only 3 were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of ME on pancreatic ductal adenocarcinoma (PDAC) treatment in eight Southern states in the USA.

PATIENTS AND METHODS

We identified uninsured or Medicaid patients (age 40-64 years) diagnosed with PDAC between 2011 and 2018 in Southern states from the North American Association of Central Cancer Registries-Cancer in North America (NAACCR-CiNA) research dataset. Medicaid-expanded states (MES; Louisiana, Kentucky, and Arkansas) were compared with non-MES (NMES; Tennessee, Alabama, Mississippi, Texas, and Oklahoma) using multivariate logistic regression. P < 0.05 was considered statistically significant.

RESULTS

Among 3036 patients, MES significantly increased odds of Medicaid insurance by 36%, and increased proportions of insured Black patients by 3.7%, rural patients by 3.8%, and impoverished patients by 18.4%. After adjusting for age, race, rural-urban status, poverty status, and summary stage, the odds of receiving radiation therapy decreased by 26% for each year of expansion in expanded states (P = 0.01). Last, ME did not result in a significant difference between MES and NMES in diagnosing early stage disease (P = 0.98) nor in receipt of chemotherapy or surgery (P = 0.23 and P = 0.63, respectively).

CONCLUSIONS

ME in Southern states increased insurance access to traditionally underserved groups. Interestingly, ME decreased the odds of receiving radiation therapy yearly and had no significant impact on receipt of chemotherapy or surgery.

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial

BACKGROUND

Disparities in posthospitalization outcomes for people with chronic medical conditions and insured by Medicaid are well documented, yet interventions that mitigate them are lacking. Prevailing transitional care interventions narrowly target people aged 65 years and older, with specific disease processes, or limitedly focus on individual-level behavioral change such as self-care or symptom management, thus failing to adequately provide a holistic approach to ensure an optimal posthospital care continuum. This study evaluates the implementation of THRIVE-an evidence-based, equity-focused clinical pathway that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home by focusing on the social determinants of health and systemic and structural barriers in health care delivery. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge.

OBJECTIVE

The study's objectives are to (1) examine referral patterns, 30-day readmission, and emergency department use for participants who receive THRIVE support services compared to those receiving usual care and (2) evaluate the implementation of the THRIVE clinical pathway, including fidelity, feasibility, appropriateness, and acceptability.

METHODS

We will perform a sequential randomized rollout of THRIVE to case managers at the study hospital in 3 steps (4 in the first group, 4 in the second, and 5 in the third), and data collection will occur over 18 months. Inclusion criteria for THRIVE participation include (1) being Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) residing in Philadelphia; (3) having experienced a hospitalization at the study hospital for more than 24 hours with a planned discharge to home; (4) agreeing to home care at partner home care settings; and (5) being aged 18 years or older. Qualitative data will include interviews with clinicians involved in THRIVE, and quantitative data on health service use (ie, 30-day readmission, emergency department use, and primary and specialty care) will be derived from the electronic health record.

RESULTS

This project was funded in January 2023 and approved by the institutional review board on March 10, 2023. Data collection will occur from March 2023 to July 2024. Results are expected to be published in 2025.

CONCLUSIONS

The THRIVE clinical pathway aims to reduce disparities and improve postdischarge care transitions for Medicaid-insured patients through a system-level intervention that is acceptable for THRIVE participants, clinicians, and their teams in hospitals and home care settings. By using our equity-focused case management services and leveraging the power of the electronic medical record, THRIVE creates efficiencies by identifying high-need patients, improving communication across acute and community-based sectors, and driving evidence-based care coordination. This study will add important findings about how the infusion of equity-focused principles in the design and evaluation of evidence-based interventions contributes to both implementation and effectiveness outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54211.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05714605; https://clinicaltrials.gov/ct2/show/NCT05714605.

Smartphone-Based Virtual and Augmented Reality Implicit Association Training (VARIAT) for Reducing Implicit Biases Toward Patients Among Health Care Providers: App Development and Pilot Testing

Background

Implicit bias is as prevalent among health care professionals as among the wider population and is significantly associated with lower health care quality.

Objective

The study goal was to develop and evaluate the preliminary efficacy of an innovative mobile app, VARIAT (Virtual and Augmented Reality Implicit Association Training), to reduce implicit biases among Medicaid providers.

Methods

An interdisciplinary team developed 2 interactive case-based training modules for Medicaid providers focused on implicit bias related to race and socioeconomic status (SES) and sexual orientation and gender identity (SOGI), respectively. The simulations combine experiential learning, facilitated debriefing, and game-based educational strategies. Medicaid providers (n=18) participated in this pilot study. Outcomes were measured on 3 domains: training reactions, affective knowledge, and skill-based knowledge related to implicit biases in race/SES or SOGI.

Results

Participants reported high relevance of training to their job for both the race/SES module (mean score 4.75, SD 0.45) and SOGI module (mean score 4.67, SD 0.50). Significant improvement in skill-based knowledge for minimizing health disparities for lesbian, gay, bisexual, transgender, and queer patients was found after training (Cohen d=0.72; 95% CI -1.38 to -0.04).

Conclusions

This study developed an innovative smartphone-based implicit bias training program for Medicaid providers and conducted a pilot evaluation on the user experience and preliminary efficacy. Preliminary evidence showed positive satisfaction and preliminary efficacy of the intervention.

Disparities in access but not outcomes: Medicaid versus non-Medicaid patients in multidisciplinary chronic pain rehabilitation

Purpose: There are known disparities in chronic pain severity, treatment, and opioid-related risks amongst individuals from lower socioeconomic status, including Medicaid beneficiaries, but little is known about whether Medicaid beneficiaries benefit in a similar way from multidisciplinary chronic pain rehabilitation. This study investigated differences in clinical outcomes between Medicaid and non-Medicaid beneficiaries who completed a 3-week multidisciplinary chronic pain rehabilitation program.Methods: Participants (N = 131) completed a broad range of clinical measures pre- and post-treatment including pain severity, pain interference, depression, anxiety, objective physical functioning, and opioid misuse risk. Patients with Medicaid were compared with non-Medicaid patients in terms of baseline characteristics and rate of change, utilizing two-factor repeated measures analyses of variance.Results: There were baseline characteristic differences, with Medicaid beneficiaries being more likely to be African American, have higher rates of pain, worse physical functioning, and lower rates of opioid use. Despite baseline differences, both groups demonstrated significantly improved outcomes across all measures (p<.001) and no significant difference in rate of improvement.Conclusions: Results suggest that pain rehabilitation is as effective for Medicaid recipients as non-Medicaid recipients. Patients with Medicaid are particularly vulnerable to disparities in treatment, so efforts to expand access to multidisciplinary pain treatments are warranted.

Cervical cancer screening barriers and facilitators from the perspectives of women with a history of criminal-legal system involvement and substance use

BACKGROUND

The wide availability of routine screening with Papanicolaou (Pap) tests and vaccinations against human papillomavirus has resulted in a decline in rates of cervical cancer. As with other diseases, however, disparities in incidence and mortality persist. Cervical cancer, is found more often, at later stages, and has worse outcomes in people who live in rural areas, identify as Black or Hispanic, and in people who are incarcerated. Studies report 4-5 times higher rates of cervical cancer incidence in people detained in jails and prisons than in community-based samples. Studies to explain cervical cancer differences have been inconclusive, though there is broad consensus that issues of access play a role. In this study, we sought to learn more from people who have a history of criminal-legal system involvement and substance use about what barriers and facilitators they perceive in accessing cervical cancer preventive health and other support services in the community.

RESULTS

We conducted semi-structured interviews with open-ended questions by telephone with 20 self-identified women, ages 22-58, in Birmingham, Alabama. Interviews were audio recorded and transcribed and the transcripts analyzed using immersion-crystallization techniques. Our team identified two main themes, making connections: the importance of interpersonal communication, which stressed barriers and facilitators related to what makes for effective and humanistic interactions in cervical health prevention and other services, and getting it done: the logistics of access and availability, which highlighted elements of cost and payment; scheduling; transportation; and clinic policies.

CONCLUSIONS

People with a history of criminal-legal system involvement and substance abuse meet with a variety of enabling and impeding factors at personal and interpersonal as well as systemic levels in obtaining cervical health services. To better ensure that women in this high-risk group have equitable access to cervical cancer prevention and treatment-and thus better cancer outcomes-will require multilevel efforts that include an emphasis on improving the human connection in health care encounters and improving the nuts-and-bolts logistics related to accessing that care.

Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study

Background

Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care.

Objective

The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children.

Methods

This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available.

Results

A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger.

Conclusions

Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Prediction of non emergent acute care utilization and cost among patients receiving Medicaid

Patients receiving Medicaid often experience social risk factors for poor health and limited access to primary care, leading to high utilization of emergency departments and hospitals (acute care) for non-emergent conditions. As programs proactively outreach Medicaid patients to offer primary care, they rely on risk models historically limited by poor-quality data. Following initiatives to improve data quality and collect data on social risk, we tested alternative widely-debated strategies to improve Medicaid risk models. Among a sample of 10 million patients receiving Medicaid from 26 states and Washington DC, the best-performing model tripled the probability of prospectively identifying at-risk patients versus a standard model (sensitivity 11.3% [95% CI 10.5, 12.1%] vs 3.4% [95% CI 3.0, 4.0%]), without increasing "false positives" that reduce efficiency of outreach (specificity 99.8% [95% CI 99.6, 99.9%] vs 99.5% [95% CI 99.4, 99.7%]), and with a ~ tenfold improved coefficient of determination when predicting costs (R2: 0.195-0.412 among population subgroups vs 0.022-0.050). Our best-performing model also reversed the lower sensitivity of risk prediction for Black versus White patients, a bias present in the standard cost-based model. Our results demonstrate a modeling approach to substantially improve risk prediction performance and equity for patients receiving Medicaid.

How do Cancer Patients in Economically Marginalized Neighborhoods Decide Where to Seek Care: Perspectives From Cancer Patients and Healthcare Professionals

BACKGROUND

The quality of cancer care affects patient outcomes. It is therefore important to understand what factors and/or barriers shape a cancer patient's decision about where to seek care. We sought to understand factors influencing decision-making for historically marginalized communities in a large metropolitan area with multiple options for cancer care, including a National Cancer Institute (NCI)-designated comprehensive cancer center.

METHODS

We conducted semi-structured interviews with cancer patients from economically marginalized neighborhoods in Washington D.C., and with healthcare professionals who work with patients from these areas. Participants were recruited through flyers, social media posts, and word of mouth. Two researchers analyzed the data using a combination of inductive and deductive approaches supported by the ATLAS. ti software.

RESULTS

A total of 15 interviews were conducted. Analysis revealed 3 major factors influencing where patients decide to seek care: health insurance, transportation, and prioritization of needs. Participants repeatedly identified navigating the bureaucracy of insurance enrollment and high medical costs as prohibitive to seeking care. Transportation was often mentioned in terms of convenience of use and proximity to the care center. Prioritization of needs refers to circumstances such as unstable housing, poverty, and mental illness, that some patients prioritize over seeking quality cancer care. Across these themes 2 findings arose: a discrepancy between stated and actual factors in choosing an oncologist, and the extent to which a cancer patient is able to choose their oncologist.

CONCLUSION

This study helps explain some of the factors that influence how cancer patients in urban settings choose an oncology center, and the barriers which prohibit access.

AIMS OF THE STUDY

This study aimed to understand how cancer patients decide where to seek treatment.

Effects of the Families First Coronavirus Response Act on Coverage Continuity and Access for Medicaid Beneficiaries

The Families First Coronavirus Response Act (FFCRA) enacted in March 2020 prohibited states from redetermining Medicaid eligibility until March 31st, 2023. However, there has been little direct evidence on how the FFCRA affected coverage continuity, health care access and utilization among Medicaid beneficiaries. In this cross-sectional study, we employ data from the 2015 to 2022 National Health Interview Survey and a difference-in-differences design to study the FFCRA effects by comparing changes in outcomes between Medicaid and privately insured individuals over time. The sample is limited to non-elderly adults aged 19 to 64 years with income below 300% of the federal poverty level. We find that Medicaid beneficiaries experienced a decline in coverage interruptions in 2021 and 2022 relative to privately insured individuals. Additionally, Medicaid beneficiaries had improved access in 2021, with less reporting of unaffordable healthcare needs and delayed medical care due to cost. There were no discernable effects on hospitalizations, ED visits, and doctor/health professional visits. The continuous Medicaid coverage provision under the FFCRA was associated with enhanced coverage stability and improved access to care for Medicaid beneficiaries. Findings highlight potential benefits from new policy initiatives to improve Medicaid coverage continuity.

Do outcomes for heart transplantation differ based on donor and recipient race?

PURPOSE

There are limited data examining the impact of both donor and recipient race on outcomes following orthotopic heart transplant (OHT). The purpose of this study was to evaluate the relationship between donor and recipient race and OHT outcomes.

METHODS

The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. A comparison was conducted based on donor and recipient race (White, Black, Hispanic, Other/Unknown). Races for which there were limited numbers were excluded from the analysis (Asian, n = 1292; American Indian, n = 132; Pacific Islander, n = 132, Multiple ethnicities, n = 225). The primary endpoint was survival at 30 days, 1 year survival, and post-transplant rejection. Logistic and Cox models were used to quantify survival endpoints.

RESULTS

A total of 41 841 OHT were included. Of the recipients, 29 894 (71%) were White, 8475 (20%) were Black, and 3472 (8%) were Hispanic. Of the donors 27 783 (66%) were White, 6277 (15%) were Black, 6576 (16%) were Hispanic, and 1205 (3%) were Unknown/Other race. In a comparison of recipient demographics, White recipients were older (54.09 ± 12.21 years) compared to Black (49.44 ± 12.83 years) and Hispanic (49.97 ± 13.27 years) recipients. All other differences between groups were not clinically significant. Black recipients were more likely to receive a heart with an "urgent" status (probability .80) compared to White (.73) and Hispanic (.75) recipients (p < .001). Hispanic recipients were more likely to receive a transplant when listed as "non-urgent" (Probability .47) compared to White (.37) and Black (.30) recipients (p < .001). In terms of outcomes, compared to White recipients, Hispanic patients experienced a decreased 30-day survival (OR 1.27; p = .011) and 1-year survival (OR 1.17; p = .016). In comparing Donor/Recipient combinations compared to a White Donor/White Recipient combination, overall survival was decreased in White donor/African American recipient (HR 1.36; p < .001), African American donor/African American recipient (HR 1.41; p < .001) and Hispanic donor/African American recipient (HR 1.30; p < .001) combinations (Table 1).

CONCLUSIONS

African American and Hispanic recipients have decreased survival compared to White recipients after heart transplant. The African American donor does not decrease survival. Racial differences still exist in donor and recipient characteristics and recipient outcomes after OHT. Increasing the donor pool for all races and ethnicities would potentially benefit all recipients. Continued study is warranted in order to minimize these differences among recipients and identify factors that could be contributing to decreased survival, in order to optimize outcomes for African American and Hispanic recipients post-transplant and eliminate disparities.

Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021

Importance

Before and during the COVID-19 public health emergency (PHE), commercially and publicly insured children may have faced different challenges in obtaining consistent and adequate health insurance.

Objective

To compare overall rates, COVID-19 PHE-related changes, and child and family characteristics associated with inconsistent and inadequate coverage for publicly and commercially insured children.

Design, Settings, and Participants

This was a cross-sectional study using nationally representative data from the 2016 to 2021 National Survey of Children's Health of children from age 0 to 17 years living in noninstitutional settings.

Exposure

Parent- or caregiver-reported current child health insurance type defined as public or commercial.

Main Outcomes and Measures

Inconsistent insurance, defined as having an insurance gap in the past year; and inadequate insurance, defined by failure to meet 3 criteria: (1) benefits usually/always sufficient to meet child's needs; (2) coverage usually/always allows child to access needed health care practitioners; and (3) no or usually/always reasonable annual out-of-pocket payments for child's health care. Survey-weighted logistic regression was used to compare outcomes by insurance type, by year (2020-2021 vs 2016-2019), and by child characteristics within insurance type.

Results

Of this nationally representative sample of 203 691 insured children, 34.5% were publicly insured (mean [SD] age, 8.4 [4.1] years; 47.4% female) and 65.5% were commercially insured (mean [SD] age, 8.7 [5.6]; 49.1% female). Most publicly insured children were either non-Hispanic Black (20.9%) or Hispanic (36.4%); living with 2 married parents (38.4%) or a single parent (33.1%); and had a household income less than 200% of the federal poverty level (79%). Most commercially insured children were non-Hispanic White (62.8%), living with 2 married parents (79.0%); and had a household income of 400% of the federal poverty level or higher (49.1%). Compared with commercially insured children, publicly insured children had higher rates of inconsistent coverage (4.2% vs 1.4%; difference, 2.7 percentage points [pp]; 95% CI, 2.3 to 3.2) and lower rates of inadequate coverage (12.2% vs 33.0%; difference, -20.8 pp; 95% CI, -21.6 to -20.0). Compared with the period from 2016 to 2019, inconsistent insurance decreased by 42% for publicly insured children and inadequate insurance decreased by 6% for commercially insured children during the COVID-19 PHE (2020-2021). The child and family characteristics associated with inadequate and inconsistent insurance varied by insurance type.

Conclusions and Relevance

The findings of this cross-sectional study indicate that insurance gaps are a particular problem for publicly insured children, whereas insurance inadequacy and particularly, out-of-pocket costs are a challenge for commercially insured children. Both challenges improved during the COVID-19 PHE. Improving children's health coverage after the PHE will require policy solutions that target the unique needs of commercially and publicly insured children.

Telehealth Availability for Cancer Care During the COVID-19 Pandemic: Cross-Sectional Study

BACKGROUND

Telehealth was an important strategy for maintaining continuity of cancer care during the coronavirus pandemic and has continued to play a role in outpatient care; however, it is unknown whether services are equally available across cancer hospitals.

OBJECTIVE

This study aimed to assess telehealth availability at cancer hospitals for new and established patients with common cancers to contextualize the impact of access barriers to technology on overall access to health care.

METHODS

We conducted a national cross-sectional secret shopper study from June to November 2020 to assess telehealth availability at cancer hospitals for new and established patients with colorectal, breast, and skin (melanoma) cancer. We examined facility-level factors to determine predictors of telehealth availability.

RESULTS

Of the 312 investigated facilities, 97.1% (n=303) provided telehealth services for at least 1 cancer site. Telehealth was less available to new compared to established patients (n=226, 72% vs n=301, 97.1%). The surveyed cancer hospitals more commonly offered telehealth visits for breast cancer care (n=266, 85%) and provided lower access to telehealth for skin (melanoma) cancer care (n=231, 74%). Most hospitals (n=163, 52%) offered telehealth for all 3 cancer types. Telehealth availability was weakly correlated across cancer types within a given facility for new (r=0.16, 95% CI 0.09-0.23) and established (r=0.14, 95% CI 0.08-0.21) patients. Telehealth was more commonly available for new patients at National Cancer Institute-designated facilities, medical school-affiliated facilities, and major teaching sites, with high total admissions and below-average timeliness of care. Telehealth availability for established patients was highest at Academic Comprehensive Cancer Programs, nongovernment and nonprofit facilities, medical school-affiliated facilities, Accountable Care Organizations, and facilities with a high number of total admissions.

CONCLUSIONS

Despite an increase in telehealth services for patients with cancer during the COVID-19 pandemic, we identified differences in access across cancer hospitals, which may relate to measures of clinical volume, affiliation, and infrastructure.

Overlooked and Damaging Impact of Structural Racism and Implicit Bias on US Health Care: Overarching Policy Implications

ABSTRACT

Marginalized populations, including racial and ethnic minorities, have historically faced significant barriers to accessing quality health care because of structural racism and implicit bias. A brief review and analysis of past and historic and current policies demonstrate that structural racism and implicit bias continue to underscore a health system characterized by unequal access and distribution of health care resources. Although advances in cancer care have led to decreased incidence and mortality, not all populations benefit. New policies must explicitly seek to eliminate disparities and drive equity for historically marginalized populations to improve access and outcomes.

Effect of chronic disease on racial difference in COVID-19-associated hospitalization among cancer patients

BACKGROUND

Research indicates that Black cancer patients have higher rates of COVID-19 hospitalization than their White counterparts. However, the extent to which chronic diseases contribute to racial disparities remains uncertain. We aimed to quantify the effect of chronic diseases on racial disparity in COVID-19-associated hospitalization among cancer patients.

METHODS

We linked Louisiana Tumor Registry's data with statewide COVID-19 data and hospital in-patient discharge data to identify patients diagnosed with cancer in 2015-2019 who tested positive for COVID-19 in 2020 and those with COVID-19-associated hospitalization. Multivariable logistic regression and mediation methods based on linear structural equations were employed to assess the effects of the number of chronic diseases (0, 1-2, ≥3) and individual chronic diseases.

RESULTS

Of 6381 cancer patients who tested positive for COVID-19, 31.6% were non-Hispanic Black cancer patients. Compared with non-Hispanic White cancer patients, non-Hispanic Black cancer patients had a higher prevalence of chronic diseases (79.5% vs 66.0%) and higher COVID-19-associated hospitalization (27.2% vs 17.2%). The odds of COVID-19-associated hospitalization were 80% higher for non-Hispanic Black cancer patients than non-Hispanic White cancer patients (odds ratio = 1.80, 95% confidence interval = 1.59 to 2.04). After adjusting for age, sex, insurance, poverty, obesity, and cancer type, number of chronic diseases explained 37.8% of the racial disparity in COVID-19-associated hospitalization, and hypertension, diabetes, and chronic renal disease were the top 3 chronic diseases explaining 9.6%, 8.9%, and 7.3% of the racial disparity, respectively.

CONCLUSION

Chronic diseases played a substantial role in the racial disparity in COVID-19-associated hospitalization among cancer patients, especially hypertension, diabetes, and renal disease. Understanding and addressing the root causes are crucial for targeted interventions, policies, and health-care strategies to reduce racial disparity.

Sociodemographic Disparities in Craniosynostosis: A Systematic Review

OBJECTIVE

Given the consequences of delayed treatment and diagnosis of craniosynostosis, this study reviews the literature on sociodemographic risk factors and disparities associated with delayed craniosynostosis treatment.

DESIGN

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed/Medline and Embase was performed by two independent reviewers. Included studies discussed craniosynostosis health disparities. Demographic characteristics and outcomes were analyzed.

SETTING

Not applicable.

PATIENTS

Patients with craniosynostosis.

INTERVENTIONS

Standard surgical intervention for craniosynostosis.

RESULTS

Our literature search yielded 273 studies, of which 18 were included for analysis. Included studies represented data from 31 256 U.S. patients with craniosynostosis. Sixty percent of patients (n = 16 510) were White, 13.8% were Hispanic/Latino, 6.2% were Black/African American, 1.3% were Asian, 0.3% were American Indian or Alaska Native, and 0.1% were Native Hawaiian or Pacific Islander. Average age at surgery was 6.36 months for White patients, 10.63 months for Black patients, and 9.18 months for Hispanic patients. Minority racial and/or ethnic status was a risk factor for delayed presentation, and increased incidence of open surgery, complication rates, hospital charges, operative time, anesthesia duration, and hospital length of stay. Government-funded health insurance was associated with delayed intervention and increased complications.

CONCLUSIONS

Minority craniosynostosis patients experience delays in intervention and increased complication rates. Our findings highlight the importance of expedited and equitable referrals, screenings, and treatment, and the need for a standardized approach to investigating longitudinal demographic and outcomes data in this population.

Accessibility to Obstetric Care in South Florida Based on Insurance: A Cross-Sectional Study

Introduction Obstetrical research confirms that earlier onset prenatal care significantly improves pregnancy and birth outcomes. Initiating care in the second trimester or having less than 50% of recommended visits has been associated with an increased risk of prematurity, stillbirth, neonatal, and infant death. Studies have shown that women on public health insurance plans initiate prenatal care substantially later into pregnancy than those on private plans. The purpose of this study is to assess whether public health insurance limits Florida patients' access to obstetric care.  Methods  A cross-sectional study was conducted by collecting data on the four most populated zip codes for Medicaid in South Florida using HealthGrades.com. The following search parameters were used: "obstetric care", "four stars and up" and "10-mile distance". Each obstetrician was called three times to assess appointment availability for fictional nulliparous women at eight weeks of gestation requesting prenatal care. Accepted insurance types (Medicaid, Cigna, and United Health Group (UHG)), time to an appointment in business days, and self-pay rates were recorded. Practices with invalid contact information and retired obstetricians were excluded. Summary statistics, chi-squared analysis, and a two-way t-test were conducted for the primary outcome.  Results  Seventy-one out of 178 obstetricians were successfully contacted, of which 31 physicians accepted all three insurances, and 40 physicians did not accept at least one insurance. Of those, 97.2% accepted UnitedHealthcare, 98.6% accepted Cigna, and 45.1% accepted Medicaid. There was a statistically significant difference when comparing acceptance rates between UHC and Medicaid as well as Cigna and Medicaid (p<0.001). There was no statistically significant difference in acceptance rates in the direct comparison of the two private insurances, Cigna and UnitedHealthcare (p=0.559). The average number of days until the next available appointment was 12.7 (SD= 7.2) for UnitedHealthcare, 20.0 (SD=6.7) for Cigna, and 17.0 (SD=8.6) for Medicaid. There was a statistically significant trend between the type of insurance and the time to the earliest appointment (p=0.002).  Conclusion  This study demonstrated patients enrolled in Medicaid in South Florida have significantly less access to prenatal care than those with private insurance. This evidence shows that decreased access to care from Medicaid plans can possibly increase the risk of adverse outcomes associated with inadequate prenatal care. This information should be considered by policymakers when considering future Medicaid expansion.

Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty

Importance

In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown.

Objectives

To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs.

Design, Setting, and Participants

This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022.

Main Outcomes and Measures

Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared.

Results

A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001).

Conclusions

This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.

A real-world evidence analysis of the impact of switching from factor VIII to emicizumab prophylaxis in patients with hemophilia A without inhibitors

BACKGROUND

This study retrospectively compared annualized billed bleed rates (ABR_b) in people with hemophilia A (PwHA) without inhibitors who switched from factor VIII (FVIII) prophylaxis to emicizumab.

RESEARCH DESIGN AND METHODS

A real-world comparison study was performed on the effect of switching from FVIII to emicizumab prophylaxis in male, non-inhibitor patients on ABR_b using an all-payer claims database (APCD) dataset from 1 January 2014, to 31 March 2021. The identification period was from 1 November 2017, to 30 September 2020.

RESULTS

One hundred and thirty-one patients were included with a total of 82 and 45 bleeds in the pre- and post-switch periods, respectively. The average follow-up period pre-switch was 978.37 days (SD 555.03), whereas the average follow-up period post-switch was 522.26 days (SD 191.36). No significant differences in mean ABR_b were observed pre-/post-switch (0.25 and 0.20, respectively; P = 0.4456).

CONCLUSIONS

The results of this study demonstrate no significant reduction in ABR_b, suggesting that switching from FVIII to emicizumab may not deliver incremental benefits to PwHA receiving prophylactic care.

The effect of insurance status on treatment modality in advanced oral cavity cancer

BACKGROUND

Insurance status has been shown to impact survival outcomes. We sought to determine whether insurance affects the choice of treatment modality among patients with advanced (T4) oral cavity squamous cell carcinoma.

METHODS

This is a retrospective, population-based cohort study using the Survival, Epidemiology, and End Results Program database. The population included all adult (age ≥ 18) patients with advanced (T4a or T4b) oral cavity squamous cell carcinoma diagnosed from 2007 to 2016. The main outcome was the odds of receiving definitive treatment, defined as primary surgical resection. Insurance status was categorized into uninsured, any Medicaid, and insured groups. Univariable, multivariable, and subgroup analyses were performed.

RESULTS

The study population consisted of 2628 patients, of whom 1915 (72.9%) were insured, 561 (21.3%) had Medicaid, and 152 (5.8%) were uninsured. The multivariable model showed that patients who were 80 years or older, unmarried, received treatment in the pre-Affordable Care Act (ACA) period, and who were on Medicaid or uninsured were significantly less likely to receive definitive treatment. Insured patients were significantly more likely to receive definitive treatment compared to those on Medicaid or uninsured (OR = 0.59, 95% CI 0.46-0.77, p < 0.0001 [Medicaid vs. Insured]; and OR = 0.48, 95% CI 0.31-0.73 p = 0.001 [Uninsured vs. Insured]), however these differences did not persist when considering only those patients treated following the 2014 expansion of the ACA.

CONCLUSIONS

Insurance status is significantly associated with treatment modality among adults with advanced stage (T4a) oral cavity squamous cell carcinoma. These findings support the premise of expanding insurance coverage in the US.

Examining inequality in the time cost of waiting

Time spent waiting for services represents unproductive time lost while fulfilling needs. We use time diary data from the nationally representative American Time Use Survey to estimate the difference between high- and low-income people in time spent waiting for basic services. Relative to high-income people, low-income people are one percentage point more likely to wait on an average day, are three percentage points more likely to wait when using services, spend an additional minute waiting for services on a typical day and spend 12 more minutes waiting when waiting occurs. The unconditional gap in waiting time suggests low-income people spend at least six more hours per year waiting for services than high-income people. The income gap in waiting time cannot be explained by differences in family obligations, demographics, education, work time or travel time. Further, high-income Black people experience the same higher average wait times as low-income people regardless of race.

Subsidized Marketplace Purchases Reduced Racial Disparities in Private Coverage Under the Affordable Care Act

The Affordable Care Act's Marketplaces, by allowing subsidized purchase of insurance coverage by persons with incomes from the poverty line to middle income, and through active outreach and enrollment assistance efforts, are well situated to reduce large African American-white private coverage disparities. Using data from the National Health Interview Survey for multiyear periods before and after Affordable Care Act implementation, from 2011-2013 to 2015-2018, this study assessed how much disparity reduction occurred when Marketplaces were implemented. Analysis compared private coverage take-up by African Americans and whites for persons with incomes between 100 and 400% of the Federal Poverty Line (FPL), controlling for African American-white income differences and other covariates. African Americans' gains were significantly greater than whites' and disparities did close. However, both groups gained considerably less coverage than they might have, and some disparity remained. To make ongoing operations more effective and to guide future subsidy extensions and increases as enacted in the American Rescue Plan, more research is needed into the incentive value of subsidies and to discover which Marketplace outreach and enrollment assistance efforts were most effective. In advancing these aims, high priority should be given to identifying strategies that were particularly successful in reaching and engaging uninsured African Americans.

Feasibility and Acceptability of a Telemedicine Triage Model Among Medicaid Patients with Low Back Pain Referred to a Spine Center

Background

The data for primary triage via telemedicine for spine related conditions are sparse but has potential to improve access, quality of care, and offer significant cost savings for Medicaid insured patients who have very limited access to care. The purpose of this study was to evaluate the feasibility and acceptability of implementing a telehealth triage framework using synchronous video conferencing appointments.

Methods

This is a prospective cohort feasibility study conducted within an academic spine center in the United States. Participants include Medicaid insured patients referred to an academic spine center for low back pain. We collected demographic information, a spine red flag survey, a patient satisfaction survey and demand and implementation feasibility metrics. Participants completed a demographic and red-flag survey followed by a telehealth spine appointment with a physiatrist. Immediately after the appointment, the participant completed a satisfaction survey.

Results

Nineteen patients met inclusion criteria but declined telehealth either due to preference for in-person appointment or lack of comfort with technology. Thirty-three participants enrolled and attended their initial telehealth appointment. Few participants reporting 1 or more red flag symptom also screened positive during their subsequent telehealth evaluation with the physician (n=7/28). Participant satisfaction was high across all domains including ease of scheduling, efficiency of virtual check in, ability to report their symptoms fully and accurately to the provider, imaging review, explanation of diagnosis and treatment plan. Most participants (n=19/20, 95%) would recommend an initial telehealth appointment.

Conclusions

The telehealth framework used was feasible and provided an acceptable form of care for Medicaid patients who were interested and able to participate in this form of care. Our acceptability results are promising but should be interpreted with caution given the proportion of patients who declined to participate.

Odds of Stage IV Bone Cancer Diagnosis Based on Socioeconomic and Geographical Factors: A National Cancer Database (NCDB) Review

BACKGROUND

There are significant differences in prognosis for osteosarcoma, Ewing sarcoma, chondrosarcoma, and chordomas based on the stage at diagnosis. The five-year survival of these bone cancers varies from 75-87% at an early stage of diagnosis and falls to 27-55% at a late stage of diagnosis.

PATIENTS AND METHODS

This study retrospectively evaluated the odds of stage I vs stage IV cancer at the time of diagnosis in patients with primary malignant bone tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma and chordoma) diagnosed in the National Cancer Database (NCDB) between 2004 and 2018. Cross tabulations with Chi-square analysis were performed to evaluate frequencies of different socioeconomic and geographical characteristics between patients with stage I vs stage IV cancer. Multivariable binary logistic regression was performed to evaluate relationships between socioeconomic and geographical factors and the odds of stage IV cancer at the time of diagnosis. Statistical significance was set at α = 0.05.

RESULTS

8882 patients with stage I and 3063 with stage IV primary malignant bone tumors were identified. The odds of stage IV bone cancer at diagnosis are increased for patients on Medicaid (odds ratio [OR] = 1.298, 95% confidence interval [CI]: 1.043-1.616) or Medicare (OR = 1.795, 1.411-2.284). Odds of stage IV bone cancer at diagnosis were decreased with female sex (OR = 0.733, 0.671-0.800), private insurance (OR = 0.738, 0.601-0.905), and those treated at community cancer programs (OR = 0.542, 0.369-0.797), comprehensive cancer program (OR = 0.312, 0.215-0.452), or academic/research facilities (OR = 0.370, 0.249-0.550). No significant relationship was identified between the stage at diagnosis and race, ethnicity, Charlson-Deyo score, or education level. Stage IV cancer at diagnosis showed was proportionally lower in chondrosarcomas (17.1%) and chordomas (2.1%) than osteosarcomas (45.0%) and Ewing sarcomas (35.8%).

CONCLUSION

Odds of stage IV bone cancer at diagnosis are greater with male sex, Medicaid or Medicare insurance status, or treatment at community cancer programs. Providers should have a low suspicion for additional evaluation when treating patients with symptoms of bone cancer and should be aware of these disparities when treating people in these groups. This is to the authors' knowledge the first such study conducted through the NCDB.

"Don't Promise Something You can't Deliver:" Caregivers' Advice for Improving Services to Adolescents and Young Adults with Autism

Approximately 50,000 youths with autism spectrum disorders (ASD) exit U.S. high schools yearly to enter adult systems of care, many of whom remain dependent on family for day-to-day care and service system navigation. As part of a larger study, 174 family caregivers for adolescents or young adults with ASD were asked what advice they would give service providers about how to improve services for youth with ASD. Reflexive thematic analysis identified a framework of five directives: (1) provide a roadmap to services; (2) improve service access; (3) fill gaps to address unmet needs; (4) educate themselves, their families, and society about autism; and (5) operate from a relationship-building paradigm with families. Education, health, and social service providers, as well as policymakers, can use these directives to better assist youth with ASD and their families in the transition to adulthood.

Relationship between Patient Experience Scores and Health Insurance

(1) Background: the patient experience may be a performance indicator in value-based reimbursement. Accordingly, providers have an incentive to understand factors that affect their patients’ experiences. This study evaluated the relationship between health insurance type and patient experience ratings. (2) Methods: individual-level demographic, health/healthcare, and patient experience data were extracted from the Full-Year Consolidated Data File of the 2019 Medical Expenditure Panel Surveys. A logistic regression was used to evaluate whether how persons—included in this study’s analytic sample (aged 18 and over with complete covariate information)—rated the healthcare they received from all their providers was associated with their health insurance types controlling for covariates. (3) Results: relative to people 18−64 years of age with private health insurance, people 18−64 years of age without health insurance were less likely to rank their healthcare as a 9 or 10—where a 10 indicates the best possible care—(OR: 0.69; p = 0.015) while people aged 65 years or over with Medicare (OR: 1.34; p = 0.002) or with Medicare/private health insurance (OR: 1.48; p < 0.001) were more likely to rank their healthcare as a 9 or 10. (4) Conclusions: Select health insurance types were associated with how patients rate their healthcare. Stakeholders could use this information to create programs aimed to improve patient experience.

Addressing racial disparities in surgical care with machine learning

There is ample evidence to demonstrate that discrimination against several population subgroups interferes with their ability to receive optimal surgical care. This bias can take many forms, including limited access to medical services, poor quality of care, and inadequate insurance coverage. While such inequalities will require numerous cultural, ethical, and sociological solutions, artificial intelligence-based algorithms may help address the problem by detecting bias in the data sets currently being used to make medical decisions. However, such AI-based solutions are only in early development. The purpose of this commentary is to serve as a call to action to encourage investigators and funding agencies to invest in the development of these digital tools.

Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis

IMPORTANCE

Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known.

OBJECTIVE

To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer.

EXPOSURES

Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database.

RESULTS

A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access.

CONCLUSIONS AND RELEVANCE

This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.