The impact of the Affordable Care Act on patient coverage and access to care: perspectives from FQHC administrators in Arizona, California and Texas

A Global Perspective on Socioeconomic Determinants of Cardiovascular Health

Cardiovascular disease (CVD) is the leading cause of mortality in the world. From 2005 to 2008, the World Health Organization (WHO) planned an initiative to reduce the mortality rate of CVD by 2030 by addressing health, finance, transport, education, and agriculture in these communities. Plans were underway by many countries to meet the goals of the WHO initiative. However, in 2020, the COVID-19 pandemic derailed these goals, and many health systems suffered as the world battled the viral pandemic. The pandemic made health inequities even more prominent and necessitated a different approach to understanding and improving the socioeconomic determinants of health (SDOH). WHO initiated a special initiative to improve SDOH globally. This paper is an update on what other regions across the globe are doing to decrease, more specifically, the impact of socioeconomic determinants of cardiovascular health. Our review highlights how countries and regions such as Canada, the United States, India, Southeast Asia, the Middle East, and Africa are uniquely affected by various socioeconomic factors and how these countries are attempting to counter these obstacles by creating policies and protocols to facilitate an infrastructure that promotes screening and treatment of CVD. Ultimately, interventions directed toward populations that have been economically and socially marginalized may aid in reducing the disease and financial burden associated with CVD.

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

Causal Effects of the Affordable Care Act (ACA) Implementation on Non-Hodgkin's Lymphoma Survival: A Difference-in-Differences Analysis

INTRODUCTION

Non-Hodgkin's Lymphoma (NHL) accounts for a substantial number of cancer cases in the United States, with a significant prevalence and mortality rate. The implementation of the Affordable Care Act (ACA) has the potential to impact cancer-specific survival among NHL patients by improving access to healthcare services and treatments.

OBJECTIVE

This study aims to assess the impact of the implementation of the ACA on cancer-specific survival among patients diagnosed with NHL.

METHODOLOGY

In this retrospective analysis, we leveraged data from the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of the ACA on cancer-specific survival among NHL patients. The study covered the years 2000-2020, divided into pre-ACA (2000-2013) and post-ACA (2017-2020) periods, with a three-year washout (2014-2016). Using a Difference-in-Differences approach, we compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014). We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities.

RESULTS

Among 74,762 patients, 56.2% were in New Jersey (42,005), while 43.8% were in Georgia (32,757). The pre-ACA period included 32,851 patients (51.7% in Georgia and 56.7% in New Jersey), and 27,447 patients were in the post-ACA period (48.3% in Georgia and 43.4% in New Jersey). The post-ACA period exhibited a 34% survival improvement (OR=0.66, 95% CI 0.58-0.75). ACA implementation was associated with a 16% survival boost among NHL patients in New Jersey (OR=0.84, 95% CI 0.74-0.95). Other factors linked to improved survival included surgery (OR=0.86, 95% CI 0.81-0.91), radiotherapy (OR=0.77, 95% CI 0.72-0.82), and married status (OR=0.67, 95% CI 0.64-0.71).

CONCLUSION

The study underscores the ACA's potential positive impact on cancer-specific survival among NHL patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.

A qualitative investigation of uninsured patient and primary care provider perspectives on specialty care eConsults

BACKGROUND

Uninsured and underinsured patients face specialty care access disparities that prevent them from obtaining the care they need and negatively impact their health and well-being. We aimed to understand how making specialty care electronic consultations (eConsults) available at a multi-site Federally Qualified Health Center (FQHC) in central Texas affected uninsured patients' care-seeking experiences and impacted their ability to receive the needed care.

METHODS

We used concepts from Ecological Systems Theory to examine individual, interpersonal, organization-level, social, and health policy environment factors that impacted patients' access to specialty care and the use of eConsults. We conducted thematic analysis of semi-structured, qualitative interviews with patients about seeking specialty care while uninsured and with uninsured patients and FQHC PCPs about their experience using eConsults to obtain specialists' recommendations.

RESULTS

Patients and PCPs identified out-of-pocket cost, stigma, a paucity of local specialists willing to see uninsured patients, time and difficulty associated with travel and transportation to specialty visits, and health policy limitations as barriers to obtaining specialty care. Benefits of using eConsults for uninsured patients included minimizing/avoiding financial stress, expanding access to care, expanding scope of primary care, and expediting access to specialists. Concerns about the model included patients' limited understanding of eConsults, concern about cost, and worry whether eConsults could appropriately meet their specialty needs.

CONCLUSIONS

Findings suggest that eConsults delivered in a primary care FQHC addressed uninsured patients' specialty care access concerns. They helped to address financial and geographic barriers, provided time and cost savings to patients, expanded FQHC PCPs' knowledge and care provision options, and allowed patients to receive more care in primary care.

Racial, ethnic and gender trends in lung cancer mortality rates in the United States-Mexico border and non-border areas

BACKGROUND

Geographic patterns of lung cancer mortality rate differ in the region bordering Mexico in contrast to the US. This study compares lung cancer mortality between border and non-border counties by race/ethnicity and gender.

METHODS

This study utilized population-level death certificate data from US Centers for Disease Control and Prevention Public Internet Wide-Ranging Online Data for Epidemiologic Research dataset between 1999 and 2020. Established algorithms were implemented to examine lung cancer deaths among US residents. We analyzed the age-adjusted data by year, race/ethnicity, gender, and geographic region. Joinpoint regression was used to determine mortality trends across time.

RESULTS

Lung cancer mortality rates were lower in border counties compared to non-border counties across time (p < 0.05). Hispanic lung cancer mortality rates were not different in border counties compared to non-border counties during the same period (p > 0.05). Lung cancer mortality among non-Hispanic White living in border counties was lower than non-Hispanic White residing in non-border counties (p < 0.01), and non-Hispanic Black living in border counties had lower lung cancer mortality than non-Hispanic Black in non-border counties in all but three years (p < 0.05). Both female and male mortality rates were lower in border counties compared to non-border counties (p < 0.05).

CONCLUSION

Differences in lung cancer mortality between border counties and non-border counties reflect lower mortality in Hispanics overall and a decline for non-Hispanic White and non-Hispanic Black living in border counties experiencing lower lung cancer mortality rates than non-border counties. Further studies are needed to identify specific causes for lower mortality rates in border counties.

Using social media listening to understand barriers to genomic medicine for those living with Ehlers-Danlos syndromes and hypermobility spectrum disorders

INTRODUCTION

Technological improvements alone have not led to the integration of genomic medicine across a broad range of diseases and populations. For genomic medicine to be successfully implemented across specialties and conditions, the challenges patients and caregivers experience need to be identified using a multi-faceted understanding of the context in which these obstacles occur and how they are experienced. Individuals affected by rare conditions, like Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD), express numerous challenges with accessing genomic medicine. Many patients living with rare diseases seek information and find comfort in online health communities.

METHODS

Social media conversations facilitated through online health communities are windows into patients' and caregivers' authentic experiences. To date, no other study has examined genomic medicine barriers by analysing the content of social media posts, yet the novel methodological approach of social media listening permits the analysis of virtual, organic conversations about lived experiences.

RESULTS/CONCLUSIONS

Using a modified social-ecological model, this study found that social-structural and interpersonal barriers most frequently impede access to genomic medicine for patients and caregivers living with EDS and HSD.

PATIENT OR PUBLIC CONTRIBUTION

Data were retrieved through social media conversations facilitated through publicly accessible health communities through Inspire, an online health community. Social media listening permits the analysis of virtual, organic conversations about lived experiences.

Temporal Changes in Counseling for and Use of Emergency Contraception

Our objective was to evaluate changes in the prevalence of emergency contraception counseling and use after policy changes in the United States between 2011 and 2019. This was a serial cross-sectional study using the National Survey of Family Growth data set from two survey windows: 2011-2013 (4,177 women) and 2017-2019 (4,477 women). The incidence of emergency contraception counseling in the prior year did not differ between the 2011-2013 and 2017-2019 survey windows (3.3% vs 2.5%; adjusted odds ratio [aOR] 0.73, 95% CI 0.51-1.05). There was a significant increase in ever use of emergency contraception between the 2011-2013 and 2017-2019 survey windows (19.0% vs 26.1%; aOR 1.44, 95% CI 1.22-1.72). This suggests that changes facilitating access to care may have a larger effect on emergency contraception access and uptake than health care professional counseling.

Health center use and hospital-based care among individuals dually enrolled in Medicare and Medicaid, 2012-2018

OBJECTIVE

To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid.

DATA SOURCES

Data were obtained from 2012 to 2018 Medicare claims.

STUDY DESIGN

We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality.

DATA EXTRACTION METHODS

Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease.

PRINCIPAL FINDINGS

After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period).

CONCLUSIONS

FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.