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Borde D, Agana-Norman DFG, Leverence R, Photos L, Shuster J, Lukose K, Pinkney J, Wright J, Waxenberg L, Allen B, Radhakrishnan NS. Outcomes of an integrated practice unit for vulnerable emergency department patients. BMC Health Serv Res 2023; 23:1449. [PMID: 38129783 PMCID: PMC10740262 DOI: 10.1186/s12913-023-10067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 09/25/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION IRB201500212. Retrospectively registered.
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Affiliation(s)
- Deepa Borde
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | | | - Robert Leverence
- University of Texas Health, 703 Floyd Curl Dr, San Antonio, TX, 78229, USA
| | - Lorrie Photos
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Jon Shuster
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Kiran Lukose
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Jacqueline Pinkney
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Joy Wright
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Lori Waxenberg
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Brandon Allen
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Nila S Radhakrishnan
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA.
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Lee JJ, Sack DE, Kam S, Reed SC, Carew B, Lloyd C, Weaver EO, Miller RF. Results of Leveraging Pharmaceutical Patient Assistance Programs to Expand Access to High Cost Medications in a Student-Run Free Clinic. J Community Health 2023; 48:919-925. [PMID: 37284916 DOI: 10.1007/s10900-023-01240-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 06/08/2023]
Abstract
High costs make many medications inaccessible to patients in the United States. Uninsured and underinsured patients are disproportionately affected. Pharmaceutical companies offer patient assistance programs (PAPs) to lower the cost-sharing burden of expensive prescription medications for uninsured patients. PAPs are used by various clinics, particularly oncology clinics and those caring for underserved communities, to expand patients' access to medications. Prior studies describing the implementation of PAPs in student-run free clinics have demonstrated cost-savings during the first few years of using PAPs. However, there is a lack of data regarding the efficacy and cost savings of longitudinal use of PAPs across several years. This study describes the growth of PAP use at a student-run free clinic in Nashville, Tennessee over ten years, demonstrating that PAPs can be used reliably and sustainably to expand patients' access to expensive medications. From 2012 to 2021, we increased the number of medications available through PAPs from 8 to 59 and the number of patient enrollments from 20 to 232. In 2021, our PAP enrollments demonstrated potential cost savings of over $1.2 million. Strategies, limitations, and future directions of PAP use are also discussed, highlighting that PAPs can be a powerful tool for free clinics in serving underserved communities.
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Affiliation(s)
- Julie J Lee
- Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Daniel E Sack
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sharon Kam
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sarah C Reed
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Babatunde Carew
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cooper Lloyd
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eleanor O Weaver
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert F Miller
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
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Welder E, Powers J, Walter AC, Bedell D, Shen WW. Providing Prenatal Care for Patients with Limited Medical Insurance Coverage. J Community Health 2022; 47:974-980. [PMID: 35986826 DOI: 10.1007/s10900-022-01133-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 12/26/2022]
Abstract
Newer immigrants to the United States, whether undocumented, recent legal immigrants, those here on temporary visas, or migrant workers, are far less likely than native-born residents of the United States to have reliable health insurance. This entire group of patients is then at risk for delayed or absent medical care. Our study focused on what effects a free, quality prenatal care program had upon prenatal care and delivery outcomes for an underinsured population, primarily of immigrant women. With a recent change in Iowa's eligibility criteria for Presumptive Medicaid (referred to as Temporary Medicaid), pregnant patients who have less than a 5-year legal permanent residency status, undocumented status, or out-of-country resident status can receive up to two months of covered antepartum care, whereas previously eligible for coverage for the entirety of their pregnancy. With that reality, several faculty members from the Department of Family Medicine at the University of Iowa started a weekly prenatal care clinic in collaboration with the longstanding Iowa City Free Medical Clinic. This study sought to compare outcomes for patients who utilized only Temporary Medicaid to those who also had access to this prenatal free medical clinic (FMC), as well as to compare outcomes for the FMC program to typical Medicaid patients who had access to full prenatal care. Compared to the Temporary Medicaid-only group, our FMC patients had a significantly greater number of prenatal visits. This increased access of continuity prenatal care led to increased screening for gestational diabetes, receipt of recommended vaccinations, and screening for group B streptococcus. Our effort has shown that expanding prenatal healthcare coverage to this underinsured population can greatly increase the quality of maternity care and reduce the potential for high-risk pregnancies, bettering the care for these pregnant women and their newborns.
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Affiliation(s)
- Emily Welder
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
| | - Jason Powers
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
| | - Alka C Walter
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
| | - David Bedell
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
| | - Wendy W Shen
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA.
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Wallace S, Johnson TJ, Hendel E, Chakravarthy V, Leanos L, Ansell DA. The Financial Impact of a Partnership Between an Academic Medical Center and a Free Clinic. Am J Med 2021; 134:1389-1395.e4. [PMID: 34283952 PMCID: PMC9172267 DOI: 10.1016/j.amjmed.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this study is to examine the association between an academic medical center and free clinic referral partnership and subsequent hospital utilization and costs for uninsured patients discharged from the academic medical center's emergency department (ED) or inpatient hospital. METHODS This retrospective, cross-sectional study included 6014 uninsured patients age 18 and older who were discharged from the academic medical center's ED or inpatient hospital between July 2016 and June 2017 and were followed for 90 days in the organization's electronic medical record to identify the occurrence and cost of subsequent same-hospital ED visits and hospital admissions. The occurrence of any subsequent ED visits or hospital admissions and the cost of subsequent hospital care were compared by free clinic referral status after inverse probability of treatment weighting. RESULTS Overall, 330 (5.5%) of uninsured patients were referred to the free clinic. Compared with patients referred to the free clinic, patients not referred had greater odds of any subsequent ED visits or hospital admissions within 90 days (odds ratio, 1.8; 95% confidence interval: 1.7-2.0). For patients with any subsequent ED visits or hospital admissions, the mean cost of care for those who were not referred to the free clinic was 2.3 times higher (95% confidence interval: 2.0-2.7) compared to referred patients. CONCLUSION An academic medical center-free clinic partnership for follow-up care after discharge from the ED or hospital admission is a promising approach for improving access to care for uninsured patients.
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Affiliation(s)
- Shelby Wallace
- Department of Health Systems Management, Rush University, Chicago, Ill
| | - Tricia J Johnson
- Department of Health Systems Management, Rush University, Chicago, Ill.
| | | | - Vidya Chakravarthy
- Department of Health Systems Management, Rush University, Chicago, Ill; Population Health, Rush University Medical Center, Chicago, Ill
| | - Lizette Leanos
- Population Health, Rush University Medical Center, Chicago, Ill; Clinical Information Systems, Rush University Medical Center, Chicago, Ill
| | - David A Ansell
- Department of Internal Medicine, Rush University Medical Center, Chicago, Ill
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Dal-Ré R, Rid A, Emanuel E, Wendler D. Addressing exploitation of poor clinical trial participants in North America and the European Union. Eur J Intern Med 2016; 34:e37-e38. [PMID: 27425655 DOI: 10.1016/j.ejim.2016.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 11/21/2022]
Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Annette Rid
- Department of Social Science, Health and Medicine, King's College, London, UK
| | - Ezekiel Emanuel
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD, USA
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Al-Mohamadi A, Al-Harbi AM, Manshi AM, Rakkah MM. Medications prescribing pattern toward insured patients. Saudi Pharm J 2013; 22:27-31. [PMID: 24493970 DOI: 10.1016/j.jsps.2013.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 01/08/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The rising costs of health care continue to make health insurance important for many countries. Health insurance may cover different aspects of health care in Saudi Arabia including the prescribed drugs. Physicians usually have different personal attitudes toward insured and uninsured patients. This study is to investigate the prescribing behavior of physicians to those groups of patients in the private setting. DESIGN AND SETTING A prospective study was conducted during the period between October 2011 and January 2012, in three Saudi private hospitals. METHOD Prescriptions for insured and uninsured patients were randomly selected and analyzed. Data regarding diagnosis, age, gender, co-morbidity, number of items and the total cost of the medication in Saudi Riyals (SR) were collected through a chart review form. RESULTS Three thousand sixty six patients' prescriptions were included in this study, 34.7% of them were females. 273 patients (75.2%) were insured while 90 were not. 24.8% were patients who paid cash. Majority (57.6%) of the patients were with diabetes plus hypertension and other co-morbidity. 20.7% of patients were taking three medications or less, while 67.8% were taking 4-10 and 11.6% were taking more than 10 medications. Analysis of differences showed that, patients who were insured have a higher number of prescribed medications (p ⩽ 0.001), and a higher total price of prescription than those who were paying cash only (p ⩽ 0.001). In a more confirmatory step, all uninsured patients (n = 90) were closely matched in the age, gender, diagnosis and hospital with similar 90 insured patients. Results of this matching process confirmed the above findings. CONCLUSION Physicians in private setting are more likely to prescribe more drugs and/or brand drugs to insured patients than for uninsured patients. Further studies to view the reasons behind this behavior and strategies to prevent such actions are needed.
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