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At least 19 recordsLinked to original sources
PubMed1996

Effects of health system changes on safety-net providers.

Growing competition in health care markets and Medicaid managed care, combined with cuts in government funds that subsidize care to the uninsured, are challenging the viability of the safety net. In response to these pressures, "safety-net" providers in fifteen communities are integrating vertically and horizontally, contracting with or forming managed care plans, and seeking to attract paying patients. Such strategies appear to be successful for community-based primary care clinics, but other providers--including hospitals that cannot quickly develop primary care capacity, most local health departments, and providers that fail to attract Medicaid patients--are more vulnerable to health system changes. While the safety net may be intact now, access to care among the uninsured is more at risk in communities without state programs or local taxes that subsidize such care.

Community Health Planning↗
PubMed2025

Implementing customized genomic sequencing reports to empower providers in safety-net neonatal intensive care units.

PURPOSE: Through our implementation study providing rapid genomic sequencing (rGS) in safety-net neonatal intensive care units (NICUs), we investigated the feasibility and perceived usefulness of customized "clinical interpretive reports" (CIRs) to help neonatal providers with interpreting, disclosing, and managing care based on rGS results. METHODS: Enrolled infants received rGS through a clinically accredited vendor. We developed 5 CIR types to provide customized interpretation of rGS results and link results to clinical management considerations, research opportunities, and resources. We developed workflows to triage, create, and deliver CIRs within 3 business days. Providers received the vendor reports and CIRs, disclosed results, and completed post-disclosure surveys. We analyzed summary statistics for the first 100 cases. RESULTS: We delivered 97 of 100 CIRs (97%) within our goal time frame (average 1.3 days) and provided clinical management recommendations in 40 of 100 (40%). Neonatal providers completed the post-disclosure surveys for 86 of 100 disclosures (86%). Most reported using the CIR before disclosure (80/86, 93%) and found it helpful at providing useful information beyond the vendor report (79/80, 99%). CONCLUSION: It is feasible and useful to develop customized rGS reports to assist non-genetics providers in safety-net NICU settings. Similar approaches may hold promise for equitably advancing genomic care in non-NICU settings.

Humans↗
PubMed1996

Academic medical centers and the care of underserved populations.

As the number of Americans at risk of being underserved continues to rise, a better understanding of safety-net providers of health care is needed to help ensure continuing care for the underserved. In this article, the authors have begun the process of defining the role of academic medical centers (AMCs) as a group in the care of those persons most at risk of being underserved--the medically indigent and members of minority and poor populations--by quantifying the amount of inpatient care that AMCs provide to these individuals. The study went beyond previous work by using nationally representative sources of data (from 1989 to 1994) and by examining more than one underserved population rather than only the medically indigent. The study focused on AMCs and other hospitals in urban areas and excluded hospitals in rural areas. The detailed findings confirm previous observations that urban AMCs of all types provide a large and disproportionate share of care for the medically indigent and the underserved members of minority and poor populations and that members of these populations constituted the majority of patients cared for in many AMCs in recent years. The findings show that the proportion of patients from underserved groups admitted to all urban hospitals is rising and that this growth is faster among AMCs than other hospitals. The authors comment that AMCs, because of their prominent and historical role in caring for the underserved, have the opportunity to lead efforts to continue such service through innovative approaches to health care and the prevention of illness. Whether AMCs can seize this opportunity when confronted by price competition and government policies that reduce AMCs' capacity to care for the underserved remains to be seen.

Academic Medical Centers↗
PubMed1998

The collision of economics and politics in Medicaid managed care: reflections on the course of reform in Maryland.

One of the most dynamic areas of health policy is the transition of Medicaid programs to managed care and market competition. Maryland has been a leader in this trend, initiating three different systems of managed care for the Medicaid population during the 1990s as it searched for an ideal plan. The Maryland experience illustrates the complex new demands that policy makers are facing. Health plans are expected not only to deliver budgetary savings, but also to improve the quality of their services and guarantee a place for safety-net providers in their delivery systems. As a result, there is a sizable gap between the original savings projected for the new Maryland system and its actual capacity for cost containment. The apparent collision between economic assumptions and political realities, however, may point the way to a constructive synthesis--a form of managed care that balances economy with important community, professional, and personal values.

Child↗
PubMed1997

Managed care and community-oriented care: conflict or complement?

Motivated by the need for fundamental change, reform of the health care delivery system is continuing despite the recent failure of national initiatives. One aspect of this reform is the restructuring of managed care systems to include low-income, at-risk populations in their health delivery program: It is a move that threatens current "safety-net" providers, which already serve these populations with programs that combine public health and traditional primary care. This paper explores this potential conflict by providing a brief history and comparison of the main features of the community-oriented primary care (COPC) and health maintenance organization (HMO) models. The authors provide a frame-work that contrasts the structure, process, and outcome characteristics of these two models, delineating key similarities and differences. The frame-work is used in profiling a service delivery system model that integrates the two systems and in discussing issues related to operationalizing the proposed integration.

Community Health Planning↗
PubMedDate not supplied

The VA health care system: an unrecognized national safety net.

The dominance of local health care markets in conjunction with variable public funding results in a national patchwork of "safety nets" and beneficiaries in the United States rather than a uniform system. This DataWatch describes how the recently reorganized Department of Veterans Affairs serves as a coordinated, national safety-net provider and characterizes the veterans who are not supported by the market-based system.

Cost-Benefit Analysis↗
PubMedDate not supplied

The status of local health care safety nets.

This paper examines variations in the composition, concentration, financing, and community context of local health care "safety nets" and the market pressures that they face. It also reviews financing mechanisms that support these systems and strategies being undertaken to retain publicly insured patients. As safety-net providers compete more aggressively, the availability of the public health, behavioral health, and social services they provide may be affected. Communities may have to consider more explicit investments in these "public goods" if competitive markets remove existing cross-subsidies.

Cost Control↗
PubMedDate not supplied

Changing state and federal payment policies for Medicaid disproportionate-share hospitals.

The Medicaid disproportionate-share hospital (DSH) program has been the subject of considerable policy debate throughout the 1990s, prompting Congress to revise the program three times since 1991. Using Medicaid administrative data and information obtained from twelve state case studies, we examined how the study states dealt with the federal reforms. We found a variety of state responses, ranging from not spending their full DSH allotments to seeking new, "DSH-like" federal money to help support safety-net providers.

Budgets↗
PubMedDate not supplied

Medicaid managed care in thirteen states.

This study examines the recent expansion of Medicaid managed care from the perspective of the thirteen states in the Urban Institute's Assessing the New Federalism project. States are moving to managed care for Medicaid both to improve beneficiaries' access and to control the growth in program costs. However, we find that despite dramatic growth in enrollment during this decade, few states are enrolling the elderly or the disabled--the most expensive Medicaid beneficiaries. We also conclude that cost-savings objectives are often at odds with goals of contracting with mainstream plans and protecting safety-net providers.

Cost Savings↗
PubMed2026

Pandemic-Related Disruptions and Hepatocellular Carcinoma Surveillance in Safety-Net Settings.

IMPORTANCE: Pandemic-related disruptions in cirrhosis care resulted in major gaps and delays in surveillance for hepatocellular carcinoma (HCC). Whether these initial declines improved and rebounded to prepandemic levels remains unclear. OBJECTIVE: To evaluate contemporary clinical practice data on HCC surveillance utilization from before the COVID-19 pandemic to 4 years after the onset of the pandemic among safety-net populations with cirrhosis. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at 5 safety-net health systems in the US. Adults with cirrhosis were evaluated longitudinally across 3 time periods: March 1, 2018, to February 29, 2020 (pre-COVID-19 period), March 1, 2020, to February 28, 2022 (COVID-19 era), and March 1, 2022, to February 29, 2024 (post-COVID-19 period). MAIN OUTCOMES AND MEASURES: The primary outcome was undergoing HCC surveillance identified using Current Procedural Terminology codes for ultrasonography, computed tomography, and magnetic resonance imaging, and corresponding International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for indication. Comparisons of HCC surveillance across time periods used paired t tests, and comparisons of HCC surveillance between subgroups within the same time period used χ2 tests. RESULTS: Among 6940 patients with cirrhosis, 4001 (57.7%) were men (median [IQR] age, 58 [52-64] years), 206 (3.0%) were Asian, 1720 (24.8%) were Hispanic, 1672 (24.1%) were non-Hispanic Black or African American, and 3081 (44.4%) were non-Hispanic White. The proportion who underwent HCC surveillance within 6 months after diagnosis was 30.8% (1940 patients) in the pre-COVID-19 era, which declined to 21.1% (1468 patients) in the COVID-19 era, and remained at 22.3% (1405 patients) in the post-COVID-19 era. Consistent trends were observed among men and women and among all age and race groups, except for Asian individuals, for whom there was an observed increase in the post-COVID-19 era. Similar trends of low HCC surveillance post-COVID-19 were observed across insurance types but was particularly concerning among uninsured or indigent care covered patients, among whom only 116 of 997 (11.9%) underwent surveillance in the most recent period. CONCLUSIONS AND RELEVANCE: In this observational study of US safety-net populations with cirrhosis, rates of HCC surveillance following pandemic-related declines remained persistently low even up to 4 years after the onset of the COVID-19 pandemic, with fewer than 1 in 4 patients having undergone guideline-concordant HCC surveillance.

Humans↗
PubMed1997

Managed care, health care reform, and the role of providers of aging services. Devolution threatens the safety-net role played by the federal government.

Managed care which emphasizes the rationalization of the way health care is financed, the devolution movement which shifts greater program responsibility to the state and local levels, and the restructuring of Medicaid along the lines of a block grant program, are issues presenting providers of aging services with a daunting set of challenges and opportunities. Providers of aging services will need to build on existing strengths, while developing new strategies, to succeed under an environment of managed care and state and local funding control.

Aged↗
PubMed1997

An empirical comparison of rural and urban safety-net hospitals.

This study compares the characteristics of rural hospitals with urban safety-net hospitals and with "other urban hospitals" (non-teaching, non-safety-net urban hospitals that provide mainstream care in the United States). The objective is to examine if there are similarities between rural and urban safety-net hospitals, both of which serve underserved populations. The authors also wish to study if there are areas in which rural and urban safety-net hospitals are closer together compared to "other" urban hospitals. Based on the results, some potential areas of cooperation between rural and urban safety-net hospitals are discussed.

American Hospital Association↗
PubMedDate not supplied

The evolution of support for safety-net hospitals.

The federal government, mostly through the Medicare and Medicaid programs, has created and maintained a set of structural mechanisms to support uncompensated care and clinical education: disproportionate-share hospital payments and direct and indirect graduate medical education payments. This paper provides a history of how these traditional supports have evolved. We note that the need to reduce federal and state spending threatens the level of these payments, while changes in the health care delivery system highlight a range of design and technical inadequacies in the current support mechanisms.

Cost Control↗
PubMedDate not supplied

What types of hospitals form the safety net?

This analysis describes hospitals that provide large amounts of uncompensated care and hospitals with sizable teaching programs, using data from the American Hospital Association. Despite current public financial support mechanisms, safety-net hospitals have a lower average total margin and a greater percentage with negative total margins than other groups of hospitals. For graduate medical education, however, the current public financial supports have assisted teaching hospitals with the largest training programs in maintaining their financial viability, although teaching hospitals' average total margins remain below those of nonteaching hospitals.

American Hospital Association↗
PubMedDate not supplied

Medicaid and managed care: opportunities for innovative service delivery to vulnerable populations.

The crisis in state "safety-net" funding for high-need, high-risk, high-cost vulnerable populations has led to the development of creative strategies and financing mechanisms by the states for delivering essential community-based services. This is also an opportunity for private-sector providers who can recognize the special needs of these populations, form links with other key constituencies and apply managed care concepts to long-term health and human service delivery.

Community Mental Health Services↗
PubMed2026

Care Navigation for Methamphetamine Use Disorder: A Randomized Clinical Trial.

IMPORTANCE: Stimulant-involved deaths continue to increase in the US, and methamphetamine use remains a weighty public health concern. Treating methamphetamine use disorders is complicated. Contingency management has demonstrated the best effectiveness but is not widely implemented. OBJECTIVE: To examine the effectiveness of dedicated care navigation in linking patients to treatment. DESIGN, SETTING, AND PARTICIPANTS: This prospective randomized clinical trial was conducted at an integrated safety-net health system in Denver, Colorado, between April 10, 2023, and December 31, 2024. Eligible participants were 18 years or older who had a methamphetamine-related encounter in an acute care setting; those with involuntary treatment holds, substance treatment in past 90 days or actively seeking treatment, and inability to provide consent were excluded. Participants completed baseline, 30-day, and 90-day study visits. INTERVENTION: Dedicated care navigation, incorporating contingency management principles, with a focus on addressing health-related social needs. MAIN OUTCOMES AND MEASURES: Linkage to treatment within 30 and 90 days of enrollment defined as a composite measure of at least 1 of the following: electronic health record data indicating a visit at the health system's substance treatment clinic, a behavioral health encounter at an outpatient clinic, temporary residential treatment, or self-reported treatment on the 30- and/or 90-day follow-up survey. RESULTS: Of 192 participants enrolled in the Beginning Early and Assertive Treatment for Methamphetamine Use trial, 156 (81.3%) were male, and the median age was 39 (IQR, 31-47) years. Most participants were unstably housed (163 [84.9%]), not currently employed (158 [82.3%]), and without regular access to a working phone (94 [49.0%]). Of the 96 participants randomized to the intervention, 60 (62.5%) engaged in 2 or more navigation sessions, 45 (46.9%) completed the 30-day study visit, and 47 (49.0%) completed the 90-day study visit compared with 44 (46.3%) and 37 (38.5%), respectively, of the 96 randomized to the control arm. No statistically significant differences in treatment linkage were observed at 30 days (24 participants [25.0%] in both arms; risk ratio, 1.00 [95% CI, 0.61-1.63]) or 90 days post enrollment, (32 [33.3%] in intervention vs 24 [25.0%] in control arms; risk ratio, 1.33 [95% CI, 0.85-2.09]). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, integrating principles of contingency management into the intervention may have increased engagement with a dedicated care navigator but did not increase likelihood of linkage to treatment for methamphetamine use disorder. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06033365.

Humans↗
PubMed1998

What Folklore Tells Us about Risk and Risk Taking: Cross-Cultural Comparisons of American, German, and Chinese Proverbs.

Two studies attempted to discriminate between a situational-economic and a cultural explanation for the recently reported finding that Chinese from the People's Republic of China (PRC) are more risk-seeking than Americans. Both studies compared American and Chinese proverbs related to risk and risk-taking. The first study added Germany as a control group for its socioeconomic similarity to the United States but its closer resemblance to the PRC in its social safety-net and cultural collectivism. Members of each culture rated American, Chinese, and German risk-related proverbs, respectively, on implied advice (to take or avoid risk) and applicability to financial or social risks. Results were consistent with the cultural explanation of national differences in risk taking: (a) Chinese and German proverbs were judged to provide more risk-seeking advice than American proverbs; (b) American proverbs were judged less applicable to risks in the social domain than Chinese and German proverbs; (c) regardless of national origin of proverbs, Chinese perceived proverbs to advocate greater risk-seeking than American raters, but only for financial and not for social risks. Copyright 1998 Academic Press.

Journal Article↗