Fuller Scope of Practice for Primary Care Providers: A Strategy to Improve Access to Specialty Care in the Safety Net Prepared for the Specialty Care Access Initiative A Partnership of Kaiser Permanente Community Benefits, California Association of Public Hospitals and Health Systems and Californ...

Medical Care, 2014

Background: Little is known as to whether medical home principles, such as continuity of care (COC), would have the same effect on health service use for individuals whose primary (or predominant) provider is a specialist instead of a primary care provider (PCP). Objective: To test associations between health service use and expenditures and (1) beneficiaries' predominant provider type (PCP or specialist) and (2) COC among beneficiaries who primarily see a PCP and those who primarily see a specialist. Research Design: This is a cross-sectional analysis of Medicare fee-for-service claims data from July 2007 to June 2009. Negative binomial and generalized linear models were used in multivariate regression modeling. Subjects: The study cohort comprised 613,471 community-residing Medicare fee-for-service beneficiaries. Measures: Beneficiaries' predominant provider type and COC index during a baseline period (July 2007-June 2008) were studied. All-cause and ambulatory care sensitive condition (ACSC) hospitalizations and emergency department (ED) visits and related expenditures and total expenditures in a 1-year follow-up period (July 2008-June 2009) were also reported. Results: Twenty-five percent of beneficiaries primarily saw a specialist. Having a specialist predominant provider was associated with 9% fewer ED visits, 14% fewer ACSC ED visits, and 8% fewer ACSC hospitalizations (all P < 0.001). Regardless of whether the beneficiary's predominant provider was a specialist or a PCP, higher continuity was associated with fewer all-cause hospitalizations and ED visits and lower expenditures for these services. Higher continuity was also associated with lower total expenditures. Conclusions: Regardless of the predominant provider's specialty, greater continuity was associated with less use of high-cost services and lower expenditures for these services.

The Annals of Family Medicine, 2020

PURPOSE We undertook a study to evaluate variation in the availability of primary care new patient appointments for MediCal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion. METHODS We placed simulated calls by purported MediCal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of MediCal managed care plans. Data from the California Health Interview Survey, MediCal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county. RESULTS Availability of PCC new patient appointments to MediCal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by MediCal enrollees. CONCLUSIONS In contrast to findings from other states, access to primary care in Northern California was limited for new patient MediCal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by MediCal enrollees.

The Permanente journal, 2015

As part of its longstanding commitment to improve the health of the communities it serves, Kaiser Permanente (KP) established the Community Ambassador Program (CAP) in the Mid-Atlantic States Region. The CAP places KP-employed nurse practitioners, midwives, and physician assistants to work in the safety-net clinics and to share best practices through a long-term community collaboration. To share the early experiences of the CAP and describe the initial results of the program&#39;s impact on the safety-net clinics. We conducted an evaluation of 18 safety-net clinics that participated in the CAP in 2012 to determine the program&#39;s early impact in expanding access to care, increasing the capacity of safety-net providers, and improving the quality of care on evidence-based measures in the year following program implementation. The safety-net clinics are comprised of federally qualified health centers, free clinics, and other community-based organizations. The clinics were asked to re...

The Internet Journal of Advanced Nursing Practice, 1997

In some states and communities, Medicaid programs, health plans, providers, and others are collaborating to improve timely access to medical and surgical specialty services for Medicaid enrollees. This report examines six models-in Connecticut, Illinois, Minnesota, New Mexico, Oregon, and Tennessee-that support innovative ways of delivering specialty care and help ensure specialty referrals for Medicaid patients are appropriate and efficient. Strategies include finding ways for specialty providers to deliver care at primary care facilities, expanding the role of primary care providers to deliver specialty care, and employing staff to communicate and coordinate care across providers. Although resources remain limited, participating organizations report better access to specialty care for Medicaid patients and early signs of improvements in quality and costs of care. However, sustaining, expanding, and replicating these models may require changes in Medicaid payment methods that recognize new types of interactions with patients beyond face-to-face visits.

2010

Access to specialty care continues to be a formidable problem for low-income uninsured patients. County officials and primary care clinic providers report wait times from 3 to 11 months for specialty care appointments in Los Angeles County Department of Health Services (DHS) facilities. More than 50 community health centers receive Los Angeles County funding for primary care services delivered to uninsured patients through the Public Private Partnership (PPP) program. However, only six sites provide support for specialty care in the program. Otherwise, PPP patients are referred to county DHS facilities for specialty procedures and consultations.

Background: Federally qualified health centers (FQHCs) were designed to provide care in medically underserved areas. Substantial and sustained federal funding has accelerated FQHC growth. Purpose: To examine temporal trends in primary care provider supply and whether FQHCs have been successful in reducing the gap in provider supply in primary care health professional shortage areas (HPSAs). Methods: Retrospective cohort study design using national county-level data from 2009 to 2013. Primary care providers included physicians, nurse practitioners, and physician assistants. Findings: Partial-county HPSAs had the highest average provider supply and the greatest increase, followed by non-HPSA counties and whole-county HPSAs. The provider gap was larger in whole-county HPSAs compared with partial-county HPSAs. Counties with one or more FQHC sites had a smaller provider gap than those without FQHC sites. An increase of one FQHC site was statistically significantly associated with a reduction in the annual provider gap. Discussion: FQHCs reduced the gap in primary care provider supply in shortage counties and mitigated uneven distribution of the primary care workforce.

Iris Publishers LLC, 2019

The purpose of the Doctor of Nursing Practice (DNP) scholarly project was implementation of a clinical practice change, use of a DNP student developed patient referral form (PRF), and evaluate medically underserved (MU) patients’ access to and utilization of specialty care services. The major objectives of the scholarly project were to evaluate if PRF implementation improved MU patients’ access to or utilization of specialty care services in an urban community health center (CHC), and to identify barriers to patients utilizing prescribed specialty care services. Donabedian’s Model guided the quality improvement project that utilized data from a retrospective chart review to evaluate an urban CHC’s specialty care referral process before and after the implementation of a DNP student developed PRF (N = 48). The DNP student observed for any difference in MU’s access and utilization of specialty care services after a clinical practice change implementing the patient referral form. Further, the DNP student evaluated potential causes of MU patients not utilizing the prescribed specialty care services. Data analysis showed that there was no statistically significant difference in specialty care access (χ2 (1) = .000, p > .05) and utilization (χ2 (1) = 1.4182, p = 0.2337) after the implementation of a DNP student developed patient referral form. The primary reason MU patients cited as not utilizing specialty care services was lack of knowledge about the appointment. Additional data analysis showed that MU patients who were referred for breast services received appointments at a statistically significantly higher rate than all other specialties (χ2 (3) = 8.800, p = 0.0321). The initial assumption of the DNP student was that specialty care services were not readily accessible to the MU population. However, the results of the scholarly projected refuted this assumption as specialty care services were found to be available to the MU population. However, the services were often not utilized due to a breakdown in the referral process. The use of system-based approaches can improve the coordination and delivery of specialty care services. Doctor of Nursing Practice (DNPs) can address challenges to healthcare access and utilization by supporting patients’ navigation through the complex healthcare system.

Primary Care [Working Title], 2021

Family practice was recognized as the 20th specialty in American medicine in 1969. With the hope that primary care would become the foundation of an improved health care system, vigorous efforts were launched in medical education, research and practice to achieve that goal. This chapter traces the history of that effort, together with negative system changes that have obstructed that goal. Although primary care physicians have been shown to improve access to care, contain costs, decrease inequities, and improve patient outcomes, they are still too few in number to meet national needs for primary care. The COVID-19 pandemic revealed the extent of inadequacy and vulnerability of the system. The U. S. still lacks a system of universal access as has been in place for many years in most other advanced countries around the world. Corporate stakeholders in a largely privatized financing and delivery system continue to challenge the future of primary care. Lessons from the failure of reform...

Health Services Research and Managerial Epidemiology, 2019

Medicare Advantage enrollment has seen tremendous growth over the past decade. However, we know comparatively little about the experience of beneficiaries in the program. Our knowledge of Medicare Advantage provider networks is particularly limited. This article is one of the first major assessments of the issue. It seeks to answer 3 important questions. First, are Medicare Advantage plan networks made up of higher quality providers? Second, how significant are the network restrictions imposed by Medicare Advantage plans with regard to access to higher quality providers? And finally, how much provider choice are Medicare Advantage beneficiaries left with? To assess these questions, I utilize geospatial data and individual provider quality measures for cardiologists, endocrinologists, and obstetricians and gynecologists from California. I find that Medicare Advantage beneficiaries generally do well in large metropolitan areas compared to traditional Medicare. However, there are conce...