Redesigning Family Medicine Training to Meet the Emerging Health Care Needs of Patients and Communities:

This paper reflects a vision of how family medicine residency training will be redesigned to prepare graduates to meet the health care needs of their patient populations and regional communities. Family physicians are needed to serve as personal physicians and as the patient’s usual source of care, as recognized in historic documents that have defined the specialty’s enduring role in society as the foundation of the health care system. Modern residency practices will include residents as junior partners and members of multidisciplinary faculty teams. Residency practices will measure and improve care consistent with the triple aim: enhancing the experience of care for patients, improving outcomes of care for populations, and reducing waste and the cost of care in the system.Curricula will include core elements of the roles of family physicians, including the development of therapeutic relationships with patients and families, recognizing patients’ needs and expectations, professionalism, the identification and management of acute and chronic illness, maternity care, and the care of hospitalized patients. Also included will be emerging expectations of family physicians, including team roles, expanded care through telehealth and patient portals, identifying and intervening in modifiable social determinants of health, addressing structural racism, closing gaps of inequitable care for their patient populations, managing addiction as a treatable chronic illness, improving performance through clinical data registries, personalized medicine, and leadership. Wellness and assurance of a satisfying career will be a priority focus of preparation for career-long practice. Residents will become competent in the comprehensive scope of practice needed to serve in the role of continuous personal physician on multidisciplinary teams that serve as the usual source of care for populations in regions where the residencies are located.

Racial and Ethnic Disparities in Perceived Barriers to Health Care Among U.S. Adults With Intellectual and Developmental Disabilities

Barriers to health care access can greatly affect one's health status. Research shows that U.S. adults with intellectual and developmental disabilities (IDD) have poor health and face barriers such as long waits for appointments. However, whether barriers differ by race and ethnicity has not been examined. We conducted a secondary data analysis using the 2002–2011 Medical Expenditure Panel Survey dataset, and compared perceived barriers of community-living U.S. adults with IDD in three racial and ethnic groups (White, Black, and Latinx). Specifically, we examined the top reasons for not having usual source of care, delaying or foregoing medical care. For Black and Latinx adults with IDD, the most-mentioned reasons for not having usual source of care, delaying or foregoing medical care were “don't like/don't trust doctors,” “don't use doctors,” and “don't know where to get care.” In comparison, the White adults with IDD group's biggest perceived barriers were location and insurance related. All groups cited that being unable to afford care was a top reason for delaying or foregoing care. Policies/interventions to improve health care access in racial/ethnic minorities with IDD must first address the topic of developing trust between patients and the health professions. Insurance and the rising costs of care are also key areas that need attention.

Relationship between insurance and access and cost of care in patients with diabetes before and after the affordable care act

PurposeThe purpose of this paper is to examine the influence of insurance coverage changes over time for patients with diabetes on expenditures and access to care before and after the Affordable Care Act (ACA).Design/methodology/approachThe Medical Expenditure Panel Survey (MEPS) from 2002–2017 was used. Access included having a usual source of care, having delay in care or having delay in obtaining prescription medicine. Expenditures included inpatient, outpatient, office-based, prescription and emergency costs. Panels were broken into four time categories: 2002–2005 (pre-ACA), 2006–2009 (pre-ACA), 2010–2013 (post-ACA) and 2014–2017 (post-ACA). Logistic models for access and two-part regression models for cost were used to understand differences by insurance type over time.FindingsType of insurance changed significantly over time, with an increase for public insurance from 30.7% in 2002–2005 to 36.5% in 2014–2017 and a decrease in private insurance from 62.4% in 2002–2005 to 58.2% in 2014–2017. Compared to those with private insurance, those who were uninsured had lower inpatient ($2,147 less), outpatient ($431 less), office-based ($1,555 less), prescription ($1,869 less) and emergency cost ($92 less). Uninsured were also more likely to have delay in getting medical care (OR = 2.22; 95% CI 1.86, 3.06) and prescription medicine (OR = 1.85; 95% CI 1.53, 2.24) compared with privately insured groups.Originality/valueThough insurance coverage among patients with diabetes did not increase significantly, the type of insurance changed overtime and fewer individuals reported having a usual source of care. Uninsured individuals spent less across all cost types and were more likely to report delay in care despite the passage of the ACA.

Sharing patient-generated data with healthcare providers: findings from a 2019 national survey

Objective Our study estimates the prevalence and predictors of wearable device adoption and data sharing with healthcare providers in a nationally representative sample. Materials and Methods Data were obtained from the 2019 Health Information National Trend Survey. We conducted multivariable logistic regression to examine predictors of device adoption and data sharing. Results The sample contained 4159 individuals, 29.9% of whom had adopted a wearable device in 2019. Among adopters, 46.3% had shared data with their provider. Individuals with diabetes (odds ratio [OR], 2.39; 95% CI, 1.66–3.45; P < .0001), hypertension (OR, 2.80; 95% CI, 2.12–3.70; P < .0001), and multiple chronic conditions (OR, 1.55; 95% CI, 1.03–2.32; P < .0001) had significantly higher odds of wearable device adoption. Individuals with a usual source of care (OR, 2.44; 95% CI, 1.95–3.04; P < .0001), diabetes (OR, 1.66; 95% CI, 1.32–2.08; P < .0001), and hypertension (OR, 1.78; 95% CI, 1.44–2.20; P < .0001) had significantly higher odds of sharing data with providers. Discussion A third of individuals adopted a wearable medical device and nearly 50% of individuals who owned a device shared data with a provider in 2019. Patients with certain conditions, such as diabetes and hypertension, were more likely to adopt devices and share data with providers. Social determinants of health, such as income and usual source of care, negatively affected wearable device adoption and data sharing, similarly to other consumer health technologies. Conclusions Wearable device adoption and data sharing with providers may be more common than prior studies have reported; however, digital disparities were noted. Studies are needed that test implementation strategies to expand wearable device use and data sharing into care delivery.

Racial and Ethnic Disparities in Access to Health Care Among Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999–2018

ABSTRACTImportanceRacial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed.ObjectivesTo determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades.DesignCross-sectional.SettingData from the National Health Interview Survey, 1999–2018.ParticipantsIndividuals >18 years old.ExposureRace and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic.Main outcome and measuresRates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes.ResultsWe included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (−2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (−1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016–2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (−4.9%) and Asians (−6.4%).Conclusions and RelevanceInsurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals.KEY POINTSQuestionIn the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities?FindingsUsing National Health Interview Survey data from 1999–2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care.MeaningDespite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.

States with fewer criminalizing immigrant policies have smaller health care inequities between citizens and noncitizens

Background In the last thirty years, major shifts in immigrant policy at national and state levels has heightened boundaries among citizens, permanent residents, and those with other statuses. While there is mounting evidence that citizenship influences immigrant health care inequities, there has been less focus on how policies that reinforce citizenship stratification may shape the extent of these inequities. We examine the extent to which the relationship between citizenship and health care inequities is moderated by state-level criminalization policies. Methods Taking a comparative approach, we assess how distinct criminalization policy contexts across US states are associated with inequitable access to care by citizenship status. Utilizing a data set with state-level measures of criminalization policy and individual-level measures of having a usual source of care from the National Health Interview Survey, we use mixed-effects logistic regression models to assess the extent to which inequities in health care access between noncitizens and US born citizens vary depending on states’ criminalization policies. Results Each additional criminalization policy was associated with a lower odds that noncitizens in the state had a usual source of care, compared to US born citizens. Conclusion Criminalization policies shape the construction of citizenship stratification across geography, such as exacerbating inequities in health care access by citizenship.