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Primary care clinicians’ strategies to overcome financial barriers to specialty health care for uninsured patients

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      Objective: This study describes strategies used by federally qualified health centers (FQHCs) to assist medically uninsured patients in obtaining specialty health care services.

      Methods: Qualitative methods were used to study strategies for obtaining specialty health care for uninsured patients. Data were gathered from 10 primary care clinicians at three FQHC clinics by means of 10 semistructured interviews, 23 brief interviews, and 45 h of direct observations. We captured additional data by studying cases of referred uninsured patients.

      Results: The following six strategies were identified: (1) quid pro quo – a specialist accepting the clinic’s medically uninsured patients was rewarded with referrals of the clinic’s insured patients; (2) over referral – clinicians referred insured patients whose needs could have been met at the FQHC; (3) brief hospitalization – when a specialist could not be obtained, high-risk patients were briefly hospitalized; (4) case building – diagnostic tests were conducted at the FQHC to justify a referral; (5) direct communication – communication between clinicians and specialists was necessary when requesting a referral; (6) specialty clinics – in return for conducting a specialty clinic at the FQHC, the specialist received all referrals of insured patients.

      Conclusion: Uninsured FQHC patients encountered difficulties accessing specialty health care, and in response, clinicians developed a range of innovative strategies.

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      Most cited references 29

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          Defining medical professionalism: a qualitative study.

          Elements of professionalism are well-described in the literature and medical schools continue to struggle with how to teach these concepts effectively. The purpose of this study was to investigate the meaning of medical professionalism to medical students, residents, academic faculty and patients and to determine areas of congruence and difference. In this qualitative study we conducted 8 focus groups to discover subjects' beliefs, perceptions and expectations of medical professionals. Sessions were audiotaped and transcribed, and themes identified through an immersion/crystallisation process. Concept maps were prepared to aid understanding. Recurring primary themes of knowledge/technical skills, patient relationship and character virtues were identified. Secondary themes were medicine as a unique profession, personal congruence and the importance of peer relationships. There was a shift in emphasis reflecting differing stages in the learner continuum. Although patients desired skilled technicians, their themes focused on relationships. Several unique themes were also identified. Some elements of professionalism are embraced by learners at all stages and by patients. Notably, when compared to components of the American Board of Internal Medicine Physician Charter, themes relating to social justice elements were lacking. Differences in emphasis by learner groups reflect the inherent challenges to teaching professionalism successfully. Future studies investigating these differing perceptions are needed to help clarify our teaching mission.

            Author and article information

            1Department of Family Medicine and Community Health, Mandel School of Applied Social Sciences, Case Western Reserve University, 11000 Cedar Avenue, Suite 402, Cleveland, OH 44106, USA
            2School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
            Author notes
            CORRESPONDING AUTHOR: James J. Werner, Department of Family Medicine and Community Health, Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA, E-mail: james.werner@
            Family Medicine and Community Health
            Compuscript (Ireland )
            September 2015
            October 2015
            : 3
            : 3
            : 18-24
            Copyright © 2015 Family Medicine and Community Health

            This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See

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