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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.

          Most cited references24

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          Integrating community health centers into organized delivery systems can improve access to subspecialty care.

          The Affordable Care Act is funding the expansion of community health centers to increase access to primary care, but this approach will not ensure effective access to subspecialty services. To address this issue, we interviewed directors of twenty community health centers. Our analysis of their responses led us to identify six unique models of how community health centers access subspecialty care, which we called Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. We determined that the Integrated System model appears to provide the most comprehensive and cohesive access to subspecialty care. Because Medicaid accountable care organizations encourage integrated delivery of care, they offer a promising policy solution to improve the integration of community health centers into "medical neighborhoods."
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            Monitoring Local Safety-Net Providers: Do They Have Adequate Capacity?

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              Medicaid patients increasingly concentrated among physicians.

              Despite increases in Medicaid payment rates and enrollment, the proportion of U.S. physicians accepting Medicaid patients has decreased slightly over the past decade, according to a national study by the Center for Studying Health System Change (HSC). In 2004-05, 14.6 percent of physicians reported that they received no revenue from Medicaid, an increase from 12.9 percent in 1996-97. There were also small increases in the percentage of physicians who were not accepting new Medicaid patients. A more striking trend is that care of Medicaid patients is becoming increasingly concentrated among a smaller proportion of physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. Relatively low payment rates and high administrative costs are likely contributing to decreased involvement with Medicaid among physicians in solo and small group practices.

                Author and article information

                Family Medicine and Community Health
                Compuscript (Ireland )
                September 2015
                October 2015
                : 3
                : 3
                : 18-24
                [1] 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
                [2] 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@ 123456case.edu
                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 https://creativecommons.org/licenses/by-nc/4.0/.

                : 22 July 2015
                : 15 September 2015
                Original Research

                General medicine,Medicine,Geriatric medicine,Occupational & Environmental medicine,Internal medicine,Health & Social care
                barriers to health care,medically uninsured,Health services accessibility,health care inequities,access to specialty care, qualitative methods


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