PDF(Pubmed)
Abstract：
BACKGROUND: While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions.
METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (California\'s Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal.
RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation.
CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.
METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (California\'s Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal.
RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation.
CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.
摘要：
背景：虽然保险是美国医疗保健不可或缺的一部分，仅覆盖可能无法确保访问，特别是对于那些公共保险。医疗补助保险患者的准入障碍植根于健康的社会驱动因素，管理式护理计划设置中的保险复杂性，以及联邦和州一级的政策。消除卫生系统层面的障碍可能揭示可持续解决方案的机会。
方法：为了了解Medi-Cal（加利福尼亚州的医疗补助计划）患者获得门诊护理的障碍，并确定改善的机会，我们在大型学术医疗中心(n=19),对临床医师和行政人员进行了半结构化访谈,对临床患者和/或完成Medi-Cal患者的转诊流程有经验的转诊样本进行了定性研究.访谈指南涵盖了在卫生系统内获得护理的四个过程步骤：(1)日程安排，(2)推荐和授权，(3)承包,（4）临床相遇。我们对采访进行了转录和归纳编码，然后组织了四个步骤的主题，以确定对Medi-Cal患者获得门诊护理的障碍和改善机会的看法。
结果：大型学术医疗中心的临床医生和行政人员发现，Medi-Cal参保患者无法获得门诊护理，包括缺乏系统层面的政策意识，围绕保险承包的复杂性，社会支持资源有限，以及向患者传播信息的不良。特别是,采访揭示了与按服务付费的Medi-Cal相比，一线员工为方便患者访问而付出的额外时间和精力，管理的Medi-Cal如何影响学术卫生系统。受访者报告说，这导致患者护理延误，护理协调欠佳，和护理碎片。
结论：我们的发现突出了系统级政策方面的差距，追求保险授权的不一致，用于调度和社会工作支持的资源有限，以及提供者和患者之间的信息传播不力，这限制了Medi-Cal保险患者在学术医疗中心获得护理的机会。许多受访者还分享了他们所经历的道德伤害，因为他们目睹了在没有系统级结构来解决这些障碍的情况下患者护理延迟。国家改革，保险组织,和机构层面对于在Medi-Cal创新努力中形成解决方案是必要的。
方法：为了了解Medi-Cal（加利福尼亚州的医疗补助计划）患者获得门诊护理的障碍，并确定改善的机会，我们在大型学术医疗中心(n=19),对临床医师和行政人员进行了半结构化访谈,对临床患者和/或完成Medi-Cal患者的转诊流程有经验的转诊样本进行了定性研究.访谈指南涵盖了在卫生系统内获得护理的四个过程步骤：(1)日程安排，(2)推荐和授权，(3)承包,（4）临床相遇。我们对采访进行了转录和归纳编码，然后组织了四个步骤的主题，以确定对Medi-Cal患者获得门诊护理的障碍和改善机会的看法。
结果：大型学术医疗中心的临床医生和行政人员发现，Medi-Cal参保患者无法获得门诊护理，包括缺乏系统层面的政策意识，围绕保险承包的复杂性，社会支持资源有限，以及向患者传播信息的不良。特别是,采访揭示了与按服务付费的Medi-Cal相比，一线员工为方便患者访问而付出的额外时间和精力，管理的Medi-Cal如何影响学术卫生系统。受访者报告说，这导致患者护理延误，护理协调欠佳，和护理碎片。
结论：我们的发现突出了系统级政策方面的差距，追求保险授权的不一致，用于调度和社会工作支持的资源有限，以及提供者和患者之间的信息传播不力，这限制了Medi-Cal保险患者在学术医疗中心获得护理的机会。许多受访者还分享了他们所经历的道德伤害，因为他们目睹了在没有系统级结构来解决这些障碍的情况下患者护理延迟。国家改革，保险组织,和机构层面对于在Medi-Cal创新努力中形成解决方案是必要的。
