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Background The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in California introduced household food insecurity (HFI) screening during eligibility certifications in 2019. This study was conducted to evaluate the screening performance of the 2-item Hunger Vital Sign ™ Screener (HVSS2) for HFI during WIC eligibility certification visits in Los Angeles County (LAC), California. Methods Study participants completed a 6-item USDA Household Food Security Survey Module (HFSSM6) assessment in either the 2020 LAC WIC Survey (July-December 2021) or the longitudinal WIC Cash Value Benefit Study (April 2021-May 2022) and had WIC administrative HVSS2 screening data within 30 days of HFSSM6 measurement ( n  = 1,113). HVSS2 performance (sensitivity, specificity, positive predictive value, negative predictive value) for detecting HFI (low or very low food security) was evaluated against the HFSSM6. Results Nearly one-third (31.1%) of LAC WIC Survey respondents and one-half (50.5%) of WIC Cash Value Benefit Study respondents had HFI based on the HFSSM6, while 15.7% and 20.0% had HFI based on HVSS2 for the two studies, respectively. The HVSS2 had high specificity (0.90–0.93), moderate-to-high negative predictive value (0.54–0.74), low sensitivity (0.29–0.38), and moderate-to-high positive predictive value (0.57–0.83) for HFI. Conclusions HVSS2 screening during WIC services has moderate-to-high negative (i.e., screen negative, are food secure) and positive (i.e., screen positive, are food insecure) predictive values for HFI. Dedicated staff training may be needed to improve the performance of the HVSS2 and to make HVSS2 data collected during WIC certifications more helpful in identifying and referring families experiencing HFI to more services.

The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations — a “Reverse Robin Hood” effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.

Background Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. Objective This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. Design We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. Main Measures Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. Key Results Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. Conclusion Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system–level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system–level interventions can be evaluated and disseminated.

Cost measures are a growing part of Medicare's value-based payment programs. Medicare Spending per Beneficiary (MSPB) is the cost measure included in Medicare's Hospital Value-Based Purchasing (VBP) Program. Beneficiaries who are dually enrolled in Medicare and Medicaid are known to have higher spending on care, but it is unknown whether spending on the MSPB measure varies based on dual enrollment and whether this has implications for the performance of safety-net hospitals. We found that after adjustment for comorbidities, dually enrolled beneficiaries had 4.3 percent higher spending, which was primarily driven by higher costs in the postacute setting associated with use of institutional postacute care. Hospitals in the highest quintile of the disproportionate share hospital index had poorer performance on the MSPB measure, and were more likely to be penalized under VBP. After adjustment for dual status, differences in MSPB performance between safety-net and non-safety-net hospitals were no longer significant. This suggests that differences in performance between the two types of hospitals were driven at least in part by differences in their patient populations. However, overall VBP payment impacts were largely unchanged after the MSPB measure was adjusted for dual-enrollment status.

The recent recession had a profound effect on all sectors of the US economy, including health care. We examined how private hospitals fared through the recession and considered how changes in their financial health may affect their ability to respond to future industry challenges. We categorized 2,971 private short-term general medical or surgical hospitals (both nonprofit and for-profit) according to their prerecession financial health and safety-net status, and we examined their operational status changes and operating and total financial margins during 2006-11. We found that hospitals that were financially weak before the recession remained so during and after the recession. The total margins of nonprofit hospitals (both safety-net and other institutions) declined in 2008 but returned to their pre-recession levels by 2011. The recession did not create additional fiscal pressure on hospitals that were previously financially weak or in safety-net roles. However, both groups continue to have notable financial deficiencies that could limit their abilities to meet the growing demands on the industry.

With the expansion of online patient portals linked to electronic health records in safety-net health care settings, we need more data on the use of these websites by patients with limited English proficiency (LEP) in order to guide their continued design, implementation, and evaluation as portals for the underserved. Cross-sectional portal data for the Los Angeles County Department of Health Services, the second largest safety-net system in the nation. We examined differences in portal use across language (English vs. non-English/LEP), covering four years since implementation. Of 425,281 patients assigned to primary care as of March 2019, 55,190 (13%) unique portal enrollments were registered. Among 54,981 portal users, LEP users had lower adjusted odds of using an active portal function (e.g., medication refill) vs. English-speakers. Even among those registered to access portals, these websites are underused, particularly by LEP patients. All systems must facilitate use for these populations, especially for time-saving active functions, which can improve outcomes. Health systems must prioritize design/usability as a factor to counter LEP underuse.

Millions of uninsured people use health care services every year. We estimated providers' uncompensated care costs in 2013 to be between $74.9 billion and $84.9 billion. We calculated that in the aggregate, at least 65 percent of providers' uncompensated care costs were offset by government payments designed to cover the costs. Medicaid and Medicare were the largest sources of such government payments, providing $13.5 billion and $8.0 billion, respectively. Anticipating fewer uninsured people and lower levels of uncompensated care, the Affordable Care Act reduces certain Medicare and Medicaid payments. Such cuts in government funding of uncompensated care could pose challenges to some providers, particularly in states that have not adopted the Medicaid expansion or where implementation of health care reform is proceeding slowly. [PUBLICATION ABSTRACT]

Implementing evidence-based practice (EBP) in a safety net healthcare system is challenging. This study examined factors associated with feasibility and potential facilitators and barriers which might affect the implementation of a new evidence-based comprehensive primary care and community health–based program aiming to promote efficient and equitable delivery of Lung Cancer Screening and Tobacco Cessation (LCS-TC). Fifty-three key informants were interviewed. Informants discussed their perceptions of adoption of screening and appropriate referral practices across 15 community health centers. They also identified barriers and facilitators to implementing the LCS-TC program. Interview data were analyzed using inductive thematic analysis. Three major themes representing facilitators and barriers were identified: (1) Allocation of resources and services coverage; (2) need for a collaborative process to engage stakeholders and identify champions; and (3) stakeholders need different types of evidence to support implementation. The top three activities identified as essential for success included provision of sufficient resources for radiologic screening (30%); using non-physician staff for screening (30%); and minimizing the time healthcare providers need to contribute (23%). Conversely, the top three barriers were lack of resources for screening and treatment (60%); insufficient time to address complex patient problems (36%); and perceived lack of patient buy-in (30%). Models for EBP implementation provide stepwise guidance; however, particular contextual factors act as facilitators or barriers to the process. Findings inform EBP implementation efforts regarding resources and key barriers to success around organizational-level supports and promotion of suitable EBP programs.

Little scholarly attention is paid to inherent conflict in safety-net health systems in which local governments both finance and deliver health services. In this paper, four typologies of role conflict are used to describe and illustrate role incompatibility in the Los Angeles County Public Safety-Net System and other municipal Safety-Net Health Systems which act as both payers and providers of health care. By connecting the dots between the potential negative outcomes conceptually illustrated in the case study and similar outcomes in empirical studies on Los Angeles County, the study suggest that the existence of role conflict in Municipal Health Care Systems can have negative effects on provider job satisfaction and the quality of health services. Governance, policy, and organizational context remedies are recommended to address potential ills of role conflict. Future directions for research are also suggested.

Background. In the human immunodeficiency virus (HIV) care continuum, retention in HIV medical care and viral suppression are key goals to improve individual health outcomes and reduce HIV transmission. National data from clinical providers are lacking. Methods. HIV providers funded by the Ryan White HIV/AIDS Program (RWHAP) annually report demographic, service, and clinical data using encrypted unique client identifiers, and data are processed and de-duplicated to create a single record for each client. We calculated retention and viral suppression for clients who received RWHAP-funded HIV medical care in 2011. We conducted multivariate logistic regression to identify factors associated with these outcomes. Results. In 2011, an estimated 512 911 HIV-infected clients received at least 1 RWHAP-funded non–AIDS Drug Assistance Program service. Of these, 317 458(61.8%) were seen for at least 1 HIV medical care visit. Of these, 82.2% were retained in HIV medical care, and 72.6% achieved viral suppression. Viral suppression was higher among retained clients (77.7%) vs clients who were not retained (58.3%). The lowest levels of retention and viral suppression were among individuals aged 13–34 years. Conclusions. The RWHAP provides HIV medical care and support services for more than half a million poor and underinsured individuals living with HIV in the United States. Rates of retention and viral suppression are relatively high compared with other national estimates but demonstrate room for improvement, especially among youth and racial minorities. Additional improvements in retention and viral suppression will contribute to achieving the goals of the National HIV/AIDS Strategy and improve individual and public health.