Safety Net Providers Research Articles

Saving the Health Care Safety Net: Progress and Opportunities.

The health care safety net provides essential clinical care and social services for low-income, uninsured, and underinsured populations in the United States. Despite these important functions, the health care safety net has experienced recurrent financial instability, growing market pressures, and workforce strain. Payment reform has also introduced unique challenges for safety net providers related to measuring and reaching quality benchmarks. A common theme among these challenges is that many of them result from applying standard health policy approaches to the safety net instead of using safety net-specific approaches. This review describes progress toward strengthening the safety net, key challenges, and opportunities moving forward.

Early integration of outpatient palliative care among adults with advanced cancer in a safety-net health system.

195 Background: Medically underserved adults with cancer present at later disease stages. The American Society of Clinical Oncology recommends all advanced cancer patients receive early intervention by a palliative care (PC) team soon after diagnosis (within 8 weeks) and during active treatment. Few studies have examined early integration of PC in the outpatient setting among advanced cancer patients within a safety-net system. This study examined patterns of outpatient PC service delivery (referrals and visits) for advanced cancer patients seen in the primary safety-net provider of cancer care for under- and uninsured adults in Dallas, TX. Methods: Patients diagnosed with advanced-stage solid tumor and who had at least one outpatient oncology visit January 1, 2018 to July 31, 2023 at the safety-net system were identified via electronic health record. The primary outcome was timeliness of outpatient PC referral (categorical outcome). Among patients with an outpatient PC referral, we used Kruskal-Wallis to test univariate associations across key characteristics, including age, race/ethnicity, cancer site, preferred language, insurance, and diagnosis year. Further, we used multivariate logistic regression to evaluate associations between key characteristics and completed PC visits among those with any outpatient PC referral. Results: Among 1,572 eligible patients (mean age 59, range: 21-94), 44% were female and 76% were non-White. Diagnoses included lung (20%), gastrointestinal (17%), colorectal (14%), breast (9%), prostate (9%), head/neck (9%), pancreatic (8%), and gynecologic (6%) cancers. Over half (n=870, 55%) of patients received an outpatient PC referral during the study period. Of those with a referral, 486 (56%) patients were referred ≤ 8 weeks of diagnosis, 157 (18%) between 9 and 24 weeks, 105 (12%) between 25 and 52 weeks, and 122 (14%) > 52 weeks. Timeliness of referral varied according to race/ethnicity and cancer type (p<.05; Table). Two-thirds of referred patients (n=576) completed a PC visit during the study period. In the adjusted regression model, compared to males, females had higher odds of completing a PC visit – (aOR, 1.40; 95% CI, 1.01-1.94). Conclusions: Just over half of advanced cancer patients received a referral to the outpatient PC team. Nearly half of referred patients had the referral ordered after 8 weeks of diagnosis. Except for gender, there were no other factors associated with PC visit completion. These findings demonstrate a need and potential for interventions targeting PC service delivery to improve care for underserved cancer patients. Time from diagnosis to PC referral.* ≤8 Weeks 9 - 24 Weeks 25 - 52 Weeks > 52 Weeks Cancer type (%) Colorectal 50 16 17 17 Lung 64 17 11 8 Pancreatic 64 19 8 9 Prostate 30 17 12 40 Race/ethnicity, (%) White 66 14 10 9 Black 54 22 12 12 Hispanic 52 17 13 18 Select cancer types shown where significant differences were found. *p<.05.

Care of Diabetes and the Sacrifice of Evidence-Based Medicine and Health Equity.

The American Diabetes Association and the European Association for the Study of Diabetes published a 2022 consensus report recommending changes in diabetes care. This Perspective raises three concerns: with how the report summarizes evidence, how it frames the social determinants of health (SDOH), and with its transnational composition and conflicts of interest. The Perspective analyzes three new clinical recommendations that change the role of metformin from first-line therapy to a first-line option, for the inclusion of weight management as a co-primary treatment goal with glycemic control for patients without cardiac or renal complications, and for addition of the SDOH as a universal component of diabetes care together with lifestyle changes and self-management support. The Perspective considers how the poor evidence assessments of the recommendations and the imprecise framing of the SDOH introduce bias. The composition of the panel's membership poorly represents and accounts for the challenges faced by vulnerable US communities or safety net providers. The report is placed in a historical context for diabetes of organized medicine's failures to overcome prejudices and promote health equity. The Perspective concludes that the report perpetuates a pattern of prejudice within organized medicine at the expense of scientific precision and health equity.

Barriers to liver transplant referral in safety net settings: A national provider survey.

Safety net systems care for patients with a high burden of liver disease yet experience many barriers to liver transplant (LT) referral. This study aimed to assess safety net providers' perspectives on barriers to LT referrals in the United States. We conducted a nationwide anonymous online survey of self-identified safety net gastroenterologists and hepatologists from March through November 2022. This 27-item survey was disseminated via e-mail, society platforms, and social media. Survey sections included practice characteristics, transplant referral practices, perceived multilevel barriers to referral, potential solutions, and respondent characteristics. Fifty complete surveys were included in analysis. A total of 60.0% of respondents self-identified as White and 54.0% male. A total of 90.0% practiced in an urban setting, 82.0% in tertiary medical centers, and 16.0% in community settings, with all 4 US regions represented. Perceived patient-level barriers ranked as most significant, followed by practice-level, then provider-level barriers. Patient-level barriers such as lack of insurance (72.0%), finances (66.0%), social support (66.0%), and stable housing/transportation (64.0%) were ranked as significant barriers to referral, while medical mistrust and lack of interest were not. Limited access to financial services (36.0%) and addiction/mental health resources (34.0%) were considered important practice-level barriers. Few reported existing access to patient navigators (12.0%), and patient navigation was ranked as most likely to improve referral practices, followed by an expedited/expanded pathway for insurance coverage for LT. In this national survey, safety net providers reported the highest barriers to LT referral at the patient level and practice level. These data can inform the development of multilevel interventions in safety net settings to enhance equity in LT access for vulnerable patients.

The Importance of Community-Based and Community-Partnered COVID-19 Testing for Reducing Disparities Among African American Populations.

Health inequalities in African American communities have been further exacerbated by COVID-19. Public health departments and other safety-net providers across the United States have partnered with community-based organizations to address barriers to COVID-19 testing in disproportionately impacted communities. This narrative review summarizes lessons learned from published examples of these community-based COVID-19 testing efforts. We searched online databases for peer-reviewed articles on community-based COVID-19 testing interventions in the United States aimed at increasing COVID-19 testing among African American populations. We abstracted information about each example and synthesized the primary lessons learned and key aspects that contributed to their success. Seven examples of community-based COVID-19 testing aimed at increasing testing among African Americans and other underserved populations were identified and described, across various U.S. locations and involving multiple types of partners (1) St. Paul, MN (faith, health centers, Mayo Clinic); (2) Chicago, IL (university hospital and health centers); (3) NC (health centers, Community Advisory Board); (4) Baltimore, MD (hospitals, community clinic, mobile clinic); (5) Marion County, FL (health department and community partners); (6) New Orleans, LA (health department and health system); and (7) New York City, NY health and hospital system, mobile clinic). Several key aspects of the COVID-19 testing models included the following: (1) close proximity of the testing site to affected communities and availability of walk-up and drive-through testing options; (2) partnerships between safety-net providers and broad community networks, which facilitated outreach and trust; (3) increased resources for safety-net providers; and (4) the use of data to identify areas of need and track impact. The merging of resources and relationships among well-equipped, safety-net providers and other health care institutions and culture-rich, community-centered organizations, to jointly address structural and systemic inequities, is key to cultivating health equity in the distribution of COVID-19 testing and other essential public health services.

A Comparative Analysis of the Demographics and Zip Codes of Patients Seen at the Indiana University Student Outreach Clinic.

Within a small geographic area, Marion County contains a stark spectrum of health outcomes and socioeconomic statuses. The Indiana University Student Outreach Clinic (IUSOC) serves as a safety net provider, offering free health and social services in the Near Eastside neighborhood of Indianapolis. The aim of this study was to characterize the demographics and geographic distribution of the IUSOC's patient population. From January to September 2023, 612 patients visited the IUSOC, and 460 self-identified as Marion County residents. 63.9% of patients were between 45 and 64 years old. 66.8% were Non-Hispanic (NH) Black, and 23.3% were Hispanic. 18.9% spoke Spanish and had limited English proficiency. Based on the Distressed Communities Index (DCI), 58.7% lived in "Distressed" zip codes, indicating economic vulnerability and disparities. The zip code with the greatest number of IUSOC patients had the highest rate of uninsured adults in Marion County. IUSOC patients are primarily middle-aged minorities who live in zip codes with low socioeconomic rankings by DCI. This information can be used to improve community resource referral pathways in the clinic.

Performance of Neurosurgeons Providing Safety-Net Care Under Medicare's Merit-Based Incentive Payment System.

Under the Merit-Based Incentive Payment System (MIPS), Medicare evaluates provider performance to determine payment adjustments. Studies examining the first year of MIPS (2017) showed that safety-net providers had lower MIPS scores, but the performance of safety-net physicians over time has not been studied. This study aimed to examine the performance of safety-net vs non-safety-net neurosurgeons in MIPS from 2017 to 2020. Safety-net neurosurgeons were defined as being in the top quartile according to proportion of dual-eligible beneficiaries and non-safety-net in the bottom quartile. Outcomes were total MIPS scores and dual-eligible proportion over time. In this descriptive study, we evaluated ordinary least squares regression models with SEs clustered at the physician level. Covariates of interest included safety-net status, year, and average Hierarchical Condition Category risk score of beneficiaries. There were 2796-3322 physicians included each year between 2017 and 2020. Mean total MIPS scores were not significantly different for safety-net than non-safety-net physicians in 2017 but were greater for safety-net in 2018 (90.7 vs 84.5, P < .01), 2019 (86.4 vs 81.5, P < .01), and 2020 (90.9 vs 86.7, P < .01). Safety-net status (coefficient -9.11; 95% CI [-13.15, -5.07]; P < .01) and participation in MIPS as an individual (-9.89; [-12.66, -7.13]; P < .01) were associated with lower scores while year, the interaction between safety-net status and year, and participation in MIPS as a physician group or alternative payment model were associated with higher scores. Average Hierarchical Condition Category risk score of beneficiaries (-.011; [-.015, -.006]; P < .01) was associated with decreasing dual-eligible case mix, whereas average age of beneficiaries (.002; [.002, .003]; P < .01) was associated with increasing dual-eligible case mix. Being a safety-net physician was associated with lower MIPS scores, but safety-net neurosurgeons demonstrated greater improvement in MIPS scores than non-safety-net neurosurgeons over time. Providers with higher-risk patients were more likely to decrease their dual-eligible case mix over time.

Expansion of the 340B Program’s Child Sites and Health Disparities Among Medicare Beneficiaries with Asthma

Background: Under the 340B Drug Pricing Program, drug manufacturers are required to provide discounts to participating safety-net providers including hospitals serving a disproportionate share (DSH) of low-income patients. The program has experienced substantial growth in participating DSH providers due in part to growth in 340B DSH child sites, which are outpatient sites included on the DSH hospitals’ cost report. However, child sites are not required to be easily accessible to vulnerable patients. Objectives: The objective of this study was to determine whether the 340B program’s expansion of child sites was associated with fewer health disparities for asthma-related care. Research Design: We conducted a retrospective analysis of Medicare beneficiaries treated for moderate to severe asthma at 340B DSH hospitals with and without child sites. Measures: We evaluated five drug treatment measures and five adverse outcome measures related to asthma occurring within the first 12 months of the diagnosis date. Results: For Medicare beneficiaries treated for asthma at 340B hospitals with and without child sites, we identified risk-adjusted disparities in drug treatments and adverse health outcomes based on race/ethnicity, dual eligibility status, and socioeconomic status. Statistically significant disparities across the ten outcomes were more likely to occur within 340B hospitals with child sites than 340Bhospitals without child sites. Differences in the magnitudes of the disparities varied by vulnerable subgroup. Conclusions: Our findings suggest that the growth in 340B child sites have not universally expanded access to higher quality care for vulnerable patients, and as such policy changes may be needed.

340B Contract pharmacy growth by pharmacy ownership: 2009-2022.

The 340B program grants eligible health care providers ("covered entities") access to discounted prices for outpatient prescription drugs. Covered entities frequently rely on retail pharmacies ("contract pharmacies") to dispense discounted drugs. This analysis describes contract pharmacy participation by ownership: the top 4 chains, grocery chains, small chains, and institutional independent pharmacies. We found that 71% of pharmacies in the top 4 chains were contract pharmacies. Forty one percentage of institutional pharmacies, 38% of grocery store pharmacies, and 22% of independent pharmacies participated in 340B in 2022. The median number of contracts per pharmacy was 2 among the top 4 chains and grocery store pharmacies vs 1 for all other pharmacy types. The median farthest distance in miles from contracting covered entities was largest for the top 4 chains (19 miles) and small chains (18 miles) and smallest for independent and institutional pharmacies (10 miles). The top 4 chains held the highest proportion of contracts with core safety-net providers (75% vs 61% of institutional pharmacies).

Food Is Medicine for Individuals Affected by Homelessness: Findings from a Participatory Soup Kitchen Menu Redesign.

Health disparities among people experiencing homelessness are likely exacerbated by limited access to healthy, fresh, and minimally processed foods. Soup kitchens and shelters serve as essential food safety nets for preventing hunger in this population, and community interest is growing in the potential of "food is medicine" interventions to improve the mental and physical wellbeing of people who receive meals from these providers. This study describes our two-phase approach to first identify and prioritize nutrition needs within an urban soup kitchen community and then test and implement new recipes and menu guidelines to help the standard soup kitchen menu better align with those priorities. We began by first conducting a nutrition needs assessment, including a collection of intercept surveys from a convenience sample of soup kitchen guests to better understand their nutrition-related health needs, dental issues, food preferences, and menu satisfaction (n = 112), as well as a nutrition analysis of the standard menu based on seven randomly selected meals. Most respondents reported at least one chronic health condition, with depressive disorders (50.9%) and cardiovascular diseases (49.1%) being the most common. Nearly all guests requested more fruits and vegetables at mealtimes, and results from the menu analysis revealed opportunities to lower meal contents of sodium, saturated fat, and added sugars and to raise micronutrient, fiber, and omega-3 content. We then applied these nutrition needs assessment findings to inform the second phase of the project. This phase included the identification of new food inventory items to help support cardiovascular and mental health-related nutrition needs, taste test sampling of new healthy menu items with soup kitchen guests, and hands-on culinary medicine training to kitchen staff on newly-developed "food is medicine" guidelines to support menu transformation. All taste tests of new menu items received over 75% approval, which exceeded satisfaction ratings of the standard menu collected during the phase 1 needs assessment. Findings from this community-based participatory research project confirm the great potential for hunger safety net providers to support critical nutrition needs within this vulnerable population through strategic menu changes. However, more research is needed on the longitudinal impacts of such changes on health indicators over time.

Growing administrative complexity in the 340B program and the rise of third-party administrators.

The 1992 340B drug discount program lowers drug costs and provides a source of revenue for safety-net providers by entitling them to discounts on drugs for all patients, including those with insurance. As 340B has grown so has the administrative complexity of the program, creating a market for third-party administrators (TPAs) to manage both formal and informal requirements in exchange for fees. Although TPAs are playing an important role in the 340B ecosystem, the TPA market is poorly understood, along several dimensions including its size, specialization, competitiveness, and scope of services offered. In this brief report, we report the results of original market research on TPA firms to address unanswered questions and identify gaps in knowledge. We identify 48 TPA firms, including 8 owned by private equity firms, 2 owned by software companies, and 6 owned by a variety of vertically integrated health care stakeholders such as pharmacies, pharmaceutical benefit managers, and pharmaceutical wholesalers. We identified 7 services offered by TPAs including patient discount cards (13), enrollment (31), auditing (45), revenue capture (42), referral management (9), inventory management (19), and 340B ESP assistance (9). Our results suggest that TPAs are involved in many diverse functions related to 340B.

Publicly Funded Family Planning Organizations' Response to the Coronavirus Disease 2019 Pandemic in Texas.

After the onset of the coronavirus disease 2019 pandemic, the use of family planning services decreased, but there are limited data on how safety net providers were affected. Between November 2020 and March 2021, we conducted in-depth interviews with administrators at health departments, federally qualified health centers and specialized family planning organizations across Texas about pandemic-related changes in family planning services. We analyzed interview transcripts using an inductive thematic approach. Administrators at the 19 participating organizations described pervasive service disruptions. Some organizations closed for 6-8weeks at the pandemic's onset owing to safety uncertainties and difficulty interpreting Texas' March 2020 executive order prohibiting "nonessential" medical services; others later suspended services after staff exposures. Health departments and federally qualified health centers commonly decreased family planning services to focus on coronavirus disease 2019 response, leaving specialized family planning organizations to absorb displaced reproductive health care clients. Some of the advantages of service delivery modifications-including telehealth, curbside and drive-through prescription pickup, and medication by mail-were difficult to realize; barriers included low reimbursement, necessary patient examinations, and clients' confidentiality concerns and lack of technological resources. Texas' diverse network of family planning organizations illustrated a range of responses to the pandemic, and organizations often focused on their core missions-public health, primary care, or family planning.

Serious Illness Conversation Training Needs among Safety Net Primary Care Providers (QI126)

Serious Illness Conversation Training Needs among Safety Net Primary Care Providers (QI126)

The effects of Medicaid expansions on dental services at federally qualified health centers

BackgroundFederally qualified health centers (FQHCs) have become safety-net providers of dental services for low-income patients. The authors examined the effects of the Patient Protection and Affordable Care Act Medicaid expansions, according to level of dental benefits, on the number of visits for dental services at FQHCs. MethodsThe authors used publicly available facility-level data on 1,400 FQHCs across the United States from the 2011 through 2019 Uniform Data System. The authors used an event-study difference-in-difference design to examine the effects of expanding Medicaid in 2014, according to the level of dental benefits, compared with nonexpansion states. Outcomes included the number of dental visits for any dental service and separately for preventive and other services. Regression models adjusted for the demographic characteristics of the FQHC's patient population, county-level factors, and center and year fixed effects. ResultsExpanding Medicaid with extensive dental benefits has increased the number of dental visits provided at FQHCs in 2014 through 2019 from 2013 by 1,329 to 7,647 visits per FQHC on average compared with FQHCs in nonexpansion states. There was an increase in visits for both preventive and other dental services. In contrast, there was no evidence of such an increase from expanding Medicaid with limited or emergency-only dental benefits. ConclusionsExpanding Medicaid eligibility with extensive dental benefits has increased the number of dental visits at FQHCs, including for both preventive and other dental services. Practical ImplicationsAs safety-net providers, FQHCs might be able to provide more oral health care for low-income patients after Medicaid expansions that offer extensive dental benefits.

FINANCIAL PERFORMANCE OF STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED FOR THE RECENT DECADE

Protection is a monetarist device explicitly intended to lessen the monetary effect of unforeseen occasions and make monetary security. The medical coverage organizations in India have quickly become quite possibly of the main area in the country that drifts around 10% in thickness computations. The Star Health and allied Insurance Company Limited is the India's first independent health care coverage organization confronting parcel of difficulties because of the mushroom development of the overall safety net providers in India during the new past. The Chennai-based wellbeing safety net provider enlisted a gross composed premium (GWP) of ₹12,952 crore in FY23, which is 13% higher than the GWP during a similar period a year prior. The Star Health and allied Insurance Company Limited enlisted a retail wellbeing premium of ₹11,948 crore in FY23, a development of 18% over FY22 figures. It secured a Gross Premium of Rs 686,514 lakh in the monetary year 2019-20 when contrasted with earlier year 2018-19 Rs 540,129 lakh, enrolling a development of Rs 146,385 lakh (27.10%). The Star Health and allied Insurance Company Limited assume a significant part in the main medical coverage market with a tremendous organization of 9600 or more clinics accessible for credit only hospitalization in India with in excess of 460 branch workplaces, subsequently this paper plans to dissect the monetary presentation during 2009 to 2018 utilizing Proportion examination from the yearly reports of the organization. This study portrays that the dissolvability position of the organization at Walk 2020 was 1.88 and return to total assets proportion is 13.94 percent, which is clear that even in the predominant Corona virus circumstance the organization's viewpoint is positive.

Free and Charitable Clinic Perspectives on the Implementation and Utilization of Telehealth Services During the COVID-19 Pandemic.

The onset of the COVID-19 pandemic challenged healthcare providers to adapt their models of care and leverage technology to continue to provide necessary care while reducing the likelihood of exposure. One setting that faced a unique set of challenges and opportunities was free and charitable clinics. In response to the emerging pandemic, The North Carolina Association for Free and Charitable Clinics (NCAFCC) offered their 66 member clinics access to a telehealth platform, free of charge. This paper explores the varied perspectives of leaders in the NCAFCC member clinics regarding the implementation of telehealth services to facilitate continuity of care for patients during the height of the pandemic. This qualitative study is part of a broader research effort to understand and contextualize the experience of implementing and using telehealth services by North Carolina free and charitable clinics during and after the COVID-19 pandemic. The research team conducted 13 key informant interviews and employed thematic analysis and grounded theory to explore critical themes and construct a model based on the CFIR to describe the use of telehealth in free and charitable clinics. Twelve clinic managers and executive directors from free and charitable clinics across the state participated in the key informant interviews providing their unique perspective on the experience of implementing telehealth services in a free and charitable clinic environment during the COVID-19 pandemic. When examined within the lens of the consolidated framework for implementation research (CFIR), 3 key themes emerged from the key informant interviews: mission driven patient centered care, resilience and resourcefulness, and immediate implementation. This study aligns with existing literature regarding telehealth implementation across other safety net provider settings and highlights the key implementation factors, organizational elements, provider perspectives, and patient needs that must collectively be considered when implementing new technologies, especially in a low-resource, high need healthcare setting. The study showcases the implementation climate, resourcefulness, and mission driven approach that allowed many NCAFCC clinics to respond to an emergent situation by adopting and implementing a telehealth platform in a period of 2 weeks or less.

Assessing Changes in Insurance Status and Access to Care Among Patients Attending Chicago Sexually Transmitted Infection Specialty Clinics From 2013 to 2019.

Public sexually transmitted infection (STI) clinics are safety net providers for uninsured and underinsured individuals but are at risk for closure due to declining budgets and shifting priorities. This study sought to assess changes in insurance status and access to preventive care among public STI clinic patients after immediate and long-term implementation of the Affordable Care Act (ACA). Patients receiving care in STI clinics administered by Chicago Department of Public Health were asked to complete an anonymous survey in 2013, 2014, and 2019. We estimated the prevalence rate ratio (PRR) of (1) being insured and (2) having access to preventive care over time, adjusted for age, race, and gender/sexual orientation, and employment status. Among 1711 respondents, compared with 2013 patients, patients were 1.41 (adjusted PRR [aPRR]) times more likely to report being insured in 2014 (95% confidence interval, 1.11-1.77) and 1.24 (aPRR) times more likely to report being insured in 2019 (95% confidence interval, 0.99-1.55). After adjusting for other significant variables (age, sex and orientation, and insurance status), reported access to preventive care increased by 34% among respondents in 2019 as compared with 2013 (aPRR, 1.34). Unsurprisingly, being insured was associated with increased preventive care access (aPRR, 1.78). Even after the implementation of the Affordable Care Act, a survey of public STI clinic patients in Chicago found a sizeable proportion of individuals without insurance, and many lacked access to preventive care, highlighting the continued need for these safety net clinics to provide STI care.

Training the next generation of learning health system scientists.

IntroductionThe learning health system (LHS) aligns science, informatics, incentives, stakeholders, and culture for continuous improvement and innovation. The Agency for Healthcare Research and Quality and the Patient‐Centered Outcomes Research Institute designed a K12 initiative to grow the number of LHS scientists. We describe approaches developed by 11 funded centers of excellence (COEs) to promote partnerships between scholars and health system leaders and to provide mentored research training.MethodsSince 2018, the COEs have enlisted faculty, secured institutional resources, partnered with health systems, developed and implemented curricula, recruited scholars, and provided mentored training. Program directors for each COE provided descriptive data on program context, scholar characteristics, stakeholder engagement, scholar experiences with health system partnerships, roles following program completion, and key training challenges.ResultsTo date, the 11 COEs have partnered with health systems to train 110 scholars. Nine (82%) programs partner with a Veterans Affairs health system and 9 (82%) partner with safety net providers. Clinically trained scholars (n = 87; 79%) include 70 physicians and 17 scholars in other clinical disciplines. Non‐clinicians (n = 29; 26%) represent diverse fields, dominated by population health sciences. Stakeholder engagement helps scholars understand health system and patient/family needs and priorities, enabling opportunities to conduct embedded research, improve outcomes, and grow skills in translating research methods and findings into practice. Challenges include supporting scholars through roadblocks that threaten to derail projects during their limited program time, ranging from delays in access to data to COVID‐19‐related impediments and shifts in organizational priorities.ConclusionsFour years into this novel training program, there is evidence of scholars' accomplishments, both in traditional academic terms and in terms of moving along career trajectories that hold the potential to lead and accelerate transformational health system change. Future LHS training efforts should focus on sustainability, including organizational support for scholar activities.

Gynecologist Supply Deserts Across the VA and in the Community

BackgroundThe Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care.ObjectiveCompare gynecologist supply in veterans’ county of residence versus at their VA site.DesignWe identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called “local”) of veterans’ VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were “inadequate-supply” counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences.ParticipantsAll women veteran FY2017 VA primary care users nationally.Main MeasuresAvailability of a VA gynecologist within 50 miles of a veteran’s VA homesite; county-level “inadequate-supply” of gynecologists.Key ResultsAmong 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women’s clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist.ConclusionsMost veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA’s critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.

Value-based payment, the safety net, and rethinking risk.

Safety-net providers can benefit from demonstrations of condition-specific and defined-scope-of-practice alternative payment models that account for the nonfinancial as well as financial risks that providers face.