VHA HSR Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Greater Los Angeles VA Medical Center, Los Angeles, CA, USA.
Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave. 72-227 CHS, Los Angeles, CA, 90095, USA.
BMC Health Serv Res. 2024 Sep 27;24(1):1139. doi: 10.1186/s12913-024-11619-3.
Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery.
The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity.
Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or "other" race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers.
The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.
对于有 Medi-Cal（即加利福尼亚州的 Medicaid）保险的患者来说，到学术医疗中心（AMC）进行门诊就诊的情况研究较少，特别是在 85%的参保人参加管理式医疗计划的情况下。随着越来越多的 AMC 与这些计划建立合作关系，需要有关患者获得医疗服务的体验和质量的数据，以指导以患者为中心的医疗服务提供方面的改进。
作者于 2022 年对在一家大型城市 AMC 进行初次就诊的 Medi-Cal 保险患者进行了半结构式、定性访谈。参与者招募是根据门诊 Medi-Cal 就诊数据库进行的。访谈指南涵盖 Medi-Cal 参保、预约和就诊体验。访谈内容被转录并进行归纳编码，然后按照四个领域的主题进行组织：可及性、负担能力、医患互动和连续性。
完成了 20 次患者访谈（55%为女性，85%为英语使用者，80%自认为是少数民族或“其他”种族，30%为西班牙裔或拉丁裔），包括初级和/或专科医疗就诊。在可及性方面，患者报告 Medi-Cal 参保和获得专科医疗服务或检查存在延迟，尽管预约安排被认为很容易。负担能力方面的问题包括自付医疗和停车费用，以及患者或家属为了配合医疗协调而旷工所导致的收入损失。参与者认为与提供者进行清晰、双向的沟通是良好医患互动的基础。一些参与者认为自己因保险身份而受到提供者的歧视。患者重视连续性，但频繁和意外的健康计划变更破坏了他们与 AMC 既定提供者的关系，导致患者感到沮丧。
AMC 的使命通常侧重于临床护理、教育、研究和公平。然而，从在 AMC 接受治疗的 Medi-Cal 保险患者的报告中可以看出，他们对提供者可及性不一致、未补偿费用、对质量的看法存在差异以及医疗服务碎片化等问题感到压力和困惑。基于患者报告的问题提出的建议，为 AMC 医疗系统层面的改进提供了机会，这些改进与 AMC 的使命是一致的。
