Keith T. Elder

African Americans’ Decisions Not to Evacuate New Orleans Before Hurricane Katrina: A Qualitative Study

OBJECTIVESnWe examined the psychosocial and personal factors that influenced African Americans decision not to evacuate New Orleans, La, before Hurricane Katrinas landfall.nnnMETHODSnWe conducted 6 focus groups with 53 African Americans from New Orleans who were evacuated to Columbia, SC, within 2 months of Hurricane Katrina.nnnRESULTSnThe major themes identified related to participants decision to not evacuate were as follows: (1) perceived susceptability, including optimism about the outcome because of riding out past hurricanes at home and religious faith; (2) perceived severity of the hurricane because of inconsistent evacuation orders; (3) barriers because of financial constraints and neighborhood crime; and (4) perceived racism and inequities.nnnCONCLUSIONSnFederal, state, and local government disaster preparedness plans should specify criteria for timely evacuation orders, needed resources, and their allocation (including a decentralized distribution system for cash or vouchers for gas and incidentals during evacuation) and culturally sensitive logistic planning for the evacuation of minority, low-income, and underserved communities. Perceptions of racism and inequities warrant further investigation.

Enhancing the Care Continuum in Rural Areas: Survey of Community Health Center-Rural Hospital Collaborations

CONTEXTnCommunity Health Centers (CHCs) and Critical Access Hospitals (CAHs) play a significant role in providing health services for rural residents across the United States.nnnPURPOSEnThe overall goal of this study was to identify the CAHs that have collaborations with CHCs, as well as to recognize the content of the collaborations and the barriers and facilitators to collaborations.nnnMETHODSnThe target population was CAHs within 60 miles of CHCs. Surveys were mailed to 386 chief executive officers of CAHs in 41 states who met the study criteria. The response rate was 40.9%. A descriptive analysis using chi-square tests compared the status of partnerships along with factors identified as barriers and facilitators to collaboration.nnnFINDINGSnOut of the 161 CAH respondents, 24 (14.9%) reported having a collaborative agreement with a CHC, and 2 indicated that they planned to develop a collaborative agreement. A common reason given for not collaborating was lack of awareness of a CHC within the service area. Other barriers identified were competition with CHCs and organizational differences. External funding to start a collaborating service was the most frequently cited factor to facilitate collaborations.nnnCONCLUSIONSnThe findings indicate that collaborations between CAHs and CHCs are a largely untapped resource. The rural health care services continuum may benefit from increased collaborations.

Medicaid 1915(c) Waiver Use and Expenditures for Persons Living With HIV/AIDS

States use of Medicaid 1915(c) waiver services for persons living with HIV/AIDS (PLWHA) has been limited. The authors examine state-level factors related to the decision to offer waiver services, as well as waiver use and expenditures in states offering waivers for PLWHA. They use fixed effects cross-sectional time series models to explore these state factors. States with Democratic governors were more likely to offer waiver services and were found to have higher rates of use and greater expenditures and to devote a larger share of long-term care dollars to waiver services for PLWHA. State supply of both institutional and residential care beds was negatively related to use and expenditures. Medicaid community-based care has been found to be related to improved outcomes and reduced costs of care. Ways to foster 1915(c) waiver expansion are important so as to increase access to care for PLWHA.

Strengthening Home and Community-Based Care Through Medicaid Waivers

Abstract States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care (LTC). We examined state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals. State level data for the period 1992 to 2001 were used to estimate random effects panel models. States with increased community-based care (e.g., home health agencies) and decreased nursing home bed capacity were positively associated with state per capita rates of use, expenditures, and the share of Medicaid LTC dollars supporting 1915c waivers. States appeared to substitute Medicare for Medicaid services for individuals eligible for both. State per capita income was positively related to each measure. State policies that facilitate decreased institutional and increased community-based capacity appear essential to state efforts to expand access to community-based services. Federal policies that address state resource issues may also spur growth in community-based LTC, which, in most states, continues to be limited.

African American women perceptions of physician trustworthiness: A factorial survey analysis of physician race, gender and age

Background/Objective Physical concordance between physicians and patients is advocated as a solution to improve trust and health outcomes for racial/ethnic minorities, but the empirical evidence is mixed. We assessed womens perceptions of physician trustworthiness based on physician physical characteristics and context of medical visit. Methods A factorial survey design was used in which a community-based sample of 313 African American (AA) women aged 45+ years responded to vignettes of contrived medical visits (routine versus serious medical concern visit) where the physicians race/ethnicity, gender, and age were randomly manipulated. Eight physician profiles were generated. General linear mixed modeling was used to assess separately and as an index, trust items of fidelity, honesty, competence, confidentiality, and global trust. Trust scores were based on a scale of 1 to 5, with higher scores indicating higher trust. Mean scores and effect sizes (ES) were used to assess magnitude of trust ratings. Results No significant differences were observed on the index of trust by physician profile characteristics or by medical visit context. However, the white-older-male was rated higher than the AA-older-female on fidelity (4.23 vs. 4.02; ES = 0.215, 95% CI: 0.001–0.431), competence (4.23 vs. 3.95; ES = 0.278, 95% CI: 0.062–0.494) and honesty (4.39 vs. 4.19, ES = 0.215, 95% CI: 0.001–0.431). The AA-older male was rated higher than the AA-older-female on competence (4.20 vs. 3.95; ES = 0.243, 95% CI: 0.022–0.464) and honesty (4.44 vs. 4.19; ES = 0.243, 95% CI: 0.022–0.464). The AA-young male was rated higher than AA-older-female on competence (4.16 vs. 3.95; ES = 0.205, 95% CI: 0.013–0.423). Conclusions Concordance may hold no salience for some groups of older AA women with regards to perceived trustworthiness of a physician. Policies and programs that promote diversity in the healthcare workforce in order to reduce racial/ethnic disparities should emphasize cultural competency training for all physicians, which is important in understanding patients and to improving health outcomes.

Commentary on "Access to primary care physicians differs by health insurance coverage in Mississippi".

The United States has crossed the precipice of health care transition with the Patient Protection and Affordable Care Act (PPACA). The PPACA has the potential to provide health insurance coverage for more than 47 million uninsured individuals in the United States; however, there is concern that thiswill stress the healthcare system, similarly toMassachusetts’ mandated care and the increased primary care wait time. Consequently, some Americans fear that their access to primary care physicians will be negatively affected. In this issue of the Southern Medical Journal, Cossman and colleagues present a timely study as many states anticipate Medicaid expansion with the PPACA. The authors assess differences in access to primary care physicians by insurance coverage type. By surveying physicians’ offices via two telephone waves (one before and one after the Supreme Court ruling on the PPACA), they found that 7% of the primary care physicians were not accepting new patients, 15% were not accepting new Medicare patients, and 38% were not accepting newMedicaid patients. The findings point to an important fact: health insurance does not ensure access to vital services. Access to health care, particularly primary care physicians, is of significant importance. In the United States, primary care is associatedwith reducedmorbidity andmortality.Countrieswith efficient primary healthcare services have fewer life-years lost resulting from preventable illnesses and lower overall healthcare expenditures. Primary care physicians are also integral to the concretizing of the patient-centered medical home, which enhances care coordination, health outcomes, and healthcare quality. If access to primary health care is compromised for private and public health insurance, this could pose significant issues going forth. It is likely that the demand for primary care physicians will continue to challenge the supply, and it appears this demand will be affected mostly by population growth and the older adult population. In addition, the shortage is likely not to abate because the number of medical students selecting a residency in general internal medicine is declining and the number of younger physicians leaving general internal medicine is increasing. Furthermore, there are numerous states similar to Mississippi with significant percentages of rural, economically challenged, and older adult residents who are influencing primary care physician shortages. Cossman et al remind us that providers remain more cautious concerning public health insurance compared with private insurance, which is problematic. The number of Americans living in poverty has increased to 46.5 million, up from 46.2 million in 2012, and the percentage being covered by employer-based insurance has decreased, whereas the number of Medicare and Medicaid beneficiaries has increased. Furthermore, 29 states are moving toward Medicaid expansion with the rollout of the PPACA. All of the aforementioned factors, therefore, indicate that more Americans will present at physicians’ offices with public health insurance. This increased level of need from public health insurance beneficiaries must be met and balanced with the level of need from those with private insurance. Because it is unlikely that Medicaid and Medicare reimbursements to providers will equal those from private insurance, access to primary care physicians must be considered carefully going forward. It is unclear whether Americans newly covered under the PPACAwill have utilization patterns similar to those with existing insurance or people who are uninsured, which could suggest an overestimation of the decrease in demand for emergency services. It is likely, however, that the demand for primary care physicians will be greater in the future. The additional demand should be the impetus for a greater emphasis on illness and disease prevention by providers. Providers should seek to promote among their patients greater self-management of health, as well as thoughtful Invited Commentary