Identifying Sources of Health Care Underutilization Among California’s Immigrants

Many studies show that immigrants face significant barriers in accessing health care. These barriers may be particularly pronounced for newer immigrants, who may face additional obstacles in navigating the health care system. Understanding the sources of health care disparities between recent and non-recent immigrants may allow for better design of policies and interventions to address the vulnerabilities unique to different subgroups of immigrants defined by their length of residency. This study employs descriptive analyses and multivariate logistic regression to estimate the likelihood of accessing and utilizing health care services based on immigration-related factors after controlling for predisposing, enabling, and health care need factors. We also employ a regression-based decomposition method to determine whether health care differences between recent and non-recent immigrants are statistically significant and to identify the primary drivers of healthcare differences between recent and non-recent immigrants. The findings support the hypothesis that significant disparities in health care access and utilization exist between recent and non-recent immigrants. We found that health care access and utilization differences between recent and non-recent immigrants were driven primarily by enabling resources, including limited English proficiency (LEP), insurance status, public assistance usage, and poverty level. These results indicate that not only are newer immigrants more likely to underutilize health care, but also that their underutilization is driven primarily by their lack of insurance, lack of adequate financial resources, and inability to navigate the health care system due to LEP. The results further indicate that immigrants with prolonged LEP may be less likely to have a usual source of care and more likely to report delays in obtaining medical treatments, than even recent immigrants with LEP

Ageing and Financial Stability

Abstract: Although the precise details are subject to major uncertainty, it seems likely that the process of population ageing will involve major shifts in financing, which may give rise to financial turbulence and systemic risk. The locus and scale of these effects will also depend on the predominant approach to retirement income provision. It is argued that the financial-stability risks arising from continuing with unsustainable pay-as-you-go systems would be more threatening than those arising from funding. Fiscal crises can have incalculable consequences for private financial markets, while pension funding involves more an adaptation by regulatory authorities to a more securitised and institutionalised financial system, that is likely to develop in any case. Concerning policy, for social security, the key issue is reform, so that the fiscal difficulties and their consequences for financial stability foreshadowed above do not arise. For institutional investors involved in funding, policy issues arising include the need for prudent person asset regulation, absence of guarantees generating moral hazard and international diversification of institutional portfolios, so that they are less dependent on the performance of the domestic economy than would otherwise be the case. Banks would not be immune to the side-effects of the various patterns ageing will generate, and an awareness of such risks as well a

Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown.OBJECTIVE To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations.DESIGN, SETTING, AND PARTICIPANTS This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decisionmaking (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019.MAIN OUTCOMES AND MEASURES The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation. RESULTS A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and$99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) agewas 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) andwere more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.216.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and$99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above$99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent.CONCLUSIONS AND RELEVANCE Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, aswell as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice