Removing Barriers and Honoring Autonomy: Rethinking Mental Health Professional Assessments in Adolescent Gender-Affirming Medical Care.

ABSTRACT: Adolescents seeking gender-affirming medical care (GAMC) face numerous barriers that may delay or inhibit their access to these services. Such obstacles include mental health professional (MHP) assessment requirements prior to initiating GAMC. MHP letters ultimately carry little benefit for patients. Their formulaic nature discourages nuance, reduces likelihood of capturing gender embodiment goals (beyond a narrow definition of gender dysphoria), and may cause clinicians to overlook presenting mental health concerns. MHP assessment requirements also reinforce the conception of gender dysphoria as a mental health disorder. Moreover, studies have not shown that requiring MHP assessment letters effectively reduces regret among patients. Fortunately, primary clinicians who provide GAMC are most often capable of assessing patients without additional input from an MHP. In this article, we provide an ethical framework for clinicians that prioritizes patient autonomy through an informed assent approach. We discuss Appelbaum's criteria and its application, and contexts in which MHP consultation is appropriate. We also address common questions about informed assent among clinicians, patients, and families. Finally, we advocate for bolstering multidisciplinary support teams involved in GAMC to facilitate the informed assent process. This approach upholds patient autonomy, expands access to GAMC, and utilizes the mental health workforce more effectively.

A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era.

Introduction: New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both benefits and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for first-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. Methods: One hundred seventy-three first-year medical and dental students participated in this curriculum. They completed an asynchronous presession module first, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices. Results: On postworkshop surveys, learners reported increased preparedness in their ability to document in a patient-centered manner (presession M = 2.2, midyear M = 3.9, p < .001), as rated on a 5-point Likert scale (1 = not prepared at all, 5 = very prepared), and also found this topic valuable to learn early in their training. Discussion: This curriculum utilizes a multipart approach to prepare learners to employ clinical notes to communicate with patients and providers, with special attention to how patients and their care partners receive a note. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.

Secret shopper studies: an unorthodox design that measures inequities in healthcare access.

Secret shopper studies are particularly potent study designs that allow for the gathering of objective data for a variety of research hypotheses, including but not limited to, healthcare delivery, equity of healthcare, and potential barriers to care. Of particular interest during the COVID-19 pandemic, secret shopper study designs allow for the gathering of data over the phone. However, there is a dearth of literature available on appropriate methodological practices for these types of studies. To make these study designs more widely accessible, here we outline the case for using the secret shopper methodology and detail best practices for designing and implementing them.

Charges for Initial Visits for Uninsured Patients at Musculoskeletal Urgent Care Centers in the US.

Importance: In recent years, specialized musculoskeletal urgent care centers (MUCCs) have opened across the US. Uninsured patients may increasingly turn to these orthopedic-specific urgent care centers as a lower-cost alternative to emergency department or general urgent care center visits. Objective: To assess out-of-pocket costs and factors associated with these costs at MUCCs for uninsured and underinsured patients in the US. Design, Setting, and Participants: In this survey study, a national secret shopper survey was conducted in June 2019. Clinics identified as MUCCs in 50 states were contacted by telephone by investigators using a standardized script and posing as uninsured patients seeking information on the out-of-pocket charge for a new patient visit. Exposures: State Medicaid expansion status, clinic Medicaid acceptance status, state Medicaid reimbursement rate, median income per zip code, and clinic region. Main Outcomes and Measures: The primary outcome was each clinic's out-of-pocket charge for a level 3 visit, defined as a new patient office visit requiring medical decision-making of low complexity. Linear regression was used to examine correlations of price with clinic policy against accepting Medicaid, median income per zip code, and Medicaid reimbursement for a level 3 visit. Results: Of 565 MUCCs identified, 558 MUCCs were able to be contacted (98.8%); 536 of the 558 MUCCs (96.1%) disclosed a new patient visit out-of-pocket charge. Of those, 313 (58.4%) accepted Medicaid insurance and 326 (60.8%) were located in states with expanded Medicaid at the time of the survey. The mean (SD) price of a visit to an MUCC was $250 ($110). Clinic policy against accepting Medicaid (ß, 22.91; 95% CI, 12.57-33.25; P < .001), higher median income per zip code (ß, 0.00056; 95% CI, 0.00020-0.00092; P = .003), and increased Medicaid reimbursement for a level 3 visit (ß, 0.737; 95% CI, 0.158-1.316; P = .01) were positively correlated with visit price. The overall regression was statistically significance (R2 = 0.084; P < .001). Conclusions and Relevance: In this survey study, MUCCs charged a mean price of $250 for a new patient visit. Medicaid acceptance policy, median income per zip code, and Medicaid reimbursement for a level 3 visit were associated with differences in out-of-pocket charges. These findings suggest that accessibility to orthopedic urgent care at MUCCs may be limited for underinsured and uninsured patients.

The Impact of Social Media on College Mental Health During the COVID-19 Pandemic: a Multinational Review of the Existing Literature.

PURPOSE OF REVIEW: During the COVID-19 pandemic, both social media use and rates of anxiety and depression among college students have increased significantly. This begs the question, what is the relationship between social media use and college student mental health during the COVID-19 pandemic? RECENT FINDINGS: Prior studies have found mixed results regarding the relationship between social media use and college student mental health. This relationship has become increasingly complex during the COVID-19 pandemic. We found that excessive or problematic social media use during the COVID-19 pandemic was correlated with worse mental health outcomes that could be mitigated by dialectical thinking, optimism, mindfulness, and cognitive reappraisal. The COVID-19 pandemic acts as a moderator by strengthening the relationship between social media use and mental health. Future studies should consider the impact of social media on college student mental health and concentrate on intervention initiatives to ensure the psychological well-being of college students during a global pandemic outbreak.

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

BACKGROUND: As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access. QUESTIONS/PURPOSES: (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs? METHODS: An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC. RESULTS: Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements. CONCLUSION: It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective. LEVEL OF EVIDENCE: Level II, prognostic study.

Urgent Care Centers Delay Emergent Surgical Care Based on Patient Insurance Status in The United States.

OBJECTIVE: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition. METHODS: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types. RESULTS: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29). CONCLUSIONS: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.

COVID-19 testing capabilities at urgent care centers in states with greatest disease burden.

While rapid and accessible diagnosis is paramount to monitoring and reducing the spread of disease, COVID-19 testing capabilities across the U.S. remain constrained. For many individuals, urgent care centers (UCCs) may offer the most accessible avenue to be tested. Through a phone survey, we describe the COVID-19 testing capabilities at UCCs and provide a snapshot highlighting the limited COVID-19 testing capabilities at UCCs in states with the greatest disease burden.