Purpose: Millions of people gained health care coverage in Los Angeles after the Affordable Care Act (ACA); however, challenges with obtaining and utilizing primary care still persist, particularly in the safety net. In this study, we explore barriers to accessing primary care services among safety-net patients in Los Angeles after Medicaid expansion and implementation of other programs for safety-net patients after the ACA. Methods: We conducted qualitative interviews, in Spanish and English, with 34 nonelderly adult patients in 1 of 3 insurance groups: Medicaid, MyHealthLA (a health care program for low-income undocumented individuals), or uninsured. We recruited participants from three sites in Los Angeles in 2017. We analyzed our interviews using a framework approach and included emerging concepts from participant responses. Results: We identified seven themes regarding barriers to accessing primary care: understanding the concept of primary care, finding a primary care provider (PCP), switching PCPs, getting timely appointments, geography and transportation, perceived cost or coverage barriers, and preferring emergency or urgent care over primary care. Patients with Medicaid were more likely to report barriers compared with other groups. Uninsured patients were less likely to understand the concept of primary care. Patients with MyHealthLA noted getting timely appointments and cost of care to be significant barriers. Conclusion: Despite Medicaid and other coverage expansions for safety-net patients after the ACA, substantial barriers to accessing primary care persist. Addressing such barriers through the development of targeted interventions or broader policy solutions could improve access to primary care for safety-net patients in Los Angeles.

primary care ought to serve a more prominent role in care transition efforts. 6 Yet there are few concerted efforts underway to develop, implement, and assess primary care-based transitions programs. In a recently published environmental scan commissioned by the Agency for Healthcare Research and Quality (AHRQ), we assessed the current state of the literature on primary carebased care transitions programs. 7 We identified numerous peer-reviewed and non-peer-reviewed studies ranging from narrow interventions to more comprehensive multicomponent initiatives. While some of the included studies had methodological limitations (there were few rigorous controlled analyses), collectively, they shed light on the types of interventions that are likely to be successful, revealing practical considerations and policy changes needed for making these initiatives sustainable. In this piece, we summarize insights from the environmental scan and make a case for an enhanced and expanded role for primary care in the care transitions process. BUNDLED VERSUS SINGLE-COMPONENT INTERVENTIONS ARE MORE LIKELY TO SUCCEED First, we found that multi-component, or Bbundled,^programs addressing multiple care transitions challenges that patients and providers face were some of the most successful. These programs often utilize clinic-based care managers and include several distinct processes such as close follow-up with a provider, post-discharge phone calls, medication reconciliation, addressing transportation barriers, and scheduling follow-up with social workers and other critical primary care team members. 8-14 Conversely, studies examining the impact of more narrowly focused programs, such as implementing automated admission notifications, medication reconciliations, or post-discharge phone calls alone, were less encouraging. Second, primary care practices with bundled transitions programs tended to be initiated early in the patient's hospital course. While primary care notifications for patient hospitalizations alone were not enough to reduce readmissions, hospitalization alerts were frequently an important component of successful interventions. These bundled programs often Breached in^to patients in the hospital prior to discharge-either to assess the patient's biopsychosocial needs, obtain accurate patient or caregiver contact

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For some drugs, safety concerns are only discovered after they have been on the market, sometimes for several years. The U.S. Food and Drug Administration (FDA) has adopted several policies that could increase the likelihood of approving a potentially unsafe medication. We attempted to quantify the number of exposures in the United States to drugs that were newly approved but later withdrawn from the market. We obtained a list of all drugs approved and subsequently withdrawn from the U.S. market due to safety concerns between 1993 and 2010. Using a representative sample of outpatient physician office visits in the National Ambulatory Medical Care Survey, we estimated the number of visits in the United States at which these unsafe drugs were prescribed. Seventeen drugs were approved and later withdrawn during this 18-year period and were prescribed at 112 million physician office visits in the United States. Nine of these drugs were prescribed more than 1 million times before their market withdrawal. New drugs that are later withdrawn due to being unsafe are frequently prescribed in the United States. To minimize the negative health consequences of prescribing potentially unsafe medications, we should reconsider some of the FDA policies that encourage the rapid approval and dissemination of new drugs.