Primary care of patients without insurance by community health centers

Characterizing the Uptake of Newly Opened Health Centers by Individuals Dually Enrolled in Medicare and Medicaid

Federally qualified health centers (FQHCs) increasingly provide high-quality, cost-effective primary care to individuals dually enrolled in Medicare and Medicaid. However, not everyone can access an FQHC. We used 2012 to 2018 Medicare claims and federally collected FQHC data to examine communities where an FQHC first opened and determine which dual eligibles used it. Overall uptake was 10%, ranging from 6.6% among age-eligible urban residents to 14.8% among disability-eligible rural residents. Community-level uptake ranged from 0% to 76.4% (median = 5.5%; interquartile range = 2.8%-11.3%). Certain subpopulations of dual eligibles are significantly more likely to use FQHCs. Our findings should inform the targeting of future FQHC expansions.

Health needs, utilization of services and access to care among Medicaid and uninsured patients with chronic disease in health centres

Introduction

Understanding the role of Medicaid for health centre patients with chronic diseases can aid policymakers in designing and improving programmes to effectively meet the needs of this vulnerable segment of the population. This study compares the number of chronic conditions, health services utilization and access to care between patients with Medicaid coverage and uninsured patients seen at US health centres.

Methods

We used data from the 2014 Health Center Patient Survey. Measures included number of chronic conditions, number of physician visits, number of prescription drugs used, access to a usual source of care, the receipt of a routine checkup, unmet need for care and unmet need for prescription drugs. We conducted bivariate analyses to determine differences of outcome measures between the Medicaid and uninsured patient groups. Multiple linear and logistic regression models were conducted to test associations of Medicaid and other health-related factors with outcome measures.

Results

Bivariate results indicated there were no differences between Medicaid and uninsured patients in number of chronic diseases, having a usual source of care and receipt of a routine checkup. Significant differences existed in health services utilization measures and unmet health needs measures. After controlling for confounding factors, the differences in these measures were still apparent. Uninsured status was linked to a reduced physician visit frequency by −3.03 (95% CI: −4.05, −2.00) as compared with Medicaid patients (p < 0.001) and was associated with a reduced frequency of prescription drugs used by −0.38 (95% CI: −0.67, −0.10, p < 0.01) after controlling for the other covariates.

Conclusion

Despite having comparable needs to Medicaid patients, uninsured patients with chronic conditions continue to have substantial unmet needs for health care services and limited access to the health care system. Health centres serve an important role in eliminating such disparity regardless of insurance status. In addition, Medicaid eligibility may also have a substantial and positive impact on improving health services utilization and access to care among these low-income patients.

Does Ownership Make a Difference in Primary Care Practice?

PURPOSE

We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices.

METHODS

This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS).

RESULTS

Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs).

CONCLUSIONS

Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.

Nonurgent Emergency Department Visits by Insured and Uninsured Adults

OBJECTIVE

To compare nonurgent emergency department (ED) visits by insured and uninsured adults in a Midwest community.

DESIGN AND SAMPLE

Records for this secondary data analysis included 84,877 nonurgent visits to a Midwest ED from September 2004 to January 2012. Insured versus uninsured visits were analyzed using t tests for continuous variables and chi-squared tests for categorical variables. Standardized residuals were compared to determine if changes over time were statistically significant.

MEASURES

Variables included demographic characteristics of patients, payment source, patients' access to primary care, acuity rating, time of visit, and the stated reason for the visit.

RESULTS

Of all nonurgent visits, 77.9% were made by insured adults. Insured nonurgent visits were more often made by adults who were female, older, White, and had a primary care provider (PCP). Nonurgent visits on weekdays between the hours of 09:00 and 18:00 were more likely to be uninsured visits. Dental issues were the fourth most common issue for uninsured visits.

CONCLUSIONS

Nonurgent ED visits occur when more appropriate options for prompt care are available in the community. Interventions should target both patients and PCPs. While patients should contact their PCP when in need of prompt care, PCPs should refer patients to facilities other than the ED when medically appropriate.

Balancing investments in Federally Qualified Health Centers and Medicaid for improved access and coverage in Pennsylvania

Two common health disparities in the US include a lack of access to care and a lack of insurance coverage. To help address these disparities, healthcare reform will provide $11B to expand Federally Qualified Health Centers (FQHCs) over the next 5 years. In 2014, Medicaid rules will be modified so that more people will become eligible. There are, however, important tradeoffs in the investment in these two programs. We find a balanced investment between FQHC expansion and relaxing Medicaid eligibility to improve both access (by increasing the number of FQHCs) and coverage (by FQHC and Medicaid expansion) for the state of Pennsylvania. The comparison is achieved by integrating multi-objective mathematical models with several public data sets that allow for specific estimations of healthcare need. Demand is estimated based on current access and coverage status in order to target groups to be considered preferentially. Results show that for Pennsylvania, FQHCs are more cost effective than Medicaid if we invest all of the resources in just one policy. However, we find a better investment point balancing those two policies. This point is approximately where the additional expenses incurred from relaxing Medicaid eligibility equals the investment in FQHC expansion.

Federally qualified health centers and private practice performance on ambulatory care measures

BACKGROUND

The 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHCs) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency.

PURPOSE

To compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures.

METHODS

The study was a cross-sectional analysis of visits in the 2006-2008 National Ambulatory Medical Care Survey. Performance of FQHCs and look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011.

RESULTS

Compared to private practice PCPs, FQHCs and look-alikes performed better on six measures (p<0.05); worse on diet counseling in at-risk adolescents (26% vs 36%, p=0.05); and no differently on 11 measures. Higher performance occurred in ACE inhibitors use for congestive heart failure (51% vs 37%, p=0.004); aspirin use in coronary artery disease (CAD; 57% vs 44%, p=0.004); β-blocker use for CAD (59% vs 47%, p=0.01); no use of benzodiazepines in depression (91% vs 84%, p=0.008); blood pressure screening (90% vs 86%, p<0.001); and screening electrocardiogram (EKG) avoidance in low-risk patients (99% vs 93%, p<0.001). Adjusting for patient characteristics yielded similar results, except that private practice PCPs no longer performed better on any measures.

CONCLUSIONS

FQHCs and look-alikes demonstrated equal or better performance than private practice PCPs on select quality measures despite serving patients who have more chronic disease and socioeconomic complexity. These findings can provide policymakers with some reassurance as to the quality of chronic disease and preventive care at Federally Qualified Health Centers and look-alikes, as they plan to use these health centers to serve 20 million newly insured individuals.

The impact of primary care: a focused review

Primary care serves as the cornerstone in a strong healthcare system. However, it has long been overlooked in the United States (USA), and an imbalance between specialty and primary care exists. The objective of this focused review paper is to identify research evidence on the value of primary care both in the USA and internationally, focusing on the importance of effective primary care services in delivering quality healthcare, improving health outcomes, and reducing disparities. Literature searches were performed in PubMed as well as "snowballing" based on the bibliographies of the retrieved articles. The areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health.

Does health care setting matter in reports of discrimination?

We investigated the associations between the health care setting types that California adults report as their regular source of care, socioeconomic status, and perceived racial/ethnic medical care-related discrimination. Data were analyzed from the 2005 California Health Interview Survey (n = 36,694). Adults who identified clinics/health centers/hospital clinics or "other settings" as their usual source of health care had increased odds for perceived racial/ethnic discrimination compared with those who utilized private and health maintenance organizations doctors' offices, although this was true only for middle, but not lower or higher, socio-economic respondents. We suggest several explanations for these findings and improvements for assessing health care-based racial discrimination.

Level of evidence of the value of care in federally qualified health centers for policy making

THE PROBLEM

Community health centers (CHCs) are part of the United States' medical care safety net. Cost effectiveness is a critical element of value in today's health policy environment. Not all cost-effectiveness studies employ formal peer-reviewed methodologies. A review of the literature on CHCs' cost effectiveness is necessary to assess whether a higher level of evidence is needed to guide future policy.

PURPOSE

We sought to review the quality of the evidence on the economic value of CHCs and indicate whether a higher of level evidence would be useful for making policy.

KEY POINTS

Evidence exists to support the general value of care in CHCs, but no evidence comes from formal economic evaluations of CHC care.

CONCLUSION

More formal cost-effectiveness evaluations would enhance the economic argument for CHCs but will remain difficult to conduct and may be unnecessary in light of other work on the value of care in CHCs.

The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.

Public finance policy strategies to increase access to preconception care

Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. Millions of women of childbearing age (15-44) lack adequate health coverage (i.e., uninsured or underinsured), and others live in medically underserved areas. Service delivery fragmentation and lack of professional guidelines are additional barriers. This paper reviews barriers and opportunities for financing preconception care, based on a review and analysis of state and federal policies. We describe states' experiences with and opportunities to improve health coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children's Health Insurance Program (SCHIP). The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.

Deserving the spotlight: health centers provide high-quality and cost-effective care

Community health centers were designed to overcome barriers to healthcare and narrow health disparities faced by underserved communities. Given the increased attention health centers are now receiving over expansion efforts, questions over their quality of care and cost-effectiveness must be addressed. This article reviews the relevant literature and documents that health centers improve access for hard-to-reach and underserved populations, provide continuous and high-quality primary care, and reduce the use of costlier providers of care, such as emergency departments and hospitals. The health center model produces substantial benefits for patients, communities, insurers, and governments.

High prevalence of overweight among pediatric users of community health centers

OBJECTIVE

With the increasing prevalence of pediatric obesity, it is important to identify high-risk populations of children to direct limited resources for prevention and treatment to those who are most vulnerable. The objectives of this study were to determine the prevalence of overweight in children who are clients of community health centers in medically underserved areas of the Health Resources and Service Administration regions II and III (Mid-Atlantic and Puerto Rico), compare this prevalence to nationally representative data, and contrast prevalence data between geographic areas and racial/ethnic groups.

METHODS

The charts from a representative sample of 2474 children using 30 community health centers in 2001 were abstracted to collect clinically measured weight and height. Overweight was defined as a body mass index of > or =95th percentile of a reference population. To generate an unbiased estimate of overweight, multiple imputations were used for missing data. These data were compared with the 1999-2002 National Health and Nutrition Examination Survey.

RESULTS

The prevalence of overweight was elevated in this sample of children aged 2 to 5 years (21.8%; 95% confidence interval [CI]: 19.1-24.8) and 6 to 11 years (23.8%; 95% CI: 16.9-27.7) compared with the 1999-2002 National Health and Nutrition Examination Survey (10.3% and 15.8%, respectively). No significant differences in prevalence were observed between Asian American (18.2%; 95% CI: 11.2-28.3), Hispanic (24.6%; 95% CI: 21.3-28.2), non-Hispanic black (25.6%; 95% CI: 20.8-30.9), and non-Hispanic white (22.8%; 95% CI: 19.0-27.0) children. Furthermore, no differences in prevalence were observed between children using community health centers in continental urban (23.7%; 95% CI: 20.6-27.2), suburban (24.0%; 95% CI: 20.0-28.5), or rural (22.9%; 95% CI: 19.3-26.9) areas.

CONCLUSIONS

The present study identified a population of children at particularly high risk for obesity based on the type of health care delivery system they use regardless of race/ethnicity or geographic characteristics. Because community health centers are experienced in prevention and serve >4.7 million children in the United States, they may be a particularly promising point of access and setting for pediatric obesity prevention.