Assessing primary care content: four conditions common in community health center practice

The context, strategy and performance of the American safety net primary care providers: a systematic review

PURPOSE

The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided.

DESIGN/METHODOLOGY/APPROACH

A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases.

FINDINGS

28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance.

ORIGINALITY/VALUE

Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context-strategy-performance relationships in the context of FQHCs.

Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States

OBJECTIVE

To examine variations in the quality and cost of care provided to patients with diabetes mellitus by Community Health Centers (CHCs) compared to other primary care settings.

RESEARCH DESIGN AND METHODS

We used data from the 2005-2008 Medical Expenditure Panel Survey (N = 2,108). We used two dependent variables: quality of care and ambulatory care expenditures. Our primary independent variable was whether the respondent received care in a Community Health Centers (CHCs) or not. We estimated logistic regression models to determine the probability of quality of care, and used generalized linear models with log link and gamma distribution to predict expenditures for CHC users compared to non-users of CHCs, conditional on patients with positive expenditures.

RESULTS

Results showed that variations of quality between CHC users and non-CHC users were not statistically significant. Patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared to non-users of CHCs.

CONCLUSIONS

These findings suggest an opportunity for policymakers to control costs for diabetes mellitus patients without having a negative impact on quality of care.

The War on Poverty's Experiment in Public Medicine: Community Health Centers and the Mortality of Older Americans

This paper uses the rollout of the first Community Health Centers (CHCs) to study the longer-term health effects of increasing access to primary care. Within ten years, CHCs are associated with a reduction in age-adjusted mortality rates of 2 percent among those 50 and older. The implied 7 to 13 percent decrease in one-year mortality risk among beneficiaries amounts to 20 to 40 percent of the 1966 poor/non-poor mortality gap for this age group. Large effects for those 65 and older suggest that increased access to primary care has longer-term benefits, even for populations with near universal health insurance. (JEL H75, I12, I13, I18, I32, I38, J14).

Diabetes care quality is highly correlated with patient panel characteristics

INTRODUCTION

Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs).

METHODS

Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined.

RESULTS

Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators.

CONCLUSIONS

Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.

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.

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.

Case-mix adjustment and the comparison of community health center performance on patient experience measures

OBJECTIVE

To assess the effect of case-mix adjustment on community health center (CHC) performance on patient experience measures.

DATA SOURCES

A Medicaid-managed care plan in Washington State collected patient survey data from 33 CHCs over three fiscal quarters during 2007-2008. The survey included three composite patient experience measures (6-month reports) and two overall ratings of care. The analytic sample includes 2,247 adult patients and 2,859 adults reporting for child patients.

STUDY DESIGN

We compared the relative importance of patient case-mix adjusters by calculating each adjuster's predictive power and variability across CHCs. We then evaluated the impact of case-mix adjustment on the relative ranking of CHCs.

PRINCIPAL FINDINGS

Important case-mix adjusters included adult self-reported health status or parent-reported child health status, adult age, and educational attainment. The effects of case-mix adjustment on patient reports and ratings were different in the adult and child samples. Adjusting for race/ethnicity and language had a greater impact on parent reports than adult reports, but it impacted ratings similarly across the samples. The impact of adjustment on composites and ratings was modest, but it affected the relative ranking of CHCs.

CONCLUSIONS

To ensure equitable comparison of CHC performance on patient experience measures, reports and ratings should be adjusted for adult self-reported health status or parent-reported child health status, adult age, education, race/ethnicity, and survey language. Because of the differential impact of case-mix adjusters for child and adult surveys, initiatives should consider measuring and reporting adult and child scores separately.

Quality-related activities in federally supported health centers: do they differ by organizational characteristics?

Recent reports suggest the need for further study of the impact of organizational characteristics on quality-related activities in health centers. To better understand these issues, a cross-sectional assessment of quality-related activities in Health Resources and Services Administration-funded health centers was conducted using a mailed questionnaire. Associations between the extent and frequency of quality-related activities and organizational characteristics, including location, size, and accreditation status, were examined. In general, the frequency and type of most quality-related activities did not vary greatly by size and location, but differed by accreditation status. The findings can be explained in part by Health Resources and Services Administration/Bureau of Primary Health Care requirements and implementation of their Accreditation Initiative.

Welfare, Work, and Health Care Access Predictors of Low-Income Children's Physical Health Outcomes

This analysis examines whether young children's (N= 494) general physical health is associated with parental employment, welfare receipt, and health care access within a low-income population transitioning from welfare to work. A latent physical health measure derived from survey and medical chart data is used to capture children's poor health, and parental ratings of child health are used to identify excellent health. Controlling for a host of factors associated with children's health outcomes, results show that children of caregivers who are unemployed and off welfare have better health than children of caregivers who are working and off welfare. Children whose caregivers are unemployed and on welfare, or combining work and welfare, have health outcomes similar to children of caregivers who are working and off welfare. Health care access characteristics, such as gaps in health insurance coverage, source of primary care setting, and type of health insurance are associated with children's general physical health. Implications of these results for state TANF programs are discussed.

Comparative Effectiveness of Health Centers as Regular Source of Care

A 4-state (Alabama, California, Georgia, Pennsylvania) retrospective analysis of claims data from 1.6 million Medicaid beneficiaries to assess the performance of community health centers compared with other Medicaid providers (office-based and hospital-based practices) served as a regular source of care to Medicaid beneficiaries, each with at least one diagnosed ambulatory care-sensitive condition (ACSC). The health centers compared with the other Medicaid providers experienced one third fewer sentinel ACS events: 5.7 and 8.2 ACS admissions and 26.1 and 37.7 ACS emergency visits, respectively, per 100 persons. Controlling for case mix and other factors, the logistic regression results for sentinel events indicated that Medicaid beneficiaries who relied on health centers for primary care were significantly less likely to experience an ACS admission (OR = 0.89, P < .0001) or an ACS emergency visit (OR = 0.81, P < .0001) than the Medicaid beneficiaries who relied on other Medicaid providers. Sentinel ACS events can serve as efficient measures for assessing provider performance and comparing effectiveness of regular sources for primary care.

Health centers at 40: implications for future public policy

As health centers celebrate their 40th anniversary, the larger American healthcare system faces challenges as daunting as any in its history. These include rising, unchecked costs of care, deteriorating access to care--especially among low-income, uninsured, and minority Americans--and unsettled quality of care for many. The authors argue that, as policymakers face the challenge of health system reform, the health centers program serves as a potential model for improving the cost-effectiveness and appropriateness of healthcare, setting the course for primary healthcare. At the same time, the program's very future depends on matters that extend into the broadest reaches of US health policy, in the areas of coverage, finance, workforce, quality improvement, and population health.

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.

The First Community Health Centers

Community health centers in the United States, first launched as a federal initiative in 1965, were rooted in models from South Africa, the American civil rights struggle, and a national commitment to address poverty. The first 2 centers, one serving a rural population in the Mississippi Delta and another a public housing project in Boston, incorporated such core principles as provision of primary care to a defined area or population; public health interventions addressing social determinants of health; emphasis on community participation; community empowerment leading to control of the new institutions; epidemiologic methods to identify problems and guide decisions; new combinations of clinical and public health personnel; and reduction of disparities in health and healthcare of the poor and minorities. The continuing relevance of these principles in today's greatly expanded health center network is reviewed.

Primary care quality: community health center and health maintenance organization

OBJECTIVE

This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO.

METHODS

Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics.

RESULTS

After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance.

CONCLUSION

Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

Clinical outcomes for low-income adults with hypertension and diabetes

BACKGROUND

Long-term management of hypertension and diabetes, which are more prevalent in minority and socioeconomically disadvantaged populations, presents challenges for healthcare providers in community health centers.

OBJECTIVES

The purpose of the study was twofold: to examine health outcomes for persons with hypertension and diabetes and to compare these outcomes for disparities in patients who were Black, Hispanic, or White.

METHODS

Medical records (N = 280) from an urban community health center that serves predominantly uninsured adults were reviewed for selected clinical outcomes of primary care. Measures included outcomes of hypertension and diabetes control, lifestyle behaviors, preventive care, and patient status. Chi-square tests, t tests, and one-way analysis of covariance were used to analyze racial/ethnic group differences.

RESULTS

Data revealed significant differences in smoking status, influenza immunization, and blood pressure. Racial/ethnic group differences were minimal compared with the overall high prevalence of risk factors such as smoking and obesity. Regular access to primary care did not result in improved clinical outcomes.

CONCLUSION

The findings support the need for more effective interventions that promote healthy lifestyle if health disparities in low-income populations with chronic conditions are to be reduced.

Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) serve as regular sources of preventive and primary care for low-income families within their communities and are key parts of the health care safety net.

OBJECTIVES

Compare admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs) among Medicaid beneficiaries relying on FQHCs to other Medicaid beneficiaries.

RESEARCH DESIGN

Retrospective analysis of 1992 Medicaid claims data for 48,738 Medicaid beneficiaries in 24 service areas across five states.

SUBJECTS

Medicaid beneficiaries receiving more than 50% of their preventive and primary care services from FQHCs are compared with Medicaid beneficiaries receiving outpatient care from other providers in the same areas. Exclusions-managed care enrollees, beneficiaries more than age 65, dual eligibles (Medicaid and Medicare), and institutionalized populations.

MEASURES

Admissions and emergency room (ER) visits for a set of chronic and acute conditions, known in the literature as ambulatory care sensitive conditions (ACSCs).

RESULTS

Medicaid beneficiaries receiving outpatient care from FQHCs were less likely to be hospitalized (1.5% vs. 1.9%, P < 0.007) or seek ER care (14.9% vs. 15.7%, P < 0.02) for ACSCs than the comparison group. Controlling for case mix and other demographic variables, the odds ratios were, for hospitalizations, OR, 0.80; 95% CI, 0.67 to 0.95; P < 0.01, and for ER visits, OR, 0.87; 95% CI, 0.82 to 0.92; P < 0.001.

CONCLUSIONS

Having a regular source of care such as FQHCs can significantly reduce the likelihood of hospitalizations and ER visits for ACSCs. If the reported differentials in ACSC admissions and ER visits were consistently achieved for all Medicaid beneficiaries, substantial savings might be realized.

Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care

Reducing and eliminating health status disparities by providing access to appropriate health care is a goal of the nation's health care delivery system. This article reviews the literature that demonstrates a relationship between access to appropriate health care and reductions in health status disparities. Using comprehensive site-level data, patient surveys, and medical record reviews, the authors present an evaluation of the ability of health centers to provide such access. Access to a regular and usual source of care alone can mitigate health status disparities. The safety net health center network has reduced racial/ethnic, income, and insurance status disparities in access to primary care and important preventive screening procedures. In addition, the network has reduced low birth weight disparities for African American infants. Evidence suggests that health centers are successful in reducing and eliminating health access disparities by establishing themselves as their patients' usual and regular source of care. This relationship portends well for reducing and eliminating health status disparities.