Community Health Centers Are Essential Providers of Health Care in Rural Communities Federally qualified community health centers (CHCs) are the nation's primary care safety net, serving a patient population of whom 68% have incomes below the poverty level, 63% identify as racial/ethnic minorities, and 82% are uninsured or publicly insured. 1 Today, nearly 1,400 CHCs operate some 13,000 healthcare delivery sites nationwide, 2 providing high-quality, cost-effective, and comprehensive primary care (often including dental and behavioral health) to all regardless of ability to pay. CHCs also provide other health and social care services including pharmacy, nutrition, care management, health education, transportation, eligibility assistance, interpretation, and community outreach. CHCs are critical to our nation's ability to respond to COVID-19 in rural and underserved communities, which are experiencing a rapid increase in cases. As of May 11, 2020, there are 85,748 cases and 3,298 deaths from COVID-19 in nonmetropolitan counties in the United States, representing 6.4% of cases and 4.2% of deaths nationwide. 3 Rural residents are at increased risk of poor outcomes due to age and health status, and there are substantially fewer healthcare resources available in rural areas, meaning that once the virus becomes more
Objective
To examine the relationship between federally qualified health center (FQHC) use and hospital‐based care among individuals dually enrolled in Medicare and Medicaid.
Data Sources
Data were obtained from 2012 to 2018 Medicare claims.
Study Design
We modeled hospital‐based care as a function of FQHC use, person‐level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30‐day unplanned returns. We stratified all models on the basis of eligibility and rurality.
Data Extraction Methods
Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end‐stage renal disease.
Principal Findings
After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person‐years among both age‐eligible (−14.8 [−17.5, −12.1]; −6.6 [−7.5, −5.6]) and disability‐eligible duals (−11.3 [−14.4, −8.3]; −6 [−7.4, −4.6]) as well as a lower probability of observation stays (−0.8 pp age‐eligible; −0.4 pp disability‐eligible) and unplanned returns (−2.1 pp age‐eligible; −1.9 pp disability‐eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person‐years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability‐eligible duals (a decrease of more than 60% compared with the pre‐PPS period) and increases in the probability of hospitalization (1.1 pp age‐eligible; 0.8 pp disability‐eligible) and ACS hospitalization (0.5 pp age‐eligible; 0.3 pp disability‐eligible) (a decrease of roughly 50% compared with the pre‐PPS period).
Conclusions
FQHC use is associated with reductions in hospital‐based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.
Federally qualified health centers (FQHCs) increasingly provide high-quality, costeffective 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.
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