Dataset Information

Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings.

ABSTRACT:

Objective

The objective of this study was to evaluate indicators of diabetes quality of care for US nonelderly, adult Medicaid enrollees with type 2 diabetes and compare federally qualified health centers (FQHCs) versus non-FQHCs.

Research design and methods

We analyzed diabetes process measures and acute health services utilization with 2012 US fee-for-service and managed care Medicaid claims in all 50 states and DC. We compared FQHC (N=121,977) to non-FQHC patients (N=700,401) using propensity scores to balance covariates and generalized estimating equation models.

Results

Overall, laboratory-based process measures occurred more frequently (range, 65.7%-76.6%) than measures requiring specialty referrals (retinal examinations, 33.3%; diabetes education, 3.4%). Compared with non-FQHC patients, FQHC patients had about 3 percentage point lower rates of each process measure, except for higher rates of diabetes education [relative risk=1.09, 95% confidence interval (CI): 1.03-1.16]. FQHC patients had fewer overall [incident rate ratio (IRR)=0.87, 95% CI: 0.86-0.88] and diabetes-related hospitalizations (IRR=0.79, 95% CI: 0.77-0.81), but more overall (IRR=1.06, 95% CI: 1.05-1.07) and diabetes-related emergency department visits (IRR=1.10, 95% CI: 1.08-1.13).

Conclusions

This national analysis identified opportunities to improve diabetes management among Medicaid enrollees with type 2 diabetes, especially for retinal examinations or diabetes education. Overall, we found slightly lower rates of most diabetes care process measures for FQHC patients versus non-FQHC patients. Despite having higher rates of emergency department visits, FQHC patients were significantly less likely to be hospitalized than non-FQHC patients. These findings emphasize the need to identify innovative, effective approaches to improve diabetes care for Medicaid enrollees, especially in FQHC settings.

SUBMITTER: Knitter AC

PROVIDER: S-EPMC9588553 | biostudies-literature | 2022 Nov

REPOSITORIES: biostudies-literature

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Publications

Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings.

Knitter Alexandra C AC Murugesan Manoradhan M Saulsberry Loren L Wan Wen W Nocon Robert S RS Huang Elbert S ES Bolton Joshua J Chin Marshall H MH Laiteerapong Neda N

Medical care 20220829 11

<h4>Objective</h4>The objective of this study was to evaluate indicators of diabetes quality of care for US nonelderly, adult Medicaid enrollees with type 2 diabetes and compare federally qualified health centers (FQHCs) versus non-FQHCs.<h4>Research design and methods</h4>We analyzed diabetes process measures and acute health services utilization with 2012 US fee-for-service and managed care Medicaid claims in all 50 states and DC. We compared FQHC (N=121,977) to non-FQHC patients (N=700,401) u ...[more]

PMID: 36040020

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Project description:IntroductionThis nationwide study builds on prior research, which suggests that Federally Qualified Health Centers (FQHCs) and other primary care providers are associated with increased access to opioid use disorder (OUD) treatment. We compare health care utilization, spending, and quality for Medicaid patients diagnosed with OUD who receive primary care at FQHCs and Medicaid patients who receive most primary care in other settings, such as physician offices (non-FQHCs). We hypothesized that the integrated care model of FQHCs would be associated with greater access to medication for opioid use disorder (MOUD) and/or behavioral health therapy and lower rates of potentially inappropriate co-prescribing.MethodsThis cross-sectional study examined 2012 Medicaid Analytic eXtract files for patients diagnosed with OUD receiving most (>50%) primary care at FQHCs (N = 37,142) versus non-FQHCs (N = 196,712) in all 50 states and Washington DC. We used propensity score overlap weighting to adjust for measurable confounding between patients who received care at FQHCs versus non-FQHCs and increase generalizability of findings given variation in Medicaid programs and substance use policies across states.ResultsFQHC patients displayed higher primary care utilization and fee-for-service spending, and similar or lower utilization and fee-for-service spending for other health service categories. Contrary to our hypotheses, non-FQHC patients were more likely to receive timely (≤90 days) MOUD (buprenorphine, methadone, naltrexone, or suboxone) (Relative Risk [RR] = 1.10, 95% CI: 1.07, 1.12) and more likely be retained in medication treatment (>180 days) (RR = 1.12, 95% CI: 1.09, 1.14). However, non-FQHC patients were less likely to receive behavioral health therapy (mental health or substance use therapy) (RR = 0.90, 95% CI: 0.88, 0.92) and less likely to remain in behavioral health treatment (RR = 0.92, 95% CI: 0.89, 0.94). Non-FQHC patients were more likely to fill potentially inappropriate prescriptions of benzodiazepines and opioids after OUD diagnosis (RR = 1.35, 95% CI: 1.30, 1.40).ConclusionsObserved patterns suggest that Medicaid patients diagnosed with OUD who obtained primary care at FQHCs received more integrated care compared to non-FQHC patients. Greater care integration may be associated with increased access to behavioral health therapy and quality of care (lower potentially inappropriate co-prescribing) but not necessarily greater access to MOUD.

Project description:ImportanceFederally qualified health centers (FQHCs) have increasingly participated in the Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs), one of the most widespread value-based programs. Although FQHCs may strengthen ACOs' ability to provide affordable care to diverse Medicare beneficiaries, evidence on ACOs' performance by FQHC participation is limited.ObjectivesTo compare beneficiary characteristics, utilization, expenditure, and quality between ACOs with and without FQHC participation and assess changes in ACO performance after including first FQHCs.Design, setting, and participantsUsing MSSP public use files, this cross-sectional study compared performance of ACOs that always had FQHC participation with ACOs that never had FQHC participation from January 1, 2016, to December 31, 2022, supplemented with staggered difference-in-differences analyses of ACOs' first-time inclusion of FQHCs on performance measures. Data analysis was performed from December 1, 2023, to February 29, 2024.ExposureParticipation of FQHCs in the MSSP.Main outcomes and measuresMeasures of ACO-assigned beneficiaries, utilization, expenditure, and quality per ACO-year.ResultsAmong 752 ACOs in the descriptive analysis, 140 ACOs always had at least 1 FQHC participant, whereas 612 ACOs never had FQHC participants. Compared with ACOs that never had FQHC participation, those that always had FQHC participation provided care to more socioeconomically disadvantaged beneficiaries (mean [SD] with dual eligibility, 2035.8 [2110.6] vs 1040.9 [1084.2] person-years; with disability, 3341.1 [3474.9] vs 1705.1 [1664.9] person-years; in racial and ethnic minoritized groups, 3690.6 [4118.4] vs 2515.1 [2762.9] person-years), with fewer primary care visits (mean [SD], 9956.6 [1926.3] vs 10 858.8 [2383.4] per 1000 person-years), more emergency department visits (mean [SD], 771.6 [190.9] vs 657.2 [160.0] per 1000 person-years), and lower levels of several quality measures. In the difference-in-differences analysis, 43 ACOs included FQHCs for the first time. Including first FQHCs was associated with increases of 872.9 dual-eligible (95% CI, 345.9-1399.8), 1137.6 disability (95% CI, 390.1-1885.1), and 1350.8 racial and ethnic minority (95% CI, 447.4-2254.1) person-years, with increases in rates of influenza immunization (5.9 percentage points [pp]; 95% CI, 1.4-10.4 pp), tobacco screening and cessation intervention (11.8 pp; 95% CI, 3.7-20.0 pp), and depression screening and follow-up (8.9 pp; 95% CI, 0.5-17.4 pp). No associations were observed between FQHC inclusion and utilization or expenditure.Conclusions and relevanceIn this repeated cross-sectional study, MSSP ACOs with FQHC participation served more socioeconomically disadvantaged Medicare beneficiaries than those without FQHC participation. The inclusion of first FQHCs was associated with increased rates of several preventive services without increasing costs. Participation of safety net practices appeared to improve access to ACOs among beneficiaries from underserved communities.

Project description:ImportanceMore than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers.ObjectiveTo examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs.Design, setting, and participantsThis retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022.ExposuresReceipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016.Main outcomes and measuresUtilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined.ResultsAmong the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, -0.4%; 95% CI -0.7% to -0.01%) and polypharmacy (DID, -0.3%; 95% CI, -0.4% to -0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations.Conclusions and relevanceThe first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

Project description:ImportanceState decisions to expand Medicaid eligibility were particularly consequential for federally qualified health centers (FQHCs), which serve 30 million low-income patients across the US. The longer-term association of Medicaid expansion with health outcomes at FQHCs is unknown.ObjectiveTo assess the 5-year association of Medicaid expansion with uninsurance rates and hypertension and diabetes outcome measures by race and ethnicity in a nationally representative population of FQHCs.Design setting and participantsUsing a difference-in-differences analysis of a retrospective cohort from the universe of US FQHCs, changes in uninsurance rates and intermediate health outcomes for hypertension and diabetes by race and ethnicity were compared between Medicaid expansion and nonexpansion states before (2012-2013) vs after (2014-2018) expansion. Data were analyzed from September 2020 to March 2021.ExposuresLocation in a state that expanded Medicaid eligibility as of 2014.Main outcomes and measuresRates of uninsurance, the proportion of patients with hypertension with a blood pressure less than 140/90 mm Hg, and the proportion of patients with diabetes with glycosylated hemoglobin levels of 9% or less, as stratified by race and ethnicity.ResultsOf the patients at 578 expansion-state FQHCs (serving 13.0 million patients per year) and 368 nonexpansion-state FQHCs (serving 6.0 million patients per year) in our study sample, 64.4% were age 18 to 64 years, 57.4% were women, 18.9% were non-Hispanic Black, and 27.3% were Hispanic. Following expansion, FQHCs in Medicaid expansion states experienced a 9.24 percentage point (PP) (95% CI, 7.94-10.54) decline in rates of uninsurance over the pooled 5-year expansion period compared with nonexpansion-state FQHCs. Across this 5-year period, expansion was associated with a 1.61-PP (95% CI, 0.58-2.64) comparative improvement in hypertension control and a 1.84-PP (95% CI, 0.71-2.98) comparative improvement in glucose control. Stratified results suggest that improvements were consistently observed in Black and Hispanic populations. The magnitude of change tended to increase with implementation time. For instance, by year 5, expansion was associated with a 3.38-PP (95% CI, 0.80-5.96) comparative improvement in hypertension control and a 3.88-PP (95% CI, 0.86-6.90) comparative improvement in glucose control among Black populations.Conclusions and relevanceIn this nationally representative cohort study, Medicaid expansion was associated with sustained increases in insurance coverage and improvements in chronic disease outcome measures at FQHCs after 5 years overall and among Black and Hispanic populations. States considering Medicaid expansion may benefit from improved longer-run health measures for underserved patients with chronic conditions.

Dataset Information

Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings.

Objective

Research design and methods

Results

Conclusions

Publications

Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings.

Similar Datasets

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