At the Intersection of Health, Health Care and Policy Cite this article as: Peter Shin, Jessica Sharac and Sara Rosenbaum Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation Health Affairs, 34, no.7 (2015):1096-1104 doi: 10.1377/hlthaff.2015.0099
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By Peter Shin, Jessica Sharac, and Sara Rosenbaum 10.1377/hlthaff.2015.0099 HEALTH AFFAIRS 34, NO. 7 (2015): 1096–1104 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
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Peter Shin ([email protected]) is an associate professor of health policy in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University, in Washington, D.C. Jessica Sharac is a senior research associate in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University. Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University.
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Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation Community health centers reach their fiftieth anniversary in 2015, along with Medicaid. Health policy makers have understood the programs’ symbiotic connection from the earliest days of their implementation. Medicaid’s expansion and growth have made the modern community health center program possible, while health centers represent one of the principal sources of primary care for the nation’s Medicaid population. With their shared mission and high level of interdependence, Medicaid and community health centers are essential for continued health system transformation in medically underserved communities nationwide—for example, by implementing delivery system reforms aimed at increasing clinical integration and improving efficiencies and by becoming medical homes for high-risk patients. Achieving this transformation will depend on the ability of community health centers and Medicaid to understand and respond to the challenges that each faces, while fully deploying the strengths that each has to offer. ABSTRACT
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ith roots in the War on Poverty and the civil rights movement,1 community health centers share a fiftieth anniversary with Medicaid this year. Since the 1965 Office of Economic Opportunity demonstration projects that launched them, community health centers have served as a bridge between the provision of clinical services and community health, combining comprehensive primary health care with community health improvement efforts that range from sanitation to education and literacy, housing and neighborhood improvements, and nutrition.
Background The fact that Medicaid and health centers would have a highly interdependent relationship was evident to policy makers from both programs’ 1096
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earliest days. This relationship was captured in a 1967 agreement2 between the Department of Health, Education, and Welfare, which administered Medicaid and Medicare, and the Office of Economic Opportunity, which by then was engaged in building on the success of the small health center demonstration to develop greater clinical care capacity “focused upon the needs of persons residing in urban or rural areas having high concentrations of poverty and a marked inadequacy of health services.”3 According to the agreement, the Office of Economic Opportunity would create a thousand community health centers by 1973, sufficient to serve an estimated twenty-five million patients. In return, Medicaid (and, to a lesser extent, Medicare) would provide as much as 80 percent of the operational financing needed to sustain these health centers once they were built.4 Ultimately, it would take nearly fifty years to
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reach this goal of health center expansion as well as to fulfill the early vision of providing access to health care in medically underserved communities, with Medicaid serving as the principal growth engine. Medicare is important to health centers, too: In 2013, 8 percent of the centers’ patients were Medicare beneficiaries, and Medicare represented 6 percent of the centers’ operating revenues.5 However, Medicaid has held the key to health center growth, just as health centers have become central to primary care access for the poor and underserved. This marriage of financing through Medicaid and access to care through community health centers has resulted in the establishment of 1,200 facilities that served nearly 9,200 high-need communities nationwide in 2013.6 Today community health centers provide a range of services, including medical, behavioral health, and enabling services such as transportation and translation. In 2013, 71 percent of the 85.6 million patient visits to health centers were for medical services, while 13 percent were for dental services, 8 percent for mental health and substance abuse services, and 8 percent for enabling services.7
Commitment To The Underserved Patient and insurance data illustrate how the relationship between Medicaid and community health centers has evolved. In 1975 the centers served 1.0 million patients, 60 percent of whom were uninsured and only 20 percent of whom were enrolled in Medicaid (Exhibit 1). In 2013 the centers served 21.7 million patients, 41 percent of whom were covered by Medicaid and
35 percent of whom were uninsured. A hundred “look-alike” health centers (which also qualify for special payments under federal health care programs) served an additional 1.0 million patients.8 In 2013 health centers served nearly one in six Medicaid beneficiaries nationally, excluding US territories (Exhibit 2). Vermont’s health centers, for example, served 21 percent of the state’s residents and 29 percent of its Medicaid beneficiaries. In four states and the District of Columbia, the proportion was 30 percent or more of Medicaid beneficiaries. Such high penetration likely results from two basic factors: the purposeful location of health centers in medically underserved communities as a source of financially and culturally accessible primary care, and the relatively limited participation in Medicaid among office-based physicians,9 who nonetheless remain the most common source of care for Medicaid enrollees.10 In 1985, 24 percent of the health centers’ patients were Medicaid enrollees, while Medicaid accounted for 15 percent of the centers’ operating revenues (Exhibit 3). In 2013 the figures were 41 percent and 40 percent, respectively. This increased concordance between patients and revenues resulted from the establishment in 1989 of special payment rules for federally qualified health centers—a group that, for payment purposes, includes both health centers that receive federal grants and those that receive their basic support through state and local grants but meet all federal requirements. These payment rules were designed to improve the alignment between reimbursement and actual cost of care for Medicaid patients.
Exhibit 1 Millions Of Patients Served At Community Health Centers, Selected Years 1975–2013
SOURCE Authors’ analysis of data for 1975–90 from the National Association of Community Health Centers and of data for 1996–2013 from the Uniform Data System (Health Resources and Services Administration). NOTES “Medicaid/CHIP patients” are enrollees in Medicaid or the Children’s Health Insurance Program (CHIP). “Other insured patients” are enrollees in Medicare, other public insurance, or private insurance. The totals (shown above each year’s group of bars) are of patients seen at federally funded community health centers. We excluded patients seen at “look-alike” health centers that do not receive federal grant funding but are certified as federally qualified health centers for Medicaid payment purposes.
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SOURCE Authors’ analysis of 2013 data from the Uniform Data System (Health Resources and Services Administration) and the Current Population Survey Annual Social and Economic Supplement (Census Bureau). NOTES For the United States (excluding territories) the share is 15.9 percent. Medicaid expansion (under the terms of the Affordable Care Act) is as of January 2015. As of mid-June 2015 Montana was awaiting federal waiver approval for its Medicaid expansion.
Medicaid: Principal Driver Of Growth
Exhibit 3 Percentage Of Community Health Center Patients And Revenues Attributable To Various Funding Sources, 1985 And 2013
SOURCE Authors’ analysis of 1985 data from the National Association of Community Health Centers and of 2013 data the Uniform Data System (Health Resources and Services Administration). NOTES “Other revenues” are Medicare, other public, and private insurance revenue; state or local and foundation/private grants; and other revenues. “Other patients” are enrollees in Medicare, other public insurance, or private insurance.
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A comparison of increases in Medicaid revenue and in federal health center grant funding over time makes Medicaid’s role in propelling health center growth clear. With the expansion in 1989 of Medicaid eligibility to include children, pregnant women, and—in many states—low-income parents, and with the enactment in the same year of the payment reforms just described, Medicaid revenues at health centers grew from $950 million in 1996 to $6.3 billion in 2013—an increase of 563 percent (Exhibit 4). During this time, federal grant funding grew at about half that rate (309 percent), from $757 million to $3.1 billion. The number of patients increased 168 percent during the same period. The growth in Medicaid revenues effectively enabled the federal government, working with communities, to support the near doubling in the number of health centers from 686 to 1,202 in the same period.5 Medicaid revenues also supported the expansion of many facilities, their number of sites, and their scope of services. Thus, the centers were able to increase the number of patients they served from 8.1 million in 1996 to 21.7 million
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Exhibit 4 Community Health Center Medicaid Revenues In Relation To Discretionary Appropriations And Patients Served, Millions Of Patients, 1996–2013
SOURCE Authors’ analysis of data on appropriations from the National Association of Community Health Centers and of data on patient numbers and Medicaid revenue from the Uniform Data System (Health Resources and Services Administration). NOTES The Health Centers Consolidation Act of 1996 requires health centers to annually submit a standard set of operational, financial, and performance reports to the Uniform Data System. Appropriations for 2011–13 include community health center funding mandated by the Affordable Care Act. Appropriations (purple line) and Medicaid revenue (orange line) relate to the left-hand y axis. Numbers of patients (bars) relate to the right-hand y axis.
in 2013. In sum, the sizable growth of health centers can be explained not by a vast infusion of federal grant funds but by strong Medicaid investment. This investment stems from three changes in federal Medicaid policy: the expansion of eligibility in 1989 described above; the expansion of coverage to include federally qualified health center services as a distinct benefit class; and the establishment of payment rules tied to the cost of clinical care furnished by physicians, nurse practitioners and physician assistants, psychologists, and social workers, as well as other ambulatory services covered under a state’s Medicaid plan, such as dental care and preventive care. Subsequent legislation applied health center payment reforms to Medicare, the Children’s Health Insurance Program (CHIP), and health plans subject to the essential health benefit requirements of the Affordable Care Act (ACA). Together, these three changes have enabled health centers to receive larger Medicaid revenues for covered services, thereby allowing federal grant funds to be used to reach additional uninsured patients and to add important health services not covered by many state Medicaid programs, such as routine adult dental care. Medicaid and grant funds together have sustained these services, once they were added.
Health Centers: Providers Of Primary Care In turn, health centers have become one of the principal sources of primary health care for state Medicaid programs. The centers’ importance can be seen in the number of patients they care for and in the degree to which their presence has enabled the rise of Medicaid managed care in underserved communities. In 2007, the latest year for which comparison data are available, health centers accounted for 9 percent of Medicaid managed care enrollees.11,12 Health centers operate managed care plans directly in eight states.13 Given their importance as Medicaid service providers, health centers have become integral to health system transformation in the poorest communities, where they are dominant.Whether their transformation is focused on becoming medical homes for the highest-risk patients or on implementing broader delivery system reforms aimed at improving clinical integration and efficiency, health centers will influence the outcome of these reform efforts because of the major role they play in achieving gains in health among Medicaid beneficiaries.
Role Of The Affordable Care Act The ACA has further propelled the Medicaid– health center collaboration in two ways. First, July 2015
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Primary Care the ACA enables states to extend Medicaid eligibility to virtually all nonelderly low-income adults, a core component of the health center patient population—93 percent of which is low income.5 Second, the ACA established an $11 billion, five-year growth fund,14 which was extended for an additional two years under the Medicare Access and CHIP Reauthorization Act of 2015. This fund has further enabled health centers to strengthen their services and expand their reach to the 20 percent of Americans who continue to lack a regular source of health care.15 As Medicaid expansion and health center growth proceed, these two reforms in combination should provide the basic financing and primary care development tools essential to improving health care quality and efficiency while reducing disparities in health and health care.
Should Special Payment Rules Continue?
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Today, when payment reform has become an integral part of system transformation, it is fair to ask whether the federal government’s special approach to paying health centers continues to make sense. In our view, the answer is yes, just as it continues to make sense for the government to make additional payments to hospitals that treat a disproportionate percentage of low-income patients. Part of this reasoning can be found in the greater levels of health risk among health center Medicaid patients, compared to the low-income population generally—a difference shown by a comparison of the health status of health center patients and that of low-income people overall.16 Another strong reason for continuing the special payment rules is the fact that some populations will remain uninsured even after health reform, and they will continue to require primary health care. Research conducted following the passage of Massachusetts’s health reform law shows that as the number of uninsured people decreased statewide, that population became increasingly concentrated at health centers,17 representing nearly 19 percent of the centers’ patients.18 The uninsured will—and should—continue to account for a high proportion of health center patients, especially in states that reject Medicaid expansion. Care must be taken to preserve the use of federal health center grant funds to care for the uninsured by ensuring that Medicaid, along with other public and private payers to which the federally qualified health center payment methodology applies, continues to cover the reasonable cost of care for their insured patients. Ensuring that covered services are paid for
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based on their reasonable costs means that health centers will not have to use grant funds to cover a portion of their costs. This means that grant funds can be used instead to furnish important health care that many insurers do not cover. One example is adult dental care, available today at 77 percent of all health centers7 but excluded by health plans sold in the federal and state-based health insurance Marketplaces and excluded or limited to emergency care by Medicaid programs in twenty states.19 Ensuring that payment for covered services is based on reasonable cost means that health centers also can use their grants to lower patient cost sharing to affordable levels, through the use of sliding fee schedules tied to family income. This ability to reduce cost sharing is particularly important for people with high-deductible Marketplace-based insurance, which—even with cost-sharing subsidies—can expose low-income patients to significant out-of-pocket responsibilities.20 But all of this does not mean that health centers and Medicaid programs cannot or should not test alternative payment strategies designed to improve the alignment of payments with desired health outcomes. Indeed, health centers are active participants in managed care and medical home reforms. For example, the federally qualified health center payment principles can be aligned with strategies designed to reduce incentives to furnish medically unnecessary care—such as an excessive number of patient visits—while taking advantage of less costly alternatives than a face-to-face visit, such as the use of telephone communication, where feasible and practical, to manage care.
Testing The Relationship Medicaid and health centers have a long history of cooperation and collaboration. Nonetheless, their relationship does have tensions, which have become more visible as health reform has accelerated. For example, Medicaid and health centers differ fundamentally in program structure and function. Medicaid is an insurer, with a primary focus on the people it insures at any given time. By definition, patients without coverage in the long or short term do not fall within the scope of Medicaid’s payment responsibility. In contrast, health centers serve their communities regardless of residents’ insurance status. Yet despite the somewhat transitory nature of Medicaid coverage because of its sensitivity to changes in family income, both Medicaid and health centers focus on the poor populations and communities who depend heavily on both programs.
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Of course, Medicaid beneficiaries and medically underserved communities are not fully synonymous. Not all Medicaid beneficiaries live in communities with health centers. Medicaid programs focus predominantly on covered services for beneficiaries instead of on the geographic communities in which beneficiaries live. This may be changing, however, as state Medicaid officers begin to think more in terms of place as they participate in broader health improvement initiatives.21 Nonetheless, the question is how to acknowledge the differences between Medicaid and health centers while moving forward with their shared mission: namely, to improve the health of the low-income population.
Moving Forward: Crucial Questions As the Medicaid–health center relationship begins its next fifty years, two basic questions arise. How important is the relationship? And should its growth be encouraged? Among Medicaid’s relationships with other programs, its alignment with health centers shows what the two programs—the main source of insurance for low-income Americans and the largest safety-net system of primary care—can achieve when they work together. Medicaid’s future as an effective source of health insurance for low-income people depends on its ability to translate coverage into appropriate health care. If anything, the need for a strong Medicaid– health center relationship has increased over the years. Low levels of private provider participation in Medicaid, evident from the program’s earliest days,22 remain a central challenge that is likely to grow as the Medicaid population increases.23 The ACA’s much-debated Medicaid primary care payment “bump” appears to have had a significant effect on acceptance rates among physicians already participating in the program,24 but it has not fostered new participation. Furthermore, the payment increase was allowed to lapse, and the number of states willing to continue enhanced payment absent a financial incentive from the federal government for doing so remains unclear.25 Even if all states were to commit to increasing Medicaid primary care payments, the results probably would be modest in light of the multifactorial nature of low Medicaid participation among physicians.26 Furthermore, health centers are, by definition, located in communities that lack primary care resources in relation to health need. Even increasing Medicaid payments to physicians could not mitigate the personnel shortages that these communities experience. Nor can simply rewarding private physicians for treating more patients in the com-
munities in which the physicians reside address the underlying maldistribution of medical professionals. Health centers also are important to Medicaid’s efforts to transform health care for people at elevated health risk. Among Medicaid patients and the poor generally, health centers have improved health outcomes for adults and children alike.27–29 Similarly, health centers serve as a key source of health care for the nation’s 9.6 million people enrolled in both Medicare and Medicaid.30 These “dual eligibles” account for 5 percent of all health center patients.16 Dual eligibles as a proportion of all Medicare health center patients (42 percent in 2009) are twice the national average of dual eligibles in the population: Approximately 21 percent of all Medicare beneficiaries were dually enrolled in Medicaid in fiscal year 2010.31 For dual eligibles—whose health is measurably more fragile than that of people enrolled in Medicare alone and who experience substantially higher health care costs32—health centers serve as a key source of health care. One notable study has shown health centers’ impact on the health of older Americans, many of whom are eligible for Medicare and Medicaid: The centers have lowered mortality among people ages fifty and older and narrowed the mortality gap between the poor and the nonpoor.33 In 2013 health centers served 1.8 million Medicare beneficiaries and participated in health system transformation efforts focusing on the Medicare population.5 More than 400 health centers are pursuing recognition as level 3 patient-centered medical homes by the National Committee for Quality Assurance under the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration.34 Payment remains a source of tension in the Medicaid–health center relationship. The federally qualified health center payment methodology initially was built on, and continues to use, a cost-related per encounter payment approach. This approach appears to be at odds with newer payment strategies, such as bundling payments for an episode of care; per case payments, in which payments are designed to reflect the cost of treating a particular condition; and annual global budgeting strategies, which combine capitation payments with quality rewards.35 Health centers have frequently expressed the desire to move away from encounter-driven financing. The incentive in this approach is to reward high volumes of face-to-face visits instead of the adoption of care structures more appropriate to patient health needs, such as combining in-person treatment with increased use of telemedicine services when feasible.36 J u ly 201 5
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Health centers More than 400 health centers are pursuing recognition as level 3 patient-centered medical homes.
To that end, examples of payment reform collaborations between Medicaid and health centers are growing, especially in states in which agencies are tackling major system transformation efforts in an attempt to strengthen health care from the ground up.37 These initiatives show, even in their early planning stages, that it is possible to redesign health center payment to reward performance and enable health centers to innovate in how they care for their patients without underfinancing appropriate care, which could result in shifting costs to federal grant funds intended for the care of uninsured populations and the provision of essential care and services not covered by insurance. Case payments for patients with serious conditions, along with the use of measurable outcomes, are fully compatible with payment safeguards that prevent cost shifting. Some examples include risk adjustment, in which payments take into account varying health and demographic factors; year-end cost reconciliation, in which differences in payments and eligible claims are settled at the end of the year; and stop-loss arrangements in connection with global payments, in which the providers’ financial risk is limited. A pilot program at three Oregon health centers, for instance, is designed to move health centers toward a value-based payment model that emphasizes health outcomes.38 Health centers offer Medicaid the potential for continuous care, regardless of brief or periodic interruptions in eligibility. This is a crucial consideration for patients with serious or chronic health conditions and those with an ongoing need for primary health care. Equally important, quality improvement collaborations between health centers and Medicaid have the potential to improve the quality of care for all health center patients.
Roles Of Health Centers And Medicaid In Family Planning Family planning is a case in point of the potential for a populationwide spillover impact from Medicaid–health center efforts to improve quality. No service may be more determinative of the immediate and long-term health of women, children, and families than family planning, and no service is more cost-effective.39 A nationwide study revealed that although many health centers offer strong family planning programs, most need to improve in terms of the level of staffing offered and the range of on-site services provided.40 Because Medicaid is such a dominant payer of family planning services, a Medicaid–health center collaboration to improve access to the full 1102
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range of family planning methods approved by the Food and Drug Administration—especially long-acting reversible contraception—and effective patient counseling would improve the quality of family planning services for all health center patients, not just those enrolled in Medicaid. Such a collaboration could be further enhanced if the Health Resources and Services Administration (HRSA), which administers the health center program, were to make service improvement funds available to health centers that participate in such quality improvement efforts with their Medicaid programs to cover start-up and clinical training costs. This three-way collaboration ultimately could reach all health center patients who are women of child-bearing age, and an estimated 20 percent of women in this age group who have low incomes are center patients.41 Such an initiative also would help achieve the goals embodied in landmark family planning recommendations released by the Department of Health and Human Services in 2014.42 Joint family planning work exemplifies the possible types of collaborations among health centers, state Medicaid programs, the Centers for Medicare and Medicaid Services (CMS), and HRSA. Each partner brings crucial resources to the table: Health centers provide access to care; Medicaid agencies, financing and quality improvement support; HRSA, start-up and quality improvement sustaining funds to reach all health center patients; and CMS, financing, technical support, and regulatory authorization. Collaborations that incorporated payment reforms could focus on population health improvement priorities beyond family planning, such as reducing the burden of chronic illness and improving the use of electronic health information. Such joint efforts require planning and a high degree of interaction, but the necessary elements for realizing population health improvement are present. In this regard, federal agencies, health centers, and state Medicaid partners might consider creating a multistate learning collaborative to promote health center payment transformation built around what Thomas Frieden of the Centers for Disease Control and Prevention has called “winnable battles.”43 Such a step would be in accord with the White House’s recently announced payment reform initiative44 and could include not only Medicaid but other insurers with health centers in their networks, which seek to move toward a performance-based payment system in the safety-net environment.
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Conclusion What is needed at this critical juncture in the evolution of US health care is a more deliberate coming together of Medicaid and community health centers, through a purposeful collaboration that builds on the valuable lessons that both programs have learned and can thus achieve what neither can accomplish alone: better and more accessible health care that rests on financing strategies designed to promote quality and
efficiency. We remain convinced that these reforms can happen without jeopardizing what health centers do best: providing comprehensive primary health care for the communities they serve, without regard to factors unrelated to the need for health care. The original vision of how the two programs would work together to advance the health of the population remains as fresh today as it was fifty years ago. ▪
The authors thank the RCHN Community Health Foundation for its generous and long-standing support of the Geiger Gibson–RCHN Community Health Foundation Research Collaborative.
NOTES 1 Lefkowitz B. Community health centers: a movement and the people who made it happen. New Brunswick (NJ): Rutgers University Press; 2007. 2 Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care—the growing importance of the community health center. N Engl J Med. 2010;362(22):2047–50. 3 Levitan SA, Taggart R. The promise of greatness. Cambridge (MA): Harvard University Press; 1976. p. 177. 4 Davis K, Schoen C. Health and the war on poverty: a ten-year appraisal. Washington (DC): Brookings Institution; 1978. Chapter 6. 5 Health Resources and Services Administration. HRSA Health Center Program: 2013 health center data: 2013 national data [Internet]. Rockville (MD): HRSA; [cited 2015 Apr 29]. Available from: http:// bphc.hrsa.gov/uds/datacenter.aspx? q=tall&year=2013&state= 6 2013 Uniform Data System data, Health Resources and Services Administration. 7 Shin P, Sharac J, Barber Z, Rosenbaum S, Paradise J. Community health centers: a 2013 profile and prospects as ACA implementation proceeds [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2015 Mar [cited 2015 Apr 29]. (Issue Brief). Available from: http://files .kff.org/attachment/issue-briefcommunity-health-centers-a-2013profile-and-prospects-as-acaimplementation-proceeds 8 Health Resources and Services Administration. HRSA Health Center Program: 2013 health center data: 2013 national look-alikes data [Internet]. Rockville (MD): HRSA; [cited 2015 Apr 29]. Available from: http://bphc.hrsa.gov/uds/ lookalikes.aspx?q=tall&year=2013 &state=national
9 Decker SL. In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff (Millwood). 2012;31(8):1673–9. 10 Sommers A. Sites of care serving Medicaid enrollees [Internet]. Washington (DC): Medicaid and CHIP Payment and Access Commission; 2015 Feb 26 [cited 2015 Apr 29]. Available from: https:// www.macpac.gov/wp-content/ uploads/2015/02/Sites-of-CareServing-Medicaid-Enrollees.pdf 11 Centers for Medicare and Medicaid Services. National summary of Medicaid managed care programs and enrollment as of July 1, 2010 [Internet]. Baltimore (MD): CMS; [cited 2015 Apr 29]. Available from: http://www.cms.gov/ResearchStatistics-Data-and-Systems/ Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/ Downloads/2010Trends.pdf 12 Health Resources and Services Administration. Bureau of Primary Health Care: section 330 grantees: Uniform Data System (UDS): calendar year 2007 data: national rollup report [Internet]. Rockville (MD): HRSA; 2008 Jul 1 [cited 2015 Apr 29]. Available from: ftp://ftp .hrsa.gov/bphc/pdf/uds/2007 nationaluds.pdf 13 According to the Association for Community Affiliated Plans, these plans are Colorado Access (CO), Prestige Health Choice (FL), AlohaCare (HI), Priority Partners (MD), Affinity Health Plan (NY), CareOregon (OR), Neighborhood Health Plan of Rhode Island (RI), and Community Health Plan of Washington (WA). Jennifer Babcock, vice president for Exchange Policy and director of Strategic Operations, Association for Community Affiliated Plans, personal communication, January 26, 2015.
14 Hawkins D, Groves D. The future role of community health centers in a changing health care landscape. J Ambul Care Manage. 2011;34(1): 90–9. 15 National Association of Community Health Centers. Primary care access: an essential building block of health reform [Internet]. Bethesda (MD): NACHC; 2009 Mar [cited 2015 Apr 29]. Available from: http:// www.nachc.com/client/documents/ pressreleases/PrimaryCareAccess RPT.pdf 16 Shin P, Alvarez C, Sharac J, Rosenbaum S, Van Vleet A, Paradise J, et al. A profile of community health center patients: implications for policy [Internet]. Menlo Park (CA): Henry J. Kaiser Family Foundation; 2013 Dec 23 [cited 2015 Apr 29]. Available from: http:// kff.org/medicaid/issue-brief/aprofile-of-community-health-centerpatients-implications-for-policy/ 17 Ku L, Jones E, Finnegan B, Shin P, Rosenbaum S (George Washington University, Washington, DC). How is the primary care safety net faring in Massachusetts? Community health centers in the midst of health reform [Internet]. (Publication No. 7878). Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2009 Mar [cited 2015 Apr 29]. Available from: http:// kaiserfamilyfoundation.files.word press.com/2013/01/7878.pdf 18 Health Resources and Services Administration. HRSA Health Center Program: 2013 health center data: Massachusetts program grantee data [Internet]. Rockville (MD): HRSA; [cited 2015 Apr 29]. Available from: http://bphc.hrsa.gov/uds/data center.aspx?year=2013&state=MA 19 Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion [Internet]. Chicago (IL): American Dental Association
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Health Policy Institute; 2014 Feb [cited 2015 Apr 29]. (Research Brief). Available from: http://www .ada.org/~/media/ADA/Science %20and%20Research/HPI/Files/ HPIBrief_0214_1.ashx Claxton G, Panchal N. Cost-sharing subsidies in federal Marketplace plans [Internet]. Menlo Park (CA): Henry J. Kaiser Family Foundation; 2015 Feb 11 [cited 2015 Apr 29]. Available from: http://kff.org/ health-reform/issue-brief/costsharing-subsidies-in-federal-market place-plans/ Crawford M, McGinnis T, Auerbach J, Golden K. Population health in Medicaid delivery system reforms [Internet]. New York (NY): Milbank Memorial Fund; 2015 Mar [cited 2015 Apr 29]. (Issue Brief). Available from: http://www.milbank.org/ uploads/documents/papers/ CHCS_PopulationHealth_Issue Brief.pdf Stevens R, Stevens R. Welfare medicine in America: a case study of Medicaid. New Brunswick (NJ): Transaction Publishers; 2003. Ku L, Jones K, Shin P, Bruen B, Hayes K. The states’ next challenge— securing primary care for expanded Medicaid populations. N Engl J Med. 2011;364(6):493–5. Polsky D, Richards M, Basseyn S, Wissoker D, Kenney GM, Zuckerman S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372(6):537–45. Snyder L, Paradise J, Rudowitz R. The ACA primary care increase: state plans for SFY 2015 [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2014 Oct 28 [cited 2015 Apr 29]. Available from: http:// kff.org/medicaid/perspective/theaca-primary-care-increase-stateplans-for-sfy-2015/ Medicaid and CHIP Payment and Access Commission. Report to the Congress on Medicaid and CHIP [Internet]. Washington (DC): MACPAC; 2013 Jun; [cited 2015 Jun 16]. Available from: https:// www.macpac.gov/wp-content/ uploads/2015/01/2013-06-15_ MACPAC_Report.pdf Chin MH, Drum ML, Guillen M, Rimington A, Levie JR, Kirchhoff AC, et al. Improving and sustaining diabetes care in community health centers with the health disparities collaboratives. Med Care. 2007; 45(12):1135–43. Lob SH, Boer JH, Porter PG, Núñez D, Fox P. Promoting best-care prac-
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tices in childhood asthma: quality improvement in community health centers. Pediatrics. 2011;128(1): 20–8. Shi L, Stevens GD, Wulu JT Jr, Politzer RM, Xu J. America’s health centers: reducing racial and ethnic disparities in perinatal care and birth outcomes. Health Serv Res. 2004;39(6 Pt 1):1881–901. Henry J. Kaiser Family Foundation. State health facts: number of dual eligible beneficiaries [Internet]. Menlo Park (CA): KFF: c 2015 [cited 2015 Apr 29]. Available from: http:// kff.org/medicare/state-indicator/ dual-eligible-beneficiaries/ National Association of Community Health Centers. Health centers and Medicare: caring for America’s seniors [Internet]. Bethesda (MD): NACHC; 2014 Dec [cited 2015 May 19]. (Fact Sheet). Available from: http://www.nachc.com/client/ documents/Medicare_FS_2014.pdf Bubolz T, Emerson C, Skinner J. State spending on dual eligibles under age 65 shows variations, evidence of cost shifting from Medicaid to Medicare. Health Aff (Millwood). 2012;31(5):939–47. Baily MJ, Goodman-Bacon A. The War on Poverty’s experiment in public medicine: community health centers and the mortality of older Americans [Internet]. Cambridge (MA): National Bureau of Economic Research; 2014 Oct [cited 2015 Apr 29]. (NBER Working Paper No. 20653). Available from: http:// www.nber.org/papers/w20653.pdf CMS.gov. FQHC Advanced Primary Care Practice Demonstration [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2015 Apr 29]. Available from: http://innovation.cms.gov/ initiatives/fqhcs/ Miller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5): 1418–28. Shin P, Sharac J, Jacobs F. Provision of telemedicine services by community health centers. Online J Public Health Inform. 2014;6(2):e185. Takach M, Buxbaum J. Developing federally qualified health centers into community networks to improve state primary care delivery systems [Internet]. Portland (ME): National Academy for State Health Policy; 2011 May [cited 2015 Apr 30]. Available from: http://www.nashp .org/sites/default/files/developing .fqhcs_.community.networks.takach .buxbaum.2.pdf Robert Wood Johnson Foundation.
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Grants: evaluating a capitated alternative payment methodology in Oregon community health centers [Internet]. Princeton (NJ): RWJF; [cited 2015 Apr 30]. Available from: http://www.rwjf.org/en/grants/ grant-records/2013/06/evaluatinga-capitated-alternative-paymentmethodology-in-oregon.html Amaral G, Foster DG, Biggs MA, Jasik CB, Judd S, Brindis CD. Public savings from the prevention of unintended pregnancy: a cost analysis of family planning services in California. Health Serv Res. 2007;42(5): 1960–80. Wood S, Beeson T, Bruen B, Goldberg DG, Mead H, Shin P, et al. Scope of family planning services available in federally qualified health centers. Contraception. 2014;89(2): 85–90. Rosenbaum S, Shin P, Wood SF, Sharac J. Using payment reform strategies to strengthen family planning services at community health centers [Internet]. Washington (DC): George Washington University; 2015 Jan 7 [cited 2015 Apr 29]. (Policy Research Brief No. 38). Available from: http:// www.rchnfoundation.org/wpcontent/uploads/2015/01/ GGRCHN_PolicyResearchBrief_38-1 .pdf Rosenbaum S, Wood S, Cunningham M, Beeson T, Shin P. Health centers and family planning update: implications of the 2014 quality family planning services guidelines issued by the CDC and the Office of Population Affairs [Internet]. Washington (DC): George Washington University; 2014 Jul 8 [cited 2015 Apr 30]. Available from: http://www .rchnfoundation.org/wp-content/ uploads/2014/07/Health-centersand-family-planning-062514-forrelease.pdf Freiden T. Winnable battles progress report [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [last updated 2013 Nov 21; cited 2015 May 19]. Available from: http://www.cdc.gov/about/ cdcdirector/winnablebattles.html Furman J, Fielder M. Continuing the Affordable Care Act’s progress on delivery system reform is an economic imperative [Internet]. Washington (DC): Council of Economic Advisers; 2015 Mar 24 [cited 2015 May 19]. Available from: https:// www.whitehouse.gov/blog/2015/ 03/24/continuing-affordable-careact-s-progress-delivery-systemreform-economic-imperative
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By Peter Shin, Jessica Sharac, and Sara Rosenbaum 10.1377/hlthaff.2015.0099 HEALTH AFFAIRS 34, NO. 7 (2015): 1096–1104 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
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Peter Shin ([email protected]) is an associate professor of health policy in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University, in Washington, D.C. Jessica Sharac is a senior research associate in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University. Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University.
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Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation Community health centers reach their fiftieth anniversary in 2015, along with Medicaid. Health policy makers have understood the programs’ symbiotic connection from the earliest days of their implementation. Medicaid’s expansion and growth have made the modern community health center program possible, while health centers represent one of the principal sources of primary care for the nation’s Medicaid population. With their shared mission and high level of interdependence, Medicaid and community health centers are essential for continued health system transformation in medically underserved communities nationwide—for example, by implementing delivery system reforms aimed at increasing clinical integration and improving efficiencies and by becoming medical homes for high-risk patients. Achieving this transformation will depend on the ability of community health centers and Medicaid to understand and respond to the challenges that each faces, while fully deploying the strengths that each has to offer. ABSTRACT
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ith roots in the War on Poverty and the civil rights movement,1 community health centers share a fiftieth anniversary with Medicaid this year. Since the 1965 Office of Economic Opportunity demonstration projects that launched them, community health centers have served as a bridge between the provision of clinical services and community health, combining comprehensive primary health care with community health improvement efforts that range from sanitation to education and literacy, housing and neighborhood improvements, and nutrition.
Background The fact that Medicaid and health centers would have a highly interdependent relationship was evident to policy makers from both programs’ 1096
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earliest days. This relationship was captured in a 1967 agreement2 between the Department of Health, Education, and Welfare, which administered Medicaid and Medicare, and the Office of Economic Opportunity, which by then was engaged in building on the success of the small health center demonstration to develop greater clinical care capacity “focused upon the needs of persons residing in urban or rural areas having high concentrations of poverty and a marked inadequacy of health services.”3 According to the agreement, the Office of Economic Opportunity would create a thousand community health centers by 1973, sufficient to serve an estimated twenty-five million patients. In return, Medicaid (and, to a lesser extent, Medicare) would provide as much as 80 percent of the operational financing needed to sustain these health centers once they were built.4 Ultimately, it would take nearly fifty years to
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reach this goal of health center expansion as well as to fulfill the early vision of providing access to health care in medically underserved communities, with Medicaid serving as the principal growth engine. Medicare is important to health centers, too: In 2013, 8 percent of the centers’ patients were Medicare beneficiaries, and Medicare represented 6 percent of the centers’ operating revenues.5 However, Medicaid has held the key to health center growth, just as health centers have become central to primary care access for the poor and underserved. This marriage of financing through Medicaid and access to care through community health centers has resulted in the establishment of 1,200 facilities that served nearly 9,200 high-need communities nationwide in 2013.6 Today community health centers provide a range of services, including medical, behavioral health, and enabling services such as transportation and translation. In 2013, 71 percent of the 85.6 million patient visits to health centers were for medical services, while 13 percent were for dental services, 8 percent for mental health and substance abuse services, and 8 percent for enabling services.7
Commitment To The Underserved Patient and insurance data illustrate how the relationship between Medicaid and community health centers has evolved. In 1975 the centers served 1.0 million patients, 60 percent of whom were uninsured and only 20 percent of whom were enrolled in Medicaid (Exhibit 1). In 2013 the centers served 21.7 million patients, 41 percent of whom were covered by Medicaid and
35 percent of whom were uninsured. A hundred “look-alike” health centers (which also qualify for special payments under federal health care programs) served an additional 1.0 million patients.8 In 2013 health centers served nearly one in six Medicaid beneficiaries nationally, excluding US territories (Exhibit 2). Vermont’s health centers, for example, served 21 percent of the state’s residents and 29 percent of its Medicaid beneficiaries. In four states and the District of Columbia, the proportion was 30 percent or more of Medicaid beneficiaries. Such high penetration likely results from two basic factors: the purposeful location of health centers in medically underserved communities as a source of financially and culturally accessible primary care, and the relatively limited participation in Medicaid among office-based physicians,9 who nonetheless remain the most common source of care for Medicaid enrollees.10 In 1985, 24 percent of the health centers’ patients were Medicaid enrollees, while Medicaid accounted for 15 percent of the centers’ operating revenues (Exhibit 3). In 2013 the figures were 41 percent and 40 percent, respectively. This increased concordance between patients and revenues resulted from the establishment in 1989 of special payment rules for federally qualified health centers—a group that, for payment purposes, includes both health centers that receive federal grants and those that receive their basic support through state and local grants but meet all federal requirements. These payment rules were designed to improve the alignment between reimbursement and actual cost of care for Medicaid patients.
Exhibit 1 Millions Of Patients Served At Community Health Centers, Selected Years 1975–2013
SOURCE Authors’ analysis of data for 1975–90 from the National Association of Community Health Centers and of data for 1996–2013 from the Uniform Data System (Health Resources and Services Administration). NOTES “Medicaid/CHIP patients” are enrollees in Medicaid or the Children’s Health Insurance Program (CHIP). “Other insured patients” are enrollees in Medicare, other public insurance, or private insurance. The totals (shown above each year’s group of bars) are of patients seen at federally funded community health centers. We excluded patients seen at “look-alike” health centers that do not receive federal grant funding but are certified as federally qualified health centers for Medicaid payment purposes.
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SOURCE Authors’ analysis of 2013 data from the Uniform Data System (Health Resources and Services Administration) and the Current Population Survey Annual Social and Economic Supplement (Census Bureau). NOTES For the United States (excluding territories) the share is 15.9 percent. Medicaid expansion (under the terms of the Affordable Care Act) is as of January 2015. As of mid-June 2015 Montana was awaiting federal waiver approval for its Medicaid expansion.
Medicaid: Principal Driver Of Growth
Exhibit 3 Percentage Of Community Health Center Patients And Revenues Attributable To Various Funding Sources, 1985 And 2013
SOURCE Authors’ analysis of 1985 data from the National Association of Community Health Centers and of 2013 data the Uniform Data System (Health Resources and Services Administration). NOTES “Other revenues” are Medicare, other public, and private insurance revenue; state or local and foundation/private grants; and other revenues. “Other patients” are enrollees in Medicare, other public insurance, or private insurance.
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A comparison of increases in Medicaid revenue and in federal health center grant funding over time makes Medicaid’s role in propelling health center growth clear. With the expansion in 1989 of Medicaid eligibility to include children, pregnant women, and—in many states—low-income parents, and with the enactment in the same year of the payment reforms just described, Medicaid revenues at health centers grew from $950 million in 1996 to $6.3 billion in 2013—an increase of 563 percent (Exhibit 4). During this time, federal grant funding grew at about half that rate (309 percent), from $757 million to $3.1 billion. The number of patients increased 168 percent during the same period. The growth in Medicaid revenues effectively enabled the federal government, working with communities, to support the near doubling in the number of health centers from 686 to 1,202 in the same period.5 Medicaid revenues also supported the expansion of many facilities, their number of sites, and their scope of services. Thus, the centers were able to increase the number of patients they served from 8.1 million in 1996 to 21.7 million
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Exhibit 4 Community Health Center Medicaid Revenues In Relation To Discretionary Appropriations And Patients Served, Millions Of Patients, 1996–2013
SOURCE Authors’ analysis of data on appropriations from the National Association of Community Health Centers and of data on patient numbers and Medicaid revenue from the Uniform Data System (Health Resources and Services Administration). NOTES The Health Centers Consolidation Act of 1996 requires health centers to annually submit a standard set of operational, financial, and performance reports to the Uniform Data System. Appropriations for 2011–13 include community health center funding mandated by the Affordable Care Act. Appropriations (purple line) and Medicaid revenue (orange line) relate to the left-hand y axis. Numbers of patients (bars) relate to the right-hand y axis.
in 2013. In sum, the sizable growth of health centers can be explained not by a vast infusion of federal grant funds but by strong Medicaid investment. This investment stems from three changes in federal Medicaid policy: the expansion of eligibility in 1989 described above; the expansion of coverage to include federally qualified health center services as a distinct benefit class; and the establishment of payment rules tied to the cost of clinical care furnished by physicians, nurse practitioners and physician assistants, psychologists, and social workers, as well as other ambulatory services covered under a state’s Medicaid plan, such as dental care and preventive care. Subsequent legislation applied health center payment reforms to Medicare, the Children’s Health Insurance Program (CHIP), and health plans subject to the essential health benefit requirements of the Affordable Care Act (ACA). Together, these three changes have enabled health centers to receive larger Medicaid revenues for covered services, thereby allowing federal grant funds to be used to reach additional uninsured patients and to add important health services not covered by many state Medicaid programs, such as routine adult dental care. Medicaid and grant funds together have sustained these services, once they were added.
Health Centers: Providers Of Primary Care In turn, health centers have become one of the principal sources of primary health care for state Medicaid programs. The centers’ importance can be seen in the number of patients they care for and in the degree to which their presence has enabled the rise of Medicaid managed care in underserved communities. In 2007, the latest year for which comparison data are available, health centers accounted for 9 percent of Medicaid managed care enrollees.11,12 Health centers operate managed care plans directly in eight states.13 Given their importance as Medicaid service providers, health centers have become integral to health system transformation in the poorest communities, where they are dominant.Whether their transformation is focused on becoming medical homes for the highest-risk patients or on implementing broader delivery system reforms aimed at improving clinical integration and efficiency, health centers will influence the outcome of these reform efforts because of the major role they play in achieving gains in health among Medicaid beneficiaries.
Role Of The Affordable Care Act The ACA has further propelled the Medicaid– health center collaboration in two ways. First, July 2015
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Primary Care the ACA enables states to extend Medicaid eligibility to virtually all nonelderly low-income adults, a core component of the health center patient population—93 percent of which is low income.5 Second, the ACA established an $11 billion, five-year growth fund,14 which was extended for an additional two years under the Medicare Access and CHIP Reauthorization Act of 2015. This fund has further enabled health centers to strengthen their services and expand their reach to the 20 percent of Americans who continue to lack a regular source of health care.15 As Medicaid expansion and health center growth proceed, these two reforms in combination should provide the basic financing and primary care development tools essential to improving health care quality and efficiency while reducing disparities in health and health care.
Should Special Payment Rules Continue?
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Today, when payment reform has become an integral part of system transformation, it is fair to ask whether the federal government’s special approach to paying health centers continues to make sense. In our view, the answer is yes, just as it continues to make sense for the government to make additional payments to hospitals that treat a disproportionate percentage of low-income patients. Part of this reasoning can be found in the greater levels of health risk among health center Medicaid patients, compared to the low-income population generally—a difference shown by a comparison of the health status of health center patients and that of low-income people overall.16 Another strong reason for continuing the special payment rules is the fact that some populations will remain uninsured even after health reform, and they will continue to require primary health care. Research conducted following the passage of Massachusetts’s health reform law shows that as the number of uninsured people decreased statewide, that population became increasingly concentrated at health centers,17 representing nearly 19 percent of the centers’ patients.18 The uninsured will—and should—continue to account for a high proportion of health center patients, especially in states that reject Medicaid expansion. Care must be taken to preserve the use of federal health center grant funds to care for the uninsured by ensuring that Medicaid, along with other public and private payers to which the federally qualified health center payment methodology applies, continues to cover the reasonable cost of care for their insured patients. Ensuring that covered services are paid for
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based on their reasonable costs means that health centers will not have to use grant funds to cover a portion of their costs. This means that grant funds can be used instead to furnish important health care that many insurers do not cover. One example is adult dental care, available today at 77 percent of all health centers7 but excluded by health plans sold in the federal and state-based health insurance Marketplaces and excluded or limited to emergency care by Medicaid programs in twenty states.19 Ensuring that payment for covered services is based on reasonable cost means that health centers also can use their grants to lower patient cost sharing to affordable levels, through the use of sliding fee schedules tied to family income. This ability to reduce cost sharing is particularly important for people with high-deductible Marketplace-based insurance, which—even with cost-sharing subsidies—can expose low-income patients to significant out-of-pocket responsibilities.20 But all of this does not mean that health centers and Medicaid programs cannot or should not test alternative payment strategies designed to improve the alignment of payments with desired health outcomes. Indeed, health centers are active participants in managed care and medical home reforms. For example, the federally qualified health center payment principles can be aligned with strategies designed to reduce incentives to furnish medically unnecessary care—such as an excessive number of patient visits—while taking advantage of less costly alternatives than a face-to-face visit, such as the use of telephone communication, where feasible and practical, to manage care.
Testing The Relationship Medicaid and health centers have a long history of cooperation and collaboration. Nonetheless, their relationship does have tensions, which have become more visible as health reform has accelerated. For example, Medicaid and health centers differ fundamentally in program structure and function. Medicaid is an insurer, with a primary focus on the people it insures at any given time. By definition, patients without coverage in the long or short term do not fall within the scope of Medicaid’s payment responsibility. In contrast, health centers serve their communities regardless of residents’ insurance status. Yet despite the somewhat transitory nature of Medicaid coverage because of its sensitivity to changes in family income, both Medicaid and health centers focus on the poor populations and communities who depend heavily on both programs.
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Of course, Medicaid beneficiaries and medically underserved communities are not fully synonymous. Not all Medicaid beneficiaries live in communities with health centers. Medicaid programs focus predominantly on covered services for beneficiaries instead of on the geographic communities in which beneficiaries live. This may be changing, however, as state Medicaid officers begin to think more in terms of place as they participate in broader health improvement initiatives.21 Nonetheless, the question is how to acknowledge the differences between Medicaid and health centers while moving forward with their shared mission: namely, to improve the health of the low-income population.
Moving Forward: Crucial Questions As the Medicaid–health center relationship begins its next fifty years, two basic questions arise. How important is the relationship? And should its growth be encouraged? Among Medicaid’s relationships with other programs, its alignment with health centers shows what the two programs—the main source of insurance for low-income Americans and the largest safety-net system of primary care—can achieve when they work together. Medicaid’s future as an effective source of health insurance for low-income people depends on its ability to translate coverage into appropriate health care. If anything, the need for a strong Medicaid– health center relationship has increased over the years. Low levels of private provider participation in Medicaid, evident from the program’s earliest days,22 remain a central challenge that is likely to grow as the Medicaid population increases.23 The ACA’s much-debated Medicaid primary care payment “bump” appears to have had a significant effect on acceptance rates among physicians already participating in the program,24 but it has not fostered new participation. Furthermore, the payment increase was allowed to lapse, and the number of states willing to continue enhanced payment absent a financial incentive from the federal government for doing so remains unclear.25 Even if all states were to commit to increasing Medicaid primary care payments, the results probably would be modest in light of the multifactorial nature of low Medicaid participation among physicians.26 Furthermore, health centers are, by definition, located in communities that lack primary care resources in relation to health need. Even increasing Medicaid payments to physicians could not mitigate the personnel shortages that these communities experience. Nor can simply rewarding private physicians for treating more patients in the com-
munities in which the physicians reside address the underlying maldistribution of medical professionals. Health centers also are important to Medicaid’s efforts to transform health care for people at elevated health risk. Among Medicaid patients and the poor generally, health centers have improved health outcomes for adults and children alike.27–29 Similarly, health centers serve as a key source of health care for the nation’s 9.6 million people enrolled in both Medicare and Medicaid.30 These “dual eligibles” account for 5 percent of all health center patients.16 Dual eligibles as a proportion of all Medicare health center patients (42 percent in 2009) are twice the national average of dual eligibles in the population: Approximately 21 percent of all Medicare beneficiaries were dually enrolled in Medicaid in fiscal year 2010.31 For dual eligibles—whose health is measurably more fragile than that of people enrolled in Medicare alone and who experience substantially higher health care costs32—health centers serve as a key source of health care. One notable study has shown health centers’ impact on the health of older Americans, many of whom are eligible for Medicare and Medicaid: The centers have lowered mortality among people ages fifty and older and narrowed the mortality gap between the poor and the nonpoor.33 In 2013 health centers served 1.8 million Medicare beneficiaries and participated in health system transformation efforts focusing on the Medicare population.5 More than 400 health centers are pursuing recognition as level 3 patient-centered medical homes by the National Committee for Quality Assurance under the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration.34 Payment remains a source of tension in the Medicaid–health center relationship. The federally qualified health center payment methodology initially was built on, and continues to use, a cost-related per encounter payment approach. This approach appears to be at odds with newer payment strategies, such as bundling payments for an episode of care; per case payments, in which payments are designed to reflect the cost of treating a particular condition; and annual global budgeting strategies, which combine capitation payments with quality rewards.35 Health centers have frequently expressed the desire to move away from encounter-driven financing. The incentive in this approach is to reward high volumes of face-to-face visits instead of the adoption of care structures more appropriate to patient health needs, such as combining in-person treatment with increased use of telemedicine services when feasible.36 J u ly 201 5
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Health centers More than 400 health centers are pursuing recognition as level 3 patient-centered medical homes.
To that end, examples of payment reform collaborations between Medicaid and health centers are growing, especially in states in which agencies are tackling major system transformation efforts in an attempt to strengthen health care from the ground up.37 These initiatives show, even in their early planning stages, that it is possible to redesign health center payment to reward performance and enable health centers to innovate in how they care for their patients without underfinancing appropriate care, which could result in shifting costs to federal grant funds intended for the care of uninsured populations and the provision of essential care and services not covered by insurance. Case payments for patients with serious conditions, along with the use of measurable outcomes, are fully compatible with payment safeguards that prevent cost shifting. Some examples include risk adjustment, in which payments take into account varying health and demographic factors; year-end cost reconciliation, in which differences in payments and eligible claims are settled at the end of the year; and stop-loss arrangements in connection with global payments, in which the providers’ financial risk is limited. A pilot program at three Oregon health centers, for instance, is designed to move health centers toward a value-based payment model that emphasizes health outcomes.38 Health centers offer Medicaid the potential for continuous care, regardless of brief or periodic interruptions in eligibility. This is a crucial consideration for patients with serious or chronic health conditions and those with an ongoing need for primary health care. Equally important, quality improvement collaborations between health centers and Medicaid have the potential to improve the quality of care for all health center patients.
Roles Of Health Centers And Medicaid In Family Planning Family planning is a case in point of the potential for a populationwide spillover impact from Medicaid–health center efforts to improve quality. No service may be more determinative of the immediate and long-term health of women, children, and families than family planning, and no service is more cost-effective.39 A nationwide study revealed that although many health centers offer strong family planning programs, most need to improve in terms of the level of staffing offered and the range of on-site services provided.40 Because Medicaid is such a dominant payer of family planning services, a Medicaid–health center collaboration to improve access to the full 1102
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range of family planning methods approved by the Food and Drug Administration—especially long-acting reversible contraception—and effective patient counseling would improve the quality of family planning services for all health center patients, not just those enrolled in Medicaid. Such a collaboration could be further enhanced if the Health Resources and Services Administration (HRSA), which administers the health center program, were to make service improvement funds available to health centers that participate in such quality improvement efforts with their Medicaid programs to cover start-up and clinical training costs. This three-way collaboration ultimately could reach all health center patients who are women of child-bearing age, and an estimated 20 percent of women in this age group who have low incomes are center patients.41 Such an initiative also would help achieve the goals embodied in landmark family planning recommendations released by the Department of Health and Human Services in 2014.42 Joint family planning work exemplifies the possible types of collaborations among health centers, state Medicaid programs, the Centers for Medicare and Medicaid Services (CMS), and HRSA. Each partner brings crucial resources to the table: Health centers provide access to care; Medicaid agencies, financing and quality improvement support; HRSA, start-up and quality improvement sustaining funds to reach all health center patients; and CMS, financing, technical support, and regulatory authorization. Collaborations that incorporated payment reforms could focus on population health improvement priorities beyond family planning, such as reducing the burden of chronic illness and improving the use of electronic health information. Such joint efforts require planning and a high degree of interaction, but the necessary elements for realizing population health improvement are present. In this regard, federal agencies, health centers, and state Medicaid partners might consider creating a multistate learning collaborative to promote health center payment transformation built around what Thomas Frieden of the Centers for Disease Control and Prevention has called “winnable battles.”43 Such a step would be in accord with the White House’s recently announced payment reform initiative44 and could include not only Medicaid but other insurers with health centers in their networks, which seek to move toward a performance-based payment system in the safety-net environment.
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Conclusion What is needed at this critical juncture in the evolution of US health care is a more deliberate coming together of Medicaid and community health centers, through a purposeful collaboration that builds on the valuable lessons that both programs have learned and can thus achieve what neither can accomplish alone: better and more accessible health care that rests on financing strategies designed to promote quality and
efficiency. We remain convinced that these reforms can happen without jeopardizing what health centers do best: providing comprehensive primary health care for the communities they serve, without regard to factors unrelated to the need for health care. The original vision of how the two programs would work together to advance the health of the population remains as fresh today as it was fifty years ago. ▪
The authors thank the RCHN Community Health Foundation for its generous and long-standing support of the Geiger Gibson–RCHN Community Health Foundation Research Collaborative.
NOTES 1 Lefkowitz B. Community health centers: a movement and the people who made it happen. New Brunswick (NJ): Rutgers University Press; 2007. 2 Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care—the growing importance of the community health center. N Engl J Med. 2010;362(22):2047–50. 3 Levitan SA, Taggart R. The promise of greatness. Cambridge (MA): Harvard University Press; 1976. p. 177. 4 Davis K, Schoen C. Health and the war on poverty: a ten-year appraisal. Washington (DC): Brookings Institution; 1978. Chapter 6. 5 Health Resources and Services Administration. HRSA Health Center Program: 2013 health center data: 2013 national data [Internet]. Rockville (MD): HRSA; [cited 2015 Apr 29]. Available from: http:// bphc.hrsa.gov/uds/datacenter.aspx? q=tall&year=2013&state= 6 2013 Uniform Data System data, Health Resources and Services Administration. 7 Shin P, Sharac J, Barber Z, Rosenbaum S, Paradise J. Community health centers: a 2013 profile and prospects as ACA implementation proceeds [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2015 Mar [cited 2015 Apr 29]. (Issue Brief). Available from: http://files .kff.org/attachment/issue-briefcommunity-health-centers-a-2013profile-and-prospects-as-acaimplementation-proceeds 8 Health Resources and Services Administration. HRSA Health Center Program: 2013 health center data: 2013 national look-alikes data [Internet]. Rockville (MD): HRSA; [cited 2015 Apr 29]. Available from: http://bphc.hrsa.gov/uds/ lookalikes.aspx?q=tall&year=2013 &state=national
9 Decker SL. In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff (Millwood). 2012;31(8):1673–9. 10 Sommers A. Sites of care serving Medicaid enrollees [Internet]. Washington (DC): Medicaid and CHIP Payment and Access Commission; 2015 Feb 26 [cited 2015 Apr 29]. Available from: https:// www.macpac.gov/wp-content/ uploads/2015/02/Sites-of-CareServing-Medicaid-Enrollees.pdf 11 Centers for Medicare and Medicaid Services. National summary of Medicaid managed care programs and enrollment as of July 1, 2010 [Internet]. Baltimore (MD): CMS; [cited 2015 Apr 29]. Available from: http://www.cms.gov/ResearchStatistics-Data-and-Systems/ Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/ Downloads/2010Trends.pdf 12 Health Resources and Services Administration. Bureau of Primary Health Care: section 330 grantees: Uniform Data System (UDS): calendar year 2007 data: national rollup report [Internet]. Rockville (MD): HRSA; 2008 Jul 1 [cited 2015 Apr 29]. Available from: ftp://ftp .hrsa.gov/bphc/pdf/uds/2007 nationaluds.pdf 13 According to the Association for Community Affiliated Plans, these plans are Colorado Access (CO), Prestige Health Choice (FL), AlohaCare (HI), Priority Partners (MD), Affinity Health Plan (NY), CareOregon (OR), Neighborhood Health Plan of Rhode Island (RI), and Community Health Plan of Washington (WA). Jennifer Babcock, vice president for Exchange Policy and director of Strategic Operations, Association for Community Affiliated Plans, personal communication, January 26, 2015.
14 Hawkins D, Groves D. The future role of community health centers in a changing health care landscape. J Ambul Care Manage. 2011;34(1): 90–9. 15 National Association of Community Health Centers. Primary care access: an essential building block of health reform [Internet]. Bethesda (MD): NACHC; 2009 Mar [cited 2015 Apr 29]. Available from: http:// www.nachc.com/client/documents/ pressreleases/PrimaryCareAccess RPT.pdf 16 Shin P, Alvarez C, Sharac J, Rosenbaum S, Van Vleet A, Paradise J, et al. A profile of community health center patients: implications for policy [Internet]. Menlo Park (CA): Henry J. Kaiser Family Foundation; 2013 Dec 23 [cited 2015 Apr 29]. Available from: http:// kff.org/medicaid/issue-brief/aprofile-of-community-health-centerpatients-implications-for-policy/ 17 Ku L, Jones E, Finnegan B, Shin P, Rosenbaum S (George Washington University, Washington, DC). How is the primary care safety net faring in Massachusetts? Community health centers in the midst of health reform [Internet]. (Publication No. 7878). Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2009 Mar [cited 2015 Apr 29]. Available from: http:// kaiserfamilyfoundation.files.word press.com/2013/01/7878.pdf 18 Health Resources and Services Administration. HRSA Health Center Program: 2013 health center data: Massachusetts program grantee data [Internet]. Rockville (MD): HRSA; [cited 2015 Apr 29]. Available from: http://bphc.hrsa.gov/uds/data center.aspx?year=2013&state=MA 19 Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion [Internet]. Chicago (IL): American Dental Association
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Health A ffairs
1103
Medicaid
&
Primary Care
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26
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H e a lt h A f fai r s
Health Policy Institute; 2014 Feb [cited 2015 Apr 29]. (Research Brief). Available from: http://www .ada.org/~/media/ADA/Science %20and%20Research/HPI/Files/ HPIBrief_0214_1.ashx Claxton G, Panchal N. Cost-sharing subsidies in federal Marketplace plans [Internet]. Menlo Park (CA): Henry J. Kaiser Family Foundation; 2015 Feb 11 [cited 2015 Apr 29]. Available from: http://kff.org/ health-reform/issue-brief/costsharing-subsidies-in-federal-market place-plans/ Crawford M, McGinnis T, Auerbach J, Golden K. Population health in Medicaid delivery system reforms [Internet]. New York (NY): Milbank Memorial Fund; 2015 Mar [cited 2015 Apr 29]. (Issue Brief). Available from: http://www.milbank.org/ uploads/documents/papers/ CHCS_PopulationHealth_Issue Brief.pdf Stevens R, Stevens R. Welfare medicine in America: a case study of Medicaid. New Brunswick (NJ): Transaction Publishers; 2003. Ku L, Jones K, Shin P, Bruen B, Hayes K. The states’ next challenge— securing primary care for expanded Medicaid populations. N Engl J Med. 2011;364(6):493–5. Polsky D, Richards M, Basseyn S, Wissoker D, Kenney GM, Zuckerman S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372(6):537–45. Snyder L, Paradise J, Rudowitz R. The ACA primary care increase: state plans for SFY 2015 [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2014 Oct 28 [cited 2015 Apr 29]. Available from: http:// kff.org/medicaid/perspective/theaca-primary-care-increase-stateplans-for-sfy-2015/ Medicaid and CHIP Payment and Access Commission. Report to the Congress on Medicaid and CHIP [Internet]. Washington (DC): MACPAC; 2013 Jun; [cited 2015 Jun 16]. Available from: https:// www.macpac.gov/wp-content/ uploads/2015/01/2013-06-15_ MACPAC_Report.pdf Chin MH, Drum ML, Guillen M, Rimington A, Levie JR, Kirchhoff AC, et al. Improving and sustaining diabetes care in community health centers with the health disparities collaboratives. Med Care. 2007; 45(12):1135–43. Lob SH, Boer JH, Porter PG, Núñez D, Fox P. Promoting best-care prac-
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33
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tices in childhood asthma: quality improvement in community health centers. Pediatrics. 2011;128(1): 20–8. Shi L, Stevens GD, Wulu JT Jr, Politzer RM, Xu J. America’s health centers: reducing racial and ethnic disparities in perinatal care and birth outcomes. Health Serv Res. 2004;39(6 Pt 1):1881–901. Henry J. Kaiser Family Foundation. State health facts: number of dual eligible beneficiaries [Internet]. Menlo Park (CA): KFF: c 2015 [cited 2015 Apr 29]. Available from: http:// kff.org/medicare/state-indicator/ dual-eligible-beneficiaries/ National Association of Community Health Centers. Health centers and Medicare: caring for America’s seniors [Internet]. Bethesda (MD): NACHC; 2014 Dec [cited 2015 May 19]. (Fact Sheet). Available from: http://www.nachc.com/client/ documents/Medicare_FS_2014.pdf Bubolz T, Emerson C, Skinner J. State spending on dual eligibles under age 65 shows variations, evidence of cost shifting from Medicaid to Medicare. Health Aff (Millwood). 2012;31(5):939–47. Baily MJ, Goodman-Bacon A. The War on Poverty’s experiment in public medicine: community health centers and the mortality of older Americans [Internet]. Cambridge (MA): National Bureau of Economic Research; 2014 Oct [cited 2015 Apr 29]. (NBER Working Paper No. 20653). Available from: http:// www.nber.org/papers/w20653.pdf CMS.gov. FQHC Advanced Primary Care Practice Demonstration [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2015 Apr 29]. Available from: http://innovation.cms.gov/ initiatives/fqhcs/ Miller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5): 1418–28. Shin P, Sharac J, Jacobs F. Provision of telemedicine services by community health centers. Online J Public Health Inform. 2014;6(2):e185. Takach M, Buxbaum J. Developing federally qualified health centers into community networks to improve state primary care delivery systems [Internet]. Portland (ME): National Academy for State Health Policy; 2011 May [cited 2015 Apr 30]. Available from: http://www.nashp .org/sites/default/files/developing .fqhcs_.community.networks.takach .buxbaum.2.pdf Robert Wood Johnson Foundation.
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40
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Downloaded from content.healthaffairs.org by Health Affairs on July 8, 2015 at UNIVERSITY OF OTAGO
Grants: evaluating a capitated alternative payment methodology in Oregon community health centers [Internet]. Princeton (NJ): RWJF; [cited 2015 Apr 30]. Available from: http://www.rwjf.org/en/grants/ grant-records/2013/06/evaluatinga-capitated-alternative-paymentmethodology-in-oregon.html Amaral G, Foster DG, Biggs MA, Jasik CB, Judd S, Brindis CD. Public savings from the prevention of unintended pregnancy: a cost analysis of family planning services in California. Health Serv Res. 2007;42(5): 1960–80. Wood S, Beeson T, Bruen B, Goldberg DG, Mead H, Shin P, et al. Scope of family planning services available in federally qualified health centers. Contraception. 2014;89(2): 85–90. Rosenbaum S, Shin P, Wood SF, Sharac J. Using payment reform strategies to strengthen family planning services at community health centers [Internet]. Washington (DC): George Washington University; 2015 Jan 7 [cited 2015 Apr 29]. (Policy Research Brief No. 38). Available from: http:// www.rchnfoundation.org/wpcontent/uploads/2015/01/ GGRCHN_PolicyResearchBrief_38-1 .pdf Rosenbaum S, Wood S, Cunningham M, Beeson T, Shin P. Health centers and family planning update: implications of the 2014 quality family planning services guidelines issued by the CDC and the Office of Population Affairs [Internet]. Washington (DC): George Washington University; 2014 Jul 8 [cited 2015 Apr 30]. Available from: http://www .rchnfoundation.org/wp-content/ uploads/2014/07/Health-centersand-family-planning-062514-forrelease.pdf Freiden T. Winnable battles progress report [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [last updated 2013 Nov 21; cited 2015 May 19]. Available from: http://www.cdc.gov/about/ cdcdirector/winnablebattles.html Furman J, Fielder M. Continuing the Affordable Care Act’s progress on delivery system reform is an economic imperative [Internet]. Washington (DC): Council of Economic Advisers; 2015 Mar 24 [cited 2015 May 19]. Available from: https:// www.whitehouse.gov/blog/2015/ 03/24/continuing-affordable-careact-s-progress-delivery-systemreform-economic-imperative
