Federally funded clinics for low-income patients as effective as private practices

The federal government has committed $11 billion to expand the operating capacity of Federally Qualified Health Centers (FQHC), which receive federal funding and enhanced Medicaid and Medicare reimbursement, and “look-alike” clinics that receive enhanced reimbursement but no federal grants.

These clinics, which serve primarily the poor and uninsured, are expected to be part of the solution to anticipated primary care shortages, as up to 32 million currently uninsured people begin to seek health care as a result of the Patient Protection and Affordable Care Act. Despite concerns that these clinics may provide less effective care because they serve more medically and socially complex patients, a new study has found that they are as effective as private primary care practices, and better on some quality measures. The study is published in the August issue of the American Journal of Preventive Medicine.

“While overall adherence to guidelines varied, physicians working at FQHC and look-alike clinics demonstrated greater adherence to guidelines than primary care physicians at private practices on six of 18 quality measures and, except for diet counseling in at-risk adolescents, similar adherence on the remaining measures despite providing care to patients with limited or no insurance and a higher burden of comorbidities,” says lead investigator L. Elizabeth Goldman, MD, MCR, from the Department of Medicine at the University of California, San Francisco.

Researchers used data from the 2006-2008 National Ambulatory Medical Care Survey (NAMCS) conducted by the National Center for Health Statistics, which collects information on ambulatory medical care provided by FQHC and look-alikes and nonfederal, office-based, direct care physicians. They evaluated quality of care using 18 previously established quality measures. The sample consisted of 31,133 visits, 22,691 to private primary care physicians and the remaining to FQHC and look-alikes.

The study evaluated four categories of quality measures: pharmacologic management of common chronic diseases, including atrial fibrillation, heart failure, coronary artery disease, asthma, and depression; preventive counseling regarding smoking cessation, diet and exercise for individuals at high risk of coronary artery disease; appropriate use of screening tests for blood pressure, electrocardiogram, and urinalysis; and appropriate prescribing in elderly patients.

Adherence to guidelines for seven of 18 measures was less than 50% for both FQHC and look-alikes and private practice physicians, with the lowest adherence for preventive counseling and the highest for statin use in coronary disease. FQHC and look-alikes performed higher on six measures, lower on one measure, and no differently than primary care physicians on eleven measures. FQHC and look-alikes demonstrated higher performance across the pharmacologic management of chronic disease and appropriate use of screening tests categories.

“Overall, adherence was greatest for many of the chronic disease measures, likely, in part, due to the strength of evidence supporting those measures,” notes Dr. Goldman. “Lower adherence to the provision of exercise counseling to adults and adolescents at high risk of coronary artery disease may be related to the lack of evidence supporting the impact of such counseling on patient health outcomes.”

Although the study did not specifically identify the mechanisms by which FQHC and look-alikes achieved higher performance, the authors suggest a number of factors may be at work. Patients at FQHC and look-alikes are more likely to be insured by Medicaid or uninsured, and traditionally have limited access to subspecialty care. Therefore, those with chronic diseases may be more likely to be managed in the clinic. Federal grants to develop stable, locally recruited workforces, and expand clinic capacity often require participation in quality improvement and performance measurement, and may also contribute to the study's findings.

“In the setting of healthcare reform, FQHC and look-alikes may need to accommodate many newly enrolled Medicaid recipients,” Dr. Goldman says. “Further research is needed to monitor these and other measures to assess whether appropriated funds meet the needs of these centers so that they can continue to provide quality care, and how new reimbursement models will impact the comparative effectiveness of these clinics.”