Health Policy$ense

Federally-Qualified Health Centers: Key Access Point to Primary Care for Expanded Medicaid Population

Pennsylvania recently became the 27th state to expand its Medicaid program, a move that will make nearly 300,000 uninsured adults newly eligible for coverage in 2015. As in other states, questions arise about the health system’s ability to meet higher demands for primary care. A new analysis by LDI and Urban Institute Senior Fellows suggests that for these newly covered people, particularly those gaining Medicaid coverage, the best bet for getting a primary care appointment is to call a Federally-Qualified Health Center (FQHC).

'Secret shopper' study
Using data from a “secret shopper” study conducted in 2012-2013, Michael Richards and colleagues found that FQHCs granted appointments to Medicaid beneficiaries at much higher rates (80%) than non-FQHC providers (56%). In the parent study, trained research assistants called a representative sample of providers in 10 states (including Pennsylvania), posing as patients requesting a new patient visit. The callers were randomized to say they had different insurance types (private, Medicaid, or self-pay). The design allowed the researchers to simulate the actual appointment availability for new patients seeking care, and to isolate the effect of insurance status from other factors that might influence appointment rates.

As shown below, FQHCs have very high appointment rates across all insurance types. Appointment rates for non-FQHC providers were lower for Medicaid, with larger disparities by insurance status, particularly between Medicaid and privately insured patients.

Appointment Rates by Caller Insurance Type,
Primary Care Simulated Patient Study, 10 states, October 2012-March 2013
- - - - - - - - - - - - - - - - - - - -

FQHCs differ from other providers in location and practice structure. FQHCs tend to be larger practices that include more non-physician professionals such as nurse practitioners. They are more often located in poorer areas with larger minority populations. But even after adjusting for demographic, geographic, and other contextual factors, the researchers found that Medicaid patients were 22 percentage points more likely to get an appointment at an FQHC than at other providers. Similarly, FQHCs added 8 percentage points to the probability of a self-pay caller getting an appointment. Reflecting the sliding scale nature of FQHC fees, self-pay patients were 30 percentage points more likely to be offered an appointment at $100 or less at an FHCQ than at a non-FHCQ provider. Importantly, the greater acceptance rates of FHQCs did not mean that Medicaid and self-pay patients waited significantly longer for an appointment.

High-poverty vs. low-poverty areas
The researchers also explored whether these patterns changed when comparing high-poverty and low-poverty areas. FQHCs were more likely to offer an appointment than non-FQHCs n both high-poverty and low poverty areas, and to the same degree. However, non-FQHC providers in low-poverty areas were less likely to offer a self-pay caller an appointment at $100 or less than non-FQHCs in high-poverty areas. Thus, in low-poverty areas, FQHCs are still more likely to offer a cheaper visit, but the difference is less when compared with non-FQHCs in high-poverty areas.

FQHCs are community health clinics that receive federal grants to provide primary care access to underserved populations. Consistent with that mission, these data suggest that Medicaid patients seeking a new provider are likely to be more successful if they look to FQHCs, and that as of early 2013 FQHCs were able to accommodate the current Medicaid population. It also suggests that FQHCs are already seeing many uninsured patients that will gain access to Medicaid in 2015.

Recognizing the central role of community health centers, the Affordable Care Act includes $11 billion in funding over five years to bolster the capacity of these centers to meet increased, and perhaps pent-up, demand for primary care services.

Pennsylvania's FQHCs
This is all good news for the newly eligible Medicaid population in Pennsylvania. According to the Pennsylvania Association of Community Health Centers (PACHC), there are more than 200 FQHCs in 45 of 67 counties providing care to about 700,000 Pennsylvanians. These health centers serve primarily low-income patients: 93% have incomes below 200% of poverty, and 68% have Medicaid or are uninsured.

The FQHCs will be key to the success of Pennsylvania’s Medicaid expansion. All private plans covering this expansion population must include FQHCs as in-network providers. And last week, the PACHC received a federal Navigator grant of more than $800,000 to provide in-person assistance to people enrolling on the Health Insurance Marketplace. Although the expansion population will not enroll in marketplace plans, these funds will enhance the centers’ ability to implement a “one-stop shopping” approach to helping uninsured patients find their way to coverage and care.