Alternative Payment Models and Performance in Federally Qualified Health Centers
Open accessAbstract
Importance: Several state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance. Objective: To assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs. Design, Setting, and Participants: This retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023. Exposure: Initial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021. Main Outcomes and Measures: The main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs. Results: A total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (–0.01 pp; 95% CI, –0.21 to 0.19 pp) or stinting on care (–0.02 visits; 95% CI, –0.08 to 0.04 visits). Conclusions and Relevance: In this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.
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- Authors
- Markowski, J., Wallace, J., Schlesinger, M., & Ndumele, C. D.
- Affiliations
- Yale University (US)
- Corresponding author
- Markowski, Justin
- Venue
- JAMA Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2024-09-01
- Volume
- 184
- Issue
- 9
- Pages
- 1065
- ISSN
- 2168-6106 (ISSN-L)
- PMC
- PMC11231906
- OpenAlex
- W4400414263
- Cited by
- 10
- References
- 28
- Citations by year
- 2026: 6 · 2025: 4
- FWCI
- 3.53
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA Internal Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Keywords
- alternative payment models, value-based payment, federally qualified health centers, Medicaid reimbursement, quality of care, colorectal cancer screening, cervical cancer screening, hypertension control, diabetes management, payer mix, risk profile, financial sustainability, fee-for-service, models of care, community health centers, state Medicaid programs, rural health care, health disparities
- MeSH terms
- Female, Humans, Male, Medicaid, Reimbursement Mechanisms, Retrospective Studies, United States, Fee-for-Service Plans
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