Alternative Payment Models and Performance in Federally Qualified Health Centers.

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.

After 50 Years, Health Professional Shortage Areas Had No Significant Impact On Mortality Or Physician Density.

Since 1965, the US federal government has incentivized physicians to practice in high-need areas of the country through the designation of Health Professional Shortage Areas (HPSAs). Despite its being in place for more than half a century and directing more than a billion dollars annually, there is limited evidence of the HPSA program's effectiveness at reducing geographic disparities in access to care and health outcomes. Using a generalized difference-in-differences design with matching, we found no statistically significant changes in mortality or physician density from 1970 to 2018 after a county-level HPSA designation. As a result, we found that 73 percent of counties designated as HPSAs remained physician shortage areas for at least ten years after their inclusion in the program. Fundamental improvements to the program's design and incentive structure may be necessary for it to achieve its intended results.

Pain severity and mobility one year after spinal cord injury: a multicenter, cross-sectional study.

BACKGROUND: Following a spinal cord injury, patients are often burdened by chronic pain. Preliminary research points to activation of the motor cortex through increased mobility as a potential means of alleviating postinjury chronic pain. AIM: The aim of this study was to assess the relationship between pain severity and mobility among patients who have sustained a traumatic spinal cord injury while controlling for clinically-relevant covariates. DESIGN: A multi-center, cross-sectional study. SETTING: The SCIMS is composed of 14 centers, all located in the United States and funded by the National Institute on Disability and Rehabilitation Research (NIDRR). POPULATION: The study cohort included 1980 patients who completed the one-year SCIMS follow-up assessment between October 2000- December 2013. METHODS: A multi-center, cross-sectional study was performed to assess the impact of mobility on self-reported pain using information from 1980 subjects who sustained a traumatic spinal cord injury and completed a year-one follow-up interview between October 2000 and December 2013. Patient information was acquired using the Spinal Cord Injury National Database, compiled by the affiliated Spinal Cord Injury Model Systems. Analyses included a multivariable linear regression of patients' self-reported pain scores on mobility, quantified using the CHART-SF mobility total score, and other clinically relevant covariates. RESULTS: After controlling for potential confounders, a significant quadratic relationship between mobility and patients' self-reported pain was observed (P=0.016). Furthermore, female gender, "unemployed" occupational status, paraplegia, and the presence of depressive symptoms were associated with significantly higher pain scores (P<0.02 for all variables). Statistically significant quadratic associations between pain scores and age at injury, life satisfaction total score, and the CHART-SF occupational total subscale were also observed (P≤0.03 for all variables). CONCLUSIONS: Among patients with moderate to high levels of mobility, pain scores decreased with increasing mobility. CLINICAL REHABILITATION IMPACT: Enhancing a patient's physical activity by increasing his or her mobility may reduce neuropathic pain if begun shortly after a spinal cord injury.