Utilization of health care services among Medicare beneficiaries who visit federally qualified health centers

Lavelle et al. BMC Health Services Research (2018) 18:41 DOI 10.1186/s12913-018-2847-x RESEARCH ARTICLE Open Access Utilization of health care services among Medicare beneficiaries who visit federally qualified health centers Tara A. Lavelle1,2, Adam J. Rose1,3* , Justin W. Timbie4, Claude M. Setodji5, Suzanne G. Wensky6, Katherine D. Giuriceo6, Mark W. Friedberg1,7, Rosalie Malsberger1 and Katherine L. Kahn8,9 Abstract Background: Previous studies have disagreed on whether patients who receive primary care from federally qualified health centers (FQHCs) have different utilization patterns than patients who receive care elsewhere. Our objective was to compare patterns of healthcare utilization between Medicare beneficiaries who received primary care from FQHCs and Medicare beneficiaries who received primary care from another source. Methods: We compared characteristics and ambulatory, emergency department (ED), and inpatient utilization during 2013 between 130,637 Medicare beneficiaries who visited an FQHC for the majority of their primary care in 2013 (FQHC users) and a random sample of 1,000,000 Medicare fee-for-service (FFS) beneficiaries who did not visit an FQHC (FQHC non-users). We then created a propensity-matched sample of 130,569 FQHC users and 130,569 FQHC non-users to account for differences in observable patient characteristics between the two groups and repeated all comparisons. Results: Before matching, the two samples differed in terms of age (42% below age 65 for FQHC users vs. 16% among FQHC non-users, p < 0.001 for all comparisons), disability (52% vs. 24%), eligibility for Medicaid (56% vs. 21%) , severe mental health disorders (17% vs. 10%), and substance abuse disorders (6% vs. 3%). FQHC users had fewer ambulatory visits to primary care or specialist providers (10.0 vs. 12.0 per year), more ED visits (1.2 vs. 0.8), and fewer hospitalizations (0.3 vs. 0.4). In the matched sample, FQHC users still had slightly lower utilization of ambulatory visits to primary care or specialist providers (10.0 vs. 11.2) and slightly higher utilization of ED visits (1.2 vs. 1.0), compared to FQHC users. Hospitalization rates between the two groups were similar (0.3 vs. 0.3). Conclusions: In this population of Medicare FFS beneficiaries, FQHC users had slightly lower utilization of ambulatory visits and slightly higher utilization of ED visits, compared to FQHC non-users, after accounting for differences in case mix. This study suggests that FQHC care and non-FQHC care are associated with broadly similar levels of healthcare utilization among Medicare FFS beneficiaries. Keywords: health care utilization, safety-net care, Medicare * Correspondence: 1 RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA 02116, USA 3 Boston University School of Medicine, Boston, MA, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lavelle et al. BMC Health Services Research (2018) 18:41 Background Federally qualified health centers (FQHCs) receive federal funding to provide comprehensive primary care in underserved communities. Three-quarters of the 20 million patients seen at FQHCs annually have incomes below the federal poverty level (FPL), and more than half are members of a racial or ethnic minority group [1]. In 2013, 35% of patients seen at FQHCs were uninsured, and another 49% had some type of public insurance including Medicaid and/or Medicare.1 The number of Medicare beneficiaries seen at FQHCs more than doubled between 2001 to 2011 (from 745,000 to nearly 1.6 million) [2]. Studies of FQHCs have consistently shown that they provide high quality primary care, but the results of research examining the overall healthcare utilization patterns of FQHC users have been mixed. Some studies have shown that FQHC users have more ambulatory visits, emergency department (ED) visits, and hospitalizations, but other studies show lower utilization [3–12]. Differences in these study outcomes relate in part to the segment of the population that was the focus of the study (e.g., younger patients, older patients, dual eligible patients), in part to the time period studied (since these studies span almost two decades), and in part to the extent that they controlled for important differences between FQHC users and FQHC non-users. The purpose of this study was to examine the volume of ambulatory visits, ED visits, and hospitalizations among a sample of Medicare beneficiaries who visited an FQHC for a majority of their primary care visits in 2013, compared with a sample of beneficiaries who received regular primary care but did not visit an FQHC. These analyses used unadjusted direct comparisons between groups as well as comparisons between matched samples of beneficiaries that controlled for observable socio-demographic and clinical differences between groups. Our focus on Medicare beneficiaries is noteworthy, because while they represented just 8% of all beneficiaries who served by FQHCs in 2013 [2], they also are characterized by an especially high level of illness burden and medical need. We expected to show that FQHC users had higher levels of ED utilization before adjustment, but that adjustment for differences in case mix would greatly attenuate or eliminate this difference. Methods Sample This study used 2013 Medicare fee-for-service (FFS) claim and enrollment files from a representative 20% sample of Medicare beneficiaries. Beneficiaries were included if, during all 12 months of 2013, they were at least 18 years of age, were eligible for both Parts A and Page 2 of 10 B, and were not enrolled in Medicare Advantage. Our inclusion criteria also required beneficiaries to have at least three ambulatory visits to a primary care provider (PCP) during 2013. Physicians, nurse practitioners, and physician’s assistants in internal medicine, general practice, family medicine, obstetrics & gynecology, adult health, community health, family practice, primary care, women’s health, gerontology, and preventive medicine were classified as PCPs. PCPs were identified using unique National Provider Identifier (NPI) codes in the outpatient and physician claim files. These were linked to National Plan & Provider Enumeration System (NPPES) Provider Taxonomy codes to identify clinician type and specialty. PCP visits were defined as an evaluation and management visit in the Part B M (...truncated)