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How do FQHCs affect accountable care organizations?

FQHCs help accountable care organizations reach a more diverse patient population and potentially enable better patient access to preventive care.

Sara Heath
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Published: 22 Nov 2024

Including federally qualified health centers in accountable care organizations isn't exactly the detriment some industry experts might think, a new JAMA Network Open study challenges.

Instead, it could increase patient access to preventive care and broaden ACOs' reach to more diverse patient populations, the study authors said.

"Engaging safety net practices in ongoing payment and delivery system reform is critical to ensure equitable access to high-value care," the researchers wrote in the study's introduction. "Serving more than 30 million individuals regardless of their ability to pay, federally qualified health centers (FQHCs) are a natural policy target to be included in numerous value-based payment models, especially those with a population health and primary care focus."

Indeed, the number of FQHCs participating in the Medicare Shared Savings Program (MSSP) has increased. In 2016, there were 60 FQHCs included in MSSP, but by 2023, that number was 4,000.

Having more FQHCs participate in ACOs is important because ACOs are proven models that boost healthcare quality, access and equity, the researchers said. FQHCs have a lot of experience serving the nation's most underserved populations, making them good conduits for ensuring the benefits of an ACO -- combined with the culturally tailored care FQHCs usually deliver -- to these high-risk populations.

But ACO leaders don't always consider FQHCs when building out the organizations, mostly because of the financial constraints and infrastructure limitations these safety-net practices have.

"Moreover, their patients usually have complex health and social needs, limited access to specialty care, and higher utilization of emergency departments (EDs) compared with non-safety net practices," the researchers added. "These features may restrict ACOs' ability to generate savings and deter the inclusion of FQHCs in their participant lists."

This latest study outlined how FQHC participation in MSSP supports more value-based care delivery to traditionally marginalized groups and might improve access to preventive care for these groups.

The researchers used public MSSP files to compare the performance of ACOs that always had FQHC participation with those that never did between January 2016 and December 2022. They then supplemented that data with information about ACOs that added an FQHC to the mix for the first time.

FQHCs diversify ACO beneficiaries

The data unsurprisingly indicated that including FQHCs in ACOs expands their reach to socioeconomically disadvantaged populations.

For example, they served more dual-eligible beneficiaries (2035.8 vs. 1040.9 person-years), more beneficiaries with disabilities (3341.1 vs. 1705.1 person-years) and more racial or ethnic minority beneficiaries (3690.6 vs. 2515.1 person-years). These findings indicate that including FQHCs in ACOs enables them to reach the populations most in need of value-based care.

The data was more mixed when examining whether safety-net clinics adversely affect ACO metrics and outcomes.

When looking at ACOs that always included FQHCs, the researchers saw fewer primary care visits and more emergency department visits among beneficiaries. These ACOs also tended to do worse on some quality measures.

But when looking at ACOs that added safety-net clinics into the mix for the first time, the researchers did not identify any of those consequences. In fact, the team observed an increase in patient access to preventive care.

ACOs that newly added an FQHC saw higher rates of flu vaccination (+6 percentage points), tobacco screening and cessation (+11.8 percentage points) and higher rates of depression screening and follow-up (+8.9 percentage points).

Also of note was the limited change in healthcare utilization and costs after adding an FQHC to an ACO. ACOs that added FQHCs did not see statistically significant changes in healthcare utilization or expenditures, indicating that these improvements in patient diversity and preventive care access might come at little cost to the ACO.

"The increase in newly attributed beneficiaries from FQHCs may enlarge the potential referral base and revenue sources of specialists and hospitals participating in the same ACO," the researchers explained. "In addition, ACOs could provide value-based accountable care relationships for Medicare FQHC users, a group historically lacking access to specialty care and care coordination."

Patients visiting a safety-net clinic that's included in an ACO could see some benefits, like easier specialty referral access. Participation in an ACO could also grant an FQHC more financial freedom to make infrastructure investments that could benefit the whole patient population visiting the clinic.

Still, it is common for safety-net clinics to decline participation in or exit ACOs, largely because of the financial challenges they face that could limit their ability to bear downside risk. Some programs, like Pathways to Success and ACO REACH, help safety-net clinics with up-front infrastructure investment to assume downside risks.

"Our study highlights the potential implication for access and quality of care among socioeconomically disadvantaged Medicare beneficiaries when these incentives to encourage safety net participation are in place," the researchers concluded.

Sara Heath has covered news related to patient engagement and health equity since 2015.

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