Friday, March 14, 2025
3/14/2025
Abstract Community health centers (CHCs) are important safety-net providers that provide comprehensive preventive and primary care to vulnerable populations in the United States, including Medicaid beneficiaries and the uninsured. CHCs are also notable for providing the spectrum of primary care services, i.e., medical, mental, and basic dental care within a single medical home. Our overall objective is to explore the impact of changes in Medicaid reimbursement rate structures on utilization and costs of providing these co-located services in CHCs, and on their financial position in general. To achieve this goal, we will first estimate regressions on pooled all-state data for 2011, 2014, and 2018, the years for all states reported rate setting information to the National Association of Community Health Centers (NAHCH), combined with the federal Uniform Data System (UDS), which encompasses all individual CHCs. Similarly, we will analyze a balanced panel for the subset of 21 states reporting rate-setting in the full longitudinal sample, years 2011-2019, yielding 3,868 center-year observations. In particular, we will evaluate effects of opting for the federal based PPS rates versus state variations known as APMs, and the effects of imposing a single bundled payment rate per visit, i.e., the “all- inclusive” rate, versus the bundled rates by services category (primary, mental, and dental care), known as the service-specific rates. Given that in both the PPS or APM regimes, states may opt for either the inclusive rate or service-specific methodologies, we will explore the interactions of these pairings of payment policies. We will then examine the policy effects in a pooling of all years, and test for validity of a balanced or unbalanced longitudinal design. In the panel data analysis, we will employ a fixed effect model, with CHC and year fixed effects that leverages variations of state policies between states and over time within states. Corresponding to Aim 1, for visits, we will explore volume in each service category separately, as well as the distribution (share) of services. Corresponding to Aims 2-3, we will explore unit-costs and financial margins respectively. We note that while the effects of Medicaid ACA expansions in the overlapping period are well documented in the earlier literature (generally increasing both volume and costs), remarkably little is known about the effects of variations in actual Medicaid payment methodologies for CHCs for these outcomes. Our study aims to fill this gap in both the health services research literature and policy literature. With that, we will use a novel study design to control the effects of the ACA Medicaid expansions to capture the separate effects of Medicaid payment approaches.
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