Primary care practices nationally vary in their performance along key clinical measures. For this reason, policymakers, payers, and providers are increasingly focused on performance accountability and aligning payment to recognize value. The Affordable Care Act (ACA) of 2010 heavily invests in primary care infrastructure, including a major expansion of the Federally-Qualified Health Center program. Health centers already serve more than 20 million predominately low income, minority, and publicly insured or uninsured patients across the country. Despite their high-risk patient population, health centers are not immune to the accountability expectations that come with public investment and increased visibility.
This dissertation is the first to thoroughly examine the factors associated with health centers' higher performance on two patient outcome measures: diabetes and hypertension control. It draws from three years of programmatic data from 1000+ health center organizations, as well as state-level data representing key environmental factors that may influence health center capacity for quality improvement. The two performance measures are quartiled and health center differences between quartiles descriptively determined. Analyses then explore the external-, organizational-, and patient-level factors statistically related to achieving high performance as well as the circumstances in which a health center increases the odds of high performance.
Findings reveal that high performance on one measure does not necessarily indicate high performance on the other, yet certain common inputs are necessary to support quality improvement efforts across both chronic conditions. Those that increase the odds include state Medicaid adult enrollment rate, number of encounters per hypertensive or diabetic patient, and use of sampling rather than full population data to report the outcome measures. Those that decrease the odds of high performance include dependency on federal health center grant funding and percents of patients who are homeless and racial/ethnic minority. Several others factors are statistically significant for only one particular measure.
Findings suggest that more visits for diabetic and hypertensive patients may be the most important contributor to improving patient outcomes. Visit frequency appears to moderate or even overcome patient complexity factors, including chronic illness, homelessness, insurance status, and minority. Results also suggest that state-level environmental factors, principally Medicaid enrollment policy, underlie organizational- and patient-level factors related to quality performance in hypertension and diabetes control. Medicaid expansion states are therefore more likely to see the most gains in quality performance and disparities reduction than non-expansion states. However, findings also indicate that federal health center funding is needed to ensure access to care, particularly for patients with high burdens of chronic illness.
|Advisor:||Cordes, Joseph J.|
|Commitee:||Gurewich, Deborah, Shin, Peter|
|School:||The George Washington University|
|Department:||Public Policy and Public Administration|
|School Location:||United States -- District of Columbia|
|Source:||DAI-A 76/06(E), Dissertation Abstracts International|
|Subjects:||Public policy, Health care management|
|Keywords:||Community health center, Diabetes, Federally-qualified health center, Hypertension, Medicaid, Quality improvement|
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