Association between Medicare spending, prevention quality indicators, and community health center penetration among low-income residents

Objective: There is currently great interest in approaches to reduce Medicare spending, while maintaining quality of care. One promising approach consists of expanded access to the Health Center Program. We examined the association between Medicare spending, prevention quality indicators, and access to primary care by the underserved across Hospital Referral Regions (HRRs).

Methods: We analyzed data from the Commonwealth Fund's Scorecard on Local Health System Performance 2012, which provides comparative data on U.S. communities (i.e., 43 indicators spanning four dimensions: access, prevention and treatment, costs and potentially avoidable hospital use, and health outcomes) to assess relative performance of their health care systems. We focus on spending and quality indicators for fee-for-service beneficiaries enrolled in Medicare Parts A and B in 2010 at the HRR level (n=306). For each HRR, we examined three measures: ambulatory care sensitive (ACS) hospital admissions per 100,000 Medicare beneficiaries, ACS emergency department (ED) visits per 1,000 Medicare beneficiaries, and Medicare payments per enrollee. Next, we merged HRR data on number of Health Center (HC) patients (from HRSA's Uniform Data System) and number of low-income (≤ 200% federal poverty level) residents (from the American Community Survey). Access to primary care by the underserved in each HRR was estimated as HC patient penetration, defined as HC patients as a proportion of low-income residents. Using Medicare population weighted bivariate (i.e., sort the data by HC penetration and compare key outcomes of the top and bottom deciles) and multivariate regression techniques, we estimated Medicare spending and prevention quality measures as a function of HC penetration.

Results: Regression estimates suggested that a standard deviation increase in mean HC penetration (i.e., from 21% to 40%) was associated with 3.4% reduction in Medicare per enrollee spending ($286, p<0.001) and a 3.4% reduction in ACS hospital admissions (206 per 100,000 beneficiaries, p<0.001). Relative to the low-penetration decile, the high-penetration decile had 8.6% lower per capita Medicare spending ($677, p<0.034) and 13.5% lower ACS hospital admission rates (754 per 100,000 beneficiaries, p<0.046). We found no statistically significant relationship between ACS ED visits and HC penetration.

Conclusions: Although a modest 3.1% of all Medicare enrollees used Health Center services in 2010, statistically significant inverse associations are evident between Health Center patient penetration among low-income residents in HRRs and (a) Medicare spending per enrollee and (b) ambulatory care sensitive hospital admissions. Health Center program expansion supported by the Affordable Care Act may yield Medicare program cost savings.