Brad Wright

Who Governs Federally Qualified Health Centers

To make them more responsive to their communitys needs, federally qualified health centers (FQHCs) are required to have a governing board comprising at least 51 percent consumers. However, the extent to which consumer board members actually resemble the typical FQHC patient has not been assessed, which according to the political science literature on representation may influence the boards ability to represent the community. This mixed-methods study uses four years of data from the Health Resources and Services Administration, combined with Uniform Data System, Bureau of Labor Statistics, and Area Resource File data, to describe and identify factors associated with the composition of FQHC governing boards. Board members are classified into one of three groups: nonconsumers, nonrepresentative consumers (who do not resemble the typical FQHC patient), and representative consumers (who resemble the typical FQHC patient). The analysis finds that a minority of board members are representative consumers, and telephone interviews with a stratified random sample of thirty FQHC board members confirmed the existence of significant socioeconomic gaps between consumer board members and FQHC patients. This may make FQHCs less responsive to the needs of the predominantly low-income communities they serve.

Implementation of the Affordable Care Act and Rural Health Clinic Capacity in Iowa

Objective: To evaluate the capacity of rural health clinics (RHCs) in Iowa as the Affordable Care Act (ACA) is implemented. Methods: We developed and fielded an online survey among the 142 RHCs in Iowa. Results: The survey response rate was 19% and this exceeds the response rate of previously published RHC studies. Responding RHCs report struggling to provide dental care and mental health services, and indicate a high degree of recruiting difficulty for physicians (80%), physician assistants, and nurse practitioners (both 50%), with referrals to specialists being common. Nearly 60% of RHC respondents anticipate an increase in the size of their patient population because of the ACA, with 14.8% expecting a substantial increase. Respondents indicated a lack of preparedness for participating in a value-based health care delivery system. While nearly all RHC respondents (90.4%) report knowing what steps they need to take to respond to the challenges health reform may present, only 19% agree that they have the human, financial, and material resources necessary to respond to those challenges. Conclusion: RHCs have limited capacity to respond to the opportunities and challenges of the ACA, and need additional resources and incentives to thrive in a reformed health care delivery system.

Trends in Observation Care Among Medicare Fee‐for‐Service Beneficiaries at Critical Access Hospitals, 2007‐2009

PURPOSE Observation care is used to evaluate patients prior to admission or discharge. Often beneficial, such care also imposes greater financial liability on Medicare beneficiaries. While the use of observation care has increased recently, critical access hospitals (CAHs) face different policies than prospective payment (PPS) hospitals, which may influence their observation care use. METHODS We used 100% Medicare inpatient and outpatient claims files and enrollment data for years 2007 to 2009, and the 2007 American Hospital Association data to compare trends in the likelihood, prevalence and duration of observation stays between CAHs and PPS hospitals in metro and non-metro areas among fee-for-service Medicare beneficiaries over age 65. FINDINGS While PPS hospitals are more likely to provide any observation care, the 3-year increase in the proportion of CAHs providing any observation care is approximately 5 times as great as the increase among PPS hospitals. Among hospitals providing any observation care in 2007, the prevalence at CAHs was 35.7% higher than at non-metro PPS hospitals and 72.8% higher than at metro PPS hospitals. By 2009, these respective figures had increased to 63.1% and 111%. Average stay duration increased more slowly for CAHs than for PPS hospitals. CONCLUSIONS These data suggest that a growing proportion of CAHs are providing observation care and that CAHs provide relatively more observation care than PPS hospitals, but they have shorter average stays. This may have important financial implications for Medicare beneficiaries.

Iowa’s Medicaid Expansion Promoted Healthy Behaviors But Was Challenging To Implement And Attracted Few Participants

As part of Iowas Medicaid expansion, the Healthy Behaviors Program was designed to provide members with incentives to complete specified healthy activities in return for waiving monthly premiums. We used claims data and interviews to document the first year (2014) of the programs implementation. Healthy activities completion rates did not exceed 17 percent. Interviews with members and clinic managers revealed low levels of awareness of the programs existence, deficits in knowledge about how the program works, and a variety of barriers to activity completion. Our findings suggest that the lack of knowledge hindered the states ability to incentivize activities and that it subjected beneficiaries to premium expenses and potential disenrollment. These results should guide federal and state policy makers in devising more effective ways of educating Medicaid beneficiaries and providers about programs that incentivize responsibility for healthy behaviors. The results suggest that efforts by federal and state governments to reform Medicaid by shifting responsibility onto program members for healthy behaviors are unlikely to succeed, especially without careful thought and design of premiums, penalties, and incentives for participants.

Do patients have a voice? The social stratification of health center governing boards

To ensure community responsiveness, federally qualified health centres (FQHCs) in the United States are required to be governed by a patient majority. However, to the extent that these patient trustees resemble the typical low‐income patients served by FQHCs, status generalization theory suggests that they will be passed over for leadership positions within the board in favour of more prestigious individuals.

The origin and disposition of Medicare observation stays.

Background:Growing use of hospital observation care continues unabated despite growing concerns from Medicare beneficiaries, patient advocacy groups, providers, and policy makers. Unlike inpatient stays, outpatient observation stays are subject to 20% coinsurance and do not count toward the 3-day stay required for Medicare coverage of skilled nursing facility (SNF) care. Despite the policy relevance, we know little about where patients originate or their discharge disposition following observation stays, making it difficult to understand the scope of unintended consequences for beneficiaries, particularly those needing postacute care in a SNF. Objective:To determine Medicare beneficiaries’ location immediately preceding and following an observation stay. Research Design:We linked 100% Medicare Inpatient and Outpatient claims data with the Minimum Data Set for nursing home resident assessments. We then flagged observation stays and conducted a descriptive claims-based analysis of where beneficiaries were immediately before and after their observation stay. Results:Most patients came from (92%) and were discharged to (90%) the community. Of >1 million total observation stays in 2009, just 7537 (0.75%) were at risk for high out-of-pocket expenses related to postobservation SNF care. Beneficiaries with longer observation stays were more likely to be discharged to SNF. Conclusions:With few at risk for being denied Medicare SNF coverage due to observation care, high out-of-pocket costs resulting from Medicare outpatient coinsurance requirements for observation stays seem to be of greater concern than limitations on Medicare coverage of postacute care. However, future research should explore how observation stay policy might decrease appropriate SNF use.

Use or Abuse? A Qualitative Study of Emergency Physicians' Views on Use of Observation Stays at Three Hospitals in the United States and England

Study objective: Accumulating evidence has shown increasing use of observation stays for patients presenting to emergency departments and requiring diagnostic evaluation or time‐limited treatment plans, but critics suggest that this expansion arises from hospitals’ concerns to maximize revenue and shifts costs to patients. Perspectives of physicians making decisions to admit, observe, or discharge have been absent from the debate. We examine the views of emergency physicians in the United States and England on observation stays, and what influences their decisions to use observation services. Methods: We undertook in‐depth, qualitative interviews with a purposive sample of physicians in 3 hospitals across the 2 countries and analyzed these using an approach based on the constant‐comparison method. Limitations include the number of sites, whose characteristics are not generalizable to all institutions, and the reliance on self‐reported interview accounts. Results: Physicians used observation status for the specific presentations for which it is well evidenced but acknowledged administrative and financial considerations in their decisionmaking. They also highlighted an important role for observation not described in the literature: as a “safe space,” relatively immune from the administrative gaze, where diagnostic uncertainties, sociomedical problems, and medicolegal challenges could be contained. Conclusion: Observation status increases the options available to admitting physicians in a way that they valued for its potential benefits to patient safety and quality of care, but some of these have been neglected in the literature to date. Reform to observation status should address these important but previously unacknowledged functions.

Voices of the Vulnerable: Community health centres and the promise and peril of consumer governance

Abstract Various efforts to give health care consumers a voice in decision-making have been attempted since at least the mid-twentieth century, with little success. In this article, I focus on one form of consumer participation: the requirement for community health centres in the United States to be governed by a consumer majority board. I examine the historical origins and theoretical assumptions motivating the requirement, summarize recent research that demonstrates how these assumptions are violated in practice, and suggest some prescriptive policy guidelines for the effective use of consumer participation in health care decision-making.

Younger Dual-Eligibles Who Use Federally Qualified Health Centers Have More Preventable Emergency Department Visits, but Some Have Fewer Hospitalizations

Objective: To determine whether younger dual-eligibles receiving care at federally qualified health centers (FQHCs) have lower rates of ambulatory care sensitive (ACS) hospitalization and emergency department (ED) visits. Data Sources: We used the 100% Medicare Part A and Part B institutional claims from 2007 to 2010 for dual-eligibles younger than 65 years, enrolled in traditional fee-for-service Medicare, who received care at an FQHC or lived in a primary care service area with an FQHC. Methods: Our cross-sectional analysis used negative binomial regressions to model ACS hospitalizations and ED visits as a function of prior year FQHC use. The model adjusted for beneficiary age, gender, race, and chronic diseases, as well as county fixed effects, time trends, and race-FQHC use interactions. Results: FQHC use is associated with a decrease in ACS hospitalization rates for whites (2.8 per 1000 persons), but an increase among blacks (2.5 per 1000 persons). FQHC use is also associated with an increase in ACS ED visits, from 27 to 33 more visits per 1000 persons per year, depending on patient race. Conclusions: ACS hospital use is higher for FQHC users than nonusers, but white FQHC users have fewer ACS hospitalizations. More research is needed to understand how this relationship varies within and between centers.

Iowa Wavering on Medicaid: From Expansion to Modernization

Iowa is one of six states to expand Medicaid through section 1115 waivers. Iowas alternative approach to Medicaid expansion, known as the Iowa Health and Wellness Plan, was the result of a bipartisan compromise, motivated by the pending expiration of a preexisting section 1115 waiver that served sixty-five thousand Iowans. The Iowa Health and Wellness Plan emphasizes personal responsibility and private involvement. Key features include beneficiary premiums, incentives for healthy behaviors, and premium assistance for some beneficiaries to purchase insurance in the health insurance marketplace. However, Iowa has struggled to implement its expansion as initially envisioned, due largely to the lack of private insurers willing and able to insure new Medicaid enrollees in the marketplace. In 2016 Iowa will dramatically increase the role of managed care in Medicaid, with the vast majority of beneficiaries receiving almost all Medicaid services through a capitated managed care organization. This article highlights the local factors driving expansion, the interplay of the state and federal political landscape, the challenges of providing consumer choice within Iowas marketplace, and the future of Iowas Medicaid program under managed care.