ABSTRACT:
Purpose: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are
similar in mission, services provided, and common patient diagnoses, but have different payment policies under Medicare. The purpose of this study is to investigate how Medicare payment and patient cost sharing differ among FQHCs and RHCs.
Methods: The study included all 2014 claims generated at FQHCs and RHCs by rural Medicare
beneficiaries. Multivariate linear regression was used to estimate the effect of facility type on Medicare payment and cost sharing, controlling for various facility, geographic, and community factors.
Findings: The average Medicare payment across all FQHCs and RHCs was $119 per claim.
Compared to rural FQHCs, Medicare payment per claim was $39.95 higher at provider-based RHCs with ≤ 49 beds, $11.83 lower at provider-based RHCs with ≥ 50 beds, and $22.32 lower at independent RHCs.
The average cost sharing across all FQHCs and RHCs was $32 per claim. Compared to rural FQHCs, cost sharing per claim was $18.59 higher at based RHCs with ≥ 50 beds, $15.03 higher at provider-based RHCs with ≤ 49 beds, and $12.96 higher at independent RHCs.
Conclusion: Medicare payment and patient cost sharing differed significantly among types of
FQHCs and RHCs. The results suggest that there may be a need to assess 1) whether the exemption from the Medicare payment limit for provider-based RHCs with ≤ 49 beds is achieving the policy objective, and 2) whether rural Medicare beneficiaries without access to a rural FQHC are disadvantaged (due to higher cost sharing amounts).
INTRODUCTION
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are both federally-designated, safety net facilities that play a vital role in improving access to health care for underserved populations, including rural communities.1,2 Several studies have found that the presence of FQHCs and RHCs helps to increase access to care, as measured by lower rates of hospitalization for ambulatory care sensitive conditions in an area.3-6 Access to care is important for overall physical, social, and mental health status, and can lead to improved outcomes (such as lower rates of chronic disease and increased life expectancy).7,8
FQHCs and RHCs both provide services typically furnished in an outpatient clinic, with an emphasis on primary care. The specific services covered by Medicare at FQHCs and RHCs are similar, with the one exception that outpatient diabetes self-management training and medical nutrition therapy for patients with diabetes or renal disease are Medicare-covered services at FQHCs, but not RHCs. Additionally, FQHCs are required to provide certain services, such as dental treatments, that are not covered by Medicare. Many FQHCs also provide additional support services, such as transportation or case management, that are not covered by Medicare (but may be covered by the state Medicaid program).9,10
Due to their status as safety-net facilities, both FQHCs and RHCs operate using special federal payment provisions meant to protect their financial stability and therefore maintain access to care for the populations they serve.10-12 However, federal policy has developed over time so that the regulations used to calculate Medicare payment and patient cost sharing differ by facility type. Other studies have looked at the patient base,13,14 quality of care,15-18 and utilization19,20 at FQHCs and RHCs, but none have empirically compared payment between the two facility types.
considerable out-of-pocket expenses, and generate a relatively large portion of federal spending (which is expected to increase in the upcoming years).23,24 Studies have shown that access to care is important for overall health status and correlates with several health outcomes,7,8 which may then lead to lower costs (both for the Medicare program and its beneficiaries). FQHCs and RHCs are intended to improve access and many rural Medicare patients receive care at these facilities. Therefore, policy and payment variations at FQHCs and RHCs serving rural Medicare patients are of particular interest.
The purpose of this study is to investigate differences in Medicare payment per claim and patient cost sharing per claim for rural Medicare beneficiaries at FQHCs and RHCs. Results will provide insight on how policy related to each facility type translates into payment differences realized in practice. Because they are similar in mission and services provided, but follow different payment regulations, understanding the variations in Medicare payment and cost sharing at each facility type is important. Potential disparities could be a source of concern to policy makers and other stakeholders.
Background
The FQHC program was created by the Omnibus Budget Reconciliation Act of 1990; FQHCs must be public or not-for-profit and governed by a board of directors, of whom a majority of the members receive care at that facility.1,10 RHCs were established by the Rural Health Clinics Act in 1977 to address the inadequate supply of providers in rural areas. Unlike FQHCs, RHCs can be for profit and must be staffed with non-physician practitioners at least 50% of the time. RHCs can be independent (freestanding) or provider-based (an integral and subordinate part of a hospital, skilled nursing facility, or a home health agency). Additionally, RHCs must be located in an area that is non-urbanized and designated as a
shortage area. A clinic cannot be recognized as both an FQHC and an RHC.2,10
concern about the complexity and administrative burden of the changes),26,27 so it is likely that the majority of FQHCs were still using the AIR during the study period. There is an upper payment limit from Medicare under the AIR. However, provider-based RHCs whose parent hospital has fewer than 50 beds (PB RHC, ≤ 49 beds) are exempt from this limit.9 Additionally, there were separate payment limits at rural and urban FQHCs to recognize the potential for higher operating costs at urban FQHCs.25,28
Each facility’s AIR is calculated by dividing allowable costs by the number of visits. Allowable costs are those that result from providing Medicare-covered services, are reasonable in amount, and are necessary for the efficient delivery of those services; they include direct and overhead costs.9,25 A visit is defined as a medically necessary face-to-face encounter between a patient and a practitioner, during which one or more RHC or FQHC services (within the practitioner’s state scope of practice) are rendered.
Encounters with more than one practitioner on the same say, or multiple encounters with the same practitioner on the same day, generally constitute a single visit and are billed as one claim. However, there are exceptions in which there can be more than one visit on a claim.9,29
Table 1: Regulations for Medicare payment and patient cost sharing at FQHCs and RHCs1,2,25
Facility
Type CHARGE MEDICARE PAYMENT COST SHARING
Federally Qualified Health Center (FQHC)
•Each facility sets their own •Must be
reasonable, and uniform for all patients
•After any applicable deductibles have been satisfied, paid 80% of their AIR, except for those that transitioned to the PPS rate •Subject to upper payment limit
under the AIR; higher limit for urban FQHCs
•Coinsurance is 20% of the lesser of: total charges or the PPS rate
•No Part B deductible for FQHC-covered services •Sliding fee scale is
mandatory
Rural Health
Clinic (RHC)
•Each facility sets their own •Must be
reasonable, and uniform for all patients
• After any applicable deductibles have been satisfied, paid 80% of their AIR
• Subject to upper payment limit under the AIR, except provider-based RHCs, ≤ 49 beds
•Coinsurance is 20% of total charges
•Part B deductible applies and is based on total charges
•Sliding fee scale is optional
Note: Information in this table only applies to payment for Medicare-covered services; some exemptions exist for certain preventive services reimbursed by Medicare at 100% of cost.9
METHODS
Study Sample and Data Analysis
We used the Medicare Master Beneficiary Summary File to identify all rural beneficiaries (in both Parts A and B) living in the U.S. or its territories, and then linked these beneficiaries with their claims generated at FQHCs and/or RHCs from January to December 2014 in the Medicare Outpatient Research Identifiable File. These claims were rolled up to the facility level to give information per
facility. Therefore, only facilities that had at least one claim from a rural Medicare beneficiary in 2014 are included in this study. We chose calendar year 2014 because it is the most recent year in which data using consistent ICD codes for the whole year were available. (ICD 9 to ICD 10 switch occurred in October 2015.) Facilities were classified into various types using the last 4 digits of their CMS Certification Number (CCN). Each FQHC delivery site and RHC, whether independent or provider-based, has a unique CCN.30 Small numbers (less than or equal to 10) of total patients or total claims per facility were
missing information and are not included in this study. Overall, this process resulted in 2,352,088 claims generated at 3,915 FQHCs (individual sites) and 7,357,302 claims generated at 3,697 RHCs over the study period.
Data analysis was performed using multivariate linear regression and Stata 14 (StataCorp LP, College Station, TX) statistical software. Robust standard errors were used in the regressions by clustering at the county level.
Variables
Dependent variables - Medicare payment is the amount paid from the Medicare Supplementary Medical Insurance (SMI) trust fund to the facility for the services reported on the outpatient claim.31 Patient cost sharing was calculated by adding the Part B deductible, blood deductible, and coinsurance amounts.31,32
Common Diagnoses
The most common diagnoses at a facility are indicative of its patient population and the types of services provided. The Medicare-covered services are similar at FQHCs and RHCs,9 and previous research has shown that the most common diagnoses of Medicare patients are similar at both facility types.12 Separate regressions were performed for each of the three most common diagnoses in the study sample to investigate if variations in Medicare payment or patient cost sharing differ by diagnosis. In these analyses, Clinical Classification Software (CCS) groupers were used to cluster patient diagnoses into a manageable number of clinically meaningful categories.38
RESULTS
Descriptive statistics
Table 2 shows that provider-based RHCs whose parent hospital had less than or equal to 49 beds (PB RHCs, ≤ 49 beds) had the highest number of claims from rural Medicare patients in 2014, and urban FQHCs the lowest number of claims from rural Medicare patients in 2014. The highest average Medicare payment per claim was almost double the lowest ($152.18 at PB RHCs, ≤ 49 beds compared to $87.12 at independent RHCs). The average patient cost sharing per claim was higher at RHCs than FQHCs, with the lowest at rural FQHCs and the highest at provider-based RHCs whose parent hospital had more than or equal to 50 beds (PB RHCs, ≥ 50 beds). 59% (or 2,325/3,915) of FQHCs in the study sample were located in an urban area. However, the average number of claims from rural Medicare patients was much higher at rural FQHCs compared to urban FQHCs (1,310 vs. 116). A small portion of RHCs were
considered to be an urban area, due to variations in the definition of rural and changes in the population of an area after the establishment of an RHC. The vast majority of FQHCs were not-for-profit; most
of the FQHCs and independent RHCs in the study sample were located in the South; the majority of provider-based RHCs in the study sample were located in the Midwest.
Table 2: Characteristics of FQHCs and RHCs that had at least one claim from a rural Medicare patient in 2014
FQHC RHC
Rural Urban Independent PB, ≤ 49 beds PB, ≥ 50 beds
Number of facilities 1,589 2,326 1,595 1,858 244
Number of claims 2,082,195 269,893 3,091,615 3,863,820 401,867
Average number of claims per
facility 1,310 116 1,938 2,080 1,647
Dependent variables
Medicare payment per claim, mean (SD) $112.39 (12.90) $121.01 (18.46) $87.12 (12.12) $152.18 (44.40) $97.24 (24.42) Patient cost sharing per claim,
mean (SD) $24.85 (6.49) $26.39 (10.66) $36.46 (11.60) $39.22 (10.37) $42.03 (16.28) Rurality
Rural, % (n) 100.00 (1,589) -- 81.32 (1,297) 92.20 (1,713) 82.79 (202) Urban, % (n) -- 100.00 (2,326) 18.68 (298) 7.80 (145) 17.21 (42)
Facility ownership
For profit, % (n) -- -- 69.47 (1,108) 12.43 (231) 19.67 (48) Not-for-profit, % (n) 95.03 (1,510) 91.83 (2,136) 26.90 (429) 57.86 (1,075) 63.11 (154) Government, % (n) 4.41 (70) 7.61 (177) 3.64 (58) 29.71 (552) 17.21 (42)
Religious, % (n) 0.57 (9) 0.56 (13) -- -- --
Provider supply
County PCP ratio, mean (SD) 54.09 (31.16) 78.71 (30.20) 48.38 (27.05) 48.69 (27.74) 50.17 (25.04) County specialist ratio, mean
(SD) 53.89 (67.83) 169.41 (124.34) 46.35 (59.90) 29.07 (48.37) 53.38 (49.24) Community demographics
County child poverty, mean %
(SD) 19.98 (6.61) 16.71 (5.20) 19.39 (6.55) 17.32 (5.93) 21.12 (6.52) County uninsured <65, mean %
(SD) 18.44 (4.95) 16.80 (5.16) 18.02 (4.61) 17.79 (5.21) 18.70 (3.86) County minority, mean % (SD) 26.76 (23.55) 38.68 (21.08) 22.10 (20.82) 19.91 (19.33) 25.19 (24.31) County elderly, mean % (SD) 16.81 (3.93) 13.57 (3.30) 16.86 (4.38) 17.96 (4.13) 16.75 (4.08)
Census Region
Northeast, % (n) 12.46 (198) 15.13 (352) 3.26 (52) 4.09 (76) 3.28 (8) Midwest, % (n) 18.75 (298) 18.06 (420) 34.67 (553) 48.17 (895) 40.98 (100) South, % (n) 42.29 (672) 34.09 (793) 46.71 (745) 29.60 (550) 38.11 (93) West, % (n) 26.37 (419) 32.67 (760) 15.36 (245) 18.14 (337) 17.62 (43)
Multivariate statistics
Medicare payment per claim
Table 3 shows that, after controlling for other factors, Medicare paid the most per claim to PB RHCs, ≤ 49 beds. PB RHCs, ≤ 49 beds received about $40 more from Medicare per claim compared to rural FQHCs. The average Medicare payment per claim in the entire all-facility sample was $119, so this is about 34% higher. Independent RHCs received about $22 less (or 18% lower than average), and PB RHCs, ≥ 50 beds received about $12 less (or 10% lower than average), in Medicare payment per claim compared to rural FQHCs. Urban FQHCs received about $6 more from Medicare per claim compared to rural FQHCs, which is 5% more than the average of $119. The control variables in the model had small and/or insignificant effects on Medicare payment per claim. Levels of rurality were explored using RUCA measures36 in the regression and results were analogous.
Table 3: Multivariate linear regression estimating the effect of facility type on Medicare payment and patient cost sharing per claim
Medicare payment per claim
Cost sharing per claim
Facility typei
Urban FQHC $ 6.01*** $ -0.42 Independent RHC $ -22.32*** $ 12.96*** PB RHC, ≤ 49 beds $ 39.95*** $ 15.03*** PB RHC, ≥ 50 beds $ -11.83*** $ 18.59***
Facility ownershipii
Not-for-profit $ 1.45 $ 0.75 Government $ -0.13 $ 0.24 Religious $ 2.50 $ 1.84
Provider supply
PCP ratio $ 0.03 $ -0.01* Specialist ratio $ 0.01 $ 0.01*** Community demographics
Poverty rate $ -0.16 $ -0.12* Uninsured <65 rate $ 0.02 $ -0.01 Minority percentage $ 0.09** $ 0.04**
Elderly percentage $ 0.25 $ -0.02
Patient cost sharing per claim
Table 3 shows that, after controlling for other factors, patients generally had higher cost sharing amounts at RHCs (especially PB RHCs, ≥ 50 beds) compared to rural FQHCs. At PB RHCs, ≥ 50 beds, patient cost sharing per claim was almost $19 higher than at rural FQHCs. The average patient cost sharing amount in the entire all-facility sample was $32, so this is almost 60% higher. Cost sharing at PB RHCs, ≤ 49 beds was about $15 more per claim compared to rural FQHCs, which is 47% higher than the average of $32. At independent RHCs, patient cost sharing was $13 more per claim (or $41% higher than average) compared to rural FQHCs. Patients had a slightly lower (insignificant) cost sharing amount at urban FQHCs compared to rural FQHCs. The control variables in the model had small and/or
insignificant effects on patient cost sharing per claim. Levels of rurality were explored using RUCA measures36 in the regression and results were analogous.
Common diagnoses
The diagnoses most common at FQHCs and RHCs in the study sample were very similar.
DISCUSSION
This study found statistically significant variations in Medicare payment and patient cost sharing based on facility type. Medicare payment per claim was highest at PB RHCs, ≤ 49 beds, which is likely due to the fact that the policy is written so that most of these facilities are exempt from the Medicare upper payment limit. The other types of RHCs (independent and PB, ≥ 50 beds) received lower payment from Medicare compared to rural FQHCs, which could have been influenced by several factors. FQHCs have a slightly wider range of services covered by Medicare, and also often provide additional support services (such as case management or transportation). Although these support services are not covered by Medicare, they could have been factored into their AIR and consequently increased payment from Medicare. PB RHCs, ≥ 50 beds received slightly higher payment than independent RHCs, which could have been due to coding practices, staff capacity, and/or the types of providers delivering care (ie MD vs. NP or PA). Last, urban FQHCs received slightly higher Medicare payment compared to rural FQHCs. Under the AIR, urban FQHCs had a higher upper payment limit from Medicare to recognize the potential for higher operating costs.25,28 Additionally, urban and rural FQHCs could have a different service mix, which may influence Medicare payment.
Patient cost sharing (which includes the deductible and coinsurance amounts) was highest at RHCs. This is likely due to the fact that policy is written so that the Part B deductible does not apply to FQHC services and sliding fee scales are required at FQHCs.25 There was slight variation in patient cost sharing at different types of RHCs, which could be due to differences in charge amounts or the use of sliding fee scales.
Conclusion
multivariate analysis had been undertaken to empirically study the effects of these policies. Significant variations were found in Medicare payment and patient cost sharing based on facility type, which could be a source of concern to policy makers and other stakeholders.
There were four limitations to this study: first, information about the level or complexity of services was not included. Second, this study focused on the cost sharing amount (what patients were responsible to pay), not actual patient out-of-pocket expenses—it excluded the effect of other payers (eg Medigap, supplemental insurance) and non-payment. Third, between October 2014 and December 2015, FQHCs were scheduled to transition from the AIR to the PPS rate. The transition was time- and resource-intensive,26,27 so most FQHCs likely did not effectively transition until 2015 (after our study period.) Nevertheless, some FQHCs could have been paid under the PPS rate during the last three months of our study period, which would introduce elements of heterogeneity in the sample. Finally, the transition to the PPS rate could also mean that current payment disparities are different from those estimated in this study.
There are two important policy implications of this study. First, if the policy objective of the exemption from the upper payment limit for PB RHCs, ≤ 49 beds is to support small RHCs in remote rural areas, then it would seem important to determine whether this objective is actually being achieved. This study found that PB RHCs, ≤ 49 beds received $39.95 more per claim from Medicare compared to rural FQHCs. However, it is unknown whether the magnitude of this enhanced reimbursement is enough to offset the higher operating cost per patient faced by small, low volume RHCs in remote areas.
Second, this study found that, after controlling for other factors, rural Medicare beneficiaries had higher cost sharing at RHCs (especially PB RHCs, ≥ 50 beds) compared to rural FQHCs. This suggests that there is a need to assess whether rural Medicare beneficiaries without access to a rural FQHC are disadvantaged due to this higher cost sharing. Higher costs could impact their ability to access health care services. Additionally, paying different amounts for the same or similar services depending on the type of facility that is most accessible may not be consistent with optimal payment policy.
In conclusion, there are almost always unintended consequences of payment policy decisions. It is important for Medicare to continuously assess how policies are realized in practice, as it affects both the Medicare program itself and the beneficiaries it serves.
Acknowledgments
Helpful comments were provided by Sarah Young, Wakina Scott, Craig Caplan, Amy
Chanlongbutra, and Kerri Cornejo at the Federal Office of Rural Health Policy. These individuals had the opportunity to comment on, but not edit, the manuscript.
Funding Sources
This study was supported by the Federal Office of Rural Health Policy (FORHP), Health
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