Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers.
This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers.
Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013).
One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs.
Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software.
Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise.
A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Shin P, Sharac J, Alvarez C, Rosenbaum S, Paradise J. Community Health Centers in an Era of Health Reform. Kaiser Family Foundation: Washington, DC; 2013.
Goldman LE, Chu PW, Tran H, Romano MJ, Stafford RS. Federally qualified health centers and private practice performance on ambulatory care measures. Am J Prev Med. 2012;43(2):142–9. doi:10.1016/j.amepre.2012.02.033.
Shi L, Lebrun LA, Zhu J, et al. Clinical Quality Performance in U.S. Health Centers. Health Serv Res. 2012;47(6):2225–49.
Epstein AJ. The role of public clinics in preventable hospitalizations among vulnerable populations. Health Serv Res. 2001;36(2):405–20.
Falik M, Needleman J, Wells BL, Korb J. Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers. Med Care. 2001;39(6):551–61.
Hadley J, Cunningham P. Availability of Safety Net Providers and Access to Care of Uninsured Persons. Health Serv Res. 2004;39(5):1527–46. doi:10.1111/j.1475-6773.2004.00302.x.
Shi L, Stevens GD. The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured. J Ambulatory Care Manage. 2007;30(2):159–70. doi:10.1097/01.JAC.0000264606.50123.6d.
Gusmano MK, Fairbrother G, Park H. Exploring The Limits Of The Safety Net: Community Health Centers And Care For The Uninsured. Health Aff (Millwood). 2002;21(6):188–94. doi:10.1377/hlthaff.21.6.188.
Zuckerman KE, Cai X, Perrin JM, Donelan K. Incomplete Specialty Referral among Children in Community Health Centers. J Pediatr. 2011;158(1):24–30. doi:10.1016/j.jpeds.2010.07.012.
Cook NL, Hicks LS, O’Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access To Specialty Care And Medical Services In Community Health Centers. Health Aff (Millwood). 2007;26(5):1459–68. doi:10.1377/hlthaff.26.5.1459.
Doty MM, Abrams MK, Hernandez SE, Stremikis K, Beal AC. Enhancing the Capacity of Community Health Centers to Achieve High Performance. The Commonwealth Fund; 2010.
McClellan MB, McKethan AN, Lewis JL, Roski J, Fisher ES. A National Strategy to put Accountable Care into Practice. Health Aff (Millwood). 2010;29(5):982–90. doi:10.1377/hlthaff.2010.0194.
Lewis VA, Colla CH, Carluzzo KL, Kler SE, Fisher ES. Accountable Care Organizations in the United States: Market and Demographic Factors Associated with Formation. Health Serv Res. 2013;48(6):1840–58. doi:10.1111/1475-6773.12102.
Fisher ES, Berwick DM, Davis K. Achieving health care reform—how physicians can help. N Engl J Med. 2009;360(24):2495–7. doi:10.1056/NEJMp0903923.
Berwick DM. Making Good on ACOs’ Promise—The Final Rule for the Medicare Shared Savings Program. N Engl J Med. 2011;365(19):1753–6. doi:10.1056/NEJMp1111671.
Fisher ES, McClellan MB, Safran DG. Building the path to accountable care. N Engl J Med. 2011;365(26):2445–7. doi:10.1056/NEJMp1112442.
Pollack CE, Armstrong K. Accountable care organizations and health care disparities. JAMA. 2011;305(16):1706–7. doi:10.1001/jama.2011.533.
Lewis VA, Larson BK, McClurg AB, Boswell RG, Fisher ES. The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff Proj Hope. 2012;31(8):1777–85. doi:10.1377/hlthaff.2012.0490.
McWilliams JM. Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value. J Gen Intern Med. 2013:1-2. doi:10.1007/s11606-013-2713-9.
Neuhausen K, Grumbach K, Bazemore A, Phillips RL. Integrating Community Health Centers Into Organized Delivery Systems Can Improve Access To Subspecialty Care. Health Aff (Millwood). 2012;31(8):1708–16. doi:10.1377/hlthaff.2011.1261.
We thank Savannah Bergquist, Kathleen Carluzzo, Tom Rundall, Aleen Saunders, Will Schpero, and Frances Wu for valuable contributions to and comments on earlier versions of this work. This work was supported by a grant from The Commonwealth Fund.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Rights and permissions
About this article
Cite this article
Lewis, V.A., Colla, C.H., Schoenherr, K.E. et al. Innovation in the Safety Net: Integrating Community Health Centers Through Accountable Care. J GEN INTERN MED 29, 1484–1490 (2014). https://doi.org/10.1007/s11606-014-2911-0
- health care reform
- health care costs
- health care delivery
- underserved populations
- safety net
- accountable care
- integrated care
- community health centers