March 25, 2023
On March 2, 2023, CDRP affiliate Robert S. Nocon, assistant professor of health systems science at Kaiser Permanente Bernard J. Tyson School of Medicine, was one of five expert witnesses to testify before the US Senate Committee on Health, Education, Labor, and Pensions. During the hearing, “Community Health Centers: Saving Lives, Saving Money,” Nocon presented findings from the CDRP’s Financial Analysis Research Agenda (FARA) project, a three-year federal contract with the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care led by CDRP director Elbert Huang and CDRP faculty affiliate Marshall Chin, which used Medicaid claims to evaluate the performance of the national Health Center Program.
“Millions of our people do not have access to the healthcare that they need, said Senator Bernie Sanders (I-VT), chairman of the Senate HELP committee, in his introduction to the hearing. Noting that working class Americans who do not have health care often use the emergency room, where the cost of primary care is 8 to 10 times higher than in community health centers, Sanders said, “When we invest in primary health care, we are going to save the system money.”
In his testimony, Nocon asserted, “We consistently find that care for patients in community health centers is associated with lower total health care costs,” pointing out that FARA confirms similar findings from over 30 years of research by diverse teams using different data sets. Previous studies using national claims data report substantial savings: total spending on health care was 24% lower for health center patients, and median annual costs for Medicare patients seen in health centers were 10% lower compared to patients in private physician offices and 30% lower compared to patients in outpatient clinics. “These findings suggest that investments in comprehensive primary care services offered by health centers reduce cost and utilization for services downstream of primary care among publicly insured patients,” said Nocon.
The FARA project used national Medicaid and Medicare claims data from 2012, 2014, and 2016 to study subpopulations of patients in greater detail—adults ages 18 to 64, children, patients eligible for both Medicaid and Medicare, diabetes patients, and patients with opioid use disorder—demonstrating that health center patients generally have lower total costs of care and similar or better quality of care. The cost savings are dramatic: “We estimate that in 2021, the health center program saved over $25 billion to Medicaid and Medicare over a 1-year period,” said Nocon—a figure that reflects greater use of primary care and reduced need for other services.
“Strong and stable funding of health centers is essential for these organizations to continue to serve as the backbone of the US primary care safety net,” which serves the country’s most vulnerable populations, who often have the greatest medical needs in combination with social risks including housing and financial instability, he concluded. “Ensuring adequate financing for health centers is a strong investment in the US healthcare system and one that research shows provides high value.”
Nocon, who began as a project manager in 2009 before pursuing a PhD in Public Health Sciences at the University of Chicago, is a longtime affiliate of the CDRP with a background in management consulting. “I wanted to focus on vulnerable populations and health disparities, and I’ve always been interested in social justice and health,” he says. “I wanted to do research on the safety net and underserved populations, so I started working as a research assistant on a project Marshall and Elbert had on evaluating the implementation of the patient-centered medical care in federally qualified health centers (FQHCs)—that project is where we gained the groundwork of working with the Medicaid data that we used for all the FARA studies.” In this early national claims-based project, the CDRP first began to build the code and the practices that would continue through a contract with NORC, which resulted in a 2016 paper in the American Journal of Public Health [“Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings”]—a predecessor to the HRSA contract that produced FARA.
“People assume that there will be greater utilization of primary health care in health centers—that’s what we show in these studies,” says Nocon. “The interesting part for policy makers is whether that increased use is offset with savings through less downstream utilization of other services.” Noting that President Biden recently released a budget proposal increasing government investment in FQHCs in fiscal year 2024, the cost savings reported in FARA and related studies will likely serve as key support for increasing spending.
The FARA project has also opened additional avenues for research by Nocon and others. Nocon’s current research uses more recent Medicaid claims data to study additional questions related to health centers, and he is pursuing new research on social determinants of health and efforts by Kaiser Permanente to address social needs including food and housing. “I’m interested in studying the business case for health care organizations to invest significant funds in those types of social risks,” he says. “For sustained investment, it’s going to have to make solid business sense. So I’m doing some interviews and quantitative studies to look at Kaiser Permanente’s business case for these investments. Kaiser has about a million Medicaid patients—it’s significant within the organization. Roughly two-thirds of Kaiser members have at least one social risk.”
“I want to emphasize how amazing it was to work with such a great group of collaborators across UChicago and our collaborating organizations on FARA,” says Nocon. “Marshall and Elbert structured FARA by involving folks across the Crown School of Social Work, the Departments of Medicine and Public Health Sciences, and a large number of doctoral and post-doctoral students—several of whom were first authors on papers. FARA also helped facilitate good collaboration across the University of Chicago around the use of Medicare and Medicaid claims data, and at the same time, [CDRP faculty affiliate] Jeanne Marsh and others began to coordinate a UChicago Medicaid working group. We were all doing projects related to Medicaid, and it’s such a hard data set to work with, so many groups got together to share lessons and share purchasing data sets. There were a lot of great things happening around this time.”
“It was a real honor to represent the work by such a large team. I was lucky to be the person who showed up in person in DC, but FARA was a ton of work by a great group of people,” he says. “As researchers we put work out there, and we have this hope that it influences policy, but to have policy makers reach out to you and ask more about this portfolio of work and to have senators and health staffers say it’s affecting millions of lives is huge. I hope everyone who contributed to this work feels that it’s making a difference.”
Learn more about the CDRP’s Financial Analysis Research Agenda (FARA) project
Watch the hearing, “Community Health Centers: Saving Lives, Saving Money”
Read Robert Nocon’s testimony
Story by Irene Hsiao