摘要：Objectives. We sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures. Results. Thirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance. Conclusions. Research is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care. Access to high-quality health care is considered a critical foundation for eliminating socioeconomic and racial disparities and increasing the quality and years of life for all persons in the United States. 1 Four major policy options for improving access to quality care are expanding employer-sponsored health insurance, which constitutes the backbone of health care coverage for most nonelderly Americans 2 ; expanding public insurance coverage through Medicare and Medicaid, which provide low-cost health care to almost all the elderly and some of the nonelderly poor based on federal poverty level and categorical requirements 3 ; expanding safety-net providers such as federally qualified community health centers, which provide low- or no-cost primary care to medically underserved populations; and providing universal coverage through health care vouchers. 4 Among the substantial body of literature examining the consequences of the lack of insurance, some researchers have recommended national health insurance through public finance. 5 – 7 However, recent literature also suggests that public health insurance coverage, such as Medicaid, is associated with quality-of-care problems, although it is unclear whether this association is because of inadequate funding levels, challenging patients, or the quality of providers and health care organizations. 8 – 10 Even less is known about the effect of public health insurance coverage on quality of care for patients seen by safety-net providers such as community health centers. Because community health centers are currently providing critical primary care to more than 16 million Americans and are in the process of expanding their service capacity by 40%, 11 , 12 it is important to know whether the quality-of-care gap remains with these safety-net providers. We sought to examine the differences in quality of care by health insurance status in community health centers. Although there is a substantial body of literature on the effect of health insurance on quality of care, many of these studies have a number of major methodological problems. 4 , 13 Those methodological problems include failure to adequately control for clinical characteristics such as comorbidities that may alter achieved quality, failure to include respondents without insurance as a comparison group, and failure to separately categorize those patients with multiple types of insurance, such as those with Medicaid and Medicare, all of which may bias results. Community health centers, as safety-net providers, are an excellent setting to study the role of insurance in quality of care. More than 75% of patients at community health centers have no medical insurance or depend on Medicaid. 14 The uninsured and the Medicaid dependent are key targeted populations for the federally funded initiative to close gaps in quality of care. Community health centers also provide patients with low- or no-cost care based on their family income. 15 , 16 This safety-net feature of community health centers provides an important opportunity to compare the quality of care of the uninsured to the care provided to patients with public and private insurance in community health centers. Comparisons of the quality of care by these 3 types of insurance coverage have rarely been undertaken simultaneously in a cohesive system. For our study, we focused on the association between insurance status and quality of diabetes care and used the National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) diabetes processes of care and outcome measures to quantify the quality of care for those diabetes patients. 17 The HEDIS measures of comprehensive diabetes care have been extensively used recently to assess quality of care in general and diabetes care in particular. 18 – 24 Diabetes affects more than 17 million Americans 25 and is among the 10 most expensive medical conditions in the United States. 26 In light of the health and economic burden of diabetes, diabetes is an important model condition in examining the relationship of insurance coverage and quality of care.
