一些州医疗补助机构已从传统的按服务收费转变为以价值为中心的替代支付模式 (APM)，以补偿联邦合格的医疗中心 (FQHC)。关于这种转变对 FQHC 绩效的影响知之甚少。为了评估 APM 与 FQHC 的临床绩效、付款人组合、风险状况和财务可持续性之间的关联。这项回顾性队列研究在 684 个 FQHC（代表 37 个州以及哥伦比亚特区）在 2009 年 1 月至 2021 年 12 月期间持续运营。FQHC 患者的付款人组合（例如保险类型）和风险状况（例如患有慢性病的患者比例）的数据从统一数据系统获得，诊所层面的财务数据（例如收入）从国税局 990 税务文件中获得。对 2022 年 11 月至 2023 年 10 月期间的数据进行了分析。2013 年 1 月至 2021 年 12 月期间，首次推出了州医疗补助计划提供的 FQHC 基于价值的支付模式（即 APM）。主要成果是 4 项经过审计的流程措施医疗保健质量（宫颈癌和结直肠癌筛查以及成人和儿童的体重指数 [BMI] 评估）和 2 项中间健康结果指标（高血压控制和糖尿病控制）。采用双重差分设计并交错实施，比较首次 APM 推出前后的 FQHC 与没有 APM 的州 FQHC 的同期变化。 2021 年，共有 684 个 FQHC（8892 个 FQHC 年）为 17823959 名患者提供服务（57.3% 女性）被纳入该研究。在实施 APM 的州的 FQHC 中，与未实施 APM 的州的 FQHC 相比，观察到 4 项流程质量指标中的 3 项有显着差异：结直肠癌筛查（3.24 个百分点 [pp]；95% CI，1.40-5.08） pp）、成人 BMI（3.19 pp；95% CI，0.70-5.68 pp）和儿童 BMI（4.50 pp；95% CI，1.83-7.17 pp）。高血压患者的血压控制（1.02 pp；95% CI，0.04-2.00 pp）和 2 型糖尿病患者的血糖控制（1.02 pp；95% CI，0.02-2.02 pp）也有适度的差异改善。与没有 APM 的州的 FQHC 相比。没有证据表明 APM 的推出与诊所选择更健康的患者（-0.01 pp；95% CI，-0.21 至 0.19 pp）或节约护理（-0.02 次就诊；95% CI，-0.08 至 0.04 次就诊）相关。在这项队列研究中，为 FQHC 引入医疗补助 APM 选项与质量的适度、统计上显着的提高相关，这些提高主要集中在具有明确激励质量的 APM 模型的 FQHC 中。这一发现表明，APM 在医疗保健安全网中既是一种经济上可行的报销模式，又是一种促进健康的模式。

Several state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance.To assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs.This retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023.Initial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021.The main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs.A total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (-0.01 pp; 95% CI, -0.21 to 0.19 pp) or stinting on care (-0.02 visits; 95% CI, -0.08 to 0.04 visits).In this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.