Conditions that are treated in an acute care setting that could have been mitigated through access to appropriate primary care are known as Ambulatory Care Sensitive (ACS) conditions. Lack of access to primary care results in the absence of regular preventive care, monitoring of chronic illnesses, and early treatment of acute conditions [1, 2]. As untreated health conditions worsen, hospitalization may be required; examples include uncontrolled asthma triggering a lung infection or unmanaged diabetes resulting in a stroke. High rates of ACS conditions that result in admission to hospitals or emergency departments are therefore an indicator of poor access to primary care.
Despite modest improvements in the number of preventable hospitalizations for ACS conditions in recent years, total costs for potentially preventable hospitalizations are estimated to exceed $30 billion annually [3]. Uninsured adults, who are less likely to have regular source of care and more likely to have unmet medical needs [4], are hospitalized for ACS conditions more frequently than Medicaid recipients or individuals with commercial insurance [5]. Efforts to improve primary care access for populations with the highest rates of hospitalizations for ACS conditions, such as the uninsured, could aid in reducing aggregate health care costs in the U.S. [6].
Free clinics, which provide medical care for free or minimal cost, are one avenue to address the medical needs of the uninsured. While free clinics do not have the resources to meet all the medical needs of these populations, they often provide care for chronic illnesses through regular monitoring, dispensing medications, and providing lab tests. Their services may be more limited than those of other primary care organizations that accept insurance due to limited funding for free clinics and reliance on medical and administrative volunteers. Clients served by free clinics frequently come from demographic groups identified as having an increased likelihood of being admitted for ACS conditions, such as uninsured [5], individuals from low-income areas [6, 7], and minorities [8, 9].
This study examines whether free clinics in North Carolina (NC) reduce hospitalizations for ACS conditions for uninsured adults. More precisely, this work considers whether hospitalization of an uninsured adult in a community served by a free clinic has lower odds of being admitted for an ACS condition. We also consider whether this relationship is stronger for ACS hospitalizations resulting from chronic conditions as compared to ACS hospitalizations resulting from acute conditions.
Literature review
As the Affordable Care Act (ACA) continues to unfold, the US healthcare system is focused on serving the medical needs of the newly insured through the exchanges and expanded Medicaid enrollment. Reduced funding under the ACA for uncompensated care at safety net facilities, such as public hospitals [10, 11], and increased demand in primary care offices, particularly from lower paying Medicaid beneficiaries [12], could result in fewer safety net options for those who remain uninsured, and, therefore, create a greater reliance on free clinics for these vulnerable groups. Furthermore, Republican control of congress and the presidency following the 2016 elections make long promised revisions to, if not outright repeal of, the ACA inevitable. Such changes could result in higher rates of uninsured adults, especially among the working poor and near poor [13].
Several studies describe free clinics and their patients [14,15,16,17]. Not surprising, the populations served are between the ages of 18 and 64, female, uninsured, and living below the Federal Poverty Level (FPL) [14, 16,17,18]. Free clinics lack resources, organizational structure, and services compared to their mainstream counterparts, but have an important and enduring role within the US healthcare delivery system [14, 15, 17, 18].
Most studies examining health outcomes or access to care in relation to free clinics typically relied on a single clinic or small cluster of clinics. Specifically studies found free clinic patients realized improvement in chronic disease management such as increased exercise [19], reduced HgbA1c, lower LDL levels, and lower blood pressure [20], high rates of recommended care (96% received HbA1c monitoring and 80% received nephropathy monitoring), and blood pressure control [21]. Although these pilot studies, occurring in a single clinic with a small sample, have limited generalizability, they offer support for free clinics’ ability to contribute to improved health outcomes for populations that are likely to be at higher risk of chronic illnesses.
One large-scale study assessed the impact of free clinics on low income or elderly hospitalized patients in Virginia (including uninsured, Medicaid, and Medicare recipients) [22]. Communities with a free clinic had lower rates of preventable hospitalizations than communities without a free clinic, but the association was only marginally significant [22]. Given that free clinics generally do not serve individuals with third party or public insurance, the inclusion of uninsured discharges with those funded by public insurance does not allow for a direct examination of the impact of free clinics on the uninsured. In addition, the measure of hospitalization for an ACS condition utilized in the Virginia study predates the Agency for Healthcare Research and Quality (AHRQ) indices for ACS conditions known as the Prevention Quality Indicators (PQI) [23]. AHRQ assembled a workgroup to assess individual and composite indicators in terms of the existing literature, validity and precision, which expanded upon the earlier studies used as the basis for determining ACS conditions in the above referenced study [23, 24]. Our study is the first large-scale, multi-year examination of the impact of free clinics on hospitalization for ACS conditions for the uninsured population using PQIs to measure ACS conditions.