Exploring the Implementation of Medicaid Alternative Payment Models and Evidence Based Practices in Federally Qualified Health Centers to Improve Diabetes Health Outcomes

About This Grant

Project Summary Diabetes mellitus (DM) is a leading cause of morbidity in the United States, costing over $400 billion annually and disproportionately affecting individuals in rural and low-income communities. Federally Qualified Health Centers (FQHCs) serve over 30 million patients each year, including 10% of all individuals with DM in the US, and primarily operate in Health Professional Shortage Areas as a critical source of care for many rural and lower income communities. However, traditional Medicaid payment models have often constrained FQHCs’ ability to deliver high-quality, coordinated chronic disease care. In response, 40 state Medicaid programs have introduced Alternative Payment Models (APMs) to incentivize FQHCs to 1) improve patient health outcomes and 2) lower costs. While evidence suggests APMs may improve DM outcomes, the mechanisms by which FQHCs implement these models—and whether rural and urban clinics adapt differently—remain unknown. This K01 proposal directly supports NIDDK’s strategic goals in Dissemination and Implementation Research and Stakeholder Engagement by partnering with FQHCs to study real-time implementation of APMs and evidence-based practices (EBPs) in DM care. The project has three aims: (1) to identify APM and FQHC features that influence implementation and characterize EBP adoption through qualitative interviews; (2) to assess the association between APM/FQHC characteristics and implementation success via a national survey; and (3) to evaluate the impact of APM types on HBA1c control rates using Uniform Data System (UDS) data and a difference-in-differences design. Guided by the Consolidated Framework for Implementation Research (CFIR) and Proctor’s Implementation Outcomes Framework, this study will generate actionable insights for policymakers and FQHC leaders. It is innovative in its integration of policy analysis, implementation science, and health economics, and in its real-time collaboration with FQHCs undergoing APM transitions. The candidate Dr. Justin Markowski, an applied health economist with prior FQHC experience and a strong publication record on rural health policy and FQHCs, will receive mentored training in implementation science, qualitative methods, survey design, and chronic disease research. This training will prepare him to develop an R01 proposal to develop and test implementation strategies to overcome the challenges identified in this K01 proposal and help FQHCs improve diabetes health outcomes. In doing so, this work seeks to inform the design of future Medicaid APMs and support NIDDK’s mission to improve the health of rural and low-income patients with diabetes through healthcare innovation and the implementation of evidence-based practices in FQHCs.