Consumer governance may harm health center financial performance

Federally qualified health centers (FQHCs), which must be governed by a patient majority, have historically struggled to remain financially viable while caring for a disproportionately low-income and uninsured population. Consumer governance is credited with making FQHCs responsive to community needs, but to the extent that patient trustees resemble the typical low-income FQHC patient, patient trustees might lack the capacity to govern, harming financial performance as a result. Thus, this study sought to empirically evaluate the relationship between FQHC board composition and financial performance.

Using data from years 2002-2007 of the Uniform Data System and the Area Resource File, and years 2003-2006 of FQHC grant applications, FQHC operating margin was modeled as a function of board and executive committee composition, the interaction between them, general time trends, other FQHC and county-level factors, and FQHC-level fixed effects. Trustees were classified as representative (ie, low-income) consumers, nonrepresentative (ie, high-income) consumers, and nonconsumers on the basis of their self-reported patient status and occupation.

Each 10 percentage point increase in the proportion of representative consumers on the board is associated with a 1.7 percentage point decrease in operating margin. This effect becomes insignificant if any consumers serve on the executive committee. There is no significant relationship between the proportion of nonrepresentative consumers and operating margin.

If consumers are given leadership roles on the board, consumer governance does not harm financial performance and may be beneficial enough in other respects to justify its being required as a condition of federal FQHC funding. Without such strengthening of the provision, consumer governance appears to harm financial performance and it is unclear from this study whether it offers other benefits that are significant enough to justify this financial risk.