Centers with the most diversified service mix sustained the greatest financial losses.

• The quartile with the highest losses also had the highest proportion of dental visits (13% in 2019) as compared to the quartile with the lowest losses or gains, for which dental visits were 1% of visits.
• The “high-loss quartile” also provided the highest proportion of enabling visits (4% vs. 1% in 2019) and the highest proportion of “other professional visits” (5% vs. 2%).
• Both groups provided an equal proportion of mental health visits (5% for each group in 2019).

Regionally, the losses were more balanced, although the South and Central regions sustained the heaviest total losses and per patient losses.

• Losses were highest for centers in the South region, at $179 million in total and $150 per patient.
• Centers in the Central region collectively lost $163 million, or $101 per patient.
• Centers in the Sacramento Valley region were close behind, in terms of per patient losses, at $100 per patient.
• These three regions serve the highest concentrations of Medi-Cal patients at 70%, 66%, and 73% of all patients, respectively, in 2019.

Between urban and rural centers, financial losses were concentrated in urban centers; they bore 94% of total losses.

While there were some minor differences in average visit decline (which affects revenues) and the average percentage of visits conducted virtually, centers of all sizes and across all regions were fairly tightly clustered, with 19%–26% average visit decline and 49%–56% of all visits conducted virtually.

The two most important differentiating factors that appears to have financially disadvantaged the larger centers were prevalence of Paycheck Protection Program (PPP) loans and level of BPHC grant funding. In both instances, the dollar amount per patient greatly favored smaller centers.

• PPP: Given that many of the largest health centers were not eligible to apply for PPP funding, these centers sustained the largest financial losses. Only 42% of centers with revenues above $36.7 million (the top quartile) received a PPP loan, while 100% of centers in the bottom three quartiles received a PPP loan.
• BPHC grant funding: Bureau of Primary Health Care (BPHC) grant funding per patient averaged $153 per patient for the centers with the smallest revenue (lowest quartile), while the largest centers (top quartile) received an average of $44 per patient. This differential also held true when evaluating based on number of patients, number of sites, and number of Medi-Cal patients.

The data analysis contained in this infographic was conducted by Capital Link, based on information from the following sources:

1. FY19 audited financial statements of 192 California FQHCs (both Section 330s and Look-Alikes), collected by Capital Link.
2. 2018 and 2019 Uniform Data System (UDS) reports submitted by 202 California FQHCs to the Health Resources and Services Administration (HRSA).
3. HRSA’s Data Warehouse for the number of California FQHC sites and the amount of COVID-19 grants issued to each California FQHC.
4. HRSA’s Health Center COVID-19 Survey, including weekly responses from health centers from April 4, 2020, through November 27, 2020.
5. US Department of Health & Human Services (HHS) Data Warehouse for the amount of Provider Relief Fund (PRF) General Distribution issued to each California FQHC health center:
   • General Distribution estimated at 2% of 2018 Net Patient Service Revenue.
6. HHS Data Warehouse for the amount of each PRF Rural Distribution issued to each rural California FQHC health center:
   • Rural Distribution based on FQHC site addresses mapped by RUCA codes 4, 5, 6, 7, 8, 9, and 10, with a fixed amount of $103,253 per rural site.
7. FCC telehealth grants as published by the PCC on July 8, 2020.
8. Small Business Administration (SBA) Paycheck Protection Program (PPP) loan amounts for each eligible California FQHC:
   • Based on surveys of health centers in several states conducted by Capital Link and the National Association of Community Health Centers (NACHC) between April 13, 2020, and June 9, 2020, and:
     • For survey nonrespondents, the SBA PPP loan amount was calculated for eligible health centers (those with 2019 UDS FTEs less than 450), from FY2019 Audited Financials: Salaries & Related Expenses, divided by 12 and multiplied by 2.5.
     • If a health center’s FY19 audit was not available, the loan amount was calculated as follows: Total Revenues (from 2019 UDS) multiplied by the California FY19 median for Personnel-Related Expense as Percentage of Operating Revenue, as calculated from the FY19 audits. The result was then divided by 12 and multiplied by 2.5.
9. COVID-19-Related Expenses include costs of purchasing personal protective equipment (PPE), telehealth implementation, and facility modifications related to COVID-19. They were estimated on a per-patient per-month basis, based on data collected from health centers in multiple states by NACHC and Capital Link between March and October 2020.

California Counties Included in Regions

Note: Counties not listed have no freestanding FQHCs with corporate headquarters in that county.

Notes

1. Holding On: How California’s Health Centers Adapted Operations and Care for Patients During the Pandemic, California Health Care Foundation, February 2021.
2. Quartiles refer to the size of the health center. The lowest quartile consists of the smallest centers; the top quartile consists of the largest centers.

Capital Link is a national nonprofit organization focused on strengthening FQHCs — financially and operationally — in a rapidly changing marketplace. Capital Link helps health centers plan for sustainability and growth, access capital, improve and optimize operations and financial management, and articulate their value.