Understanding California's Safety Net: Identifying the Health Care Providers Delivering Primary Care to Medi-Cal Enrollees

As of August 2024, more than 14.4 million individuals were enrolled in California's Medicaid program, better known as Medi-Cal. Many Medi-Cal enrollees receive their primary care from Federally Qualified Health Centers (FQHCs) (California Health and Human Services Agency, 2025). The literature surrounding FQHCs—which receive enhanced reimbursement for providing care to Medi-Cal enrollees—is considerable. Additionally, because of their regular reporting requirements to the Health Resources and Services Administration's Health Center Program through the Uniform Data System (UDS), data on their provision of care are readily available (Rosenbaum et al., 2019). However, FQHCs are not the only sources that Medi-Cal enrollees turn to for their care. There are other non-FQHC clinics and providers that Medi-Cal enrollees rely on for their primary care. The care that non-FQHC providers deliver to Medi-Cal enrollees might be significant, but it is not well documented or understood.

The extent to which different subgroups of Medi-Cal enrollees use non-FQHC providers for their primary care needs likely varies, and developing a better understanding of that variation could inform efforts to improve support for these providers and patient populations. Disparities in care are pervasive across the U.S. health care system, including within Medi-Cal. In particular, Black patients typically receive less-adequate care and have worse health outcomes compared with non-Hispanic White patients (Thomas et al., 2024). In addition, prior research has shown that visits by some patient groups tend to be concentrated in a small number of providers, suggesting that reaching these specific providers or provider groups with trainings and programs to help improve care quality could have a large impact on reducing disparities (Bach et al., 2004). Ongoing efforts aim to reduce these disparities within California and the Medi-Cal population to improve care for all (Cummings, 2022; Rittenhouse et al., 2023). To support this work, a better understanding of which providers deliver care to Medi-Cal enrollees is needed. Identifying the universe of providers who serve different subpopulations of Californians could help target supports to these providers to improve the quality of care they deliver to patients.

In this study, we sought to develop an understanding of the providers that are delivering primary care services to Medicaid enrollees in California. In particular, we explored the degree to which individuals enrolled in Medi-Cal—California's Medicaid program—use Federally Qualified Health Center (FQHC) and non-FQHC providers and how use of non-FQHC providers varies by enrollee characteristics, including race or ethnicity, age, and geography. To do so, we used Medi-Cal data from 2022 to identify the providers delivering primary care services to enrollees in FQHC and non-FQHC settings, pinpoint key characteristics about these providers, examine what percentage of providers deliver a high proportion of primary care visits to Medi-Cal enrollees, and determine whether this percentage varies by Medi-Cal enrollee group and county. In this summary, we provide the key findings for each of our research questions.

Key Findings

What percentage of all primary care visits are with non-FQHC providers, and does this vary by the characteristics of Medi-Cal enrollees?

• More than two-thirds of all primary care visits were with non-FQHC providers. Across the more than 20 million primary care visits made by Medi-Cal enrollees in 2022, 70 percent of visits were to non-FQHC providers, and 30 percent were to FQHC providers.
• Younger Medi-Cal enrollees were more likely to receive their primary care from non-FQHC providers. Compared with FQHC visits, non-FQHC visits were more likely to be made by those age 18 and younger, White enrollees, English-speaking enrollees, enrollees in Northern California, and enrollees in micropolitan areas.

Who are the providers delivering primary care visits to Medi-Cal enrollees?

• Nearly all providers that delivered primary care services to Medi-Cal enrollees provided some of those visits in non-FQHC settings. Most of the providers (identified via National Provider Identifier [NPI]) (93 percent) delivering primary care services to Medi-Cal enrollees in 2022 provided at least some of their primary care visits in the non-FQHC setting. Thirteen percent (3,097 providers) provided primary care in both FQHC and non-FQHC settings, 7 percent (1,712 providers) in FQHC settings only, and 80 percent (19,192 providers) in non-FQHC settings only.
• Compared with FQHC providers, non-FQHC providers were more often located in Northern California, in metropolitan areas, and in smaller practices.
• Non-FQHC providers, on average, served a smaller number of unique Medi-Cal patients compared with FQHC providers—an average of 446 versus 1,024 unique patients, respectively—and provided fewer primary care visits on average compared with FQHC providers—1,086 visits versus 2,567 visits, respectively.
• Solo and small practices (1–3 NPIs) accounted for more than 2.1 million (15 percent) non-FQHC primary care visits by Medi-Cal enrollees in 2022. Another 12.1 million non-FQHC primary care visits (85 percent) were provided by practices with 4–10 NPIs (11 percent), 11–24 NPIs (7 percent), 25–49 NPIs (10 percent), 50 or more NPIs (50 percent), and those with unknown practice sizes (5 percent).¹
• Small practices are particularly important to Medi-Cal enrollees who identify as Asian or Pacific Islanders, accounting for 27 percent of non-FQHC primary care visits for this group.
• Small practices accounted for a much larger share of non-FQHC primary care visits in four more-populous southern counties—Riverside (29 percent), Orange (26 percent), San Bernardino (25 percent), and Los Angeles (22 percent)—and two smaller northern counties—Sutter (26 percent) and Yuba (31 percent).

What percentage of providers deliver a high proportion of primary care visits to Medi-Cal enrollees? Does this vary by the characteristics of Medi-Cal enrollees?

• A small percentage of providers deliver most of the primary care visits provided to Medi-Cal enrollees. Medi-Cal primary care visits were provided by a smaller share of NPIs for non-FQHC visits than for FQHC visits. Among non-FQHC visits, 6 percent of NPIs provided 50 percent of visits, and 20 percent of NPIs provided 80 percent of visits. Among FQHC visits, 10 percent of NPIs provided 50 percent of visits, and 30 percent of NPIs provided 80 percent of visits.
• A particularly small percentage of providers deliver most of the primary care visits for Vietnamese, Chinese, and American Indian/Alaska Native enrollees. Eighty percent of non-FQHC primary care visits for these groups of Medi-Cal enrollees were provided by 2 percent, 4 percent, and 7 percent of providers, respectively.
• Non-FQHC providers are more often in small practices. A greater proportion of providers delivering primary care services in non-FQHC practices were in smaller practices compared with providers delivering primary care services in FQHC practices. Although 13 percent of NPIs delivering non-FQHC primary care visits were in practices with ten or fewer NPIs, only 2 percent of NPIs delivering FQHC primary care visits were in practices of the same size.
• The providers that deliver most of the care to Asian and Pacific Islander enrollees are more frequently operating in small practices. Between 25 and 30 percent of the NPIs delivering 80 percent of non-FQHC primary care visits to Chinese, Vietnamese, and non-English speaking Asian or Pacific Islander enrollees were in practices with 1–3 NPIs.
• There were substantial variations in the percentage of providers delivering 80 percent of primary care visits across counties, ranging from 5 to 80 percent of all NPIs in a county delivering 80 percent of non-FQHC primary care visits. In addition, there were variations across counties in the percentage of NPIs that provided 80 percent of non-FQHC primary care visits to Medi-Cal enrollees by racial and ethnic enrollee groups.

Conclusions

These findings underscore the important role that non-FQHC providers play in the delivery of care to Medi-Cal enrollees. In addition, these non-FQHC providers—especially those in small practices with a large share of Medi-Cal and uninsured enrollees—work without the additional financial supports that are provided to FQHCs, which can put them at more financial risk because of lower reimbursement rates within Medi-Cal. Smaller practices, which likely rely on an overall smaller staff and might not have access to supports and trainings available to larger practices, are particularly vulnerable. Without the proper financial and strategic support, efforts to enhance the quality of care these providers deliver to their patients might not receive the priority they deserve, contributing to potential disparities in care quality. This study provides a better understanding of which providers, particularly those working outside FQHC settings, deliver care to Medi-Cal enrollees. Supplied with this information, efforts targeting quality improvement can be better directed toward the providers serving the greatest proportions of Medi-Cal enrollees. Providing access to trainings and other quality improvement activities to high-use providers might contribute to a reduction in health disparities within California and the Medi-Cal population.