JMIR Publications

ABSTRACT

Background:

Digital health technologies are increasingly promoted as mechanisms to improve care coordination, enhance access, and reduce health care costs. However, whether community-level digitalization is associated with lower primary care spending in Medicare-participating safety-net settings remains unclear, particularly in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

Objective:

This study examined the association between county-level digitalization and Medicare primary care spending across US counties. Specifically, we assessed whether higher digitalization was associated with lower spending, whether observed associations reflected persistent differences between counties or changes within counties over time, and how digitalization interacted with health care access and socioeconomic conditions.

Methods:

We conducted a county-level observational study of 3,016 US counties from 2017 to 2023. Digitalization was measured using the Digital Health Index (DHI) digitalization subindex, and the outcome was geographically adjusted per capita Medicare spending for FQHC and RHC services. A hybrid within-between panel model was used to distinguish between-county and within-county associations. Additional analyses included threshold models, digital development trajectory analyses, and interaction models. Using 2023 cross-sectional data, multivariable regression and Extreme Gradient Boosting (XGBoost) models with Shapley Additive Explanations (SHAP) were applied to evaluate the relative contributions of digitalization, health care access, and socioeconomic conditions to spending variation.

Results:

Higher county-level digitalization was associated with lower Medicare primary care spending. In longitudinal analyses, the association was driven primarily by persistent between-county differences (β=-67.62, 95% CI -73.51 to -61.74; P<.001), whereas within-county changes in digitalization were not significantly associated with spending (β=-2.72, 95% CI -9.10 to 3.67; P=.40). Compared with counties in the lowest digitalization tertile, spending was substantially lower among counties in the highest tertile (β=-165.05, 95% CI -179.74 to -150.36; P<.001). Counties characterized by early and sustained digital development also demonstrated significantly lower spending (β=-123.34, 95% CI -138.24 to -108.43; P<.001). In 2023 cross-sectional analyses, health care access exhibited the strongest inverse association with spending (β=-71.13, 95% CI -81.20 to -61.07; P<.001), followed by digitalization (β=-48.48, 95% CI -59.75 to -37.21; P<.001). SHAP analyses identified health care access and digitalization as the most important contributors to county-level spending variation.

Conclusions:

Greater digitalization was associated with lower Medicare primary care spending in FQHC and RHC settings. However, the association reflected longstanding structural differences across counties rather than short-term changes in digital capacity. These findings suggest that digitalization functions as a component of broader health system capacity and may contribute to improved primary care efficiency when supported by sustained investment, adequate health care access, and favorable local conditions.