Access to specialty care and medical services in community health centers

Although community health centers (CHCs) provide primary health services to the medically underserved and poor, limited access to off-site specialty services may lead to poorer outcomes among underinsured CHC patients. This study evaluates access to specialty health services for patients receiving care in CHCs, using a survey of medical directors of all federally qualified CHCs in the United States in 2004. Respondents reported that uninsured patients had greater difficulty obtaining access to off-site specialty services, including referrals and diagnostic testing, than did patients with Medicaid, Medicare, or private insurance.     

Limits to the safety net: teaching hospital faculty report on their patients' access to care

Many major teaching hospitals might not be able to offer adequate access to specialty care for uninsured patients. This study found that medical school faculty were more likely to have difficulty obtaining specialty services for uninsured than for privately insured patients. These gaps in access were similar in magnitude for public and private institutions. Initial treatment of uninsured patients at academic health centers (AHCs) does not guarantee access to specialty and other referral services, which suggests that there are limits to relying on a health care safety net for uninsured patients. AHCs and affiliated group practices should examine policies that limit access for uninsured patients.     

The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.     

The quality of chronic disease care in U.S. community health centers

Community health centers (CHCs) are responsible for providing care for more than fifteen million Americans, many of whom are members of groups who have been documented to receive low-quality care. This study examines the quality of care for patients with chronic disease in a nationally representative sample of federally funded CHCs. Fewer than half of eligible patients received appropriate care for the majority of indicators measured, and uninsured patients received poorer care than insured patients. Although the quality of chronic disease care in CHCs compares favorably with that of care received in other settings, gaps in quality were observed for the uninsured.     

Managed care and community health centers

This study has two objectives: (1) to examine the relationship between the involvement of community health centers (CHCs) in managed care and various center characteristics, including patient, provider, services, and financial characteristics, that are critically linked with the fulfillment of their mission and (2) to identify factors significantly associated with CHCs' involvement in managed care. Regarding the first objective, the study indicates that CHCs involved in managed care have more diversified sources of revenue and depend less on grant funding than other CHCs, and they serve a significantly smaller proportion of uninsured and homeless patients. Involvement in managed care is also associated with greater financial vulnerability, reflected in higher costs and net revenue deficits. Regarding the second objective, the study finds that CHCs have become involved in managed care largely in response to external market pressures, such as the prospect of reduced federal grant funding. Other significant factors include center size, location, and the percentage of users who are Medicaid patients.     

Characteristics of ambulatory care patients and services: a comparison of community health centers and physicians' offices

The overall aim was to determine whether health care delivery for vulnerable populations served by community health centers (CHCs) was comparable to care for mainstream Americans primarily seen in physicians' offices (POs). Data came from the 2006 National Ambulatory Medical Care Survey. Patient visits occurring in CHCs were largely from younger, uninsured or Medicaid-insured, minority populations, while POs catered mainly to older, Medicare- or privately-insured, White patients. Communities served by CHCs were more often in low-income, low-education, urban regions. A greater proportion of visits to CHCs were from diabetic, obese, and depressed patients; CHCs also offered more evening/weekend visits and provided more health education during visits, but spent less time per visit than POs and had more difficulty referring patients to specialists. Results affirmed the significant role of CHCs as safety-net providers for vulnerable populations, and indicated that CHCs provide adequate care compared with POs although there remains room for improvement.     

FQHC (Federally Qualified Health Center): harnessing the incentives of cost reimbursement

Community health centers (CHCs) are federally supported primary care providers to the low-income and uninsured. The federally qualified health center (FQHC) legislation requires states to pay CHCs for Medicaid services on the basis of reasonable cost. The statute generated controversy, particularly in a time when, for most providers, cost-related reimbursement has given way to fixed payments and managed care. This article examines the impact of FQHC on revenue and utilization of CHCs, using data for 328 centers that were in continuous operation between 1989 (the year the legislation was enacted) and 1992, the first year of full implementation. During this period, the CHCs Medicaid revenue grew rapidly. FQHC is estimated to account for under one third of the total increase, while inflation and growth in utilization due to expanded Medicaid eligibility are estimated to account for the other two thirds. At the same time, the change to cost-related reimbursement had a significant increase in total service users and Medicaid recipients receiving care from CHCs. Although some expected that cost-reimbursement would lead to inflationary increase in utilization, this did not occur. There was no statistically significant relationship between the change in payment methodology and changes in encounters per user. The experience of FQHC indicates that, for safety net providers of primary care, cost-related reimbursement is not "inherently inflationary." Results of this study raise the question of whether payment within constraints, but bearing relationship to cost, is not an appropriate approach to developing primary care capitation rates for these providers--and assuring maintenance of the safety net for the uninsured.     

The impact of managed care on the mix of vulnerable populations served by community health centers

This article examined the impact of managed care involvement on vulnerable populations served by community health centers (CHCs), while controlling for center rural-urban location and size, and found that centers involved in managed care have served a significantly smaller proportion of uninsured patients but a higher proportion of Medicaid users than those not involved in managed care. The results suggest that the increase in Medicaid managed care patients may lead to a reduced capacity to care for the uninsured, thus hampering CHCs from expanding access to health care for the medically indigent.     

A national study of problematic care experiences among Latinos with diabetes

Despite the large disease burden of diabetes, little is known about the care experiences of Latinos with diabetes across diverse primary care settings. This study compares problematic care experiences among Latinos with diabetes across usual care sites (community health centers [CHCs], private physician practices, or without a usual source of care), using a national sample of Latino diabetic patients (N=583). Nearly half of the respondents reported at least one problematic care experience during their last clinician visit. Compared with respondents treated primarily by private physicians, respondents receiving care in CHCs or without a usual source of care reported more problematic care experiences. However, patient health insurance coverage and acculturation accounted for the highest proportion of explainable differences in problematic care experiences between CHCs and private physician offices. Initiatives should clarify the extent to which the care experiences of Latino diabetics, particularly uninsured and less acculturated patients who tend to be cared for by CHCs, can be improved through clinician communication and patient self-management interventions.     

Primary care of patients without insurance by community health centers

Community health centers (CHCs) are in a strong position to meaningfully contribute to health promotion, early detection, and improvement in health care outcomes for some of the most vulnerable person in the nation, since almost one in three users of federally funded CHCs was uninsured in 1994. The purpose of this article is to compare uninsured CHC users with uninsured people nationwide. Data for the analysis came primarily from two population-based surveys: the 1994 National Health Interview Survey (NHIS) and the 1995 Community Health Center (CHC) User Survey.     

Changes in Insurance Status and Access to Care in an Integrated Safety Net Healthcare System

This paper focuses on a cohort of uninsured patients that have accessed outpatient healthcare services in an urban safety net, evaluating the degree to which they switch insurance status and the impact this switching has on access to care. The results indicate that in an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Uninsured patients who switch to insured status were found to be more likely to visit specialty points of care and less likely to visit urgent points of care than the continuously uninsured. It is well documented that insurance coverage and continuity of care influence health status. Continuity of insurance coverage also has an impact on access to care for those receiving services within a safety net healthcare system.     

The financial performance of community health centers, 1996-1999

This paper presents recent financial health trends of community health centers (CHCs) between 1996 and 1999, a time characterized by fiscal and operating challenges. Results show that many individual CHCs have been subject to large changes in payer-mix among uninsured and Medicaid users. Troubling is the finding that more than half of all CHCs reported operating deficits in 1997, 1998 and 1999. CHCs experiencing large increases in the share of uninsured users and those participating in Medicaid managed care appear to have been disproportionately affected. The analyses presented support recommendations for enhanced data collection and for further monitoring of CHCs' financial health.     

Adoption of health information technology in community health centers: results of a national survey

To the extent that health information technology (IT) improves health care quality, differential adoption among providers that serve vulnerable populations may exacerbate health disparities. This first national survey of federally funded community health centers (CHCs) shows that although 26 percent reported some electronic health record (EHR) capacity and 13 percent have the minimal set of EHR functionalities, CHCs serving the most poor and uninsured patients were less likely to have a functional EHR. CHCs cited lack of capital as the top barrier to adoption. Ensuring comparable health IT capacity among providers that disproportionately serve disadvantaged patients will have increasing relevance for disparities; thus, monitoring adoption among such providers should be a priority.     

Use of Enabling Services by Asian American, Native Hawaiian, and Other Pacific Islander Patients at 4 Community Health Centers

Objectives. We sought to examine the utilization and impact of enabling services, such as interpretation and eligibility assistance, among underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients served at 4 community health centers.Methods. For this project, we developed a uniform model for collecting data on enabling services and implemented it across 4 health centers that served primarily AANHOPI patients. We also examined differences in patient characteristics between users and nonusers of enabling services.Results. Health center patients used many enabling services, with eligibility assistance being the most used service. In addition, compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured (P < .05).Conclusions. For underserved AANHOPI patients at community health centers, enabling services are critical for access to appropriate care. We were the first to examine uniform data on enabling services across multiple health centers serving underserved AANHOPI patients. More data on enabling services and evaluation are needed to develop interventions to improve the quality of care for underserved AANHOPI patients.Community health centers (CHCs) are safety nets for some of the country''s most vulnerable patients, but many of these patients are unable to access or use this needed medical care without enabling services.¹ Major barriers to care include an inability to pay, culture and language, and insurance status.^2,3 Enabling services have been identified by the National Association of Community Health Centers as key facilitators to health care delivery and are defined as nonclinical services that are specifically linked to a medical encounter or provision of medical services that aim to increase access to health care and improve health outcomes.⁴ Enabling services at CHCs include language interpretation, health education, and financial or insurance eligibility assistance. Enabling services have long been considered to be critical components of health care delivery for CHC patients, who are disproportionately low-income, uninsured, and of minority backgrounds. However, despite the perceived importance and potential of enabling services for improving health care for vulnerable populations, little is known about the utilization of enabling services at CHCs or the impact of these services on health care access and outcomes among medically underserved populations. In particular, no studies have examined enabling services and their impact on medically underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients at CHCs.Few studies have examined the effect of enabling services at CHCs on health care access and outcomes among people of color.^5–9 The results of these few studies suggest that enabling services can make a significant contribution to improved access and quality of care. For example, case management has been shown to be effective at improving specific disease conditions.^10,11 Interpretation services have been shown to increase both timeliness of care¹² and patient satisfaction and decrease the number of emergency room visits, thereby reducing costs.⁵Medically underserved AANHOPI patients at CHCs, in particular, rely more on enabling services such as interpretation and eligibility assistance for access to medical care. A lack of enabling services leads underserved AANHOPI patients and other people of color to underutilize medical services at CHCs, and causes such patients to be underrepresented in the health care system.^13–15 For example, communication difficulties stemming from language or cultural issues are common reasons for AANHOPI persons to avoid health services^16,17 and to feel less confident that they can get needed care as compared with non-Hispanic Whites.¹⁶ Enabling services at CHCs can help underserved AANHOPI patients obtain culturally and linguistically appropriate and effective health care.Culturally proficient health care reduces health disparities between racial/ethnic groups.¹⁸ Culturally and linguistically appropriate enabling services can help to overcome barriers within the health care system by improving patient–provider interactions, increasing patient knowledge and understanding of treatments, and improving patient safety.¹⁹ Interpretation services can help patients navigate the health care system more easily and can improve patient–provider communication, resulting in increased medical visits and improved health outcomes. Eligibility assistance and enrollment in health insurance programs can alleviate patient financial concerns associated with care.Federally qualified health centers are required to provide annual reports to the US Bureau of Primary Health Care as part of the Uniform Data System and to submit information on some of the enabling services provided by their health centers. However, the current Uniform Data System does not adequately capture the full scope of enabling services provided and needed by federally qualified health centers to demonstrate the critical impact of these services, nor does it document the need to adequately finance health centers to ensure full primary care access and utilization among medically underserved patients. As of 2007, the Uniform Data System report included only the number of full-time equivalent staff and encounters for case managers and education specialists and full-time equivalents only for outreach workers, transportation staff, and a category for “other enabling services.”²⁰Enabling services are often jeopardized during times of political and financial pressures, because the services are usually nonbillable or nonreimbursable.²¹ Although some CHC staffs and federal officials have indicated that enabling services improve health care access and outcomes among medically underserved patients, such services have not been adequately supported or funded.²²Our study aimed to rectify the lack of research in this area by collecting important new data on the needs for enabling services at CHCs and the impact of enabling services on the medical care and outcomes of medically underserved AANHOPI patients.     

Community health center integration: experience in the State of Ohio

In the face of severe financial challenges and demands to improve quality and service to patients, many community health centers (CHCs) have aligned or integrated with other CHCs, physician groups, or hospitals. Yet the nature of and rationale for these organizational decisions are not well understood. Our research applied an organizational theoretical framework to test whether strategic adaptation theory or institutional theory best describes the integration activity of CHCs in Ohio. We collected primary data from case studies of seven CHCs selected for geographic representation and studied December 2000-January 2001. Semi-structured interviews and a case study database supported our chain of evidence. We found that CHC integration activity was substantial (five of seven CHCs integrated) and extremely varied. Consistent with strategic adaptation theory, we determined that CHC integration actions were predominantly center-specific, rational responses to environmental challenges and were initiated to improve operations or financial performance. Rarely did CHCs initiate major organizational change merely to mimic other CHC actions, as might have been expected of highly institutionalized organizations. Understanding the basis for CHCs' strategic decisions while monitoring financial health will remain critical as lawmakers and administrators work to develop policies that both maintain progress made and improve primary care access for the poor, the uninsured, and those with special health care needs served by these important safety net providers.     

Specialty hospitals, ambulatory surgery centers, and general hospitals: charting a wise public policy course

The number of U.S. specialty hospitals and ambulatory surgery centers has been increasing. Advocates of these facilities believe that they will increase competition and improve health services. General hospitals, however, complain that specialty facilities select only the most profitable patients, which reduces general hospitals' ability to pay for care of the uninsured and other unprofitable services. Physician ownership also raises conflict-of-interest concerns. Congress has enacted a moratorium on payments to new specialty hospitals as it ponders the questions that will determine future policy. Can the competitive playing field be leveled, or will future development of these facilities be highly regulated or banned?     

Health care reform and family planning services

With the reforms expected for US health care, the question remains as to the impact on family planning services. Although the focus is on health care finance reform, the mix of patients seen, the incentives for decision making, and the interactions between health care providers will change. Definition of key concepts is provided for universal access, managed competition, and managed care. The position of the obstetrician/gynecologist (Ob/Gyn) does not fit well within the scheme for managed health care, because Ob/Gyns are both primary care providers and specialists in women's health care. Most managed health care systems presently consider Ob/Gyn to be a specialty. Public family planning clinics, which have a client constituency of primarily uninsured women, may have to compete with traditional private sector providers. "Ambulatory health care providers" have developed a reputation for high quality, cost effective preventive health care services; this record should place providers with a range of services in a successful position. Family planning providers in a managed competition system will be at a disadvantage. 3 scenarios possible under managed competition are identified as the best case, out of the mainstream, and most likely. The best case is when primary reproductive health care services, contraception, sexually transmitted disease screening and management, and preventive services are all obtained directly from reproductive health care providers. Under managed care, this means allowing for an additional entry gatekeeper to specialized services. The benefits are to clients who prefer seeing reproductive health care providers first; reproductive services would be separated from medical services. The out of the mainstream scenario would place contraceptive services and other preventive services as outside the mandated benefits. The government would still provide Title X type programs for the indigent. The most likely scenario is one where primary care providers offer contraceptive services, and some family planning providers would expand their services to include nonreproductive health care. Abortion services are presently out of the health care mainstream, and efforts will need to be made to identify impact on reproductive and family planning practices and to advocate for specific provisions in health care reform.     

Specialty care referral patterns for the underserved: a study of community health centers on the South Side of Chicago

Little is known about the primary-specialty care interface for underserved patients. In order better to understand inter-physician communication patterns in urban community health centers (CHCs), we conducted a retrospective chart review of specialty care referrals for patients from four South Side Chicago CHCs. Of the 406 identified referrals, 74% (n=301) were made from CHCs that employed referral coordinators and 64% (n=258) were made to affiliated specialists. Chart documentation of whether or not the patient attended the referred specialty visit was present for 43% (n=176) of referrals, and communication from the specialist to the referring clinician was present for 31% (n=127) of referrals. Employing CHC referral coordinators was positively associated with documented specialty clinical communication (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.2). Use of referral coordinators to facilitate care and integrating delivery systems to increase information sharing appear to improve care coordination, but further investigation is warranted.     

Creating community-based access to primary healthcare for the uninsured through strategic alliances and restructuring local health department programs.

In 2003, the Wilkes County Health Department joined with county healthcare providers to develop the HealthCare Connection, a coordinated and continuous system of low-cost quality care for uninsured and low-income working poor. Through this program, local providers of primary and specialty care donate specialty care or ancillary services not provided by the Health Department, which provides case management for the program. Basing their methods on business models learned through the UNC Management Academy for Public Health, planners investigated the best practices for extending healthcare coverage to the underinsured and uninsured, analyzed operational costs, discovered underutilized local resources, and built capacity within the organization. The HealthCare Connection is an example of how a rural community can join together in a common business practice to improve healthcare access for uninsured and/or low-income adults.