Expanding care versus expanding coverage: how to improve access to care

The Bush administration has proposed expanding insurance coverage as well as community health centers (CHCs) to increase access to care for uninsured people. This paper examines the relative effects of insurance coverage and CHC capacity on access to care. Communities that have both high insurance coverage and extensive CHC capacity tend to have the best access, although the former appears more important. Funding of insurance coverage expansions is likely to produce greater gains in access than if an equivalent level of funding were invested in CHCs. Policymakers should consider CHC expansions as complementary to insurance coverage expansions rather than as a substitute.     

Impact of community health centers and Medicaid on the use of health services.

The impact of improved access to health care through the Federal community health center (CHC) and Medicaid programs was examined in five urban low-income areas. Data on access to care and physician, hospital, and dental services utilization were collected by baseline and followup health surveys in the CHCs'' services areas. There was a shift in use from hospital clinics to CHCs. Followup surveys indicated that 23 percent of the population reported CHCs as usual source of care. Travel time to source of care was reduced for users of CHCs. Medicaid coverage of the population in the survey areas increased from 16 to 37 percent between the baseline and followup surveys, an interval of 4 to 7 years. Increases occurred in the use of physicians and dental care between the baseline and followup surveys, but the rates scarcely kept pace with the national rates. Respondents who reported CHCs as their usual source of care, however, had a higher rate of physician visits and a lower rate of hospitalization compared with those using private physicians or hospital clinics as the usual source of care. Respondents with Medicaid coverage usually had higher physician and hospital use, irrespective of usual source of care. Both CHC and Medicaid programs contributed to increased use of dental care by providing financial and dental care resources. Although these two programs greatly facilitated the use of health services, disparity in physician and dental utilization remains between the five low-income areas and the averages for the nation.     

Assessing primary care content: four conditions common in community health center practice

Under managed care, community health center (CHC) care patterns will be increasingly subject to outside scrutiny. This article discusses results of medical records reviews assessing quality of care at CHCs for acute otitis media, diabetes, asthma, and hypertension. As a group, these safety net providers meet or exceed prevailing practice across other health care settings; however, there is substantial variation among sites. Regression analyses indicate that the individual CHC used by a patient is the most consistent determinant of whether a patient receives recommended care. Drawing on these results, the article explores approaches for improving care and discusses the implications for performance measurement among CHCs and other safety net providers.     

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.     

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.     

Caring for Young Children with Asthma: Perspectives from Urban Community Health Centers

Asthma disproportionately affects low-income, minority youth, with notable disparities among children <5 years of age. Understanding the perceptions of urban community health centers (CHCs) regarding treating young children with asthma could improve care for these patients. This study uses data from semi-structured focus groups with staff from eight urban CHCs. Themes emerged in three domains. Within the parent/family domain, providers noted low rates of follow-up visits, low health literacy, and—for young children specifically—misunderstanding about the diagnosis. At the CHC level, providers needed more staff, space, and comfort with applying the guidelines to infants and young children. CHCs reported asthma registries, population health oversight, and an asthma champion improved care. At the system level, providers wanted improved communication with emergency departments and community outreach programs. Reducing these multi-level barriers may improve care.     

Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states

Background  

Federally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions.     

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.     

Primary Health Care in Community Health Centers and Comparison with Office-Based Practice

We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006–2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.     

Assessing Indian public health standards for community health centers: a case study with special reference to essential newborn care services

The main objective of the study is to identify the availability of infrastructure facility, human resources, investigative services, and facility based newborn care services with respect to Indian Public Health Standards (IPHS) at community health centers (CHC) of Bharatpur District of Rajasthan State. Data were collected from service providers at CHC through well structured questionnaire at thirteen CHCs situated at Bharatpur District of Rajasthan State. It was found that infrastructure facilities were available in almost all the CHCs, but shortage of manpower especially specialists was observed. Availability of investigative services was found quite satisfactory except ECG. It was also observed that none of the CHCs have fully equipped facility based newborn care services (including newborn corner and newborn care stabilization unit). As per IPHS suggested in the revised draft (2010) important deficiencies were revealed in the studied CHCs of Bharatpur district and by additional inputs such as recruiting staff, improving infrastructure facilities, CHCs can be upgraded.     

The effect of the right care,right place,right time (R3) initiative on Medicare health service use among older affordable housing residents

Objective

To determine the effect of an affordable housing-based supportive services intervention, which partnered with health and community service providers, on Medicare health service use among residents.

Data Sources

Analyses used aggregated fee-for-service Medicare claims data from 2017 to 2020 for beneficiaries living in 34 buildings in eastern Massachusetts.

Study Design

Using a quasi-experimental design, a “difference-in-differences” framework was employed to isolate changes in outcomes, focusing on changes in pre- and post-intervention health service use across two stages of the intervention. Phase 1 encompassed the initial implementation period, and Phase 2 introduced a strategy to target residents at high risk of poor health outcomes. Key health service outcomes included hospitalizations, 30-day hospital readmission, and emergency department use.

Data Collection

Medicare claims data for 10,412 individuals were obtained from a Quality Improvement Organization and aggregated at the building level.

Principal Findings

Analyses for Phase 1 found that hospital admission rates, emergency department admissions and payments, and hospital readmission rates grew more slowly for intervention sites than comparison sites. These findings were strengthened after the introduction of risk-targeting in Phase 2. Compared to selected control buildings, residents in intervention buildings experienced significantly lower rates of increases in inpatient hospitalization rates (−16% vs. +6%), hospital admission days (−25% vs. +29%), average hospital days (−12% vs. +14%), hospital admission payments (−22% vs. +33%), and 30-day hospital readmission rates (−22% vs. +54%). When accounting for the older age of the intervention residents, the size of the decline recorded in emergency department admissions was 6.7% greater for the intervention sites than the decline in comparison sites.

Conclusions

A wellness-focused supportive services intervention was effective in reducing select health service use. The introduction of risk-targeting further strengthened this effect. Age-friendly health systems would benefit from enhanced partnerships with affordable housing sites to improve care and reduce service use for older residents.     

Exploring the limits of the safety net: community health centers and care for the uninsured

This paper explores the extent to which community health centers (CHCs) are able to manage their uninsured patient caseloads. We found that CHCs can provide primary care, medications, and medical supplies to most of their uninsured patients on site but are limited in their ability to provide diagnostic, specialty, and behavioral health services. Uninsured patients often fail to receive additional services for which they are referred, and it is much more difficult for CHC physicians to arrange specialty or nonemergency hospital care for their uninsured patients than for their insured patients.     

Preparing for managed care: family practice residents and capitated care in community health centers

This article examines the financial impact on patients of family practice residents when a community health center (CHC) serving as a residency training site is converted to a capitated payment system. The costs in this analysis included using and educating family practice residents at CHCs, the cost of patient encounters at CHCs, and the cost of contracted capitated services. These costs were measured against capitated per member per month (pmpm) payments received by the CHC. If capitated patients were cared for by residents, the CHC would lose $8.42 pmpm. The CHC faced a $5.98 pmpm loss if it used staff physicians rather than residents. This analysis suggests there are educational costs associated with training physicians in capitated health care delivery systems. Family practice residencies and CHCs must prepare for the conversion to capitated systems; academic centers with managed care contracts must control patient encounter costs and utilization to remain competitive.     

Community Health Centers and racial/ethnic disparities in healthy life.

This study examined disparities in health status among individuals of different racial and ethnic groups cared for by the nation's community health centers (CHCs) and compared these results with the findings for individuals using non-CHC sites as their usual source of care. The sample consisted of CHC users from the 1994 CHC User Survey and non-CHC users from the 1994 National Health Interview Survey. Bivariate comparisons were made between individuals' race/ethnicity and their experience of healthy life, an integrated measure that incorporates both activity limitation and self-perceived health status. Multiple regressions were followed to examine the independent association of race/ethnicity with healthy life experience for both CHC and non-CHC users while controlling for sociodemographic correlates of health. Among CHC users, racial and ethnic minorities did not have worse health than whites, but among non-CHC users there were significant racial and ethnic disparities: whites experienced significantly healthier life than both blacks and non-white Hispanics. These findings persisted after controlling for sociodemographic correlates of health. The results indicate that while racial/ethnic disparities in health persist nationally, these disparities do not exist within CHCs, safety-net providers with an explicit mission to serve vulnerable populations.     

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.     

True believers? Characteristics of general practitioners in Victorian community health centres

Abstract: General practitioners have been part of multidisciplinary services in Victorian Community Health Centres (CHCs) for 20 years. This model institutionalises a high degree of integration between general practitioners and other primary care and community service personnel. Of 51 eligible full-time general practitioners in Victorian CHCs, 46 were interviewed, using a structured questionnaire. General practitioners in CHCs were younger less experienced and more likely to be female than other general practitioners. Nearly three-quarters were salaried. The philosophy of practice and the conditions of employment were the commonest reasons for entering CHC practice. Teamwork and the conditions of employment were felt to be the biggest advantages of CHC practice, while difficulties with management and the perceived loss of professional ownership and control were the commonest disadvantages. None reported interference from the CHC management in their clinical practice. Nearly a quarter of full-time CHC general practitioners do not undertake any formal community health promotion activities. Forty-five per cent of respondents intended to leave their CHC within the next five years. Universal health insurance has diminished the impact of CHC general practice. The philosophy of CHCs and the salaried nature of the employment continues to attract general practitioners. High staff turnover is a feature of CHC general practice, in part related to young doctors making an initial, but not long-term commitment to CHC practice. However, the loss of professional control and management difficulties should be addressed, as these may contribute to the high turnover.     

Improving access to health care in Latino communities.

Public debate about health care reform often focuses on the need for health insurance coverage, but in Latino communities many other barriers also inhibit access to medical care. In addition, basic public health services often go underfunded or ignored. Thus, health care reform efforts, nationally and in each State, must embrace a broader view of the issues if the needs of Latino communities are to be served. This report reviews and summarizes information about the mounting problems Latino communities face in gaining access to medical care. Access to appropriate medical care is reduced by numerous financial, structural, and institutional barriers. Financial barriers include the lack of health insurance coverage and low family incomes common in Latino communities. More than 7 million Latinos (39 percent) go without health insurance coverage. Latinos without health insurance receive about half as much medical care as those who are insured. Structurally, the delivery system organization rarely reflects the cultural or social concerns of the communities where they are located. Therefore, providers and patients fail to communicate their concerns adequately. These communication problems are exacerbated by the extreme shortage of Latino health care professionals and other resources available. Institutional barriers often reflect the failure to consider what it means to provide good service as well as high-quality medical care. Reducing these barriers to medical care requires modifying governmental and institutional policies, expanding the supply of competent providers, restructuring delivery system incentives to ensure primary care and public health services, and enhancing service and satisfaction with care.     

Health centers and health insurance: complements, not alternatives

While some consider health centers and universal health insurance to be opposing concepts, we consider them to be complementary. Health centers play a vital role regardless of the type of insurance system in place because they reduce barriers to care and provide quality culturally competent care to vulnerable populations. The current private employer-based US healthcare system does not create incentives for providers to care for low-income and vulnerable populations. Even in countries with universal health coverage, health centers increase access to care and improve health outcomes. Instead of arguing whether health centers or health insurance should be expanded, the debate should focus on how best to use safety net providers as health insurance coverage expands.     

Community Health Centers and Emergency Preparedness: An Assessment of Competencies and Training Needs

Community health centers (CHCs) provide care to a large number of medically underserved Americans. As primary care providers and trusted members of their communities, CHCs need to be prepared to respond to emergency and disaster situations, as they may be relied upon for medical care and other support services. Focus groups were conducted with CHC medical directors and administrators from New York City. Participants discussed previous emergency preparedness training, future training needs, applicability of competencies, and usefulness of two training programs. Participants indicated that they had more experience with preparedness training than many of their colleagues, although participants still reported further training needs. In particular, emergency roles and responsibilities, decontamination and containment, and personal preparedness were given as needed training topics for staff. The training resources were reported to be useful and beneficial. Participants also reported that most of the competencies were appropriate for CHC clinicians. During an emergency, people want to receive care from their normal provider, and for many, that provider is a CHC. This and other research suggests that the emergency preparedness needs facing CHCs are significant and should be addressed.     

America's Health Centers: Reducing Racial and Ethnic Disparities in Perinatal Care and Birth Outcomes

Objective. To examine whether community health centers (CHCs) reduce racial/ethnic disparities in perinatal care and birth outcomes, and to identify CHC characteristics associated with better outcomes.
Background. Despite great national wealth, the U.S. continues to rank poorly relative to other industrialized nations on infant mortality and other birth outcomes, and with wide inequities by race/ethnicity. Disparities in primary care (including perinatal care) may contribute to disparities in birth outcomes, which may be addressed by CHCs that provide safety-net medical services to vulnerable populations.
Methods. Data are from annual Uniform Data System reports submitted to the Bureau of Primary Health Care over six years (1996–2001) by about 700 CHCs each year.
Results. Across all years, about 60% of CHC mothers received first-trimester prenatal care and more than 70% received postpartum and newborn care. In 2001, Asian mothers were the most likely to receive both postpartum and newborn care (81.7% and 80.3%), followed by Hispanics (75.0% and 76.3%), blacks (70.8% and 69.9%), and whites (70.7% and 66.7%). In 2001, blacks had higher rates of low birth weight (LBW) babies (10.4%), but the disparity in rates for blacks and whites was smaller in CHCs (3.3 percentage points) compared to national disparities for low-socioeconomic status mothers (5.8 percentage points) and the total population (6.2 percentage points). In CHCs, greater perinatal care capacity was associated with higher rates of first-trimester prenatal care, which was associated with a lower LBW rate.
Conclusion. Racial/ethnic disparities in certain prenatal services and birth outcomes may be lower in CHCs compared to the general population, despite serving higher-risk groups. Within CHCs, increasing first-trimester prenatal care use through perinatal care capacity may lead to further improvement in birth outcomes for the underserved.