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QUALITY: Community Health Centers Fill Unmet Needs -- Better Than You Might Think

Community health centers (Federally Qualified Health Centers) are an aspect of the recently enacted fiscal stimulus package that hasn't gotten much attention. Perhaps that's because they mostly serve a population we often overlook. Perhaps that's because they are misunderstood—and underestimated.

President Obama earlier this month described his vision for their growth:

These health centers will expand access to care by helping people in need, many with no health insurance, obtain access to comprehensive primary and preventive healthcare services...That helps relieve the burden on emergency rooms across the country, which have become primary care clinics for too many who lack coverage, often at taxpayer expense.

The stimulus package provides $2 billion to the clinics—$1.5 billion for infrastructure and another $500 million for operations. That's a whole lot of money in the world of community clinics. They currently serve 16–18 million people (depending on which authoritative source you ask), in medically underserved inner cities and rural areas, and that will now grow. Other stimulus legislation provisions, involving primary care workforce development, Medicaid and health IT funds, as well as the recent expansion of the State Children's Health Insurance Program, will also expand resources available to the clinics. The money is particularly welcome, advocates say, because the clinics are trying to meet rising demand as more people become uninsured during the recession.

Governed by community boards that include patients, the clinics provide primary care, as well as education and related support services. Dental and behavioral health care are in high demand. The clinics take all comers, with sliding payment scales. In 2007, about one-in-three patients were children and teens. About 40 percent of the patients were uninsured in recent years; that's rising. Blacks and Hispanics were disproportionately represented. The clinics are also a key source of care for the homeless and for migrant workers.

Those facts and figures might be expected. What could be more surprising for anyone who doesn't know much about CHCs is that they can teach the rest of the country a thing or two about how to provide cost-effective primary care, according to presentations at a recent briefing sponsored by the Alliance for Health Reform, United Health Foundation and the National Association of Community Health Centers.

The best of the community health centers (and nobody would argue that they are all "the best", just as not all of the clinics and practices serving affluent and better-insured Americans are "the best") are already providing the kind of patient-centered primary care that the rest of the country is talking about moving toward.

Paloma Hernandez, the CEO of Urban Health Plans, an organization serving the South Bronx and New York City, says her clinics are more than a "medical home." They are a "health home." She told the Alliance briefing:

Urban Health Plan has been in existence since 1974. It was founded by a physician who happens to be my father who started out as a private practitioner on one corner, worked there as a solo practitioner before Medicaid and Medicare was enacted, moved over into a group practice, and in 1974, we became Urban Health Plan. ...He grew up in the community, has been a part of the community for 70 years. So we have 35 years of service to the South Bronx community.

We have currently four primary care sites. We have built our latest, which was built about eight years ago, it is a 40,000-square foot facility that no one ever thought we would fill. In eight years that we've been opened, we've had 110-percent growth in our visits.

We are currently expanding into another borough in Queens. We have five school health programs, four sites at homeless shelters, adult day treatment programs, and in dental clinic and in a boys and girls club. We also have a large support services site that houses our WIC program, community health worker program and that sort of program.

We have a health literacy site... the attempt is really to reduce health disparities by increasing health literacy. We predominantly serve a Latino population and we provide a broad array of services from primary specialty care, diagnostic services, and support services. We have been fully implemented with our electronic health record since September of 2006. What this has done for us is it actually has increased productivity. It has increased our ability to document properly and it's increased our efficiency overall.

Lastly, we are an economic engine in our community. We employ over 400 people, many of whom come, get trained and move on to other jobs and that's great. We understand that that's part of the mission that we also provide. ...These are some of the components that make up a medical home and health centers really believe that they're not necessarily a medical home but more so a health care home because of the type of services that we provide. We provide not only primary care but dental care, behavioral health services.

So when you look at us, it's a place where people come and get a continuum of services that address not only their primary health care needs but deal with the person as a whole.

Sara Rosenbaum and health care research colleagues at George Washinton University have found that CHCs by several measures outperform other settings in providing preventive health care for medically vulnerable and high risk populations. The private sector is taking note. According to Reed Tuckson, MD, executive vice president and chief of medical affairs at UnitedHealth Group, commercial insurers would be wise to bring more health centers into their networks. "In our United Health Care business, we are doing that. We're trying to make sure that every [nearby] community health center ... is enrolled in the network there. Also because we know that community health centers provide such good quality care and especially for certain patients, it's the ideal place to be because of the expertise that they have in managing some of the more comprehensive and complex problems where disease is comingled with socioeconomic challenges."

Community health centers can help build the primary care workforce. Young physicians who rotate through community clinics during their training often choose to become primary care doctors, Tuckson said, a trend that can be built upon with the right loan forgiveness and training opportunities. As the NACHC's Dan Hawkins said, the bottom line of solving the workforce problem "is going to be to 'grow our own.'"

BTW, Obama's appointment of Mary Wakefield as the next administrator of Health Resources Services Administration has been warmly welcomed, both because as a nurse-policymaker she understands care from the inside-out and because of her insights and experience in rural healthcare.

We could do even better if policy supported good care

Community health centers have stepped up again and again to deliver excellent care under trying and difficult circumstances.

HRSA supported a national program of Health Disparities Collaboratives to help CHCs learn about improved chronic care delivery and while there are some excellent cases of improvement, many participants have been frustrated in their efforts to spread and sustain the good work.

This is due to policies that reward volume of services over quality of care. Volume is not the same as quality. CHCs and those they serve will benefit from President Obama's stimulus and ongoing support, but they will benefit more from a thorough evaluation of those policies that thwart the good intention and professional ethic of those working in CHCs.

- Eliminate the illogical and tangential work driven by "billing" and "volume"
- Fund the full scope of comprehensive primary care by supporting more than just "office visits"
- Measure and reward aspects of care that meaningfully improve the health quality of those served ("I can get care when I need it," "I have a primary care practitioner who knows me," "My PCP cares for the bulk of my needs," and "My PCP organizes and coordinates my health care.")

If America is ever going to have a high performing health system it must create a policy and payment environment that supports comprehensive primary care.