Innovative Community-Based Approaches to Program and Policy Development Aimed at Reducing

Disparities in Primary Care

Sam S. Shekar, M.D., M.P.H.

Associate Administrator

for Primary Health Care and

Assistant U.S. Surgeon GeneralAmerican Public Health Association (APHA)

131st Annual Meeting and ExpositionNovember 15 - 19, 2003

Health centers that receive a federal grant are called Federally Qualified Health Centers (FQHCs)

HRSA provides federal grant funding to health centers to deliver primary and preventive care

Authorized under 2002 Amendments of the Health Centers Consolidated Care Act of 1996, section 330 of the Public Health Service Act

Consolidated health centers include:– Community Health Centers– Migrant Health Centers– Health Care for the Homeless Programs– Public Housing Primary Care Programs– School-Based Health Centers

FQHCs and Health Centers

$6M annual budget 50,000 encounters/year 14,000 patients/year Services:

– General primary care– Preventive screenings– Chronic disease management– Enabling services

Source: BPHC, 2002 Uniform Data System (UDS)

Typical Health Center

30 clinicians/clinical professionals

10 enabling staff 40 administrative staff

11.3 Million served 44.7 Million patient encounters >3,400 service sites 88.1% below 200% poverty 38.9% uninsured 63.9% racial/ethnic minority Serve all ages

–

12.8 % 4 and under–14.3 5-12 years–20.2 13-24 years–45.6 25-64 years– 7.0 65 and over

Presidential InitiativeCalendar Year (CY) 2002

Source: Uniform Data System, CY 02, June 2003

Health Centers:Sources of Funding

(FY 2002 est)

Self Pay6%

Other 3rd Party8%

SCHIP2%

Other Federal3%

Medicare6%

State/Local/Other19%

Medicaid31%

Federal HC Grant25%

Source: BPHC, 2002 UDS

Health Centers and MedicaidRelationship: -- 1/3 of Health Center Patients -- 1/3 of Health Center Total Revenue -- 2/3 of Health Center Patient Revenue

Result:Decreased Avoidable Hospitalizations – Health Center Medicaid patients are 22% less likely to be hospitalized for potentially avoidable conditions than those obtaining care elsewhere. Falik et al. Medical Care Vol. 39, No 6; 2001.

Health Center Medicaid patients are 11% less likely to be hospitalized for potentially avoidable conditions than those with a usual source of care who obtained care elsewhere. Ambulatory Care Sensitive Conditions (ACSC) II Study to be published.

Lower Health Care Costs – Cost of treating Health Center Medicaid patients is 30-34% less than cost for those receiving care elsewhere; 26-40% lower for Rx; 35% lower for diabetics; 20% lower for asthmatics. Center for Health Policy Studies. Final Report; November 1994.

President’s Initiative to Expand Health Centers

By 2006:

• 1,200 new or expanded health centers• 6 million additional people

74.9

57.3

39.4

98.5*

0

20

40

60

80

100

120

CHC U.S. CHC U.S.

Usual Source of Care 3 or more doctor visits

Per

cen

tAccess to Care: Uninsured Health Center Patients Face

Fewer Primary Care Access Barriers than Uninsured Overall

Source: Carlson et al. Primary Care of Patients without Insurance by Community Health Centers (CHCs). Journal of Ambulatory Care Management (JACM). 2001. *p<.001

A national effort to improve health outcomes for all medically underserved people

HRSA Health Disparities Collaboratives

• Care Management Collaboratives– Diabetes, Cancer, Cardiovascular, – Asthma, Depression, HIV/AIDS

• Prevention Collaboratives – Diabetes– Healthy weight, tobacco use, blood pressure,

cholesterol, immunizations, lead screening, oral health

• Finance Redesign Pilot

• Perinatal Risk Management – Planned

HRSA Health Disparities Collaboratives

Patient self-managementEvidence based decision supportClinical information system to monitor clinical

outcomesDelivery system designed for patient and

family goalsOrganization of health care for qualityCommunity partnerships

The Care Model includes six essential elements for improving the care of people with chronic illness:

Health Center Patients With Diabetes Are Twice As Likely To Have Their Glycohemoglobin

Tested on Schedule

0

10

20

30

40

50 43%

20%Health Center Patients

National Norm

Source: MDS Associates, Evaluation of the effectiveness and Impact of Community Health Centers, based on the National Health Interview Survey, 1999

Collaborative SuccessCollaborative Success

“With federally funded health centers having fully embraced the (Health Disparities Collaborative) model…this has become arguably the largest, most important health care quality improvement initiative in the country.

It’s exactly what the health care system needs right now - a demonstration that it is possible both to improve care dramatically and even reduce health care costs.”

Tracy Orleans, Ph.D., senior scientist at the Robert Wood Johnson Foundation Advances Online, Robert Wood Johnson Foundation Newsletter, October 2002

HCAP PartnershipsHealthy Communities Access Program (HCAP) Newly Established Legislative Authorization (340 Public Health

Service (PHS) Act

New Direction– Stronger Emphasis on Health Care for Underserved– Strengthens Vertical Integration– Improves Chronic Care Coordination– Builds Information Technology Systems– Assists Infrastructure Development

Healthy Community Access Program – FY 2003 35 new HCAP communities in 20 states received awards in FY

2003 129 HCAP communities received continuing funds. Currently, HRSA has a total of 164 HCAP grantees in 43 states

Public Health Center Entities

Public Health Center Entities

Under section 330(l)(2)(A), the Secretary may allocate up to 5% of its section 330 dollars to public centers or entities that do not independently meet governing board requirements.

In 2002, 39 public entities currently received $41 million of community and migrant health center funds.

Public Health Entity Examples• Multnomah County Public Health Department – Portland, Oregon• Will County Community Health Center – Joliet, Illinois• City of Austin Primary Care Department – Austin, Texas• Lexington-Fayette County Health Dept. – Lexington, Kentucky• Denver Health and Hospitals – Denver, Colorado• Palm Beach County Health Dept. – West Palm Beach, Florida

BUILDING HEALTHY COMMUNITIES: BUILDING HEALTHY COMMUNITIES:

ONE PATIENT AND FAMILY,ONE HEALTH CENTER AT A TIME!