Uncertain Future

By David Thill

Nation’s Community Health Centers seek to retain funding with a looming financial deadline.

Editor’s note: Traditionally, patients had two options for seeking healthcare: the doctor’s office or the hospital. However, advances in medical research, technology, and team-based care – and the developing shift to value-based care – have left patients with a host of options for obtaining the treatment they need. In this continuing series, we examine ongoing changes in health systems, and how they affect patients, doctors, and, of course, Repertoire’s readers.

Community Health Centers have traditionally served as a source of affordable primary clinical care to residents in some of the nation’s economically hardest-hit communities. But without continued funding from the federal government – which Congress must pass before October 1 – the future of many Community Health Centers, and the effect their closures could have on the American healthcare system, is uncertain.

Health Centers are among the “gatekeepers of public health,” says Amy Simmons Farber, director of communications at the National Association of Community Health Centers, noting that 25 million Americans utilize Health Centers. Many of these clinics now offer a broader range of care, including behavioral health services, and are making efforts to address systemic issues like the opioid epidemic.

The basics of Health Centers
Originally an outgrowth of President Lyndon Johnson’s War on Poverty, Community Health Centers have existed in the United States for just over 50 years, says Simmons Farber. A recent NACHC report, “Strengthening the Safety Net,” describes Community Health Centers as “locally-based, locally-owned, and locally-governed” small businesses. Health Centers boost the economies of the communities they serve, says the report.

The report also says that many Community Health Centers offer integrated services, “bringing together medical, oral health, mental health, substance abuse treatment, and other critical services under one roof.” Eighty-two percent of Health Centers offer behavioral health, 76 percent offer oral health, and 40 percent offer pharmacy services, the report says, adding that 68 percent of Health Centers have become recognized as Patient Centered Medical Homes – “a standard shown to be related to better clinical performance.”

The Health Resources and Services Administration lays out several fundamental components of Community Health Centers, as part of its official Health Center Program. Among these fundamentals are:

  • Health Centers deliver high quality, culturally competent, comprehensive primary care, as well as supportive services such as health education, translation and transportation that promote access to healthcare.
  • Patients are served by Community Health Centers regardless of their ability to pay; Health Centers charge for services on a sliding fee scale.
  • Health Centers develop systems of patient-centered and integrated care that respond to the “unique” needs of diverse medically underserved areas and populations.

According to Simmons Farber, Community Health Centers “treat the most chronically ill and economically disadvantaged patients for a fraction of the cost of a hospital emergency room visit.”

Political realities
An estimated 9 million patients could lose access to healthcare if Congress fails to extend funding for the country’s Community Health Centers by a September 30 deadline, or “funding cliff.” Should Congress fail to extend funding beyond the end of September, the effect on the American healthcare system would be “devastating,” says Simmons Farber.

Failure to extend funding would result in a 70 percent budget cut to Health Centers and the closing of 2,800 Community Health Center sites throughout the country, according to HRSA estimates. Healthcare costs will “sky-rocket,” says Simmons Farber, “because access to preventive and primary care will be compromised for millions of people who would have no alternative but to seek primary care services in a hospital setting, or delay or avoid care altogether.”

Simmons Farber notes that 55 percent of Community Health Centers are located in rural areas, “where options for care are few or scarce and the nearest provider could be 100 driving miles in any direction.” Therefore, she says, patients in rural areas could be most affected by a failure to extend funding. HRSA estimates that one in six rural residents in the United States rely on Health Center services.

Simmons Farber says cuts would put the “entire U.S. healthcare delivery system at risk.” But, she adds, Community Health Centers have broad bipartisan support, because of the program’s “established record of keeping down healthcare costs while managing chronic disease in economically challenged populations.”

Nevertheless, NACHC and its members are taking no chances. The organization’s 2017 Policy and Issues Forum, held in March in Washington D.C., brought together nearly 3,000 advocates – including clinicians, nurses, board members, and patients – to lobby members of Congress to extend funding.

Health Centers are not “just another healthcare program,” says Simmons Farber. “They are problem-solvers that look beyond the medical chart to not only prevent illness but also address the factors that actually cause poor health….They are innovators in treating chronic conditions that are typically ignored until they become a costly illness.”

The NACHC report can be found at http://www.nachc.org/wp-content/uploads/2017/03/Strengthening-the-Safety-Net_NACHC_2017.pdf.

How do Community Health Centers work?

Originally a part of President Lyndon Johnson’s War on Poverty, the Health Center Program “has grown from two health centers to nearly 1,400 health centers operating more than 10,400 sites in every U.S. state, the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin,” according to the Health Resources and Services Administration.

The National Association of Community Health Centers estimates that 25 million Americans receive care from Community Health Centers, many of them in economically disadvantaged urban and rural areas.

Here is a look at the services a Community Health Center must offer to receive federal funding through the Health Center Program:

  1. Required and Additional Services: Health Centers must provide all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals. Health Centers that request funding to serve homeless individuals and their families must provide substance abuse services among their required services.
  1. Staffing Requirement: To receive HRSA funding, a Health Center must maintain a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary. Staff must be appropriately licensed, credentialed, and privileged.
  1. Accessible Hours of Operation/Locations: Services must be provided at times and locations that assure accessibility and meet the needs of the population served.
  1. After Hours Coverage: Health Centers must provide professional coverage for medical emergencies during hours when they are closed.
  1. Hospital Admitting Privileges and Continuum of Care: Health Center physicians must have admitting privileges at one or more referral hospitals, or have another such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, the Health Center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking.
  1. Sliding Fee Discounts: A system must be in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. Among other things, that system must provide a full discount to individuals and families with annual incomes at or below 100 percent of federal poverty guidelines. For patients with incomes between 100 percent and 200 percent of the guidelines, fees must be charged in accordance with a sliding discount policy based on family size and income.
    Additionally, as per HRSA, “No patient will be denied health care services due to an individual’s inability to pay for such services by the health center, assuring that any fees or payments required by the center for such services will be reduced or waived.”
  1. Quality Improvement/Assurance Plan: Health Centers must have ongoing Quality Improvement/Quality Assurance programs that include clinical services and management, and that maintain the confidentiality of patient records. Among other things, the programs must include a clinical director whose focus of responsibility is to support the quality improvement/assurance program and the provision of high quality patient care.

Additionally, periodic assessments must be made of the appropriateness of the utilization of services and the quality of services provided. These assessments must identify and document the necessity for change in the provision of services by the Health Center, and, where indicated, must result in the institution of said change.

(For full details on services, as well as more information about the Health Center Program, visit https://www.bphc.hrsa.gov/programrequirements/index.html.)

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