Emily Jones

Safety-Net Providers After Health Care Reform: Lessons From Massachusetts

BACKGROUND National health reform is designed to reduce the number of uninsured adults. Currently, many uninsured individuals receive care at safety-net health care providers such as community health centers (CHCs) or safety-net hospitals. This project examined data from Massachusetts to assess how the demand for ambulatory and inpatient care and use changed for safety-net providers after the states health care reform law was enacted in 2006, which dramatically reduced the number of individuals without health insurance coverage. METHODS Multiple methods were used, including analyses of administrative data reported by CHCs and hospitals, case study interviews, and analyses of data from the 2009 Massachusetts Health Reform Survey, a state-representative telephone survey of adults. RESULTS Between calendar years 2005 and 2009, the number of patients receiving care at Massachusetts CHCs increased by 31.0%, and the share of CHC patients who were uninsured fell from 35.5% to 19.9%. Nonemergency ambulatory care visits to clinics of safety-net hospitals grew twice as fast as visits to non-safety-net hospitals from 2006 to 2009. The number of inpatient admissions was comparable for safety-net and non-safety-net hospitals. Most safety-net patients reported that they used these facilities because they were convenient (79.3%) and affordable (73.8%); only 25.2% reported having had problems getting appointments elsewhere. CONCLUSIONS Despite the significant reduction in uninsurance levels in Massachusetts that occurred with health care reform, the demand for care at safety-net facilities continues to rise. Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after health care reform programs are established.

Access to oral health care: the role of federally qualified health centers in addressing disparities and expanding access.

OBJECTIVES We examined utilization, unmet need, and satisfaction with oral health services among Federally Qualified Health Center patients. We examined correlates of unmet need to guide efforts to increase access to oral health services among underserved populations. METHODS Using the 2009 Health Center Patient Survey, we performed multivariate logistic regressions to examine factors associated with access to dental care at health centers, unmet need, and patient experience. RESULTS We found no racial or ethnic disparities in access to timely oral health care among health center patients; however, uninsured patients and those whose insurance does not provide dental coverage experienced restricted access and greater unmet need. Slightly more than half of health center patients had a dental visit in the past year, but 1 in 7 reported that their most recent visit was at least 5 years ago. Among health center patients who accessed dental care at their health center, satisfaction was high. CONCLUSIONS These results underscore the critical role that health centers play in national efforts to improve oral health status and eliminate disparities in access to timely and appropriate dental services.

The Health IT Regional Extension Center Program: evolution and lessons for health care transformation.

OBJECTIVE Assess the Regional Extension Center (REC) programs progress toward its goal of supporting over 100,000 providers in small, rural, and underserved practices to achieve meaningful use (MU) of an electronic health record (EHR). DATA SOURCES/STUDY SETTING Data collected January 2010 through June 2013 via monitoring and evaluation of the 4-year REC program. STUDY DESIGN Descriptive study of 62 REC programs. DATA COLLECTION/EXTRACTION METHODS Primary data collected from RECs were merged with nine other datasets, and descriptive statistics of progress by practice setting and penetration of targeted providers were calculated. PRINCIPAL FINDINGS RECs recruited almost 134,000 primary care providers (PCPs), or 44 percent of the nations PCPs; 86 percent of these were using an EHR with advanced functionality and almost half (48 percent) have demonstrated MU. Eighty-three percent of Federally Qualified Health Centers and 78 percent of the nations Critical Access Hospitals were participating with an REC. CONCLUSIONS RECs have made substantial progress in assisting PCPs with adoption and MU of EHRs. This infrastructure supports small practices, community health centers, and rural and public hospitals to use technology for care delivery transformation and improvement.

Access to Mental Health Services Among Patients at Health Centers and Factors Associated with Unmet Needs

Cross-sectional 2009 Health Center Patient Survey data describe the mental health status of health center patients, utilization of mental health services, and factors associated with unmet need for mental health treatment. One in five health center patients accessed mental health services in the past year, and over half of the patients who received counseling received this treatment at a health center. Patients who were unable to access mental health care cited affordability as a concern. Unmet need for mental health treatment was reported by one in three patients. Multivariate analysis found that the odds of reporting unmet need were higher for patients who lacked a usual source of care and patients with serious mental illness.

Unmet Need Among Homeless and Non-Homeless Patients Served at Health Care for the Homeless Programs

This study compared the level of unmet need for medical, dental, mental health (MH), and substance use disorder (SUD) treatment between homeless and non-homeless patients served at Health Care for the Homeless programs. Using the 2009 Health Center Patient Survey, logistic regression models were used to assess the relationship between homelessness and unmet need for care. Descriptive statistics were then used to examine reasons for unmet need. Homeless patients were just as likely as non-homeless patients to have medical and dental treatment needs met. However, they were significantly more likely to report an unmet need for MH counseling and less likely to report an unmet need for SUD treatment. The primary reasons underlying unmet need were an inability to afford care and a lack of knowledge about where to obtain it. Results highlight the benefits of allotting additional funding to HCH programs so that they have the capacity to expand their overall scope of services.

Medication‐Assisted Opioid Treatment Prescribers in Federally Qualified Health Centers: Capacity Lags in Rural Areas

PURPOSE This study explores correlates of on-site availability of substance use disorder treatment services in federally qualified health centers, including buprenorphine treatment that is critical to addressing the opioid epidemic. METHODS We employed descriptive and multivariable analyses with weighted 2010 Assessment of Behavioral Health Services survey data and the 2010 Uniform Data System. FINDINGS In 2010, 47.6% of health centers provided on-site substance use disorder treatment, 12.3% provided buprenorphine treatment for opioids, and 38.8% were interested in expanding buprenorphine availability. Urban health centers, those in the West, and health centers with electronic health records had higher odds of offering on-site substance use disorder treatment. Compared with on-site mental health treatment, substance use disorder treatment was available in fewer clinic sites within each organization. Health centers in rural areas had lower odds of providing on-site buprenorphine treatment (OR = 0.49, 95% CI: 0.26-0.94), and those in the South had lower odds of providing on-site buprenorphine treatment compared with health centers in other regions. Rural health centers had lower odds of expressing interest in expanding the availability of buprenorphine treatment (OR = 0.58, 95% CI: 0.35-0.97). CONCLUSIONS Improving access to substance use disorder treatment in primary care is a critical part of the strategy to combat the opioid use disorder epidemic. These findings highlight the important role of health centers as portals of access to substance use disorder treatment services in underserved communities. Recent investments to expand treatment capacity in health centers will expand the availability of substance use disorder services, but urban/rural and regional disparities should be monitored.

Building a national data repository to measure and improve health center quality

Community health centers provide access to high-quality care for underserved populations and have a history of success with quality improvement initiatives, due to their mission and data reporting requirements. Investments in the health center infrastructure can bolster efforts to create a Nationwide Health Information Network to better utilize the available data. Aggregation, stratification by health center type, and use of patient-level quality data enable the development of quality measures that can be used to target health center resources and further improve quality. Health centers are fertile testing grounds for strategies to utilize data and performance measures to fuel quality improvements.

Opting Out of Medicaid Expansion: Impact on Encounters With Behavioral Health Specialty Staff in Community Health Centers

OBJECTIVE This study examined how state decisions not to expand Medicaid have affected behavioral health services utilization in health centers. Because health center revenues are adversely affected, the ability to provide on-site nonrequired services, such as specialty mental health and substance abuse treatment services, is compromised. METHODS Using 2012 Uniform Data System data and the projected health center insurance case mix in 2020, the authors estimated the amount of additional revenue that could accrue to health centers if all states were to expand Medicaid by 2020. Using the estimated percentage of total revenues supporting the provision of specialty behavioral treatment services, the authors also estimated the number of encounters with behavioral health specialists that might be possible in 2020 if all states expand Medicaid by then. State-specific estimates are provided. RESULTS If all states expand Medicaid by 2020, it is estimated that nearly

Sharing a Playbook: Integrated Care in Community Health Centers in the United States

230 million in additional revenue could accrue to health centers in states that opted out of expanding Medicaid in 2014. An estimated

Homeless Caseload is Associated with Behavioral Health and Case Management Staffing in Health Centers

11.3 million would likely be used for mental health services and