Peter Shin

The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations

Many of the U.S. states with the largest anticipated Medicaid expansions are also the ones that have less primary care capacity. These states could face surging demand from the newly insured population without having sufficient primary care resources available.

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.

The inverse care law: Implications for healthcare of vulnerable populations

Past and present, those with the greatest healthcare needs often receive the least adequate healthcare. This phenomenon, termed the “inverse care law,” has implications for healthcare and outcomes for vulnerable populations including low-income persons, racial and ethnic minorities, and the uninsured among others. This article reviews disparities in health status and access to healthcare for vulnerable populations. It illustrates how concentration of risk factors within individuals, families, and communities worsens the paradox between healthcare need and access and highlights the models of healthcare delivery needed to adequately meet the needs of vulnerable populations.

Scope of family planning services available in Federally Qualified Health Centers

OBJECTIVES Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. STUDY DESIGN An original survey of 423 FQHC organizations was fielded in 2011. RESULTS Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. CONCLUSION There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. IMPLICATIONS With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings.

Cost savings associated with the use of community health centers.

This study assesses the potential cost savings associated with the use of community health centers, based on econometric analyses of the 2006 Medical Expenditure Panel Survey. After controlling for health status, health insurance coverage, income, age, and other factors, this study finds that patients who receive a majority of their ambulatory care at community health centers have significantly lower annual overall medical expenditures (24%) and ambulatory expenditures (25%) than those who do not. These results are consistent with other studies indicating that, by providing good quality primary care, community health centers can reduce the utilization of other medical services.

Adoption of health center performance measures and national benchmarks.

This study examines the adaptability of standardized performance measurement tools in 3 community-based health centers. Although health centers have considerable experience in the area of performance reporting, they do not currently participate in a national reporting system that is transparent and standardized. The analysis of the data collected from health centers indicates that not only can these safety net providers readily integrate standardized measures, the quality of care being provided compare favorably to national benchmarks. With evidence of solid performance may come the types of financial adjustments essential to permitting health centers to move more decisively into the broader private health insurance markets that may exist in their service areas.

Special Issue Introduction: Building a Stronger Science of Community-Engaged Research

This special issue in the journal Progress in Community Health Partnerships (PCHP) stems from growing encouragement for community engagement in federally funded research, increasingly involving community stakeholders in developing models of care delivery that incorporate the unique cultural, social, demographic, economic, and resource needs of their communities. The idea for this issue was initially articulated at a February 2010 National Institutes of Health Clinical and Translational Science Award (CTSA) Community Engagement (CE) Key Function Committee Meeting. We also conducted a PubMed search in May 2012 which showed a consistent and increasing incorporation of the community engagement concepts into the work of biomedical and translational scientists; similarly, Doug Brugge recently commented on a SCOPUS literature search, also noting an increase in scholarship related to community-based participatory research.1

Food insecurity, food assistance and health status in the U.S. community health center population.

Objectives. This study explored the relationship between food insecurity, food assistance, and self-reported health status among community health center (CHC) clients. Methods. Using data from the 2009 Community Health Center Patient Survey (n = 4,562), representing Federally Qualified Health Center clients, we conducted logistic regression analyses to identify the association between food insecurity and fair/poor health status, controlling for food assistance and sociodemographic factors. Results. Approximately 1/3 of the sample (31.9%) reported fair/poor health status, 10.9% reported food insecurity, and 52.6% reported public food assistance. Multivariate analyses revealed that, among women, those with food insecurity had significantly higher odds of reporting fair/poor health status (AOR = 2.14, 95% CI 1.20–3.82). Conclusions. Expansion of financial access to health care via the Patient Protection and Affordable Care Act coupled with recent funding cuts to the Supplemental Nutrition Assistance Program means that CHCs play an increasingly important role in addressing food insecurity.

The role of community health centers in responding to disparities in visual health.

BACKGROUND Community health centers (CHCs) are nonprofit community-based providers of primary and preventive health care for medically underserved populations. At the same time, nationally, racial/ethnic minorities and low-income populations are disproportionately affected by poor access to comprehensive eye and vision care and are more likely to experience adverse outcomes. OVERVIEW This report describes the fundamentals of CHCs, including mission, their patients, the types of health care and enabling services that they provide, the quality and cost-effectiveness of their care, and how they are funded. This report also reviews the demographics of vision disparities among at-risk populations, the economic impact of undiagnosed and untreated vision problems, and the similarities between those at risk for vision problems and the patients targeted by CHCs. CONCLUSIONS Aimed at responding to disparities in access to health care services and health status outcomes, CHCs are optimally positioned to contribute to improved access to comprehensive eye and vision care as well as to the reduction of disparities in visual health status. There is need for extensive research in further defining and addressing disparities in access to optometric care in medically underserved populations and the potential role that CHCs can play in meeting those needs.

The Role of Community Health Centers in Providing Behavioral Health Care

The prevalence of behavioral health problems is higher for low-income individuals, yet this population is less likely to receive behavioral health treatment. Community health centers have their advantages as behavioral health-care providers because they serve a majority low-income population and are located in medically underserved areas. Their role in providing behavioral health care is expected to expand under health reform as they are expected to double their patient capacity, and due to increased insurance coverage for individuals with behavioral health problems. However, the ability of community health centers to provide behavioral health care is compromised by provider shortages and funding shortfalls.The prevalence of behavioral health problems is higher for low-income individuals, yet this population is less likely to receive behavioral health treatment. Community health centers have their advantages as behavioral health-care providers because they serve a majority low-income population and are located in medically underserved areas. Their role in providing behavioral health care is expected to expand under health reform as they are expected to double their patient capacity, and due to increased insurance coverage for individuals with behavioral health problems. However, the ability of community health centers to provide behavioral health care is compromised by provider shortages and funding shortfalls.