Program Goals

As part of The Commonwealth Fund’s efforts to support delivery system improvement and innovation, the Program on Vulnerable Populations is designed to ensure that low-income, uninsured, and otherwise disadvantaged minority populations are able to obtain care from high-performing health systems capable of meeting their special needs. To achieve this mission, the program makes grants to:

• Identify policy levers that can achieve equity in health care access and quality and address concerns faced by vulnerable populations across the continuum of care;
• Identify promising care delivery practices and models and develop and disseminate policy recommendations to support such innovations so that care systems can better serve vulnerable populations;
• Encourage state and local planning efforts to achieve systems of care that meet the specific needs of vulnerable populations; and
• Document and track health care utilization and quality for vulnerable populations at the state level.

The program is led by Pamela Riley, M.D., M.P.H. 

The Issues

In the United States, vulnerable populations, including low-income people, the uninsured, and racial and ethnic minorities, have greater difficulty accessing health care, receive worse care overall, and experience poorer health outcomes than the general population. Members of vulnerable populations also have disproportionately high special needs arising from personal, social, and financial circumstances, any of which may negatively affect health and hamper efforts to obtain care. High-performing health systems for vulnerable populations must be equipped to address these needs.

While the traditional safety-net health system is critical for providing care to vulnerable populations, many members of vulnerable groups do not rely on it as their main source of care. That is why improvements in health care delivery must be made not only within the safety net but across the broader health system as well. All patients should have access to high-performing health care systems capable of providing care that is patient-centered, population-based, comprehensive, high-quality, accountable, and integrated across the continuum of needed services.

Recent Projects

Promoting Integration of Safety-Net Systems 
With continuing weakness in the economy, the number of people relying on publicly funded health care has grown, while the revenue states have available to support that care has shrunk. Simply put, safety-net providers are being forced to do more with less.

Public hospitals and community health centers that operate within integrated systems appear best equipped to handle the needs of vulnerable patients efficiently. Integrated health care systems offer vulnerable patient populations access to specialty services, continuity in relationships with providers, and better-coordinated care than smaller independent practices or hospitals typically do. Under the direction of Leighton Ku, Ph.D., George Washington University researchers have been examining the degree to which safety-net providers are part of larger systems of care, identifying examples of different approaches to integration, and analyzing policies that would facilitate greater integration of safety-net systems. In a Commonwealth Fund brief laying out the keys to greater integration, Ku and his team note that success will require flexible strategies that accommodate variations in community and state needs.

The use of federal safety-net funding to encourage the spread of integrated care systems has the potential to lower health care costs and ensure the sustainability of the safety net. Under the leadership of Barbara Wynn, M.A., at the RAND Corporation, project staff are researching the current and projected flow of federal safety-net funding to determine how those monies might be used to facilitate the integration of community health centers and hospitals. They will also identify policy levers that could promote integration of the care systems serving vulnerable populations.

The integration of federally qualified health centers—a critical source of comprehensive health care services for vulnerable populations—with each other and with public and private community hospitals has the potential to improve the quality and efficiency of care in urban and rural communities across the nation. The laws and regulations guiding the structure and financing of these organizations, however, may impede integration—among them, health centers’ legal obligation to serve all community residents, regardless of income, insurance status, or ability to pay, as well as limits on affiliation. Led by Sara Rosenbaum, J.D., at the George Washington University, Commonwealth Fund–sponsored researchers analyzed these legal barriers and demonstrated how successfully integrated safety-net providers overcame them, whether through co-location of services or umbrella affiliations in which health centers remain independent partners yet agree to act collaboratively to achieve specific goals. Their report, Assessing and Addressing Legal Barriers to the Clinical Integration of Community Health Centers and Other Community Providers, was published by the Fund in July 2011.

Identifying Shared Resources for Care Coordination and Delivery System Improvement
Federally Federally qualified health centers are already experienced in providing a range of medical and support services to patients, many of which are required components of the medical home model. With the influx of $11 billion in new funding for health centers under the health reform law, states will have an opportunity to leverage the capabilities of their health centers to improve care delivery for all residents, including those in other primary care settings.

Under the direction of Mary Takach, M.P.H., and Neva Kaye at the National Academy for State Health Policy (NASHP), a Commonwealth Fund–supported project examined ways in which health centers can serve as community "utilities," fostering connections with other Medicaid primary care providers to help beneficiaries get the services they need to manage their health and reduce costly visits to the hospital. In a May 2011 report published by the Fund and NASHP, the team highlighted promising community utility models involving partnerships between states and health centers, as well as the policy options available at the state level to replicate these models. The authors note that such partnerships could help states accommodate the needs of the 20 million additional Medicaid beneficiaries expected after health reform is fully implemented.

At the Center for Health Care Strategies, Inc., Nikki Highsmith, M.P.A., under a Commonwealth Fund grant, documented how some states are supporting small independent physician practices that serve Medicaid patients by establishing networks of shared resources. By sharing such services as coverage for evening and weekend appointments, patient registry reports and panel management, and electronic systems for ordering and tracking tests, these typically underresourced providers are able to ensure their patients have access to a wide range of medical home services. The project identified the types of organized practice supports that are most needed by highvolume Medicaid practices and produced a set of design considerations for state Medicaid agencies. Read the March 2011 Fund report Driving Value in Medicaid Primary Care: The Role of Shared Support Networks for Physician Practices to learn more.

Future Directions

Monitoring and Tracking to Guide Planning and Policy
States have a large role in ensuring access to health care for vulnerable populations. To understand the extent to which states are meeting this responsibility—and how they are going about it—The Commonwealth Fund plans to develop a state scorecard assessing health care access, utilization, and equity among vulnerable populations, as well as state policies, resources, and programs that address their needs. The Fund will also likely support projects that identify sources of care for vulnerable populations as part of broader efforts to assess and improve their access to quality care.

Promoting Statewide Planning Efforts for Care of Vulnerable Populations
Many states have not undertaken a systematic review of their policies and programs for vulnerable populations, and as such may be ill-prepared to seize new opportunities in the Affordable Care Act for strengthening their health care safety net. But in Iowa, health care leaders are preparing for a comprehensive planning effort to identify strategies that they and policymakers in other states could follow to achieve a high performance health care system for their vulnerable populations. Under the leadership of the University of Iowa’s Peter Damiano, D.D.S., M.P.H., this Commonwealth Fund–supported project will convene an advisory group of state officials and safety-net providers to determine the current funding, expenditures, and infrastructure of Iowa’s safety net, and then develop strategies for improving its integration.

Establishing Sustainable Financing for Safety-Net Systems
Funded by a combination of patient care revenue, local and state taxes, and supplemental payments from disproportionate-share payment programs, public hospitals contend with wide fluctuations in their funding streams and near-constant financial uncertainty. Under the leadership of Nancy Kane, D.B.A., at Harvard University, researchers will collect audited financial statements from approximately 150 large, urban public hospitals to analyze their funding streams and financial sustainability, with the goal of setting a baseline for monitoring their viability over the next decade as reforms in the Affordable Care Act take hold.

Identifying Promising Models and Opportunities for Delivery System Reform
For vulnerable populations, accessing specialty care services is at least as great a problem as accessing primary care. Under the direction of Anna Sommers, Ph.D., at the Center for Studying Health System Change, a team will study existing and emerging models for financing specialty care for Medicaid enrollees—for example, using physician assistants to provide specialty care at lower cost—to identify those that are sustainable and to consider policy options for promoting their adoption.

Another Commonwealth Fund project, led by Wendy Holt, M.P.P., at DMA Health Strategies, will focus on the "enabling services"—transportation, interpretation, psychosocial support, and outreach, among others—that safety-net providers typically offer patients to overcome personal, social, geographic, financial, and environmental barriers to care. The DMA team will research current approaches to the financing and provision of enabling services and produce recommendations for ensuring that vulnerable individuals are able to take full advantage of their coverage, regardless of where they choose to seek care.

Mongan Commonwealth Fund Fellowship Program in Minority Health Policy (formerly Commonwealth Fund/Harvard University Fellowship in Minority Health Policy)

Moving toward a high-performance health care system requires trained, dedicated physician leaders who can transform health care delivery systems and promote policies and practices that improve access to high-quality care and health outcomes for vulnerable populations, including racial and ethnic minorities and economically disadvantaged groups. With the passage of the Affordable Care Act, it is more important than ever that the needs of vulnerable populations be represented by well-trained clinician leaders as the provisions of the new law are implemented. Since 1996, the Mongan Commonwealth Fund Fellowship Program in Minority Health Policy (formerly the Commonwealth Fund/Harvard University Fellowship in Minority Health Policy) has played an important role in developing physician leaders who will address the health needs of vulnerable populations.

Based at Harvard Medical School under the direction of Joan Reede, M.D., Dean for Diversity and Community Partnership, the year-long fellowship offers intensive study in health policy, public health, and management for physicians committed to transforming delivery systems for vulnerable populations. Fellows also participate in leadership forums and seminars with nationally recognized leaders in health care delivery systems, minority health, and public policy. Under the program, fellows complete academic work leading to a master of public health degree at the Harvard School of Public Health, or a master of public administration degree at the Harvard Kennedy School of Government.

Beginning with the July 2012 entering class, the fellowship program will include an optional second year of practicum experience to supplement the fellows’ academic and leadership development training, with practical experience creating high performance health care for vulnerable populations. Fellows chosen for the second-year practicum will spend one year in a health care delivery system setting, a federal or state agency, or a policy-oriented institution. The practicum is a competitive program open to first-year fellows, with a variable number of placements available per year.

A total of 80 fellows have graduated from the program since it began. In 2011–12, five physicians were selected for the fellowship program. For more information about the fellowship, including how to apply, visit the Mongan Commonwealth Fund Fellowship Program in Minority Health Policy page.

To apply for a grant from The Commonwealth Fund’s Vulnerable Populations program, visit Applicant and Grantee Resources.