Nakela L. Cook, M.D., M.P.H., LeRoi S. Hicks, M.D., M.P.H., A. James O'Malley, Ph.D.
Community health centers (CHCs) provide primary health care services to more than 15 million Americans, many of whom are members of racial or ethnic minorities, have low income, are uninsured, or have coverage through Medicaid. To improve access to care in underserved communities, the federal government recently increased the number of CHCs.
There are concerns, however, that CHCs lack adequate capacity to provide a full range of services to their patients. A Commonwealth Fund–supported study has found that CHC patients—particularly those who are uninsured or covered by Medicaid—have difficulty obtaining off-site specialty services, including referrals to medical specialists, diagnostic testing, and mental health and substance abuse treatment.
In "Access to Specialty Care and Medical Services in Community Health Centers" (Health Affairs, Sept./Oct. 2007), a research team led by Nakela Cook, M.D., M.P.H., of Massachusetts General Hospital and Harvard Medical School, surveyed 814 medical directors of federally qualified CHCs to better understand the challenges centers and patients face in obtaining access to off-site specialty services. The survey focused on two issues: the relationship between access to specialty medical and mental health services and patients' insurance status, and other factors associated with access to off-site specialty services for uninsured and Medicaid patients.
The researchers received completed surveys from approximately half the medical directors. About 75 percent of the CHCs had on-site mental health services, about 80 percent had on-site diagnostic testing, and about 50 percent had diagnostic x-ray services available.
Medical directors re-ported that about 25 percent of CHC visits resulted in medically necessary referrals for services not provided by the centers, regardless of patients' insurance category.
Getting specialty medical care outside the CHC usually posed little problem for patients with Medicare or private insurance. However, access to off-site specialty services was difficult for patients who were uninsured or covered through Medicaid and was even more challenging for patients who needed off-site mental health and substance abuse services. Such access was difficult for uninsured patients even if the CHC was affiliated with a medical school or a hospital. Access to off-site mental health services was somewhat easier if the CHC had on-site mental health services.
Barriers to care most often cited by the medical director included providers unwilling to take patients of certain insurance types, patients who could not pay up front as required, and patients lacking full coverage for needed services. "The effect of these barriers varied significantly by insurance status," the authors note.
Despite the frequent need for specialized medical and mental health services, CHC medical directors report major problems obtaining them for uninsured and publicly insured patients. "Given that federal policies expanding the number of CHC sites have not led to a substantial increase in the availability of many on-site specialty services," the authors write, "the problem of difficult access for services may increase if additional resources and planning are not devoted to assuring access to outside specialty services or bringing a greater array of services into CHCs."
One potential solution is earmarking additional funds for providing such services and requiring off-site facilities to deliver a defined amount of specialty care to patients referred from CHCs. Citing their finding that centers affiliated with medical schools or hospitals—and those with on-site mental health services—reported greater access to specialty services, the authors also suggest that policymakers encourage CHCs to seek out such affiliations. Additional research is also needed to explore other aspects of CHCs associated with referral success.
If policymakers plan to extend access to primary care for the uninsured by increasing the number of CHCs, they must also address the problem of access to secondary and tertiary levels of care, say the authors. Because CHC patients are disproportionately minority and low-income, these improvements could go a long way in correcting disparities in health outcomes across racial and socioeconomic groups, they conclude.
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