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Lost in the Shuffle: Community Health Center Patients Needing Specialty Care

By Mary Agnes Carey, CQ HealthBeat Associate Editor

September 30, 2008 -- So far, so good for patients at Codman Square Health Center in Dorchester, a Boston neighborhood where patients at the community health care (CHC) facility can usually get the medical services they need from Boston Medical Center if Codman can't provide it.

But about 10 miles north, patients at the Lynn Community Health Center might not be so lucky.

There, the center's Executive Director Lori Abrams Berry scrambles to find her patients access to specialty health care services, such as access to ophthalmologists or orthopedists. A gastrointestinal specialist comes to the center for two hours a month but that may be changing. "Apparently he doesn't want to do it anymore," Berry said.

Sometimes a physician at nearby North Shore Medical Center can help, and the new Massachusetts health care law has improved access to specialty care. If that doesn't work, Berry is forced to send patients down to Boston, but for those who don't have a car, public transportation can be difficult to navigate, especially if the patient is not fluent in English. High gasoline prices don't help either.

"We do what we can to get our patients what they need," Berry said, but it takes time and energy away from running a community health center in the city of 90,000 residents, many of whom are low-income.

By design, CHCs provide preventative and primary care services to those in need regardless of ability to pay. More than 7,000 sites across the country serve more than 16 million people a year, many who are racial or ethnic minorities, poor, and either without health insurance or covered under Medicaid. Expanding the number of CHCs has been a priority for President Bush—he views them as a critical player in helping millions of Americans without health care insurance get medical care—and Bush is expected to sign legislation (HR 1343) that authorizes about $13 billion for the centers through fiscal 2012.

Despite CHCs' success as primary care providers, center directors and medical researchers have documented a nagging and growing problem: trying to find patients the specialty medical services they need that community health care centers can't provide. While privately insured patients also may have trouble accessing some medical specialties, patients who are on Medicaid have a tougher time because of the program's low reimbursement for specialty care. That means uninsured patients may be required to pay a specialist up front before receiving care, experts said.

"Community health centers all over the country are seeing this. [Patients] need specialty referrals and you can't get them," said Ken Green, executive director of the Community Health Center of Snohomish County in Everett, Wash. "It's very, very challenging. There is no silver bullet for this mess."

Laurie E. Felland, a researcher with the Center for Studying Health System Change who has studied CHCs, said finding specialty care for patients is on ongoing problem. "A lot of it is tied to Medicaid reimbursement and all the issues of declining charity care by private physicians and the ongoing issues with private physicians accepting Medicaid patients.

"The managed care evolution that came in the early 90s and early part of this decade so stripped private practice physicians of any . . . extra payment that they would use to cross-subsidize care for uninsured people that they neither have the time nor the resources to cover the cost of caring for uninsured people anymore," said Dan Hawkins, senior vice president for programs and policy at National Association of Community Health Centers.

A report published last year in the journal Health Affairs found that center patients covered by Medicaid or who are uninsured had a difficult time obtaining access to diagnostic tests, medical specialists, hospital admissions, and high-tech services. The most frequent barriers that medical directors reported were that health care providers were unwilling to take patients covered by certain insurers, that patients who did not have health insurance were unable to pay up front for services, and that services patients needed would not be covered by their insurer or the health center.

One common problem community health care center directors cited was access to screening services. "A lot of them had a lot of trouble getting their patients a colonoscopy," said Bruce Landon, a Harvard Medical School professor who was the study's principal investigator. "They had to make individualized calls for every single one of them. They had to beg the person to do it and if they didn't have insurance it was just very hard."

A December 2007 report from the Center for Studying Health System Change (HSC) said that one veteran community health center director "noted CHCs are 'back to begging for specialty care almost like the 1970s when there were fewer specialists relative to the population.' "

Center directors use their professional and personal relationships with physicians in private practice, at public hospitals, or the non-for profit safety net community hospital to find specialty providers. Patients also might end up in the emergency room, where it costs far more to deliver health care than in a doctor's office or a medical clinic and contributes to overcrowding in the nation's ER departments.

Officials at the Health Resources and Services Administration (HRSA), the federal agency that oversees CHCs, acknowledge the shortage of specialty care but said the demand for preventative and primary medical care services, the key mission of CHCs, also remains strong. "We're still trying to fulfill our primary mission which is around providing preventative and primary health care services," said Jim Macrae, associate HRSA administrator for primary health care. Draft guidance the agency issued last fall details how centers can expand their medical services to include specialty care if they have the resources or relationships with other facilities to do so.

"I think it's one of the most difficult issues for us. It's basically balancing the needs of patients that we see in our health center, that our resources are going as far as they can go . . . " Macrae said. "Our belief is that if we invest more in primary health care, if we do more of a focus around some of those basic preventative services, it will actually reduce the need for specialty care in the long term and we hope reduce the inappropriate uses of the emergency room and most importantly create a health care home for our patients, which we really think is important."

Some CHCs are collaborating with safety net hospitals and other organizations to expand access to needed services, according to the HSC report. Better financial screening systems for public hospital patients in Phoenix and Cleveland have made free or deeply discounted specialty and ancillary care more readily accessible to CHC patients. In Miami, the centers are working with the school system to expand school-based services and in Phoenix health centers have partnered with new dental schools to provide teaching sites and volunteer opportunities to help train future clinicians, HSC found.

CHCs that can find specialists willing to work at the centers do so but demand surpasses supply. For example, Berry has ophthalmologists come to her center once a month but they can't keep up with the needs of 1,600 diabetes patients who must undergo annual retinal screening. In Fremont, Ohio, Joe Liszak, CEO of Community Health Services, had to hire an obstetrician for the center's patients when private physicians would not take the center's patients. Since gynecological care is considered part of primary medical care, that expansion of services was allowed, he said.

Complicating matters is that CHC patients' often suffer from several chronic conditions and may need medical interpreters, which few specialists provide. Green said his center spends over $400,000 a year just on interpreter services, with patients speaking as many as 60 different languages. "Private practices aren't set up for that," he said.

Even CHCs that have few problems finding specialty care for their patients—such as Codman Square Health Center in Boston—worry that the weakening economy and growing number of uninsured could hurt their patients' access to specialty care. Currently, center patients can get the care they need at Boston Medical Center and one of its affiliated health centers. "I think it's a national model," said Codman CEO Bill Walczak. "There are several hundred thousand people who are cared for in a pretty seamless system."

That access could change if the cost of the Massachusetts health care overhaul continues to rise. While Walczak supports the law, which is aimed at providing near universal coverage to the state's residents, he fears that budget shortfalls could reduce funding for some of the hospitals that provide care to his center's patients.

"What's going to happen with the safety net? What happens if we have to cut out programs?" he asked in an interview. "The reality is the system for low-income people is so fragile in this country that it doesn't take much to disturb or destroy it . . . It wouldn't take a whole lot to undermine a really good system like we have in Boston."

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