Community health centers exist for one reason— to care for patients regardless of ability to pay, resident status, or cultural
differences.
The growing number of uninsured and constant threats to funding are but two of
the challenges faced by providers who say the rewards of caring for this
population outstrip the hassles.
A typical spring day in Anchorage, Alaska finds Dr. Thomas Hunt at Anchorage
Neighborhood Health Center, caring for a homeless pregnant patient and a
Laotian woman—also pregnant—who is mentally challenged and doesn’t speak English. He works nearly 80 hours a week as a family practice physician
and the medical director of a community health center that serves both urban
and rural patients from a number of cultures with high-risk pregnancies, HIV,
diabetes, substance abuse, and other challenging medical needs.
Thousands of miles away, internist Gary Wiltz worries about the state of mental
health services in rural Franklin, Louisiana, a town 100 miles southwest of New
Orleans. As the CEO of Teche Action Board Inc., he oversees the Franklin
Community Health Center (CHC) and three satellite clinics. When Wiltz arrived
in 1982 as a National Health Service Corps provider, he had a staff of 10 or 12
and worked out of a crumbling old house in a practice he humbly referred to as “Southern Exposure,” in reference to a 1990s CBS show “Northern Exposure” about a family practitioner and the challenges he faced in the fictitious town
of Cicely, Alaska. Today, Wiltz oversees a staff that includes two ob/gyns, a
family practitioner, four nurse practitioners, a physician assistant, a
pharmacist, and is in desperate need of a pediatrician. The CHC serves 15,000
area residents. “When someone comes into our center, we look at their resources to see not if we’re going to treat them, but how,” says Wiltz.
Therein lies the primary mission of community health centers: to care for all who enter, regardless of ability to pay or any other barrier,
whether it’s financial, cultural, or related to citizenship status. From the U.S. Virgin
Islands and Maine to Hawaii and Pohnpei (six hours west of Hawaii), CHCs serve
people in 12 time zones. “When I look at the globe, I realize we’re on about a quarter of the planet,” says Dr. Thomas Curtin, the chief medical officer for the National Association
of Community Health Centers (NACHC). Curtin also serves on the board of his
local health center—the one in East Jordan, Michigan, which he joined in 1978 as a National Service
Health Corps scholarship student.
A presidential initiative
The number of CHCs and the communities and patients they serve has grown in
recent years. Much of the growth can be attributed to an initiative signed in
October 2002 by President George W. Bush, expanding the role of CHCs. Community
health centers are one type of Federally Qualified Health Center (FQHC) and the
terms often are used interchangeably. FQHCs also include Migrant Health
Centers, Healthcare for the Homeless Health Centers, and Public Housing Primary
Care Centers. The designation also includes FQHC look-alike programs and
outpatient clinics operated by tribal organizations, though grant funding
differs. The nonprofit CHCs must meet four core statutory requirements,
including targeting of resources in high-need areas, ensuring services to all
regardless of ability to pay, offering access to comprehensive primary care
service, and governance by the community being served. The president committed
funding that would ensure growth in the numbers of CHCs and to expand their
reach into previously unserved areas.
At the time the president launched the initiative, CHCs served about 10 million
people. The goal was to increase that number by about 6 million by the end of
2007. In 2001, a year before the legislation was signed, there were 748
federally funded health centers. The initiative aims to reach more people by
adding access points, or actual clinic locations in communities. “The president wanted to expand the number of access points by 1,200,” says Dr. Donald Weaver, the deputy associate director for Primary Health Care
at the Health Resources and Services Administration (HRSA). “We now have more than 1,100 and hope by the end of the year to achieve that goal
[of 1,200 more],” he says. To that end, federal health center funding was close to $1.8 billion
in 2006.
Touting CHCs as the answer for health coverage for the poor and uninsured, the
president also looks to them to lower health-care costs. NACHC data shows that
while national per capita spending rose 49 percent from 1999 to 2005,
health-center costs per patient increased only 26 percent. According to NACHC,
the average annual cost of medical and dental care for a CHC patient is $515,
or about $1.40 a day. Perhaps more telling are outcomes data. A study in the
May 16, 2007, on-line version of Health Services Research reported on the
cost-effectiveness and improvements in diabetes care among CHCs. Hunt says that
based on his benchmark comparisons, the Anchorage CHC does a
better-than-average job in diabetes and HIV care. “And I think one reason we are better than average in those two diseases is that
we have wrap-around services. It would be very hard to accomplish without them,” he says. Also termed enabling services, these services include translation,
transportation, case management, health education, home visitation, and extras
that help improve patients’ access to care.
Community health centers, staffed mainly by primary care physicians and
mid-level providers and supported by administrative staff members, generally
provide care during regular Monday-through-Friday hours. Many also offer some
sort of 24-hour call. Dentists, pharmacists, mental health providers, and other
professionals may assist to provide comprehensive primary care. Because of the
employment/contract arrangement, physicians leave much of the business details
to their CEOs, support staff, and governing boards.
Emphasizing access
The mission of a CHC is not just about serving the uninsured, but about access
to care. Curtin says that even if the country someday comes up with a universal
health plan, “It won’t deal with some of our rural areas, some of our frontier areas in Alaska. It
won’t deal with some of our most urban areas where no one will set up a practice,” he says. Access to care remains a huge barrier for uninsured patients and
affects the total cost of care. More than $18 billion was wasted on emergency
department visits in the United States in 2006 for problems that could have
been handled by a primary care provider. NACHC data says that health-center
patients with Medicaid are 19 percent less likely to use the emergency
department for avoidable conditions; they’re appropriately seeing their primary care physicians at CHCs for non-emergent
care.
Transportation, language, and geographic barriers remain for patients accessing
care, but financial barriers still present the biggest hurdles—both for patients and for health centers’ viability. According to NACHC, the typical health-center patient mix is about
40 percent uninsured, 36 percent Medicaid, 15 percent private insurance, and 8
percent Medicare. A typical private physician practice compares at roughly 5
percent uninsured, 10 percent Medicaid, 56 percent private insurance, and 21
percent Medicare. Approximately 70 percent of CHC patients have family incomes
at or below poverty level. With the sliding fee scale, only six percent of
total revenue comes from self-paying patients.
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Providers with a Mission
Gary Wiltz went from his hometown of New Orleans to Franklin, Louisiana in 1982
with the National Health Service Corps to a small community health center that
is now the multiple-site Teche Action Board Inc. “I had a three-year commitment that’s obviously turned into a lifetime,” says Wiltz. He’s raised two children, worked, and worshiped in a communal environment. He even
holds public office in St. Mary parish. Although Wiltz jokes that something in
the water made him stay, it’s more likely the small-town life. “The phone book is about one-quarter inch thick, the newspaper is 10 pages thick.
I’m one minute and 45 seconds from my office and two minutes from the hospital,” he says.
Mostly, it’s the people he cares for. “If I had to give the most overriding or compelling reason I’ve stayed, it would be the gratitude of the patients we serve. It’s being given the opportunity to make a difference and see the difference in
your lifetime,” says Wiltz.
His sentiment is matched by his peers around the country. Long-term CHC
providers say they appreciate not only the gratitude they receive from
patients, but the ability to practice medicine free of the business headaches
that often come with private practice. “Any provider who works at a health center is going to practice ‘real medicine,’“ says Joe Pierle, the CEO of the Missouri Primary Care Association. “They’re not going to deal with all of the [operational] headaches, and they’re going to see patients with some of the most complex situations. We’re also implementing the chronic care model, which I would argue was started by
health centers nationally. I see our care as more than just health care. It’s holistic and comprehensive and the future,” says Pierle.
Daren Wu of Open Door Family Medical Centers in Ossining, New York says the
greatest benefit of six years with his health center is practicing medicine as
he was trained in school. It’s the idealistic way he and many physicians hopefully still have in their minds.
“If a patient doesn’t have insurance, we just see him. And it’s very liberating from that standpoint. You’re taking care of people and it’s phenomenally rewarding; it’s actually spiritually rewarding to take care of this patient population,” he says.
Thomas Curtin, who serves as the chief medical officer for the National
Association of Community Health Centers, says that physicians can practice
primary care, move into chief medical officer positions, or become involved at
state levels. Primary care associations offer committee involvement in various
issues that impact health care in the state. “And you can continue to be involved on the national level,” says Curtin. CHC physicians may become involved with Centers for Disease
Control or National Institutes of Health research on issues such as HIV,
immunizations, or pandemic flu preparation.
For physicians who love to teach, most centers offer involvement in health
professional teaching. “We have medical students and residents and nursing students all of the time and
I enjoy that,” says Thomas Hunt, the medical director of Anchorage Neighborhood Health Center
in Anchorage, Alaska. Hunt also enjoys the many outdoor opportunities his
location offers—at least in the “glorious summers”—as well as his involvement in the community. He’s been with the center for 12 years.
“I’m passionate about equal access to health care on principle,” says Hunt. “This just seems to me a compelling career in that it gives me an opportunity to
act on principle and still earn a living. The sense of social justice keeps me
here,” he says.
Hunt is just the kind of physician fellow Alaskan and recruiter Amy Chang is
looking for to fill spots in four northwestern states. “We’re looking for mission-driven physicians; that’s the bottom line. We want physicians who really have it in their hearts to work
for the underinsured and medically underserved,” says Chang.
Wu knows that those physicians who contemplate joining a CHC will find their
reward. He admits that the work is not particularly glamorous or outrageously
compensated. What it is: satisfying, despite the challenges of navigating patients through the
complicated health-care system. Wu says, “You just go home at the end of a tough day and look in the mirror and say, ‘I really did something wonderful for a lot of people today.’“ g
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