It takes a community: One approach to health care for the uninsured

The promise of forgiveness of his medical education debt drew Gary Wiltz, MD, to Franklin, La., a small bayou town in rural St. Mary Parish. In exchange, the internist set up shop at the Teche Action Clinic under the auspices of a National Health Service Corps program aimed at getting doctors into physician shortage areas.

That was 20 years ago. He's still there, now CEO at the center, which serves a mix of uninsured, Medicaid and Medicare patients, as well as a small number of privately insured people.

So when Dr. Wiltz, who spends about half his time seeing patients and the other half on administrative duties, talks about what it takes to run a health center, he speaks from experience.

In sum: "Local problems deserve local solutions, by local people ... using federal money."

That federal funding has burgeoned in recent years, fueling a surge in the number of community health centers across the country. Dr. Wiltz and others are cautioning the stampede of newcomers to keep their focus local and to not underestimate the difficulties involved in establishing and maintaining a successful health center.

The growth is driven by a funding initiative President Bush launched in 2002 to double the capacity of federally qualified health centers within five years.

Every year since then the president has recommended, and Congress has approved, large annual increases in the federal grant program that helps establish and support these facilities. Bush's proposed fiscal 2006 budget includes a $304 million increase from 2005. If that passes Congress, health center funding will have grown about 50%, from $1.3 billion in 2002 to $2 billion.

By 2006, 700 new or expanded centers will have been added to the national network of clinics. Between core centers and satellite clinics, there will be a total 3,600 sites serving 16 million people, according to the Dept. of Health and Human Services.

The initiative is a cornerstone in Bush's plan to expand health care access, and the demand is great. Between 2000 and 2003, the number of people without health insurance grew by 5 million, and the number enrolled in Medicaid jumped by 9 million. Increasingly, community health centers are becoming the one place low-income and uninsured patients can rely on for their health care needs.

"The numbers aren't getting any better," Dr. Wiltz said. "In Louisiana, our uninsured rate is 25%."

Working for the money

The competition for community health center money has grown with the funding levels.

"There has been something of a feeding frenzy," said Daniel Hawkins, vice president for federal, state and public affairs for the National Assn. of Community Health Centers.

That's in part because although the increased funding helps enormously, HHS has had enough money to approve only one out of three qualified applicants.

"There has been an incredibly high level of demand for the new funds," he said. "But there is also an incredibly high level of need."

Once approved, the clinics can receive hundreds of thousands of dollars in federal money.

That has been a significant catalyst, said Cynthia Taueg, vice president of community health at St. John Health, a network of medical centers and hospitals in Michigan. The network's application for a new health center was approved last April.

"The demand is really what prompted us, but the federal funding and the initiative to expand community health centers were significant factors," she said.

But some people may be getting this equation backwards, said Tracey Conti, MD, medical director of Mathilde Theiss Center, a community health center in Pittsburgh.

"A lot of people say, 'Oh, you get all that money,' but it's a lot of work," she said.

The clinics have to be financially sustainable, despite serving a low-income population. Many have gone under from poor planning, Dr. Wiltz said.

"In the past, there were community health centers that were 80% Medicaid, and when the reimbursement rates were good, they did well. But when the reimbursement rates were low, some of them folded because they couldn't sustain the level of services," he said.

The application process alone requires a lot of work, and that is before seeing any federal money, Taueg said.

"You have to do a community assessment. And that includes looking at the demand, the need, whether it's in a medically underserved area, as well as looking at whether you can find a site. The feds don't pay for your site preparation or your location. We had to look at location statistics, the health profile of the area and not only put together a businesses plan, but a health plan," she said.

It takes a certain kind of physician to run a community health center, Dr. Conti said. "If you're not in the business of serving the uninsured, it's not for you."

Proving their worth

Besides having a workable business model, health centers are constantly under pressure to prove their effectiveness, Dr. Wiltz said.

"We are mandated by the feds to track the clinical outcomes of the people we treat and the diseases we are treating them for. I can tell you we have 2,300 people enrolled in a registry to track the diabetes care," he explained. "When we started tracking it six years ago, our average hemoglobin A1c was 9.5. Since then we have gotten it down to 7.8."

Those data also are submitted to a national diabetes collaborative that collects the information for the purpose of improving performance measures nationally. All health centers are required to join a collaborative, including ones for cardiovascular disease, depression and asthma.

There are other ways the centers prove their effectiveness, Dr. Wiltz said. Teche was one of the first clinics in the country to pass an inspection by the Joint Commission on Accreditation of Healthcare Organizations. HHS has its own accreditation for the centers, but many clinic directors expect the JCAHO inspections to replace it in the near future.

"We're held to a higher standard than the private sector. When you're doing the Joint Commission, that's like good housekeeping. They're opening your cabinets, they're looking under your bed, they come in and check everything," Dr. Wiltz said.

Another federal requirement, dictating health center leadership, helps ensure that facilities continue to meet not only quality standards but also the particular health needs of their communities.

"What makes us unique is that all community health centers are run by a board of directors, and at least 51% of the board has to be consumers or patients of the center," Dr. Wiltz said. "There is no other model in the country like that. They set the policy, they're the ones who determine the fees, they're the ones who determine what services will be offered."

Located just an hour west of Dr. Wiltz's Teche Action Clinic, Abbeville Community Health Center is one of the new clinics established with the help of the government's largess. It is motivated by the community-centric goal embodied in this government standard.

Housed in a brick-shaped, modular building that sits on one of the town's few main roads, it is conveniently located near the Super Wal-Mart. People can come to the clinic to have their health care needs met and get in a day of shopping, explained Roderick Campbell, director of the clinic, which opened in February.

The building is small but clean and welcoming to the women sitting in the waiting area with their children. The kids keep busy, playing and generally aggravating their mothers.

The small-town atmosphere that pervades the clinic is by design.

"We're trying to remove barriers to access," Campbell said. "It only takes one bad experience to turn patients away from the health care system."

The public's involvement with the clinic is crucial to its success. "We stress the community angle," he said.

Not only are community members integral to the operation of the clinic, but its physicians regularly attend local events to offer health advice and free screenings, speak at local schools, give seminars, and generally take part in all aspects of community life.

Campbell, like many of his coworkers, is a local resident.

Room for growth

In terms of capacity, the health centers are also prepared to respond to the needs of the community.

For example, while the Abbeville clinic currently houses only a family physician, a dentist and part-time psychiatrist, the board decided to purchase a couple of pieces of bordering properties with the expectation of future growth.

The more services the clinic can offer, the less its relative administrative burden will be, Campbell said. "That's where you get economy of scale."

Teche has already expanded several times over the years. From its humble beginnings 30 years ago as a primary care provider for migrant workers drawn to the area by the sugarcane crops, the clinic now also offers mental health and dental services, pediatric and vision care, and access to a discount pharmacy.

The center took over the Women, Infant and Children nutrition program when the state no longer wanted to handle it and hired the only obstetrician serving the area when he was being forced into retirement by medical liability premiums and other overhead costs.

Despite its size, Teche is also preparing for future growth, having recently purchased a building across the road to house the discount pharmacy that, during peak times, fills 400 prescriptions a day.

Barriers to health care are no longer just a problem for low-income people, Dr. Wiltz said. Even he sometimes finds it hard to balance his checkbook, he said.

"If you're middle class, and you are taking care of parents on a fixed income and trying to put your kids through college, we're getting squeezed," he said.