Health centers struggle with specialty care access

Community facilities are also patchy when it comes to adoption and effective use of health information technology.

By Doug Trapp — Posted June 14, 2010

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Community health centers have a tough time meeting all of their patients' needs, and health reform is expected to increase the burden on these facilities.

A survey of federally qualified community health centers found that nearly all of them have difficulty getting specialty care for their uninsured patients. In addition, most have not adopted advanced electronic medical records, which can help with such care coordination.

However, health centers affiliated with hospitals have fewer problems than unaffiliated centers when it comes to accessing imaging and off-site follow-up treatment for patients. For the purposes of this survey, the researchers defined affiliated as the ability to refer patients to a hospital for specialist or subspecialist care.

The survey, conducted by the Commonwealth Fund from March 2 to May 27, is based on responses from nearly 800 health center executive directors. More than 1,200 community health center organizations operate in the U.S. and its territories, according to the National Assn. of Community Health Centers.

"Community health centers are a vital component of our health care system, and this survey gives us a comprehensive picture of their current capacity to provide patient-centered, high-quality care," said Commonwealth Fund President Karen Davis.

Health centers are expected to care for many of the 32 million people who are projected to gain coverage under the health reform law. The NACHC estimates that the number of Americans who obtain care at a health center could double to 40 million by 2015. The health reform law's Medicaid expansion is expected to cover an additional 16 million people after it launches in 2014, according to the Congressional Budget Office.

Some health center officials said they agreed with many of the findings in the report, and they also said they are concerned about recruiting the medical staff needed to care for these millions of new patients. "That will be a challenge for all the health centers," said Greg Nycz, executive director of the Family Health Center of Marshfield in Wisconsin. The center, which operates more than 20 sites, needs primary care physicians, dentists and mental health care professionals just to meet existing demand, he added.

Some health centers already are at capacity. The Loudoun Community Health Center in Leesburg, Va., offers extended hours three nights a week and on Saturdays, but it still has 500 patients on its waiting list. "We're out of space," said Debra Dever, the center's CEO.

The Loudoun center is in a space formerly occupied by Inova Loudoun Hospital, near the hospital's radiology group. This allows fast access to x-rays and other imaging, Dever said. The hospital also provided $200,000 of the center's $3 million budget.

However, the Loudoun center does not have a formal contract with Inova. The center employs a full-time staffer to search for specialty care for its patients, 60% of whom are uninsured, Dever said.

The Marshfield health center has few problems with primary and specialty care access because it contracts with a large group practice to see its patients, Nycz said. But the health center also relies on hospital charity care programs for advanced imaging and other inpatient care, because it does not have the resources to provide these services itself. "No health center does," he said.

EMR adoption still hit-and-miss

The Commonwealth Fund survey found that 40% of community health centers have electronic medical records, but how effectively those EMRs are used varies.

Health centers will have to improve their ability to monitor patients transferred to hospitals and those being referred to other centers, said Virgilio Licona, MD. He's associate medical director for Salud Family Health Centers, which operates nine sites in northeast Colorado and cares for 74,000 patients. "That's going to be a tremendous challenge for everyone."

The Loudoun health center has an EMR that tells doctors when referrals go out, Dever said. But it does not notify the health center when a patient visits a hospital without one.

Salud is gradually implementing an EMR at its sites. The process is costly and labor-intensive, two of the reasons adoption of EMRs in the U.S. has been gradual, Licona said.

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Lack of specialty access

The vast majority of federally qualified community health centers say they have problems connecting their uninsured patients to needed specialty care. Centers reporting difficulty, 2009:

Uninsured patient Medicare patient Medicaid patient*
Health centers with hospital affiliations 80% 46% 69%
Unaffiliated health centers 91% 60% 79%
Total 91% 49% 71%

*Fee-for-service patients

Source: "Enhancing the Capacity of Community Health Centers to Achieve High Performance," Commonwealth Fund, May (link)

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