Testimony to the House Public Health Committee, Subcommittee on Indigent Health Care and Treatment

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Testimony to the House Public Health Committee,
Subcommittee on Indigent Health Care and
Treatment

• José E. Camacho
• Executive Director
• Texas Association of Community Health Centers
• October 13, 2008

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The Community Health Center ProgramFederally
Qualified Health Centers (FQHCs)

• Includes all Community, Migrant, Public Housing
  Primary Care, and Homeless Health Centers
• Local, non-profit or public entity, community
  owned health care providers
• Four decades of Federal, State, and Local
  community investment in primary care
  infrastructure

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The Community Health Center ProgramFederally
Qualified Health Centers (FQHCs)

• Providing communities the opportunity to respond
  to community-based health care needs
• National
• 1,200 funded organizations, 100 Look Alikes
• 7,000 service delivery sites
• 18 million patients served
• Texas
• 58 funded organizations, 6 Look Alikes
• 300 service delivery sites
• 770,000 patients served

Source National Association of Community Health
Centers, U.S. Health Center Fact Sheet BPHC,
HRSA, DHHS Uniform Data System, 2007
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Improving Service Delivery to the Medically
Underserved

• Since 1996, Health Centers have strived for
• Stronger health outcomes for patients by moving
  to integrated health care
• Consistency in results by adopting measures and
  outcomes for clinical practice and access to care
• Increased ability to track and verify results
• Lower cost to the health care system

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What is a Federally Qualified Health Center?

• Non-profit or public entity
• Community board structure
• Broad range of services
• Medical
• Dental
• Mental health and Substance Abuse treatment
• Pharmacy
• Community outreach, transportation, eligibility
  and enrollment services, patient and community
  education
• Culturally sensitive care
• Required to be located in a medically underserved
  area
• Required to see patients regardless of insurance
  status or ability to pay using a sliding fee
  scale for services

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The Sliding Fee Scale An FQHC Requirement

• Based on annual income and family size
• Nominal co-payments only for patients at or below
  100 Federal Poverty Level (FPL)
• All patients are expected to participate in the
  cost of care at a level they can afford. FQHCs
  are not free clinics.
• Full charge for patients at or above 200 FPL
• Sliding scale discount for patients with incomes
  between 101 and 199 FPL
• Each community board determines sliding scale
  rates

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Texas FQHC Clients by Insurance Status, 2007
Source BPHC, HRSA, DHHS Uniform Data System,
2007
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Texas FQHC Clients by Income Level, 2007
Source BPHC, HRSA, DHHS Uniform Data System,
2007
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Texas FQHC Clients by Ethnicity and Race, 2007
Source BPHC, HRSA, DHHS Uniform Data System,
2007
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Texas Health Center Client Characteristics
Compared to the State Population
Chart sources BPHC, HRSA, DHHS Uniform Data
System Reports, 2006 and 2007. U.S. Census
Bureau Income, Poverty, and Health Insurance
Coverage in the United States 2007, issued
August 2008. U.S. Census Bureau Texas
Quickfacts. http//quickfacts.census.gov/qfd/stat
es/48000.html.
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FQHCs Provide Proven High Quality, Cost
Effective, Accessible Care

• Health center uninsured patients are
• less likely to have an unmet medical need, 
• less likely to have postponed or delayed seeking
  needed care,
• more likely to have had a general medical visit,
• significantly less likely to have had an
  emergency room visit, and 
• less likely to have a hospital stay compared to
  other uninsured. (Hadley J and Cunningham P.
  Availability of Safety Net Providers and Access
  to Care of Uninsured Persons. October 2004
  Health Services Research 39(5)1527-1546.)
• Despite the high prevalence of chronic conditions
  among health center patients, health centers meet
  or exceed practice standards for diabetes, acute
  ear infections, asthma, and hypertension. (Ulmer
  C. et al. Assessing Primary Care Content Four
  Conditions Common in Community Health Center
  Practice. Journal of Ambulatory Care
  Management. 23(1)23-38, 2000, Jan.)
• FQHC Medicaid patients are less likely to use the
  emergency room or be hospitalized for primary
  care sensitive conditions than Medicaid
  beneficiaries using other providers for primary
  care. (Falik M, Needleman J, Herbert R et al.
  Comparative Effectiveness of Health Centers as
  Regular Source of Care. January-March 2006
  Journal of Ambulatory Care Management
  29(1)24-35.)
• For more studies on FQHC quality of care,
  improvement of access to care, cost
  effectiveness, and reduction of health
  disparities, see http//www.nachc.com/literature-s
  ummaries.cfm

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Innovative Clinical Care and Improved Health
Outcomes

• Integration of behavioral health and primary care
• Redesigning clinic processes to increase access
• Chronic disease management
• Improved health outcomes in diabetes,
  cardiovascular disease, asthma, hypertension
• Reduction or elimination of health disparities

Huang E, et al. The Cost-Effectiveness of
Improving Diabetes Care in U.S. Federally
Qualified Community Health Centers. June 2007
Journal of General Internal Medicine, 21(4) supp
139. Landon BE, et al. Improving the Management
of Chronic Disease at Community Health Centers.
March 2007 New England Journal of Medicine
356(9) 921-934. Hicks LS, et al. The Quality
of Chronic Disease Care in US Community Health
Centers. November/December 2006 Health Affairs
25(6) 1713-1723.
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Growth in Patients Served at Texas FQHCs by
Coverage Type, 2001-2007
Source BPHC, HRSA, DHHS Uniform Data System,
2007
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Texas FQHC Provider Trends, 2000 - 2007
94 Increase
Source BPHC, HRSA, DHHS Uniform Data System,
2000 and 2007
Note Mid-Level Providers includes Physician
Assistants, Nurse Practitioners, and Certified
Nurse Midwives. Mental Health includes mental
health and substance abuse professionals.
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Significant Need for FQHC Services in Texas

• Texas FQHCs employ
• 0.5 of physicians licensed in Texas
• 0.8 of dentists licensed in Texas
• Texas FQHCs currently have 148 provider vacancies
  for providers to serve in rural and urban
  medically underserved areas.
• Today, Texas FQHCs serve only
• 11 of uninsured Texans living at or below 200
  FPL
• 7 of non-elderly Medicaid beneficiaries
• There is tremendous need for expansion.

Sources Compares 2007 UDS data to 2006-2007
state population data from Kaiser Family
Foundation, State Health Facts Online,
www.statehealthfacts.kff.org.
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FQHC Business Model

• Ideal business model
• 1/3 Federal grants to serve the uninsured
• 1/3 Patient-related revenue
• Including cost-based reimbursement in Medicaid
• 1/3 State and local contracts and grants,
  foundation grants, other funding sources
• Difficult for Texas health centers to achieve
  this balance
• High numbers of uninsured in Texas

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Texas FQHC Revenue, 2007
Source BPHC, HRSA, DHHS Uniform Data System,
2007
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Health Center Revenue vs. Patient Insurance
Status, 2007
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Source BPHC, HRSA, DHHS Uniform Data System,
2007
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Health Center Costs of Care - 2007

• Average Cost per Patient per Year Cost
• Medical Costs per Medical Patient 372
• Dental Costs per Dental Patient 307
• Mental Health Costs per Mental Health Patient
  377
• Total Cost per Total Patient 503
• Average Cost per Patient Visit per Year
• Medical Cost per Medical Patient Visit 114
• Dental Costs per Dental Patient Visit 135
• Mental Health Costs per Mental Health Patient
  Visit 59
• Pharmacy Costs per Medical Patient Visit 16
• Lab X-ray cost per Medical Patient Visit 12

Includes the total cost of all services, not
including donations, over total users.
Source BPHC, HRSA, DHHS Uniform Data System,
2007
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What FQHCs Need for SuccessHow Texas Can Support
FQHCs as One Solution for Addressing Health Care
for Indigent Populations

• A Robust Primary Care Provider Base
• Support loan repayment for primary care providers
  who serve in rural and urban underserved areas
• Increased State Investment in Health Center
  Operations
• Reauthorize the FQHC Incubator program with
  changes to sustain existing health centers
• Increase funding for the Community Primary Care
  Services program at DSHS
• Support for Health Center Infrastructure
  including Facilities, Equipment, and Technology