PRIMARY HEALTH CARE

Programs included in this section are:

• Health Centers
• Free Clinics Medical Malpractice
• Hansen’s Disease Activities

Health Centers

Notes:
^a FY 07 target differs from that shown in the FY 08 Congressional Justification due to a higher than expected continuing resolution funding level. The FY 07 target may differ from that shown in budget narrative tables. Whereas budget narrative tables are continually updated, performance reporting guidelines do not permit (except as noted above) changing a previously established target for the “reporting” year.
^b FY 08 and 09 targets differ from those established during the FY 07 OMB PART reassessment to reflect expected budget levels.

INTRODUCTION

Health Centers are community-based and patient-directed organizations that serve populations lacking access to high quality, comprehensive, and cost-effective primary health care. The Health Center Program’s performance measures help the Program track progress in reaching HRSA’s Strategic Plan goals of improving access to care, improving the quality of care, and improving health outcomes.  The more specific HRSA objectives the Program aims to achieve include: increase the utilization of preventive health care and chronic disease management services, expand the availability of health care, and expand the capacity of the health care safety net. The Health Centers Program has funded new and expanded Health Center organizations as a major strategy to reaching performance goals relating to the numbers of patients served and their demographic mix. Efforts to achieve other performance goals involve strategies that include: sharing best practices so that health centers learn from one another what works in improving performance; providing technical assistance and training on issues such as quality improvement and risk management; enhancing health information technology assistance; and support of a unique model of health care delivery that emphasizes prevention, health-related enabling services, outreach, follow-up, and cultural competency.

DISCUSSION OF RESULTS AND TARGETS

Long-Term Objective: Increase the utilization of preventive health care and chronic disease management services, particularly among underserved, vulnerable and special needs populations.

1.II.B.2. Rate of births less than 2500 grams (low birth weight) to prenatal Health Center patients compared to the National low birth weight rate.

Appropriate prenatal care management can have a significant effect on the incidence of low birth weight (LBW) which is the risk factor most closely associated with neonatal mortality. In turn, improvements in infant birth weight can contribute significantly to reductions in infant mortality rates. This measure reflects both on quality of care and health outcomes for Health Center women of child-bearing age, a key group served by the program.

This measure is benchmarked to the national rate to demonstrate how Health Center performance compares to performance of the nation overall. The goal is to achieve a rate 11% below the national average even as Health Centers continue to serve a higher-risk prenatal population than represented nationally in terms of socio-economic status, health status and other risks factors that might predispose Health Center patients to higher risk for low birth weight and adverse birth outcomes.

In 2006, 7.7 percent of Health Center patients had low birth weight infants, a rate that was 7.2 percent lower than seen nationally (8.3 percent 2006 national low birth weight rate). In addition, Health Center low birth weight rates have continued to follow a steady pattern at about 7%, unlike increases observed in the national rate. As indicated above, the FY 09 target is to achieve a rate of 11% below the national rate, as previously achieved in 2005.

1.II.B.3. Percentage of adult Health Center patients with diagnosed hypertension whose blood pressure is under adequate control (less than or equal to 140/90).

Health Center patients, including low-income individuals, racial/ethnic minority groups and persons who are uninsured, are more likely to suffer from chronic diseases such as hypertension and diabetes. Clinical evidence indicates that access to appropriate care can improve the health status of patients with chronic diseases and thus reduce or eliminate disparities.

This measure focuses on quality of care and improved health outcomes for one of the most prevalent chronic conditions facing Health Center patients, hypertension. Clinical evidence indicates that controlling blood pressure (hypertension) can reduce the health risk associated with the conditions such as heart disease and stroke. An analysis of billing data reported in the UDS over a five year period from 2001-2006, indicates a steady increase in the percentage of patients with a primary diagnosis of hypertension during the reporting year (13.9% to 15.3%).

In 2004 and 2005, 42.7% of hypertensive Health Center patients had their blood pressure under control. In 2006, the figure was 44.4%, exceeding the target. The FY 08 and FY 09 targets are 42.0% and 43%, respectively. Targets for the measure are particularly ambitious as they propose to demonstrate improvements in a chronic condition that requires treatment with both lifestyle modifications, usually as the first step, and, if needed, with medications. Lifestyle factors to treat high blood pressure include weight control, exercise, healthy diet, limiting alcohol use, and other lifestyle modifications that are often challenging interventions that improve only slowly over time. National data supports this as according to CDC data for 1999-2002, only 32% of adults demonstrated adequate high blood pressure control.

This measure replaces a previous, related measure in which control of hypertension was self-reported via the periodic Health Center User Survey last conducted in 2002. Currently data for this new measure is reported by a subset of grantees participating in the Health Disparities
Collaboratives. Future progress on the measure will be reported annually by all grantees via the Uniform Data System (UDS) beginning in 2009.

1.II.B.4. Percentage of adult Health Center patients with type 1 or 2 diabetes with most recent hemoglobin A1c (HbA1c) under control.

This measure also focuses on quality of care and improved health outcomes for one of the most prevalent chronic conditions facing Health Center patients, diabetes. An analysis of billing data reported in the UDS over a five year period from 2001-2006, indicates a steady increase in the percentage of patients with a primary diagnosis of diabetes during the reporting year (5.6% to 7.1%).

Uncontrolled diabetes can lead to non-traumatic amputations, blindness, end-stage renal disease, and hospitalizations for diabetes-associated cardiovascular disease. These and other health problems associated with diabetes contribute to an impaired quality of life, substantial disability among people with diabetes and resulted in an estimated $92 billion in direct costs nationally in 2002.

Clinical evidence indicates that controlling blood glucose through such activities as chronic care management provided in Health Centers benefits people with either type 1 or type 2 diabetes. In general, for every 1% reduction in results of A1C blood tests (e.g., from 8.0% to 7.0%), the risk of developing eye, kidney, and nerve disease is reduced by 40%.

This measure is developmental and future progress will be monitored and reported annually by all grantees via the Uniform Data System (UDS) beginning in 2009. The FY 09 target will be established after the collection of baseline data.

Long-Term Objective: Expand the capacity of the health care safety net

1.I.A.1. Number of patients served by Health Centers

Monitoring the number of patients served annually by Health Centers is key to assessing the program’s performance in increasing access to care for underserved and vulnerable populations. Not only do Health Center patients gain access to care, they gain access to a comprehensive health care home (also referred to as medical home). A health care home is a regular/usual, continuous, and patient-centered source of primary care, such as that offered by Health Centers. A health care home prevents sickness, manages chronic illness, and reduces the need for avoidable, costlier care such as emergency room visits and hospitalizations. This is key as an estimated 56 million Americans lack access to a health care home because they live in communities where there is an acute shortage of primary care providers. The lack of such physicians is associated with higher mortality rates and health care disparities. (The National Association of Community Health Centers (NACHC) and the Robert Graham Center: 2007).

The number of patients served by Health Centers reached 13.1 million in 2004 and 14.1 million in 2005. The 15 million patients served by Health Centers in 2006 exceeds the target by over 380,000 patients and is almost 1 million additional patients than served in 2005. The growth in number of patients served has been fueled by the President’s Health Centers Initiative which was designed to impact communities across the Nation through the support of new access points and significantly expanded sites. Based on final FY 07 appropriation amounts, Health Centers are projected to serve 16.1 million patients by the end of 2007 and reach 17.05 million patients by the end of 2009.

1.D.I.A.2. Total number of new or expanded sites

As a result of FY 07 activities, Health Center patients were served through 4,033 comprehensive primary care delivery sites. The Health Center Program supported a total of 122 new and expanded sites in FY 06 and 337 new and expanded sites in FY 07, exceeding the targets. The Program has accomplished its goal of establishing 1,200 new or expanded sites since 2002. The program anticipates supporting 40 new and expanded sites in FY 09.

Long-Term Objective: Increase the utilization of preventive health care and chronic disease management services, particularly among underserved, vulnerable and special needs populations.

1.II.B.1. Percentage of pregnant Health Center patients beginning prenatal care in the first trimester

Monitoring timely entry into prenatal care assesses both quality of care as well as Health Center outreach efforts and focuses on a process that is associated with improving birth outcomes. Identification of maternal disease and risks for complications of pregnancy or birth during the first trimester can help reduce the risk of low birth weight. Results over the past few years demonstrate improved performance as the percentage of pregnant Health Center patients that began prenatal care in the first trimester grew from 57.8 percent in 2000 to 61.3 percent in 2006, virtually meeting the target.

It should be noted that Health Centers serve a higher risk prenatal population than seen nationally and targets for this measure propose an ambitious steady increase in the percentage of women beginning first trimester prenatal care. Specific characteristics more prevalent in the Health Center population that are also associated nationally with late entry into prenatal care include serving a higher proportion of:

• Transient populations such as migrant and homeless women;
• Teen prenatal patients (19% of Health Center prenatal patients are teens as compared to
  10% nationally); and
• Racial and ethnic minorities that nationally also often have late or no entry into prenatal
  care programs (3rd trimester entry is highest in Black/African American (6%) and
  American Indian or Alaska Native (7.7%) populations) as compared to non-Hispanic
  Whites (2.1%) (Martin JA, Hamilton BE, Sutton PD, et al. National Center for Health
  Statistics: 2006)

 Based on appropriation amounts, the Health Center program anticipates increasing the percentage of pregnant patients beginning prenatal care in the first trimester to 61.5% in 2008 and 61.6% in 2009.

Long-Term Objective: Expand the availability of health care, particularly to underserved, vulnerable, and special needs populations

1.II.A.1. Percentage of Health Center patients who are at or below 200% of poverty

To improve the health status of the nation’s underserved communities and vulnerable populations, safety-net programs must target access to care for people of low income. According to 2006 UDS Health Center data, nearly 92% of patients were at or below 200 percent of the Federal Poverty Level. The total number (13.81 million) of individuals at or below 200 percent of poverty served in 2006 is nearly 10% above the target (12.57 million). The percentage of patients at or below 200% of poverty has risen for the eleventh year for which UDS data have been collected. The FY 09 target is to serve at least 86% of Health Center patients at or below 200% of poverty.

1.II.A.2. Percentage of Health Center patients who are racial/ethnic minorities

To improve the health status of the nation’s underserved communities and vulnerable populations, safety-net programs must target access to care for people of racial/ethnic minority groups. According to UDS Health Center data, in CY 06 the population served was 23.0% African American (AA), 36.1 percent Hispanic, and 4.5 percent Asian/Other for a rounded total of 64%, meeting the target. These percentages represent almost twice the percentage of African Americans and over two and a half times the percentage of Hispanics reported in the overall U.S. population. It is currently estimated that the percentage of minority patients will hold steady at about two-thirds of all patients served. The FY 09 target is 64%.

1.II.A.3. Percentage of Health Center patients who are uninsured

To improve the health status of the nation’s underserved communities and vulnerable populations, safety-net programs must also target access to care for people who are uninsured. According to UDS Health Center data, in CY 06 the population served included almost 6 million uninsured individuals, which was nearly 40% of the client population served, just slightly below the target.

• Over one quarter of the children served by Health Centers are uninsured.
• Almost one half of adult Health Center patients are uninsured.
• About three quarters of Health Center patients are either uninsured or Medicaid recipients.

In comparison, nationally, research reveals that caseloads of private physicians in the primary care specialties include 4% uninsured and 7% Medicaid for a total of 11% (National Ambulatory Medical Care Survey: 2001), down from the 19% in the previous study (National Ambulatory Medical Care Survey: 1998). Additional reports note that:

• The percentage of physicians providing any free or reduced cost care decreased to 68.2 percent in 2004-05 from 71.5 percent in 2000-01.
• Their overall number of charity care hours per 100 uninsured people also declined from 7.7 hours in 1996-97 to 6.3 in 2004-05, an 18 percent decline (Cunningham P and May J, Center for Studying Health System Change: 2006).
• Physicians also limited the number of new Medicaid and uninsured patients in their practice. In 2001, approximately one-fifth of physicians were not accepting any new Medicaid patients, and 16 percent were not accepting any new uninsured patients (Cunningham P, Center for Studying Health System Change: 2002).

At the same time, the number of uninsured in the nation has increased steadily from 38.7 million in 2000 to nearly 47 million or 15.8% of the US population in 2006 (U.S. Census Bureau). In 2004- 2006, 40% of Health Center patients were uninsured, falling slightly below the targets of 41%. The FY 09 target is 41%.

At Health Centers, efforts to increase SCHIP enrollment through outreach have shifted a major portion of uninsured children to the publicly-insured. Nearly 37% of all Health Center patients are children and the percentage of uninsured children has decreased from 35% in 1999 to approximately 26% in 2006. However, the program is still committed to continuing to increase the number of uninsured served proportional to Health Center growth. Indeed, while the number of uninsured Health Center patients increased by only 150,000 per year between 1998 and 2001, it increased by nearly 500,000 in 2003, by nearly 400,000 in 2004, by over 350,000 in 2005, and by more than 365,000 in 2006.

Long-Term Objective: Expand the capacity of the health care safety net.

1.I.A.2. Percentage of grantees that provide the following services either on-site or by paid referral: Pharmacy, Preventive Dental Care, and Mental Health/Substance Abuse

Access to pharmacy, oral health, and mental health/substance abuse (MH/SA) services is critical to ensuring overall health and well-being of Health Center populations. Inadequate access to pharmacy services often leads to problems with drug interactions, inappropriate doses, and failure to adhere to prescribed therapy. Lack of access to oral health care services is the primary reason for significant disparities in oral health status among vulnerable populations. MH/SA disorders, such as depression and abuse of alcohol are prevalent among underserved populations, and treatment is not accessible in many local communities. Of the 1002 grantees reporting in 2006, 83% reported that they provided pharmacy services either on-site or by paid referral. The figures for dental care and mental health/substance abuse services were 83% and 79%, respectively. The percentage of Health Centers providing these services on site or by paid referral met or exceeded their respective 2006 targets. The FY 09 targets therefore reflect maintaining current levels of these services.

 1.E. Percentage increase in cost per patient served at Health Centers

This efficiency measure focuses on maximizing the number of Health Center patients served per dollar. It also monitors Health Center performance in keeping cost increases below annual national health care cost increases while maintaining access to high quality services. The efficiency measure also utilizes a metric that speaks to the program as a whole. By looking at growth in total cost per patient, the full complement of services that make Health Centers a "health care home" are captured. Total cost includes all financial costs (excluding donations) for: Medical, Lab and X-Ray, Dental, Mental Health, Substance Abuse, Pharmacy and Enabling Services (translation, transportation, case work, outreach, etc.).

In 2005, the average cost per patient served at Health Centers grew by only 2.1 percent and in 2006, while costs grew at a slightly higher rate (4.6%), performance not only met but was under the target growth rate of 5.4%. This is about 33 percent below the 6.8 percent projected growth rate for national health expenditures in 2006. In fact, in the past 4 years, cost increases at Health Centers have been at least 20 percent below national cost increases. By restraining increases in the cost per individual served at Health Centers below national per capita health care cost increases, the Health Center Program has served a volume of patients that otherwise would have required additional funding to serve and demonstrates that it delivers its high quality services at a more cost-effective rate. Given recent performance of the program, annual targets in growth are set at 20 percent below forecasted national rates. Successful restraint of the cost per individual served at Health Centers below national per capita health care cost increases may, in part, be related to the Health Centers’ strategic use of a multi- and interdisciplinary team model of care that treats the “whole patient,” with a focus on continuity of primary care and enabling services.

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

Measure: Rate of births less than 2500 grams (low birth weight) to prenatal Health Center patients compared to the national low birth weight rate.
FY 06 target: 11.0% below national low birth weight rate
FY 06 result: 7.2% below national low birth weight rate

This measure is benchmarked to the national rate to demonstrate how Health Center performance compares to performance of the nation overall. In 2005, 7.3 percent of Health Center patients had LBW infants, a rate that was 11 percent lower than seen nationally (8.2 percent - 2005 national LBW rate). While the incidence of LBW rates fell slightly for health center prenatal patients in 2006, separation between the Health Center’s rate and the national rate was only 7.2 percent, (8.3 percent -2006 preliminary national LBW rate).

The program serves a prenatal care population at higher risk than that seen nationally. With the extensive expansion of health center services since 2002 through the development of new health center sites, more high risk prenatal patients who were previously underserved are being served, thus impacting the level of this rate. While the Program addresses LBW through the implementation of preventive prenatal health care in new organizations, there will be a delay before the benefit of these efforts is realized. The Program will take the following to address this issue:

• Technical assistance to health centers on the delivery of quality health through State Primary Care Associations.
• Outreach to patients to encourage timely entry into prenatal care, and patient education on healthy behaviors that can impact birth weight.
• Information to clinicians to help them in the identification of maternal disease and risks for complications of pregnancy or birth during the first trimester.
  
  Despite the recent slight increase in LBW, results over the past few years demonstrate that Health Center patients have continued to follow a steady LBW pattern at about 7 percent, unlike increases observed in the national rate (Source: Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2006. National vital statistics reports; vol. 56 no. 7. Hyattsville, MD: National Center for Health Statistics. 2007) The Program will continue its effort to remain below the national LBW rate, while serving a higher-risk prenatal population than seen nationally.

Free Clinics Medical Malpractice