Community health centers to play a key role in health care reform

WASHINGTON–The new medical office Lawrence Cross has in mind to serve Norwalk’s neediest residents will be unusual in almost every conceivable way.

For one thing, the exam rooms will be inside a van, not a bricks-and-mortar building. So one of the most important new staff members he’ll need to hire is a driver.

And even more critical than the doctor, who will only ride along a couple days a week, is the dental hygienist, along with a pricey portable chair for teeth cleanings.

Then there’s the target patient group: Norwalk’s public housing residents and the city’s homeless population.

“We think we can serve a few hundred patients” to start and ramp up significantly from there, says Cross, executive director of the Norwalk Community Health Center.

Cross sealed up this vision–spelled out in a 200-page grant application to the federal Department of Health and Human Services–in an envelope on Wednesday and sent it off to Washington.

His application was one of at least seven that Connecticut’s community health centers put in the mail this week. Like Cross’s Norwalk facility, each health center hopes to tap into new federal money–up to $650,000 per facility annually for the next two years–that’s available under the national health reform law.

That law seeks to vastly expand the role of community health centers–federally funded, nonprofit clinics that provide care to low-income people and those in medically under-served areas. CHCs also get critical funding from state governments and private sources.

Well before Congress approved the health reform law, CHC providers watched as their patient rolls swelled as more and more uninsured patients turned to these shoe-string operations for basic care. CHCs serve all comers–Medicaid patients, the uninsured, and the under-insured.

Nationally, CHCs have seen 3.3 million new patients in the last two years, and of those, 1.8 million are uninsured, according to the National Association of Community Health Centers. Connecticut’s 14 community health centers experienced a 10 percent jump in new patients from 2008 to 2009, said Evelyn Barnum, CEO of the Community Health Center Association of Connecticut.

“We are seeing more patients than ever,” said Cross, who said his Norwalk clinic added 800 new patients from just May through November. “When you look at the graph [of new patients], it’s virtually a straight line up.”

Much of that expansion was made possible by the federal stimulus law approved by Congress last year. That measure set aside $2 billion for CHCs to expand their capacity–allowing them to hire new nurses and doctors, as well as add on new exam rooms and buy new equipment.

The federal health reform law aims to take that expansion much further.

The grant applications that Cross and other CHC officials submitted this week are part of an $11 billion five-year expansion of community health centers envisioned under health reform. A major chunk of that money is designed to create “new access points,” expanding the number of clinics where low-income patients can get medical care.

“We serve 20 million patients now and over the next five years, we plan to serve 40 million,” said Amy Simmons, of the National Association of Community Health Centers (NACHC).

For Connecticut’s incoming governor, Dan Malloy, that looks like a windfall. In a recent interview, Malloy said he believes that CHCs could be key to dealing with the spiraling expense of Medicaid, the state-federal health insurance program for the poor.

“Medicaid represents the largest single increase in projected expenses going into the next fiscal year, in excess of $500 million,” Malloy noted. Asked how he planned to tackle that huge bill, Malloy said “we need to examine what services we deliver, to whom we deliver them, and how cost effective that delivery system is.”

Malloy said one possible way to lower the state’s Medicaid expenses is to have more of those patients treated at CHCs. “We’re looking at that as one of the ways of providing health care at less cost, with a larger contribution from the federal government,” he said.

Unlike a private practice doctor, who loses money on Medicaid because of low reimbursements, CHCs get what’s called a “fair payment rate,” i.e. a bigger federal check, when they treat those low-income patients.

And health centers often save state and federal treasuries billions of dollars, because they provide preventive services that keep low-income patients out of emergency rooms. One recent study by researchers at George Washington University found that last year alone, health centers saved Medicaid $11.3 billion in unnecessary hospitalizations and other acute care costs.

So CHC providers say it’s no wonder Malloy hopes to tap into the CHC model. They say it’s a smart move, but that it cannot be done overnight. Nor, they say, can it be done entirely on the federal government’s tab.

To be sure, as the federal government has channeled more funds into community health centers, many cash-strapped states have pulled back. Nearly two dozen states cut funding for CHCs in the last year, with 4 eliminating state aid entirely, said the NACHC’s Simmons.

“Some state policymakers have used the most recent federal investments in health centers … as a rationale for cutting critical funding,” NACHC’s president, Tom Van Coverden, recently wrote in a letter to Health and Human Services Secretary Kathleen Sebelius. “Our deep concern is that a continuation of this backslide will significantly impair the growth, development and stability of health centers as a key component” of health reform.

Connecticut CHCs have fared far better than those in other states, although Barnum said state funding for CHCs did take a small hit–about a $293,000 funding reduction–when officials imposed across the board cuts to Connecticut agencies, including the Department of Public Health, the agency that channels money to Connecticut’s health centers.

“Right now, they’re relying on an infusion of federal dollars,” Barnum said of Connecticut’s CHCs. “That’s the explanation for how they’re managing it all.”

She said another key issue in the coming ramp-up is finding the doctors and nurses to handle the increased patient load. “Workforce is going to be a bigger issue than bricks and mortar,” she said.

Cross echoed that sentiment, but said he and other providers are ready for the challenge. “We have plenty of exam rooms and a great track record of recruiting,” Cross said.

Indeed, he already has a new doctor lined up–an internist he snagged from New York City–to work two days a week in his hoped-for mobile medical van. He expects to hear back about his federal grant application in April

“If the health centers aren’t open, these patients have nowhere to go,” Cross said. “They will overwhelm the hospitals, and they won’t get good care.”