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Appendix B HRSA-Supported Primary Care Systems and Health Departments T he statement of task directed the committee to explicitly consider HRSA-supported primary care systems and health departments. This appendix provides an overview of these entities. HRSA-SUPPORTED PRIMARY CARE SYSTEMS While most primary care in the United States is delivered outside of HRSA-supported primary care systems, these systems served 19.5 million patients in 2010 (HRSA, 2011j) and play a critical strategic role in ad- dressing health disparities. The most widely recognized of these primary care systems are the health centers funded under the Health Center Pro- gram or designated as federally qualified health center (FQHC) look-alikes. These centers are community-based and patient-directed organizations that provide comprehensive primary care and preventive services in medically underserved communities for vulnerable populations with limited access to health care. In addition, HRSA supports other primary care systems as well. Health Centers HRSA supports two classes of health centers (HRSA, 2011k). The first are Health Center Program grantees or federally funded health cen- ters. These are public and private nonprofit health care organizations that meet certain criteria under the Medicare and Medicaid programs (Sec- tions 1861[(aa)][(4)] and 1905[(l)][(2)][(B)], respectively, of the Social Se- curity Act) and receive funds under Section 330 of the Public Health 163
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164 PRIMARY CARE AND PUBLIC HEALTH Service Act. They include community health centers, migrant health centers, Healthcare for the Homeless centers, and Public Housing Primary Care centers. These health centers are required to report administrative, clinical, and other information to the Bureau of Primary Health Care within HRSA. The second class of health center comprises federally qualified health center (FQHC) look-alikes, health centers that do not receive grant fund- ing under Section 330 but have been identified by HRSA and certified by the Centers for Medicare & Medicaid Services (CMS) as meeting Section 330 requirements. Although FQHC look-alikes do not receive Section 330 funding, they report to the Bureau of Primary Health Care and are eligible for other FQHC1 benefits through CMS. As mentioned in Chapter 3, this report uses the term “health center” to refer to Health Center Program grantees and FQHC look-alike organi- zations. The term does not refer to FQHCs that are sponsored by tribal or urban Indian health organizations, except for those that receive Health Center Program grants. All HRSA-supported health centers are required to meet certain criteria to maintain their health center designation. Health centers must meet per- formance and accountability requirements established by HRSA. They must be governed by a community board, at least 51 percent of whose members represent the population served by the center. Additionally, health centers must provide comprehensive primary health care and supportive services and use a sliding-scale system to charge patients without health insurance. These services include well-child care, nutritional assessment and referral services, blood pressure and weight management, clinical breast examina- tion, and prenatal services. Most important, health centers must be located in a medically underserved area or serve a specified medically underserved population (HRSA, 2011b). Migrant health centers are a strong example of health centers that serve a medically underserved population, focusing on communities of migrant and seasonal farm workers who face unique health care challenges. These challenges may be due to a relatively small number of individuals requir- ing care over a large geographic area, the transient nature of migrant and seasonal farm work, and/or the inability of existing health centers to handle the cyclical nature of seasonal work and the influx and outflow of patients. Approximately 90 percent of migrant health centers are funded as Health Center Program grantees serving special populations; the remaining 10 per- 1 The term FQHC is a designation determined and used by CMS to indicate that an entity can be reimbursed using specific methodologies statutorily designed for FQHCs. Here the term FQHC is used to indicate these CMS-designated entities, and includes designated Health Center Program grantees, FQHC look-alikes, and outpatient health clinics associated with tribal or urban Indian health organizations that are not administered or overseen by HRSA.
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165 APPENDIX B cent operate under migrant health voucher programs in which primary care services for migrant workers are subcontracted to existing local providers (National Center for Farmworker Health, 2011a,b). FQHCs (and rural health clinics, described next) are reimbursed by Medicare through a Prospective Payment System (PPS). This system estab- lishes a fee to be paid to the provider regardless of the service rendered, and is designed to encourage comprehensive care. There is no limit on the number of visits each patient can make per year. The reimbursement is based on yearly cost reports, which take into account the overall cost of operations relative to clinical production. Medicare and Medicaid PPS rates are set by the respective agencies but are generally similar. In 2010, 1,124 health centers served more than 19 million patients. Approximately one-third of these patients were individuals aged 18 or younger, 7.3 million were uninsured, and nearly 863,000 were migrant or seasonal farm workers and their families (HRSA, 2011j). Table B-1 presents more detailed information on health centers. TABLE B-1 Snapshot of Health Centers Characteristic Number Percentage Total Patients 19,469,467 Patients by Age Children (<18) 6,251,866 32.11 Adults (18-64) 11,885,206 61.05 Geriatric patients (65 and over) 1,332,395 6.84 Number of Patients by Insurance Status Uninsured 7,308,655 37.54 Uninsured children (0-19) 1,393,640 7.16 Medicaid/CHIP 7,505,047 38.55 Medicare 1,461,485 7.51 Other third party 2,699,183 13.86 Patients below the poverty level 10,726,964 55.10 Staffing Total staff 131,660.23 Primary care physicians 9,592.10 Nurse practitioners 3,807.86 Physician assistants 2,034.20 Certified nurse midwives 520.28 Dentists 2,881.89 NOTE: CHIP = Children’s Health Insurance Program. SOURCE: HRSA, 2011j.
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166 PRIMARY CARE AND PUBLIC HEALTH Rural Health Clinics Another HRSA-supported clinical service is the rural health clinic pro- gram, initiated to increase primary care services for Medicaid and Medicare patients in rural communities. As of August 2011, more than 3,800 rural health clinics were in operation across the United States, with 28 states containing more than 50 such centers (CMS Rural Health Center, 2011). Rural health clinics must meet certain criteria to maintain their rural health clinic designation. They must be located in a nonurbanized medically underserved or health professional shortage area. They must utilize a team of physicians and other practitioners, such as nurse practitioners, physician assistants, and certified nurse midwives, and must be staffed at least 50 per- cent of the time by nonphysician practitioners. Rural health clinics are not required to provide any preventive health, preventive dental health, or case management services. The scope of their services is limited to emergency care; outpatient primary care; and basic laboratory services such as urine testing by stick or tablet, blood sugar tests, and the collection of cultures for transmittal to a certified laboratory for analysis (HRSA, 2006). Disease-Specific Health Centers HRSA supports a number of disease-specific health centers. These centers focus on serving populations with particular diseases or areas with concentrated rates of a particular disease resulting from geographic prox- imity to exposures and other factors. The most renowned of these centers are Ryan White clinics, which exist as a part of the Ryan White Program. That program, the largest federal program focused exclusively on HIV/ AIDS care, was designed to increase federal funding for centers providing primary care to HIV/AIDS patient (HRSA, 2011a). The Ryan White Program has six parts. Part A funds are used to pro- vide care for people living with HIV, including outpatient and ambulatory medical care, oral health care, mental health services, substance abuse outpatient care, and assistance with health insurance premiums and cost sharing for low-income individuals (HRSA, 2011e). Part B provides grants to states and U.S. territories to improve the quality, availability, and or- ganization of HIV/AIDS health care and support services (HRSA, 2011f). Part C gives grants directly to service providers to support outpatient HIV early intervention services, and provide primary care and ambulatory care (HRSA, 2011g). Part D focuses on services to families and awards funds to public and private organizations for such activities as community outreach, prevention programs, primary and specialty medical care, and psychosocial services. It also supports efforts to improve access to clinical trials and re- search for vulnerable populations (HRSA, 2011h). Finally, Part F provides
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167 APPENDIX B funds for a variety of programs, including the Special Projects of National Significance Program, the AIDS Education and Training Centers Program, dental programs, and the Minority AIDS Initiative (HRSA, 2011i). In 2010, the Ryan White Program was funded at approximately $2.2 billion (HRSA, 2011d). Local Variability Like local health departments (discussed below), HRSA-supported pri- mary care systems vary widely. Health centers and rural health clinics serve a variety of populations and population sizes. Nationally, for example, health centers serve an average of 2,416 patients per center site; however, this number varies from 488 patients per site in Alaska to 3,408 patients per site in Washington state and 5,972 patients per site in the U.S. territory of Puerto Rico (National Association of Community Health Centers, 2011). This variability results from a number of factors, including the size of the overall population and the geographic distribution of both the general and underserved populations, the degree of stability of these populations, the number and location of the centers, and the presence of alternative sources of care in the community. While health centers may vary from program to program, there is some standardization for entities within each funding program. As noted earlier, for instance, rural health clinics must meet a number of requirements to receive that designation. These requirements not only set minimum service levels, but also include services that these clinics cannot provide using program funds. Additional sources of funding may impose further require- ments or allow centers to provide additional services. For example, some centers may be associated with academic institutions and may use the center as a teaching environment for medical interns and residents. These centers may provide expanded services using institutional funding. The presence of auxiliary staff, such as social workers, mental health and substance abuse personnel, and community health workers,2 varies from center to center as well. HEALTH DEPARTMENTS Health departments have primary responsibility for the provision of essential public health services. The governmental public health system, embodied in health departments, evolved in response to the hunger, malnu- 2 A community health worker is defined as a person who links members of the community to health services. The designation encompasses promotores de salud (community health workers in Spanish) and patient navigators (who work with specific patients), as well as other terms.
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168 PRIMARY CARE AND PUBLIC HEALTH trition, scurvy, and infectious diseases that were epidemic in the American colonies. Early public health interventions often were based in policy, with colonies enacting laws to regulate waste disposal and the quarantining of ships. Smallpox inoculation was another early demonstration of the effec- tiveness of public health interventions, dramatically reducing the mortality rate from that disease among the vaccinated (Novick and Mays, 2005). Since the colonial period, health departments have evolved to meet the public’s changing needs and grown in influence. Currently, federal health agencies can set a national health policy agenda and steer the system by al- locating resources across the designated priorities. While national agendas are set at the federal level, states play a pivotal role in the system, often acting as intermediaries between the federal government and local munici- palities (Novick and Mays, 2005). Local health departments often are the primary entities implementing public health activities in local communities. State Health Departments State health departments provide essential expertise and other support for local public health departments and in 26 states act as the local public health department for some or all of their state’s communities. These health departments are responsible for the state’s public health—including preven- tive, protective, and wellness services—and the allocation of public health resources according to local needs. Structure and Governance Some state health departments are independent organizations, while others operate within an umbrella agency that is also responsible for such functions as Medicaid, services for the elderly, and public assistance (ASTHO, 2011a). Public health agencies are more likely to be independent in states with larger populations: this is the case in 71 percent of states with medium-sized populations and 65 percent of those with large populations (ASTHO, 2011a). Governance relationships between state and local agencies vary, and these variations affect the way public health services are delivered. In 14 states, governance is wholly or largely centralized such that the state gov- ernment has primary responsibility for leading local agencies, including decision-making authority in most matters related to budget, the issuance of public health orders, and the appointment of local health officials. In five states, a shared governance model is used whereby either local or state gov- ernments may lead local agencies, with responsibility for decisions regard- ing budget, the issuance of public health orders, and the appointment of local health officials (ASTHO, 2011a). Finally, 27 states have a governance
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169 APPENDIX B structure that is wholly or largely decentralized. Mainly local employees lead the local agencies, and local governments have some decision-making authority. Expenditures and Revenues For fiscal year (FY) 2009, state health department revenues were re- ported for 48 states; they totaled $31.5 billion. If revenues are estimated for the two remaining states and the District of Columbia, the total is about $34 billion. State health department revenues come from federal sources (45 percent); state general funds (23 percent); other state funds (16 per- cent); fees and fines (7 percent); Medicare and Medicaid (4 percent); and other sources (5 percent), such as tobacco settlement funds, payment for direct clinical services (other than Medicare and Medicaid), foundations, and other private donations. Average revenue per capita was $126 in FY 2009 (ASTHO, 2011a). Total state health department expenditures for FY 2009 for the 48 states for which data are available were $22.5 billion. If revenues are estimated for the two states without expenditure data and the District of Columbia, the total is about $25 billion. Almost half of these expenditures were for either the Special Supplemental Nutrition Program for Women, In- fants, and Children (WIC) (24 percent of the total) or improving consumer health (also 24 percent), a category that includes access to care programs and direct clinical services, such as tuberculosis treatment, adult day care, early childhood programs, and local health clinics. Thirteen percent of state health department expenditures were for infectious disease programming, while 8 percent was dedicated to chronic disease prevention. Six percent went to improving the quality of health care and 5 percent to each of the following: all-hazards preparedness, environmental protection, adminis- tration, and other. A small portion was spent on health laboratories (2 percent), injury prevention (2 percent), health data (1 percent), and vital statistics (1 percent) (ASTHO, 2011a). Workforce In 2010, state (including the District of Columbia) health departments were estimated to have about 107,000 full-time employees. Of these, more than 27,000 were assigned to local health departments and another 17,000 to regional or district offices. The greatest numbers of these employees were administrative and clerical personnel, followed by public health nurses. On average, state health departments had about 288 vacant positions but were recruiting for only about 15 percent of these—likely as a result of hiring
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170 PRIMARY CARE AND PUBLIC HEALTH freezes in many states (87 percent of states have had such a freeze in effect since 2008). As one would expect, state health departments serving larger popu- lations employed larger numbers of full-time equivalents. The average number of employees in the state health departments serving the smallest populations was 876, while those serving midsized populations had an average of 2,045 employees and those serving the largest populations an average of 3,537. Considered on a per capita basis, smaller states employed more staff: 82 per 100,000 persons, compared with 47 for midsized states and 27 for large states (ASTHO, 2011b). Priorities and Responsibilities Top priorities cited by state health leaders included improving infra- structure and increasing capacity in terms of technology and workforce capacity (17 percent of states); quality improvement (9 percent); health promotion and prevention (8 percent); obesity, nutrition, and physical ac- tivity (6 percent); and emergency preparedness (6 percent). Responsibilities of state health departments included vaccine order management and inven- tory distribution, behavioral risk factor surveillance, reportable diseases, vital statistics, and testing of likely bioterrorism agents (ASTHO, 2011a). Local Health Departments Local health departments are formed at the discretion of the state or local jurisdiction and often perform a broad range of services depending on the jurisdiction. To address some of this variability, in 2005 the Na- tional Association of County and City Health Officials (NACCHO) led the development of the “Operational Definition of a Functional Local Health Department” (NACCHO, 2005). This definition identifies the essential functions a citizen should expect a state, local, tribal, or territorial health department to perform. Furthermore, standards for local public health have been established, and voluntary accreditation for local health depart- ments started in 2011. The Public Health Accreditation Board, a national nonprofit organization, based the public health standards on the 10 essen- tial public health services (see Box 1-2 in Chapter 1) and the NACCHO definition. This accreditation is endorsed by NACCHO and is encouraged as a way of ensuring consistent and quality local public health services for all communities across the United States. Nonetheless, great variability re- mains among local health departments in terms of population size served, jurisdiction, and governance; expenditures and revenues; workforce; role and scope of services; and information technology.
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171 APPENDIX B Population Size, Jurisdiction, and Governance The majority of local health departments serve small populations. Ap- proximately 63 percent serve fewer than 50,000 people, and only 5 percent serve 500,000 or more. The population size served often is governed by the department’s geographic jurisdiction. In 2010, 68 percent of health depart- ments served county systems, 21 percent served cities or towns, 8 percent served multiple counties, and 4 percent served multiple cities or a county and a city located outside of the county line (NACCHO, 2011a). Many health departments (75 percent) also are associated with one or more local boards of health, which serve to represent local perspectives and needs, in- stitute public health regulations, set and impose fees, and administer other activities (NACCHO, 2011a). Expenditures and Revenues Local health departments vary greatly in their expenditures and reve- nues. According to NACCHO’s 2010 National Profile (NACCHO, 2011a), roughly one-third of all local health departments had total expenditures of less than $1 million, another third had expenditures of $1-$4.99 million, and under 20 percent had expenditures of $5 million or more (it should be noted that 19 percent of health departments did not provide this informa- tion). Smaller health departments tended to spend more per person than larger ones ($48 for those serving fewer than 25,000 people versus $37 for those serving more than 1 million). Health departments governed by both state and local authorities reported higher median expenditures per person than those governed solely by state or local governments ($67 versus $46 and $38, respectively). This trend also pertains to local health department revenues. Smaller health departments reported median revenues of $54 per person, whereas median revenues for larger health departments were the same as median expenditures ($37 per person). Health departments operat- ing under a shared governance model also experienced a higher median per capita than those governed solely by state or local governments ($67 versus $52 and $39, respectively), a trend that echoes local health department expenditures organized by these categories (NACCHO, 2011b). Local health departments varied by population size in revenue sources as well. Federal direct and pass-though funds accounted for approximately 20 percent of revenues for local health departments serving fewer than 500,000 persons and for nearly 30 percent of those for departments serving populations of 500,000 or more. The percentage of revenues derived from Medicaid funding differed the most by population size. Larger local health departments serving more than 500,000 people received only 9 percent of their revenues from Medicaid, which accounted for more than 20 percent
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172 PRIMARY CARE AND PUBLIC HEALTH of revenues for those serving fewer than 25,000 people (NACCHO, 2011a). Many, regardless of size, received just less than 50 percent of their revenues from state and local sources. Workforce The differences among local health departments are further exempli- fied by their workforces. While 87 percent of local health departments had fewer than 100 full-time employees in 2010, the median number ranged from 4 (for local health departments serving populations of fewer than 10,000) to 530 (for local health departments serving populations of 1 million or more). The percentage of full-time employees rose with the population size (73 percent for those serving populations of fewer than 10,000 to nearly 100 percent for those serving populations of 1 million or more). Most local health departments employed a range of personnel. Positions in at least 50 percent of local health departments included ad- ministrative personnel (97 percent), public health nurses and managers (96 and 85 percent, respectively), environmental health workers (81 percent), emergency preparedness staff (65 percent), health educators (57 percent), and nutritionists (55 percent). At the median, local health departments employed 17 full-time employees, 4 administrative or clerical personnel, 4 public health nurses, 2 environmental health workers, and 1 public health manager (NACCHO, 2011a). Role and Scope of Services Local health departments provided a variety of services directly or through contracts with service providers in 2010 (NACCHO, 2011a). Lo- cal health departments offered the following 10 services most frequently: adult immunization, communicable disease surveillance, childhood im- munization, tuberculosis screening, food service establishment inspection, environmental health surveillance, food safety education, tuberculosis treat- ment, school/child care facility inspection, and population-based nutrition services. Other common roles included monitoring and health surveillance, the development and enforcement of health policies and regulations, emer- gency response, communication of health issues, and mobilization of com- munities around important health issues (NACCHO, 2011a). Additional roles included serving as the source of primary and preventive care for a large portion of the uninsured population and Medicaid recipients, devel- oping and training the county’s health workforce, and linking the public to appropriate health services.
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173 APPENDIX B Information Technology Local health departments reported using information technology (IT) to varying degrees (NACCHO, 2011a). One issue of concern is interoper- ability with other IT systems. While 52 percent of local health depart- ments could share some data, only 14 percent had IT systems that were fully compatible (NACCHO, 2010). Immunization registries were the most commonly used form of IT, followed by electronic health records, practice management systems, health information exchanges, and nationwide health information networks. Many local health departments reported using elec- tronic syndromic surveillance systems for such activities as the detection of influenza-like and foodborne illnesses, the establishment of case definitions, and the evaluation of interventions (NACCHO, 2011a). REFERENCES ASTHO (Association of State and Territorial Health Officials). 2011a. ASTHO profile of state public health. Arlington, VA: ASTHO. ASTHO. 2011b. Budget cuts continue to affect the health of Americans: Update May 2011. Arlington, VA: ASTHO. CMS Rural Health Center. 2011. Medicare certified rural health clinics as of 7/12/2011. https://www.cms.gov/MLNProducts/downloads/rhclistbyprovidername.pdf (accessed Oc- tober 24, 2011). HRSA (Health Resources and Services Administration). 2006. Comparison of the rural health clinic and federally qualified health center programs. Rockville, MD: HRSA. HRSA. 2011a. About the Ryan White HIV/AIDS Program. http://hab.hrsa.gov/abouthab/ aboutprogram.html (accessed November 15, 2011). HRSA. 2011b. Authorizing legislation: Section 330 of the Public Health Service Act (42 USC section 254b) authorizing legislation of the health center program. http://bphc.hrsa.gov/ policiesregulations/legislation/index.html (accessed January 4, 2012). HRSA. 2011c. Health center program terminology tip sheet. http://bphc.hrsa.gov/ technicalassistance /health_center_terminology_sheet.pdf (accessed January 19, 2012). HRSA. 2011d. HIV/AIDS program funding. http://hab.hrsa.gov/data/reports/funding.html (accessed October 25, 2011). HRSA. 2011d. HIV/AIDS programs part A—grants to emerging metropolitan and transitional grant areas. http://hab.hrsa.gov/abouthab/parta.html (accessed November 15, 2011). HRSA. 2011f. HIV/AIDS programs part B—grants to states and territories. http://hab.hrsa. gov/abouthab/partbstates.html (accessed November 15, 2011). HRSA. 2011g. HIV/AIDS programs part C. http://hab.hrsa.gov/abouthab/partc.html (accessed November 15, 2011). HRSA. 2011h. HIV/AIDS programs part D—services for women, infants, children, youth and their families. http://hab.hrsa.gov/abouthab/partd.html (accessed November 15, 2011). HRSA. 2011i. HIV/AIDS programs SPNS—Special Projects of National Significance (part F). http://hab.hrsa.gov/abouthab/partfspns.html (accessed November 15, 2011). HRSA. 2011j. Uniform Data System 2010 national data. http://bphc.hrsa.gov/uds/view. aspx?year=2010 (accessed November 17, 2011).0 HRSA. 2011k. What is a health center? http://bphc.hrsa.gov/about/index.html (accessed Oc- tober 24, 2011).
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174 PRIMARY CARE AND PUBLIC HEALTH NACCHO (National Association of County and City Health Officials). 2005. Operational definition of a functional local health department. Washington, DC: NACCHO. NACCHO. 2010. The status of local health department informatics. Washington, DC: NACHHO. NACCHO. 2011a. 2010 national profile of local health departments. Washington, DC: NACCHO. NACCHO. 2011b. Changes in size of local health department workforce. Washington, DC: NACCHO. National Association of Community Health Centers. 2011. Key health center data by state, 2010: National Association of Community Health Centers. National Center for Farmworker Health. 2011a. About community and migrant health cen- ters. http://www.ncfh.org/?sid=37 (accessed October 24, 2011). National Center for Farmworker Health. 2011b. Migrant health voucher programs. http:// www.ncfh.org/index.php?pid=65 (accessed October 24, 2011). Novick, L. F., and G. P. Mays. 2005. Public health administration: Principles for population- based management. Sudbury, MA: Jones and Bartlett, Inc.