U.S Department of Health & Human Services
Health Resources & Services Administration

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Presentation to the National Association of Community Health Centers

 

by HRSA Associate Administrator Sam S. Shekar

March 25, 2004
Washington, D.C.

For a printable version of the Power Point presentation, please see the PDF version.
Slide 1

Update from the Bureau of Primary Health Care: Busting Myths/Shaping a New Future

Sam S. Shekar, M.D., M.P.H.
Associate Administrator for Primary Care and Assistant U.S. Surgeon General
Health Resources and Services Administration
U.S. Department of Health and Human Services
Slide 2

U.S. Health Care Crisis

- U.S. ranks 28th in infant mortality; 20th in life expectancy
- Racial/ethnic minorities below poverty at greatest risk of poor health
- 44 million uninsured
- 50 million underserved
- Safety Net Intact but Endangered – Institutes of Medicine (IOM)
Slide 3

Health care products and services cost Americans nearly $1.6 trillion in 2002.  Here’s how the money was divided:

Hospitals: 31 %
Physicians: 22 %
Other Professional Services: 10 %
Prescription Drugs: 10 %
Nursing Home and Home Health: 9 %
Administration and Overhead: 7 %
Research and Construction: 4 %
Medical Devices and Equipment: 3 %
Government Public Health Activities: 3 %

(Source: CMS, Office of the Actuary)
Slide 4

From Movement to Mainstream: Less than half of 1% of total Medicare/Medicaid funds was spent at Health Centers in FY 2002. Almost $500 billion was spent through the Medicare and Federal/State Medicaid programs in FY 2002 (Medicare: $241.9 billion;
Medicaid: $225.5 billion). The share of Medicare/Medicaid dollars spent at Health Centers was $2.1 billion.
Slide 5

Selected Health Center Revenue 1990-2002

- In 1990, 24.9 % of Health Center revenue was from Medicaid; this rose to 31.9 % in 2002.
- In 1990, 40 % of Health Center revenue was from the Health Center appropriation; this declined to 20 % in 2002.
Slide 6

Strengthening Health Centers
Myth #1: Health Centers are relics of the 1960s that see a relatively small number of patients.
Slide 7

Typical Health Center

- $6M annual budget
- 50,000 encounters/year
- 14,000 patients/year
- 30 clinicians/clinical professionals
- 10 enabling staff
- 40 administrative staff

Services:
- General primary care
- Preventive screenings
- Chronic disease management
- Enabling services

(Source: BPHC, 2002 UDS)
Slide 8

Strengthening Health Centers
Myth #2:  Health Centers don’t play well together.
Slide 9

Strengthening Health Centers: Integrated Service Delivery Initiative

ISDI is where network development begins.
ISDI networks are the foundation for:
- Shared, Integrated Management Information System (SIMIS)
- Information and Communication Technology (ICT) Programs
Slide 10

Expanding Health Centers
Myth #3: Health Centers are few in number and not located in my community.
Slide 11

Health Center Program – FY 2002

(Map shows locations of Consolidated Health Centers)  The number of persons served has increased substantially and our commitment to our core population groups remains largely unchanged. We are still taking care of America’s most needy and thus reducing disparities in access to care.

National/Regional UDS rollups are posted on the BPHC Web site.

11.3 million served
44.7 million patient encounters
 >3,400 service sites
 88.1% below 200% poverty
 38.9% uninsured
 63.9% racial/ethnic minority
 Serve all ages:
   12.8 %    4 and under
   14.3%     5-12 years
   20.2%     13-24 years
   45.6%     25-64
   7.0%       65 and over
Slide 12

Presidential Initiative Years One & Two Combined

In years one and two (2003 and 2004) of the Presidential Initiative to expand Health Centers, the targeted goals for new access points and expanded medical capacity were exceeded. The target goal for new access points was 220; the actual achieved was 271. The target for expanding medical capacity was 210; the actual was 219.
Slide 13

Health Care Quality
Myth #4: Health Care for the poor equals poor health care.
Slide 14

HRSA/BPHC is committed to continued growth in the number of Health Centers accredited by JCAHO. Since the initiative to increase accreditation began in 1997, the number of Health Centers with JCAHO accreditation has grown from 47 in 1997 to 290
in 2003.
Slide 15

Access to Care: Uninsured Health Center Patients Do Not Face Access Barriers

Chart shows that, in 2001, 98.5% of uninsured Health Center patients had a usual source of care, while 74.9% of the U.S. population had a usual source of care. In 2001, 57.3 % of Health Center patients made three or more annual doctor visits, while 39.4 % of the U.S. population made three or more doctor visits.
Slide 16

Mammography Screening

Bar chart shows data that mammography screenings among Health Center females were higher in 2002 than for females with incomes below 200% of the Federal Poverty Level (FPL) throughout the nation.
 
- Of Medicaid-covered women who were treated in Health Centers, 96% received mammography screenings, compared to 75% of Medicaid-covered U.S. women with incomes below 200% of the FPL.
 
- Of uninsured women who were treated in Health Centers, 78% received mammography screenings, compared to 71% of uninsured U.S. women with incomes below 200% of the FPL.
 
- Of African American women who were treated in Health Centers, 86% received mammography screenings, compared to 78% of African American women with incomes below 200% of the FPL.
 
- Of Hispanic women who were treated in Health Centers, 88% received mammography screenings, compared to 79% of Hispanic women with incomes below 200% of the FPL.
 
(Source: 2002 User Survey)
Slide 17

Cancer Screening: Pap Tests

Bar chart shows that, in 2002, Pap tests among Health Center females were higher than for U.S. females with incomes below 200% of the Federal Poverty Level (FPL).
 
- Of Medicaid-covered women who were treated in Health Centers, 94% received pap tests, compared to 90% of Medicaid-covered
women who earned below 200% of the FPL.
 
- Of uninsured women who were treated in Health Centers, 86% received pap tests, compared to 77% of uninsured women who
earned below 200% of the FPL.
 
- Of African American women who were treated in Health Centers, 92% received pap tests, compared to 89% of African American
women who earned below 200% of the FPL.
 
- Of Hispanic women who were treated in Health Centers, 95% received pap tests, compared to 91% of Hispanic women who earned
below 200% of the FPL.
Slide 18

Obesity and Public Health

Obesity-related deaths are gaining on tobacco-related deaths.
 
Chart shows a breakdown of Deadly Habits, giving a list of preventable deaths in the United States, the numbers in 1990 compared to 2000, and the percentage of all deaths that these numbers represent.
 
Tobacco use is losing ground to poor diet and physical inactivity as the nation’s leading cause of preventable deaths.
 
Tobacco 1990: 400,000 preventable deaths; percentage of all deaths: 19%
Tobacco 2000: 435,000 preventable deaths; percentage of all deaths: 18.1%

Poor Diet/Physical Inactivity 1990: 300,000 deaths; percentage of all deaths: 14%
Poor Diet/Physical Inactivity 2000: 400,000 deaths; percentage of all deaths: 16.6%

Alcohol 1990: 100,000 deaths; percentage of all deaths: 5% 
Alcohol 2000: 85,000 deaths; percentage of all deaths: 3.5%

Microbial Agents 1990 90,000 deaths; percentage of all deaths: 4%
Microbial Agents 2000 75,000 deaths; percentage of all deaths: 3.1%

Toxic Agents 1990 60,000 deaths; percentage of all deaths: 3%
Toxic Agents 2000 55,000 deaths; percentage of all deaths: 2.3%

Motor Vehicles 1990 25,000 deaths; percentage of all deaths: 1%
Motor Vehicles 2000 43,000 deaths; percentage of all deaths: 1.8%

Firearms 1990 35,000 deaths; percentage of all deaths: 2%
Firearms 2000 29,000 deaths; percentage of all deaths: 1.2%

Sexual Behavior 1990 30,000 deaths; percentage of all deaths: 1%
Sexual Behavior 2000 20,000 deaths; percentage of all deaths: 0.8%

(Chart Source: Journal of the American Medical Association)
(Washington Post, March 10, 2004)
Slide 19

Chart compares the percentage of uninsured Health Center patients who received health promotion counseling on the topics of diet, activity, smoking, alcohol, drugs and STDs to the percentage of uninsured U.S. adults who received such counseling:
 
- 54% of uninsured adult Health Center patients received dietary counseling, compared to 43% of uninsured U.S. adults.
 
- 57% of uninsured adult Health Center patients received physical activity counseling, compared to 49% of uninsured U.S. adults.
 
- 75% of uninsured adult Health Center patients received counseling on smoking, compared to 64% of uninsured U.S. adults.
 
- 68% of uninsured adult Health Center patients received alcohol counseling, compared to 53% of uninsured U.S. adults.
 
- 55% of uninsured adult Health Center patients received drug counseling, compared to 39% of uninsured U.S. adults.
 
- 54% of uninsured adult Health Center patients received STD counseling, compared to 36% of uninsured U.S. adults.
 
Even among the nation’s most disenfranchised – those least likely to get any care, let alone counseling – uninsured Health Center patients are far more likely to receive this important, effective counseling than the uninsured who obtain care elsewhere.
 
(Source: Primary Care of Patients Without Insurance by Community Health Centers, Journal of Ambulatory Care Management; Gaithersburg; Apr 2001; Barbara Lepidus Carlson; Jill Eden; Daniel O’Connor; Jerrilynn Regan; Volume: 24: Issue 2:Page 47.)
Slide 20

The number of patients registered in all disease management collaboratives at Health Centers has grown from 1,685 in March 1999 to 139,295 in October 2003.
Slide 21

The number of patients enrolled in diabetes collaboratives at Health Centers grew from 4,343 in February 2003 to 92,472 in October 2003.  Patients’ average HbA1c level actually declined as the number of incoming patients increased dramatically. Even slight declines in patients’ HbA1c levels dramatically improve their health.
Slide 22

Low Birth Weight: U.S. Versus Health Centers

Graph compares the rate of low birth weight per 1,000 births in the U.S. compared to Health Centers from 1999 to 2002:
 
1999: U.S.  7.6
1999: Health Centers  7.4
 
2000: U.S.  7.6
2000: Health Centers  7.1
 
2001: U.S.  7.7
2001: Health Centers  7.1
 
2002: U.S.  7.8
2002: Health Centers  7.0
 
(Source: Uniform Data System, 2000-2002)
Slide 23

Low Birth Weight Disparity (2002):  Women patients at Health Centers gave birth to fewer low birth weight babies than the general population: 7.1 per 1,000 births among Health Center patients, compared to 7.6 per 1,000 in the total U.S. population. Among African American women patients at Health Centers, the rate of low birth weight babies (10.6/1,000) is significantly lower than for all African American women in the U.S. (13.1/1,000). As a result, Health Centers are reducing the disparity between the rate of low birth weight babies born to African American women and those born to all U.S. women. Among women treated at Health Centers, the disparity between African American women and all women’s rates is 3.5 babies/1,000 births; in the general population, the disparity is 5.6 babies/1,000 births.
Slide 24

Myth #5: Health Centers are inefficient.
Slide 25

Health Center Medicaid Managed Care Savings
 
Table compares savings for diabetes patients (primary and secondary diagnosis) treated in Health Centers operating Medicaid Managed Care plans (HC) with other community providers.  (Data are based on State health plan claims for January 1, 2000, through December 31, 2001.)
 
The table compares five categories:
 
% patients with a hospitalization  HC: 2.08%  Other: 7.89%
Average payment per inpatient  HC: $3,545.62  Other: $10,894.45
Average days stay    HC: 3   Other: 5
Average payment per office visit  HC: $67.42  Other: $65.52
Average total annual cost per patient  HC: $343.41  Other: $1,591.03
 
(Source: CareSouth Data Profile, State Budget and Control Board)
Slide 26

- Cost of treating Health Center Medicaid patients is 30-34% less than cost for those receiving care elsewhere; 26-40% lower for prescription costs; 35% lower for diabetics; 20% lower for asthmatics.
(Center for Health Policy Studies. Final Report; November 1994.)
 
- Health Center Medicaid patients are 22% less likely to be hospitalized for potentially avoidable conditions than those
obtaining care elsewhere.
(Falik et al. Medical Care Vol. 39, No 6; 2001.)
 
- Health Center Medicaid patients are 19% less likely to use a hospital emergency room and 11% less likely to be hospitalized for potentially avoidable conditions than those with a usual source of care who obtained care elsewhere.
(ACSC II Study to be published.)
Slide 27

Mean outcomes at nine Health Centers in 1999 outperformed the National Medicaid mean in the nine of 11 categories: childhood immunizations; adolescent immunizations; adolescent well-care visits; cervical cancer screenings; checkups after delivery;
well-child visits; children’s access to care (12-24 months); children’s access to care (25 months to 6 years); and children’s access to care (7-11 years).  The National Medicaid mean outperformed Health Centers in prenatal care first trimester and eye exams for diabetics.
Slide 28

Health Center Medicaid Savings: In 2002, Medicaid patients spent $1.8 billion at Health Centers.  If these patients had been forced to seek treatment elsewhere, they would have spent an estimated $2.4 billion to receive the same treatment. Hence, Health Center treatments saved the Medicaid system $600 million.
Slide 29

Myth #6: Health Centers can’t care for their complex patients.
Slide 30

Disposition of Patient Visit to a Health Center:
 
53.1% were given return appointment
27.3% were told to return as needed
8.9% were given no follow-up
7.2% were given a specialty referral
2.0% were given a telephone follow-up
0.3% were hospitalized
 
(Source: 2002 Visit Survey)
Slide 31

Collaborative Success
“With federally funded Health Centers having fully embraced the (Health Disparities Collaborative) model…this has become arguably the largest, most important health care quality improvement initiative in the country. It’s exactly what the health care system needs right now - a demonstration that it is possible both to improve care dramatically and even reduce health care costs.”
 
(Tracy Orleans, Ph.D., senior scientist at the Robert Wood Johnson Foundation Advances Online, Robert Wood Johnson Foundation Newsletter, October 2002)
Slide 32

Myth #7: Health Centers are not feeling the national clinician shortage.
Slide 33

2002 Health Center Workforce Growth Targets and Performance, Selected Disciplines

Bar chart shows Health Center growth targets and performance in five disciplines:
 
Physicians:  
 Target:   618
 Performance:  555
 
Nurse Practitioners/
Physician Assistants/
Certified Nurse Midwives 
 Target:   333
 Performance:  376
 
Nurses
 Target:   808
 Performance:  519
 
Dentists
 Target:   126
 Performance:  151
 
Administration
 Target:   1,381
 Performance:  1,710
Slide 34

Health Care Partnerships
Myth #8: Health Centers don’t have access to NHSC providers because of their HPSA scores.
Slide 35

Health Care Partnerships
Myth #9: Health Centers are poorly integrated between the Federal, State and local levels.
Slide 36

National Partners
- National Association of Community Health Centers (NACHC)
- National Health Care for the Homeless Council (NHCHC)
- National Center for Farmworker Health (NCFH)
Slide 37

State Primary Care Associations
- Workforce Recruiters
- State Partners in State Strategic Planning (SSP)
- Leading the Accreditation Strategy
- Emergency Preparedness and Coordination
Slide 38

National Health Care
Myth #10: Health Center care is not for everyone.
Slide 39

Changing the Health Care System

[Image shows an inverted triangle with tertiary care at the top, secondary care in the middle and primary care at the bottom tip.]

Health care is currently dominated by expensive hospitalizations (tertiary care) and specialized outpatient care (secondary care), with smaller investments in primary care and preventive care.
Slide 40

Current System Failing the Nation
- 2/3 of surveyed physicians say their training was inadequate to coordinate chronic care
- >50% of hypertensives,  diabetes, asthma managed inadequately
-  Average Medicare beneficiary sees nearly 7 different physicians

(Source: IOM – Transforming Health Care Quality)
Slide 41

Current System Failing the Nation
- 58% of obese patients received no weight loss counseling
- 50% of those who develop cervical cancer had not had up-to-date screening
- <50% of depression in a primary care setting diagnosed

(Source: IOM – Transforming Health Care Quality)
Slide 42

A majority of Americans are now considered to have at least one “pre-Disease” or “Borderline” condition.

Bar chart identifies the number of American adults (in millions) who have diabetes, hypertension, osteoporosis, and high cholesterol, compared with the number who have a pre-disease or borderline condition.
 
Diabetes   
 With disease  18 million
 Pre/Borderline  40 million
 
Hypertension
 With disease  50 million
 Pre/Borderline  45 million
 
Osteoporosis
 With disease  10 million
 Pre/Borderline  34 million
 
High Cholesterol  
 With disease  37 million
 Pre/Borderline  68 million
 
(Source: Prevalence figures based on National Health and Nutritional Examination Survey III by CDC.)
Slide 43

Changing the Health Care System

[Image on left shows an inverted triangle with tertiary care at the top, secondary care in the middle and primary care at the bottom tip.  Image on right shows a right-side-up triangle with primary care at the base in the largest space, secondary care
in the middle and tertiary care at the smallest tip]
 
Instead of a system dominated by expensive secondary and tertiary care that is often complicated and inefficient, a system founded on a strong primary and preventive care base can improve the nation’s health by addressing and resolving problems early and effectively.

In such a system, costs are lower and the probability of a successful outcome is higher.
Slide 44

America’s Health Centers’ ultimate challenge and goal:
Be THE model for primary health care in the United States.