| FQHC Expansion Prince George's County, MD Highlights Quality and Cost Benefits of Expanding FQHC Services in Prepared by Greater Baden Medical Services, Inc. and the Christopher King, FACHE, MHS, CHES Prince George’s County continues to be challenged by the need for an infrastructure that meets the complex health needs of its low income and/or uninsured/underinsured residents. According to the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, approximately 130,000 of the county’s 846,123 residents do not have health insurance and nearly 68,100 individuals are covered by a Medicaid managed care program. Sixty-six percent of the county’s residents are African American; 27% White; and the county is experiencing a growing Hispanic population (10%). As a racially, ethnically and linguistically diverse jurisdiction, the county’s health status mirrors disparities that commonly plague minority populations. For example, the county has the highest heart disease mortality rate in the metropolitan area and its cancer mortality rate is higher than the national average. The county is also the 2nd leading jurisdiction in the state with persons infected with HIV/AIDS. In all cases, African Americans are disproportionately affected. These data and projections are critical areas of consideration as disparities in access and quality of care continue to exist among minority populations. Several barriers have impeded access to healthcare services. For example, despite a median household income of $ 55,256, the county’s wealth has overshadowed a need for health services to accommodate pockets of poverty that can be found in various portions of its 311,750 acres. In addition, some low-income full time workers choose to forego health insurance to cover the costs of basic needs. The county’s morbidity and mortality rates, coupled with a large pool of diverse residents who are under/uninsured warrant a comprehensive, well coordinated, geographically dispersed, safety net infrastructure that can demonstrate improvements in the county’s overall health status. In the meantime, the county will continue to experience the social and economic ramifications that are spawned by limited access and inappropriate utilization of healthcare services. Ranging from uncompensated and unnecessary emergency room visits to the advancement of chronic diseases that limit functionality, the future of the county’s health is dependent upon leadership that is committed to supporting a health model that will promote prevention; and, ultimately improve access and quality of care for vulnerable populations. This paper will explore how expanding the capacity of the county’s federally qualified health center (FQHC), Greater Baden Medical Services, Inc. (GBMS), will be a practical and cost-effective measure for improving healthcare access and health outcomes for low income and/or under/uninsured residents. Highlights will include: background on the rationale for federally qualified health centers, Greater Baden’s performance in Prince George’s County, and the improved health outcomes and cost effectiveness of FQHC expansion. back to table of contents History, Mission, and Cost Effectiveness of Federally Qualified Health Centers Excerpt from: Altman, S.H., Reinhardt, U.E., & Shields, A.E. (1998). The future U.S. healthcare system: Who will care for the poor and uninsured? Chicago: IL, Health Administration Press. The FQHC program was viewed as a vehicle for bringing both newly insured and low-income people and those who remained uninsured into the healthcare system; educating patients on how to gain access to and utilize care; and as a means of addressing the myriad of social, demographic and poverty related problems that are commonly associated with and, indeed, which in some cases can give rise to poor health. In 1975, the FQHC program was established under Section 330 of the Public Health Services Act which defined, in federal law, federally qualified health centers as organizations that received funding under the statute to include community health centers, migrant health centers, health care for the homeless programs and health care public housing programs. These organizations could either be public or non-profit organizations and had to accomplish the following:
Nationally, the average annual of cost of care per patient in health centers is approximately $515 or about $1.40 a day per patient . This figure is 10 times less than the average per capita spending on personal health care, despite the provision of supportive services that are available in health centers (case management, transportation, translation services). Figure 1 illustrates how health center per patient costs grows slower than national per capita health expenditures. back to table of contents
Greater Baden Medical Services, Inc. Greater Baden Medical Services (GBMS) is a Joint Commission accredited federally qualified 501(c)(3) health center that was founded in 1972. Its mission is “to serve as a community partner to provide primary health services and facilitate health promotion/disease prevention activities in an efficient, effective, and comprehensive manner for the individuals and communities served, regardless of ability to pay.” Its vision is to be “the leading safety net provider for persons in southern Maryland and to be perceived as such by all.” The health center provides primary care services to communities in Prince George’s, Charles, and St, Mary’s Counties. Services include, but are not limited to: case management, diagnostic testing, immunizations, physical examinations, well child care, community based health education, and dental and mental services. Currently, services are offered in seven primary care clinics; four are housed in Prince George’s county*.
In 2006, approximately 4% (7,300) of the county’s estimated Medicaid and uninsured population received healthcare services at Greater Baden; 55% were uninsured – making Greater Baden the state’s health center with the highest percentage of uninsured patients. Thirty-percent of patients served were members of a Maryland Medicaid managed care organization. Nearly 1,925 of the patients served were treated for diabetes and/or some form of cardiovascular disease.
Nearly 70% were African American; 14% White; and 14% Hispanic. The majority, 4,739, had incomes below 100% of the federal poverty limit. Greater Baden medical providers commonly treat adults with cardiovascular disease, diabetes, HIV/AIDS, and sexually transmitted infections. Immunizations and preventive care services are provided to its pediatric population. Consistent with national trends, pediatricians are providing care to a growing number of children who are overweight or obese. Over 50% of the board of directors consists of persons who use its services. Therefore, board members believe the health center must serve as a partner to improve the overall health status of the communities served. Furthermore, in a complex and constantly changing healthcare environment, the board is actively involved in the agency’s quality improvement initiatives. Funded mainly by a diverse stream of grants, the health center has a strong record of grant development and grant management practices. In fiscal year 2006, 65% of its operating budget was supported by grants. The health center’s mission is executed by 65 racially, ethnically and linguistically diverse employees who are a reflection of the patients served. Professional clinical staff include: primary care physicians, pediatricians, nurse practitioners, nurses, dentists, and a psychologist. With a philosophical approach that is based on patient centeredness and teamwork, GBMS has a structured performance improvement process that involves patients and employees at all levels. Greater Baden is the only federally qualified health center in Prince George’s County. A sliding fee scale is used for low income patients; however, patients who are not able to pay the fee are not turned away. Greater Baden has a 35 year history of providing primary care services to disenfranchised populations in Prince George’s County. As a Joint Commission Accredited Healthcare Organization, the health center has established itself as a healthcare provider that meets national standards in patient safety and quality of care. The health center is also a member of the National Health Disparities Collaborative – a collaboration of health centers that identify and implement evidence based measures to improve chronic disease health outcomes for vulnerable populations. As a result, the center implements interventions targeted at health literacy, patient centered care, community partnerships, clinical data collection and analysis, patient self-management goal setting, and continuous quality improvement. The health center also has a track record of garnering support from private foundations and entities to support its mission. While 35 states have specific programs to provide direct assistance to FQHCs, Greater Baden does not receive financial support from the state to subsidize the costs of its services. back to table of contents Prince George’s County: A Community of Need Prince George’s county has some of the poorest morbidity and mortality statistics in the state. Nationally, African Americans are disproportionately affected by a variety of chronic disease conditions. This reality has special implications for the overall health of the county - since 66% of its population is African American.
The county experiences high rates of acute and chronic disease conditions. For example, in 2004, there were 1,420 deaths caused by heart disease. As of March 2006, there were 4,535 documented cases of HIV/AIDS – placing the county 2nd behind Baltimore City. The county also falls behind Baltimore city as the state’s 2nd leading jurisdiction in cases of syphilis, gonorrhea, and chlamydia. Data from the Behavioral Risk Factor Surveillance System (BRFSS) estimates that in 2005, approximately 69.1% of adults and 64.4% of children in the county were overweight or obese.
Since the majority of uninsured persons in the county do not have a primary care provider, the county hospital’s emergency room resources are inappropriately used. Results of this misuse have contributed to the hospital system’s ailing financial hardships and have compromised the system’s overall ability to efficiently execute its mission. In 2005, there were 232,662 emergency department visits in the county; 81,664 or 35.1% of the encounters could have been prevented or remedied by a primary care visit – translating to a potential cost savings of $3.3 million to $19.6 million. Even though Prince George’s Hospital Center sees many residents who are low income and/or uninsured/underinsured, it does not have an extensive outpatient infrastructure. Moreover, coordination between agencies that treat persons with low incomes is limited and not supported by any county authority. Currently, Prince George’s County does not have the essential primary care resources to meet the needs of its uninsured/underinsured populations. While many private practitioners treat uninsured patients, they are reluctant to see large numbers; and most uninsured patients, especially those with low incomes, are unable to afford other services that accompany primary care, such as laboratory services, x-rays, and medications. Access to dental care also serves as a limitation. A sliding fee scale is used for Greater Baden dental patients who are income eligible, however, services are only provided in Brandywine and Nanjemoy (Charles County). Due to overhead costs, private dental practices in the county provide little to no dental care for the uninsured. The provision of dental care for adults with chronic disease is especially important as oral health is important for chronic disease management. Overwhelmed with high rates of infant mortality, cardiovascular disease, diabetes, HIV/AIDS, depression, and substance abuse, the county is in need of a spectrum of public health services. Specialized health intervention models should be on the forefront of county and state leaders’ agendas. Three sources of data have been used to estimate the number of uninsured persons in the county: (1) Behavioral Risk Factor Surveillance System (BRFSS); (2) Kaiser Family Foundation’s Commission on Medicaid and the Uninsured; and, (3) the United States Census Bureau. The following chart provides a comparison of the three agencies over a 6 year time period. ESTIMATE - TOTAL NUMBER OF UNINSURED IN PRINCE GEORGE’S COUNTY: 2000-2005*
Nearly 1 out of every 7 Prince George’s County residents is uninsured; however, Greater Baden clinics see a very small fraction of the county’s market that is eligible and targeted for its services (5%). Such findings shed insight on the economic burden the county continues to experience as a result of poor access and/or inappropriate utilization of healthcare services/expenditures – many of which go uncompensated. Most importantly, the findings present a sound argument for increasing access to care by expanding primary care access points. back to table of contents Considering its diversity, coupled with morbidity and mortality data, Prince George’s County epitomizes the national health disparities crisis. With appropriate action, the county has the potential to serve as a nationally recognized leader in reducing or eliminating disparities. The inclusion of an expanded culturally sensitive preventive health model as part of its public health continuum will serve as a significant milestone. Without access to preventive services, such as primary care, residents are more likely to delay preventive measures and develop chronic conditions. Consequently, quality of life and overall productivity can be negatively impacted due to the inability to work or achieve other activities of daily living. In addition, when residents do not have access to primary care, they are more likely to use emergency rooms for the treatment of health episodes that can be prevented by having a relationship with a medical home, or primary care provider.
Due to the nature of its mission, an expanded FQHC model is a sensible approach that will help improve the health status of the county. Compared to private providers, Greater Baden services are unique because its healthcare professionals specialize in addressing an array of psychosocial issues experienced by vulnerable populations. Taking the “whole” person into account as part of its treatment methodology is the key to ultimately improving the health outcomes for the population it serves. As the county explores how to improve utilization of primary care services and decrease unnecessary and uncompensated emergency room visits, the expansion of geographically dispersed primary care access points will be a key component. Due to limited square footage in each of its clinics, Greater Baden only sees a small percentage of persons who should benefit from its services. Increased access points, including a larger dwelling inside the beltway, will allow the health center to expand its capacity and increase the number of persons who obtain primary care services. The following chart provides a geographic distribution of poverty inside the beltway.
One of the unique and most paradoxical aspects about the county is that despite its wealth, it consists of pockets of poverty. According to the poverty distribution table (presented to the right), there is a population of need in the central to northern tier of the county. This would include communities such as Langley Park, Bladensburg, Chillum, College Park City, Riverdale Park, and Brentwood. Many of these communities are comprised of large Spanish speaking populations, which require culturally appropriate health service intervention. When comparing the poverty distribution chart to GBMS patient utilization zip codes, findings clearly demonstrate that the vast majority of low income uninsured persons in the northern tier of the county are not accessing primary care services. The chart below identifies where the majority of patients reside who received services from GBMS in 2006. Ten leading zip codes of GBMS patients in 2006
There are approximately 162,000 uninsured persons in Baltimore City; there are 38 community health centers available to its population. There are approximately 73,000 uninsured persons in Washington, DC; it has 40 primary care safety net access points. In Prince George’s County, there are four community health centers; and nearly130,000 of its residents are uninsured.
GBMS patient utilization data compared to the number of persons who are uninsured, clearly demonstrates that the health center only serves about 5% of the population in need. Due to limited county support and no state support for ongoing operations, Greater Baden has not been able to expand its services to adequately meet the needs of the low-income, uninsured community. Various jurisdictions and states use different models to support and sustain their local health center’s viability. For example, some health centers in Baltimore city are affiliated with hospitals, which provide them with varying forms of supportive services. The District of Columbia has allocated over 15 million dollars over a three year period to support its safety net health centers through a “medical homes” project. As leaders continue to explore how the county’s healthcare infrastructure can be re-designed, the evidence presented in this paper supports the need for increased access to primary care services. Support for the expansion of its pre-existing FQHC will not only increase access to care and improve health status for many of the county’s residents, it will be economically prudent. With adequate primary care coverage for its vulnerable populations, the county will experience a decrease in uncompensated healthcare expenditures. As a community partner in the county since 1972, Greater Baden Medical Services has established itself as the leading safety net provider in southern Maryland. The health center’s board is committed to assessing the public health needs of Prince George’s County and serving as a community partner to ensure the provision of services that are consistent with its mission. With capital and/or ongoing financial support from its stakeholders, GBMS leadership believes the health center is in a strong position that can improve the health of the community and ameliorate the county’s healthcare economic status. back to table of contents Quality and Cost Benefits of Expanding FQHC Services
Utilization Patterns and Cost Statistics
Altman, S.H., Reinhardt, U.E., & Shields, A.E. (1998). The future U.S. healthcare system: Who will care for the poor and uninsured? Chicago: IL, Health Administration Press. Barclay, P. & Salamon, S. (January, 2007). Use of Maryland Hospital Emergency Departments: An update and strategies to address crowding. Baltimore: MD, Maryland Health Care Commission. Hoffman, C., Carbaugh, A., Moore, H.Y. & Cook, A. (November, 2005). Health Institute of Medicine (2003). Unequal treament: Confronting racial and ethnic disparities in healthcare. Washington: D.C., National Academy of Sciences. National Association of Community Health Centers (December, 2006). America’s health centers:making every dollar count. Fact sheet # 0706, Bethesda, MD. Maryland Department of Health and Mental Hygiene and the Centers for Disease Control. (2000 - 2005). Behavioral Risk Factor Surveillance System. Schwartz, K. & Hoffman, C. (January, 2007). Health insurance coverage of America’s children. Washington: D.C.,The Kaiser Commission on Medicaid and the Uninsured. The Kaiser Commission on Medicaid and the Uninsured. (2006). Health insurance coverage in America: 2005 data update, Washington D.C. United States Census Bureau. (2005). American community survey. Suitland, MD. United States Census Bureau. (August, 2006). Income, poverty, and health Insurance coverage in the United States: 2005. Suitland, MD Quality and Cost Benefits of Expanding FQHC Services in |
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Several studies have been conducted to explore the quality of care and cost benefit of FQHCs. Most notably, the majority of findings suggest that the total healthcare costs are much lower – from 22 to 67 percent – due to the significant reduction of specialty referrals, hospital admission rates, and lengths of stay for patients who use FQHCs compared to other providers. 