[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
A REVIEW OF COMMUNITY HEALTH CENTERS: ISSUES AND OPPORTUNITIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON
OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
MAY 25, 2005
__________
Serial No. 109-31
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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------------------------------
COMMITTEE ON ENERGY AND COMMERCE
JOE BARTON, Texas, Chairman
RALPH M. HALL, Texas JOHN D. DINGELL, Michigan
MICHAEL BILIRAKIS, Florida Ranking Member
Vice Chairman HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RICK BOUCHER, Virginia
PAUL E. GILLMOR, Ohio EDOLPHUS TOWNS, New York
NATHAN DEAL, Georgia FRANK PALLONE, Jr., New Jersey
ED WHITFIELD, Kentucky SHERROD BROWN, Ohio
CHARLIE NORWOOD, Georgia BART GORDON, Tennessee
BARBARA CUBIN, Wyoming BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
HEATHER WILSON, New Mexico BART STUPAK, Michigan
JOHN B. SHADEGG, Arizona ELIOT L. ENGEL, New York
CHARLES W. ``CHIP'' PICKERING, ALBERT R. WYNN, Maryland
Mississippi, Vice Chairman GENE GREEN, Texas
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DeGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MIKE DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire TOM ALLEN, Maine
JOSEPH R. PITTS, Pennsylvania JIM DAVIS, Florida
MARY BONO, California JAN SCHAKOWSKY, Illinois
GREG WALDEN, Oregon HILDA L. SOLIS, California
LEE TERRY, Nebraska CHARLES A. GONZALEZ, Texas
MIKE FERGUSON, New Jersey JAY INSLEE, Washington
MIKE ROGERS, Michigan TAMMY BALDWIN, Wisconsin
C.L. ``BUTCH'' OTTER, Idaho MIKE ROSS, Arkansas
SUE MYRICK, North Carolina
JOHN SULLIVAN, Oklahoma
TIM MURPHY, Pennsylvania
MICHAEL C. BURGESS, Texas
MARSHA BLACKBURN, Tennessee
Bud Albright, Staff Director
David Cavicke, Deputy Staff Director and General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Oversight and Investigations
ED WHITFIELD, Kentucky, Chairman
CLIFF STEARNS, Florida BART STUPAK, Michigan
CHARLES W. ``CHIP'' PICKERING, Ranking Member
Mississippi DIANA DeGETTE, Colorado
CHARLES F. BASS, New Hampshire JAN SCHAKOWSKY, Illinois
GREG WALDEN, Oregon JAY INSLEE, Washington
MIKE FERGUSON, New Jersey TAMMY BALDWIN, Wisconsin
MICHAEL C. BURGESS, Texas HENRY A. WAXMAN, California
MARSHA BLACKBURN, Tennessee JOHN D. DINGELL, Michigan,
JOE BARTON, Texas, (Ex Officio)
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Duke, Elizabeth M., Administrator, Health Resources and
Services Administration, U.S. Department of Health and
Human Services............................................. 13
Goetcheus, A. Janelle, Medical Director, Unity Health Care... 54
Hawkins, Daniel R., Jr., Vice-President, National Association
of Community Health Centers................................ 44
Manifold, Roderick V., Executive Director, Central Virginia
Health Services, Inc....................................... 61
Shi, Leiyu................................................... 58
Sibilsky, Kim, Executive Director, Michigan Primary Care
Association................................................ 40
Smith, Dennis, Director, Center for Medicaid and State
Operations, Centers for Medicare and Medicaid Services,
U.S. Department of Health and Human Services............... 18
Additional material submitted for the record:
Duke, Elizabeth M., Administrator, Health Resources and
Services Administration, U.S. Department of Health and
Human Services:
Letter dated August 17, 2005, to Hon. Tammy Baldwin,
enclosing response for the record...................... 124
Letter dated August 17, 2005, to Hon. John D. Dingell,
enclosing response for the record...................... 121
Smith, Dennis, Director, Center for Medicaid and State
Operations, Centers for Medicare and Medicaid Services,
U.S. Department of Health and Human Services, letter dated
September 16, 2005, enclosing response for the record...... 127
(iii)
A REVIEW OF COMMUNITY HEALTH CENTERS: ISSUES AND OPPORTUNITIES
----------
WEDNESDAY, MAY 25, 2005
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Oversight and Investigations,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:03 p.m., in
room 2322 of the Rayburn House Office Building, Hon. Ed
Whitfield (chairman) presiding.
Members present: Representatives Whitfield, Stearns, Bass,
Walden, Ferguson, Burgess, Blackburn, Barton (ex officio),
Stupak, Inslee, Baldwin, and Waxman.
Also present: Representative Green.
Staff present: Anthony Cooke, majority counsel; Mark
Paoletta, chief counsel; Chad Grant, legislative clerk; Jeanne
Haggerty, majority counsel; Edith Hollman, minority counsel;
and Voncille Hines, staff assistant.
Mr. Whitfield. At this time, I would like to call this
hearing to order.
As you know, this is the Energy and Commerce Committee's
Subcommittee on Oversight and Investigations, and today's
hearing is entitled: ``A Review of Community Health Centers.''
And I certainly want to thank all of those who will be
participating today as witnesses.
And at this point, I will recognize myself for an opening
statement.
We convene this afternoon to review community health
centers. I look forward to today's hearing with particular
interest, because I hope to bring, and I think this
Subcommittee hopes to bring, national attention to the
opportunities of this program for improving the lives and
health of many Americans while at the same time bringing focus
to the important role primary preventive health care can play
in controlling health care costs.
To meet the promises we have made through the Medicaid and
Medicare programs to provide health care we must always seek
ways to use the taxpayers' money wisely and promoting
preventing medicine for our most needy citizens is just one
such opportunity.
I might also say that the President has recognized the
promise of community health centers by placing them at the
center of an initiative to expand the access and services of
these important safety net institutions. Since 2002, this new
funding to the community health center program has added the
capacity to serve an additional 3 million Americans.
As the committee with principal authority over community
health centers, we should look forward to learning directly
from the health centers with us here today and to find out how
this new money is going to work.
I might also say that when we decided to have this hearing,
a lot of people were quite concerned, because they said, ``Oh,
my gosh. Why do they want to have a hearing about community
health centers? Is it because their Congressional District does
not have enough? Is it because they have got to find money to
save in Medicaid? What is the reason?'' And since I was one of
those that thought up the idea of having it, and I know that
Ranking Minority Member Stupak has had a real interest in this,
and I know we have a witness from Michigan here today who is
running a successful community health center, but my only
interest was that, one, I don't think that enough attention of
the Congress has been focused on these health centers. And two,
I think that they are providing an invaluable service in
providing access to, particularly a lot of people who are
uninsured, and I might add, uninsured people who do have jobs
but whose employer is not paying their health care for them,
and yet these people are paying the taxes so that people on
Medicaid get their health coverage, people on Medicare get
their health coverage, and they are paying their taxes, but yet
they can't afford to buy their own health coverage for their
own families.
And so we wanted to focus on these community health
centers. What are the opportunities out there for expansion?
Are there some new initiatives that we may think of, new models
that we could look at? You know, there are some unique things
about these health centers. They do have some limited liability
prospects under the Tort Claims Act. They get a discount on
prescription drugs. So there are a lot of great attributes to
these community health centers. And the real reason that we are
having this hearing is simply to get a better understanding of
how it works. Is there a well thought through policy on the
relationship between the community health centers and Medicaid,
between the community health centers and Medicare? Are there
other avenues that we may need to go?
So I just wanted to mention that as a clarification. I
certainly do not view this as a hearing of a way to save $10
billion next year for Medicaid. So I just want to set that in
the record, set that straight. And I do look forward to the
testimony, and what we might learn, and, hopefully, can come up
with some conclusions that will help improve health care for
everyone in America.
[The prepared statement of Hon. Ed Whitfield follows:]
Prepared Statement of Hon. Ed Whitfield, Chairman, Subcommittee on
Oversight and Investigations
We convene this afternoon to review community health centers. I
look forward to today's hearing with particular interest because I hope
to bring national attention to the opportunities of this program for
improving the lives and health of many Americans while, at the same
time, bringing focus to the important role primary, preventative health
care can play in controlling health care costs. To meet the promises we
have made through the Medicaid and Medicare programs to provide health
care, we must always seek ways to use the taxpayers' money wisely--and
promoting preventative medicine for our most needy citizens is just one
such opportunity.
Today there are over 900 community health centers providing a
spectrum of primary health care services through 3600 urban and rural
sites located in every state and territory. According to the Bureau of
Primary Healthcare, community health centers in 2003 treated over 12
million people in medically underserved areas, including 4.8 million
uninsured. Indeed, 90% of CHC patients live under 200% of the federal
poverty line. In 2003, these community health centers delivered
mammograms to over 200,000 women, gave check-ups and other health
services to 1.6 million children and administered over 2.2 million
immunizations. The primary healthcare services given by these community
centers also included pre-natal care, mental health services, blood
pressure and cholesterol checks and care of chronic diseases such as
diabetes. I have a community health center in my District and know the
vital role it plays in providing care to my constituents.
Community health centers play a critical role in our nation's
healthcare safety net. The purpose of our oversight hearing today is to
evaluate the effectiveness of the program in reaching the medically
underserved and to listen to ideas that could build upon the program's
areas of success. One such potential area of success, which is of
particular interest in this time of tightening budgets, is the role of
community health centers in giving the regular, preventative care that
both enhances their patients' daily health but also keeps them out of
hospitals and emergency rooms where the cost of providing care is more
expensive. Healthy people naturally utilize fewer health care services
thereby decreasing the burdens on our health care system and the
Medicaid and Medicare programs. As one example, a study in 1980 found
that a set of Medicaid patients, who used community health centers, had
a 30% to 65% lower hospitalization rate and used 12% to 48% less total
Medicaid funds than a similar group of Medicaid patients who did not
use such health centers.
The President has also recognized the promise of community health
centers by placing them at the center of an initiative to expand the
access and services of these important safety net institutions. Since
2002, this new funding to the community health center program has added
the capacity to serve an additional 3 million Americans. As the
Committee with principal authority over community health centers, we
should look forward to learning directly from the health centers with
us here today how this new money is going to work.
Finally, I would note here that there is surprisingly little recent
research on the issue of whether community health centers create
savings to our public health programs such as Medicaid, through their
provision of preventative care. As such, I recently asked the
Government Accountability Office to study this important connection and
I look forward to its report.
I welcome today's witnesses and appreciate their appearance here. I
hope this hearing will leave us all with a more complete understanding
of the community health center program and ways in which it might
better serve the medically underserved of this nation while, at the
same time, helping to control overall healthcare costs.
Mr. Whitfield. And with that, I yield back the balance of
my time and recognize the gentleman from Michigan, Mr. Stupak.
Mr. Stupak. Thank you, Mr. Chairman, and thank you for
holding this hearing.
First, I want to welcome Kim Sibilsky, the Executive
Director of the Michigan Primary Health Care Association, who
has dedicated many, many years to making sure that Michigan has
one of the best community health care systems in the country. I
look forward to hearing her testimony today.
Community health centers are one of the few success stories
in the health care field. They provide quality primary care at
a fraction of the cost to the uninsured, but also provide care
to the insured. Not only are community health centers the
epitome of doing more with less by being incredibly resourceful
in using the funding they receive, but also community health
centers lower the costs of health care overall by keeping
people out of the hospital emergency rooms where the cost of
care is much greater. As a result, the community health care
program continues to enjoy strong, bipartisan support.
Under both the Clinton and Bush Administrations, Congress
has expanded the budget and the geographic coverage of these
centers. In the most recent dismal health care disparities
report of 2004, which I have placed in the exhibit book, the
Department of Health and Human Services reports ever decreasing
quality of care and less access for most disadvantaged and poor
groups except those who receive care in community health
centers.
But community health centers face serious challenges. The
linchpin that keeps these centers financially afloat is the
Medicaid reimbursement. About one-third of their income comes
from Medicaid. Along with the base Federal grant and SCHIP,
Medicaid is what allows these centers to care for the
uninsured, those who have limited health care insurance, and
those with no place else to go. Yet Medicaid is under attack.
The Energy and Commerce Committee has been ordered to cut
Medicaid by $15 billion to $20 billion over 5 years. This cut
is equivalent to completely eliminating Federal funding for
Medicaid coverage between 1.8 and 2.5 low-income parents for
each of the next 5 years. States simply can not afford these
cuts. Michigan's high unemployment rate makes Ms. Sibilsky's
job and that of rural health centers and federally qualified
health centers more difficult. This is especially true with
Medicaid cuts expected to be between $15 billion to $20
billion.
The fact is that States are already struggling, making
cuts, and impacting the community health centers. When States
decide to reduce their Medicaid roles or cut coverage services,
the community's health centers can't throw out these people or
stop providing care. The patients still need health care, and
the centers are legally obligated to provide it. When States
cut Medicaid, the community health centers are hit with a
double whammy: community health centers lose Medicaid payments
for their current patients and community health centers get new
patients who are being turned away from or can't afford their
private providers.
Attached to my statement is an overview of how Michigan
community health centers are being hit. Michigan, for example,
stopped paying for dental care for adult Medicaid patients. But
that service is more utilized than any other by patients in the
State's community health care centers. They have to keep
providing it. The poor oral health has serious long-term
effects on people's health, morbidity, and employability. But
who will pay for it?
Who also will pay for the health care of those whose
employers can no longer afford it? Many employers are
struggling to compete in the global economy and can no longer
offer affordable health insurance to their employees. When
employers cut insurance coverage, the burden falls to Medicaid
and community health centers. Twenty-seven percent of the
adults on Medicaid in Michigan have a job. Ms. Sibilsky says it
better than I could: ``When you restrict enrollment in public
programs, the cost to providing care does not disappear and the
savings are not absolute. People will eventually receive the
care they need. It may not be in the best and most cost-
effective location at a time when progression of illness can be
headed off and the most expensive care prevented, but in the
end, anyone can walk into a community hospital and receive some
level of care.'' Michigan centers are already confronting
higher co-payments, longer waiting periods for new patients,
reduction in services, and losses in the hundreds of thousands
of dollars for ineligible oral health care. Community health
centers face still more challenges. Who is going to provide the
money for capital expenditures, something the Federal
Government doesn't pay for? A number of these centers are
becoming very adept at private fundraising, but more and more
often they are competing with other worthy causes, which are
losing their funding because of shortsighted political
decisions made here in Washington. The centers need computers,
equipment, expanded facilities, and staff.
The President has a commendable goal of creating many new
health centers, but we can't improve health care if the
tradeoff is letting the existing centers stay barely alive. In
addition, the President's budget slashes funding from $300
million this year to $11 million next year for the Health
Professions Program, which specifically provides Federal
funding to bring physicians and other health care providers to
under-served populations, the exact same populations served by
community health centers.
It is distressing, Mr. Chairman, to see a program that is
so successful, so efficient, so economical, and so praised face
problems of this size and complexity. I hope this hearing today
will provide more than a feel-good experience for the members
and we begin to discuss how arbitrary budget cuts in Washington
directly affect our ability to provide quality health care and
coverage to those most in need.
Mr. Chairman, I yield back the balance of my time.
Mr. Whitfield. Thank you, Mr. Stupak.
At this time, I will recognize the gentleman from Oregon,
Mr. Walden, for his opening statement.
Mr. Walden. Well, thank you very much, Mr. Chairman. I
appreciate your holding this hearing. I have been a big
advocate of the centers. I spent 5 years on a community
hospital board, chaired and worked on committees in the Oregon
legislature and enacted the Oregon Health Plan in an effort to
better serve and better utilize Medicaid funding to try and do
preventive work as well.
I hadn't planned to get into the argument over Medicaid
funding, but just for the record, I believe the target that we
have to achieve on all areas within our jurisdiction in this
committee is something to the order of $10 billion and not $15
billion. And we do have other ways we can generate revenues,
too, from things like spectrum auction.
I would also point out that we did support, as I recall on
the floor and in the budget resolution that has been passed,
the Medicaid Commission is due to report on how we can achieve
greater efficiencies in Medicaid. And as an employer, I
certainly sympathize with the cost of health care. My own
insurance policies in my company, premiums went up close to 20
percent this year. So there are a lot of conflicting pressures
on health care delivery, and it is our opportunity and
challenge to figure out how best to take care of people who
need health care in the most efficient and affordable way
possible. And it is not through the emergency room door. It is
through clinics like this.
And I want to brag a bit in terms of what has happened in
my home State of Oregon, where we have 23 community health
centers which support over 125 sites in urban, rural, and
frontier areas.
Now I want to talk about a frontier area. My District is
the second biggest in the Nation other than the five single-
member States. And let us cut to the chase and go right on out
to Wheeler County where there are 1,713 square miles. That is
about the same as the population in the county. Okay. That is
the size an area as big as the State of Rhode Island. And
located there is the Asher Clinic, the sole life-saving source
for health care. The two surrounding counties of Wheeler
County, Sherman and Gilliam, none of these three counties has a
hospital. They have clinics. They have physician assistants.
One, I guess, now has a doctor but for many years didn't. This
clinic out in Wheeler County faced some difficulty and initial
rejection to be able to get qualified as a Federal health
center and was facing a shortfall of $80,000 a year. That is a
huge sum in a community like that, a county of 1,700 people or
thereabouts. So they contacted me and my staff in May 2003, and
we helped them work through some of the paperwork and all, and
I really want to commend Elizabeth Duke and her folks for their
work on this effort as well, because they were, in 2004, able
to receive a health center grant for $229,500, and you would
have thought they won the $100 million lottery. And I went out
to Wheeler County not long after that to help them celebrate a
bit. And you know, we really are talking about life saving, a
source of health care. Because you can drive, in parts of my
District, 100 miles in any direction before you hit the first
stop light. And if you have a crisis in health care, if clinics
like this don't exist, you are out of luck unless you wait for
a helicopter to come pick you up and transport you somewhere,
which is the alternative, or you race in a car somewhere to try
and find health care.
And so I am a firm believer in these federally qualified
clinics. I believe they can be, and are, a very productive way
to help people who don't have health insurance get care before
it is an emergency and improve their own qualities of life.
So Mr. Chairman, I appreciate your oversight on this. We
are spending a lot of money in this area. It is our obligation
to look at what is working and what is not, as we do in this
subcommittee and as you do very aggressively as our chairman.
And I think it is good to point out once in a while where
things are working and use, as an example, these clinics, and
if there are problems, let us figure out where things work
better and apply those standards elsewhere. But we have got big
challenges in this Congress when it comes to the delivery of
health care services. And if you add up the promises that have
been made from Social Security, Medicare, and Medicaid, we
bankrupt the next generation if we don't get it right now.
And so hopefully, as we look at issues involving, for
example, the work this subcommittee has done on AWP versus ASP
on how we pay for drugs versus what it costs to actually get
them. There are some false economies there and actually some
perverse incentives to drive up costs of pharmaceuticals to
Medicaid and robs money, I believe, from actually being able to
expand and deliver service. It could be as much as $15 billion
over 10 years. These are issues that we have looked at in this
committee and need to look at closely as we try to reform
Medicaid to be able to deliver the most service most
efficiently to the most number of people.
And so I welcome this hearing, and I appreciate your and
our staff's work in this area.
And I yield back the remaining 3\1/2\ seconds.
Mr. Whitfield. Thank you, Mr. Walden, for being so generous
with your time.
And Mr. Waxman, you are recognized for your opening
statement.
Mr. Waxman. Thank you very much, Mr. Chairman.
Well, it is clear from what I have heard so far that there
is strong, bipartisan support for the community health centers.
It is one of the real successes of our Federal health policy.
But I want to make one point that Mr. Stupak indicated. We
will be doing a real disservice to the community health centers
if we make some of the cuts in Medicaid that are being
proposed. It may not be the $15 billion or $20 billion,
although we still don't know if somebody might just come up
with something more than $10 billion, but $10 billion is not a
small amount of money. It is the Medicaid program that is the
lifeblood of these centers. If we had not established the
federally Qualified Health Centers Program in Medicaid in 1989
guaranteeing community health centers that they would be
covered providers in the Medicaid program and reimbursed at a
fair level that recognized their costs, many centers just would
not be viable. And it is hard to praise those centers when they
are not around anymore. It is a crucial source of payment, and
they are not going to be around anymore if we make some of
these cuts in Medicaid.
If we cut the Medicaid program and we take away the
guarantee of coverage for eligible people, we will be damaging
the community health center program just as directly as if we
slashed its funding. If we accede to State calls for
flexibility and take away the payment and coverage guarantees
we have given to FQHCs, then it is the viability of the
community health centers that will be directly threatened.
It is easy to voice support for these centers but miss the
crucial link to a robust Medicaid program. Certainly the
administration, in my view, has been hypocritical in touting
their support for community health centers while they work for
constant changes in Medicaid, which would damage these
institutions beyond repair.
In addition to Medicaid, community health centers see the
uninsured. Well, we will have many more uninsured if there is
not a Medicaid eligibility for them to get that coverage. We
will have more uninsured, less payment, and the community
health centers, and other providers, will not be able to absorb
those costs.
I thank you, Mr. Chairman, for holding this hearing. Let us
keep all of these things in mind, because there are a lot of
times we don't want the unforeseen consequences to occur when
we adopt legislation, but let us take the time in this
Oversight Committee to foresee what would happen if we make
short-term cuts in Medicaid to deal with the budget and then
have very foreseen consequences that could be so harmful to a
program that has been working well.
Mr. Whitfield. Mr. Ferguson, do you have an opening
statement? And while you are preparing, I would like to
recognize and welcome Mr. Green of Texas, who is a member of
the Energy and Commerce Committee. He does not happen to be a
member of this subcommittee, but we know of his intense
interest in community health centers and welcome him here
today. It is the policy of the subcommittee that if you are not
a member of the subcommittee, you can not make an opening
statement, but you can certainly ask questions and make
comments during that period. And I know you are excited about
the number of health centers in Texas, and I was going to be
really astute and give you the number, but now I can't seem to
find it, but I think there are something like 35 grantees, or
so, in Texas.
But at this time, I recognize Mr. Ferguson for his 5-minute
opening statement.
Mr. Ferguson. Thank you, Mr. Chairman.
I am sorry I was walking in a couple of minutes late.
I want to thank you for holding this hearing about an
initiative that has received great support from the President
and the administration and is currently providing care to
millions of poor and under-served Americans in our country
today. In a short time, community health centers have emerged
as viable sources of health care for the poor of our Nation. In
fact, 90 percent of people that have used community health
centers are people under 200 percent of the Federal poverty
level. Community health centers in 2003 treated over 12 million
people in medically under-served areas, including 4.8 million
uninsured patients. That same year, 1.6 million children
received check-ups or other health services from CHCs and they
administered over 2.2 million immunizations. Pre-natal care,
mental health services, blood pressure, mammograms, and
cholesterol checks and care of chronic diseases, such as
diabetes, all take place at community health centers every day.
All of these statistics are impressive, but we can do more.
I am thankful that we are going to have this opportunity today
to delve into what we can do to help make community health
centers serve the community better. For instance, is it
possible to open up the grant process to faith-based groups to
help provide these health services to the poor and under-
served? Today, for instance, there are over 500 Catholic-
sponsored health clinics for the poor, serving the exact same
patient population as community health centers, but they are
not eligible for Federal funding.
I thank the chairman for holding this important hearing. I
look forward to hearing from our expert panel. And I welcome
their suggestions.
Thank you, Mr. Chairman. I yield back.
Mr. Whitfield. Thank you, Mr. Ferguson.
At this time, I recognize Ms. Baldwin for her opening
statement.
Ms. Baldwin. Thank you, Mr. Chairman.
I want to commend you for holding today's hearing on
community health centers.
Like my colleagues, I, too, am a strong supporter of
community health centers and their mission. I represent a
District with two federally qualified health centers, and I
like to visit them frequently. I am constantly impressed with
the excellent job that they do with extremely limited
resources. I think each of us knows the large role that
community health centers play in responding to the health needs
of our uninsured, our under-insured, and low-income
constituents and other targeted communities within our
constituency.
But the community health centers are also the first to talk
with me when I visit about the unmet needs that exist in our
community that they are simply not able to meet, the people
that they must turn away on a daily, weekly, and monthly basis.
As just one example, because of the fact that no dentist in the
largest county in the District that I represent has accepted
new Medicaid patients in over 2 years, the Madison Community
Health Center has tried very hard to fill some of that role.
They have just expanded and moved into a new building with
dental suites. They can currently serve over 12,000 individuals
per year who need dental care, but it is estimated that 63,000
more people in that one county need dental care but don't
receive it.
There are two closing points that I want to make. Even
acknowledging what a huge fan I am of community health centers
and the incredible job that they do in our community, I just
want to say that they are clearly a response to the crisis of
uninsurance in our country, but in my view, not the solution.
And I remain committed to the belief that this Congress ought
to declare health care to be a right and not a privilege, that
we ought to ultimately tackle the challenge of universal health
care.
Also, I want to underscore what several other colleagues
have said in their opening statements about my strong concerns
on how community health centers will be impacted by the
impending cuts anticipated in the Medicaid program. Obviously,
we all agree that community health centers' role and mission
are vital, and at a time when the situation is so dire, we need
them to have the capacity to respond to as many in need as
possible.
With that, Mr. Chairman, I yield back my remaining time.
Mr. Whitfield. Thank you, Ms. Baldwin.
At this time, I will recognize the gentleman from Texas,
Dr. Burgess, for his opening statement.
Mr. Burgess. Thank you, Mr. Chairman.
The District that I represent actually has just crossed the
finish line with its first community health center. My District
is truly a cross-section of the country. Within its boundaries,
you will find a mix of rich, poor, middle income, rural,
suburban, urban, black, Anglo, and Hispanic citizens. You will
also see sharp differences in the health needs of different
communities and how they are impacted by the very health
disparities.
For instance, in one part of my District, you will see some
of the highest infant mortality rates anywhere in the country,
and indeed, higher than some areas in parts of the world that
we feel are less developed. In other parts of my District, the
population is healthier but without ready access to health
insurance. A new community health center in Denton, Texas is
beginning to make a difference by giving community residents
access to a physician at free or reduced cost. This will not
only improve their short-term health, but will help with the
creation of a medical home.
I am also actively seeking out stakeholders in the city of
Fort Worth to look at standing up a clinic in Southeast Fort
Worth to meet the needs of this community. This area of Fort
Worth, having yet to really catch the wave of economic
development that has benefited other areas of the city, is
crying out for the type of assistance that a community health
center can provide.
As we proceed from this hearing, I hope to be able to tap
some of the expertise here in the room and assist my
constituents that look to establish a community health center
back home.
Thank you, Mr. Chairman, for calling this hearing, and I
will yield back.
Mr. Whitfield. I thank you, Dr. Burgess.
At this time, I recognize the gentleman from New Hampshire
for his opening statement.
Mr. Bass. Thank you, Mr. Chairman.
This is an interesting hearing. Community health care
centers are a very important part of almost every Congressional
District and every State in the country. I have the benefit of
having at least three or four in my District. I believe there
are seven altogether in the State of New Hampshire. And what
they do, as may have been mentioned before, is provide a bridge
for adequate health care between those who qualify for Medicaid
and those that buy a health insurance policy. I note that the
budget for community health care centers has gone up almost
double in the last 4 or 5 years because we recognize, as does
the administration, this is an important part of the whole
health care picture in this country.
It is a good hearing, a good time for a hearing. I will be
interested to know whether there are any issues involved with
whether the competitive bidding process or application process
for grants ends up resulting in having lots of community health
care centers in some parts of the country or in some States and
not in others where they may be needed.
So Mr. Chairman, I appreciate your calling this hearing,
and I look forward to hearing from the witnesses.
Mr. Whitfield. Thank you, Mr. Bass.
And I am going to ask unanimous consent that we also enter
into the record about nine documents that specifically relate
to the health centers. The staffs on both sides of the aisle
have reviewed this, and I think it will be helpful to complete
the record with that.
So without objection, these documents, a total of nine of
them, will be entered into the record.
[The information referred to appears at the end of the
hearing.]
Mr. Whitfield. We are going to pause for just 1 minute. I
have been told that the Chairman of the Full Committee is on
his way, and I know that he did want to make an opening
statement. So I am going to ask for your patience for a minute.
We will see if he is going to be here.
Mr. Green. Mr. Chairman, while we are waiting for the
opening statement, could I just ask unanimous consent to place
a statement into the record?
Mr. Whitfield. Yes. That will be fine.
Thank you, Mr. Green.
While we are waiting on the Chairman, I would like, at this
time, to call the first panel to the witness stand.
The first panel consists of Dr. Elizabeth Duke, who is the
Administrator of Health Resources and Services Administration
with the U.S. Department of Health and Human Services. Dr.
Duke, we are delighted that you are here with us today, and we
look forward to your testimony. In addition, Mr. Dennis Smith,
who is the Director of the Center for Medicaid and State
Operation, the Centers for Medicare and Medicaid Services at
the U.S. Department of Health and Human Services.
So we do welcome you all here today.
And at this time, the Chairman of the Full Energy and
Commerce Committee, Mr. Joe Barton of Texas, has just arrived.
And I know he has a specific interest in community health
centers. And at this time, we would recognize him for his
opening statement.
Chairman Barton. Well, first, Mr. Chairman, happy birthday
to you.
If I had known a little bit sooner, we would have had a
cake, but you are now old enough to vote, and we appreciate
that.
Mr. Whitfield. I am 52 today.
Chairman Barton. Today is your birthday, so happy birthday.
I need to give Congressman Ferguson, Mr. Embryo himself,
credit for that. You know, we were all embryos once, and that
is going to be on your tombstone.
But to get to the subject of today's hearing, Mr. Chairman,
community health centers get little national attention. As the
chairman of the committee with direct jurisdiction over the
program, I personally want to learn more about how these
centers work, what role they actually play in delivering health
care, and what cost savings they might achieve. And I believe,
Mr. Chairman, this hearing is one of the first hearings any
committee of the Congress has held on community health centers
in a long, long time, and I want to commend you for that.
The program itself is decades old. It was intended then and
now to serve the poor. It was a small program, but now it is a
large one. We operate over 3,600 urban and rural size in every
State and Territory, and community health centers serve more
than 12 million people.
I am interested in knowing more about the care offered by
these centers and the impact that they have on both patients
and the general health care system in America.
It has been reported that community health centers lower
the cost of Medicaid. We are told that even as far back as 1980
there was a study that found a set of Medicaid patients who use
community health centers use between 12 to 48 percent less
total Medicaid funds than a similar group of Medicaid patients
who did not use community health centers. That is back in 1980.
Well, now we are in 2005. Is the same thing true today?
I am also interested in learning whether community health
centers have been successful or can be successful in moving
routine patient care out of emergency rooms to clinics where
the quality is better and the care costs are dramatically
lower.
The President has also included community health centers in
his domestic health care agenda, and the President's initiative
since 2001 has increased the number of community health centers
by 334. As the primary authorizing committee, we must remain
informed about how these additional centers have been allocated
around the country.
I really want to thank you, Mr. Chairman, on your birthday,
for holding this hearing. I look forward to the committee's
review, and we look forward to moving forward, possibly in
legislative areas, if this hearing shows that we need to.
With that, I yield back.
[The prepared statement of Hon. Joe Barton follows:]
Prepared Statement of Hon. Joe Barton, Chairman, Committee on Energy
and Commerce
The subject of today's hearing, community health centers, seems to
get little national attention. But, over a number of years, these
centers have been slowly building a track record that suggests
promising developments in the difficult area of health care. Community
health centers have seemed to be both helping patients live healthier
lives while, at the same time, controlling overall costs. Like any
member of Congress hearing something like this--I want to learn more.
And as Chairman of the Committee with direct jurisdiction over this
program--I want to find how to support the good work of these centers.
The community health center program is not new. Indeed it has its
roots in efforts during the 1960's to promote health services within
underserved communities. By-passing the bureaucracies of state
governments, federal money went directly to community based
organizations delivering basic health services to some of the most
needy among us.
Today, this effort continues in over 900 community health centers
which operate 3600 urban and rural sites in every state and territory
and serve over 12 million people. In 2003, these community health
centers delivered mammograms to over 200,000 women, gave check-ups and
other health services to 1.6 million children and administered over 2.2
million immunizations. Pre-natal care, mental health services, blood
pressure and cholesterol checks--all to a patient population 90% of
whom lived under 200% of poverty. I am interested in learning more
about the care offered by these centers and looking at ways, such as
through extended hours, to enhance access to these services.
While these centers have made important differences in the lives
and health of their patients, there may also be good news about the
role these centers play in the health of our vital Medicaid and
Medicare programs. As one example, a study in 1980 found that a set of
Medicaid patients, who used community health centers, had a 30% to 65%
lower hospitalization rate and used 12% to 48% less total Medicaid
funds than a similar group of Medicaid patients who did not use such
health centers. In other words: an ounce of prevention may, indeed, be
worth a pound of cure. Community health centers treat people
preventatively in a doctor's office instead of finding them in the more
expensive setting of an emergency room. This lowers costs to programs
such as Medicaid without sacrificing the quality of the health care
delivered to beneficiaries.
The President has made support and expansion of Community Health
Centers a priority in his domestic health care agenda. For example,
since 2001, the President's Initiative has increased the number of
community health center sites by 334 locations. As the primary
authorizing Committee, we must remain well informed of developments in
this program and be ready to seize opportunities to leverage and apply
more broadly the good ideas they have developed.
I thank the Chairman of the Subcommittee, Ed Whitfield, for holding
this hearing today. I look forward to the Committee's review of
community health centers and the chance to look at the issues and
opportunities involved in this program.
Mr. Whitfield. And thank you, Mr. Chairman.
At this time, I recognize the gentlelady from Tennessee,
Ms. Blackburn, for her opening statement.
Ms. Blackburn. Thank you, Mr. Chairman.
And I want to thank you, also, for holding this hearing.
And I want to thank the witnesses for taking the
opportunity to come and talk with us about the community health
center program. I know Mr. Smith is a little familiar with my
District. He has been on the road with me in that District. And
you know we have some fine community health centers there. And
we thank you for your time today.
And as we look at this issue, I want us to carefully
examine the effectiveness of the centers, because these centers
provide direct health care services for some of America's
population that is most in need of quality, low-cost health
care. And having that access is important.
As the cost of health care has been dramatically rising
over the past decade, this committee must ensure that these
health centers are performing adequately and in the most cost-
efficient manner before we dedicate new funding for the
program. I look forward to the responses from these agencies on
how the health centers are conducting risk management training
and implementation of efforts for quality performance reviews
that minimize the risk of malpractice claims and medical
liability.
And again, I thank you very much for your time.
And Mr. Chairman, I thank you for the hearing.
Mr. Whitfield. And I have already introduced our witnesses
on the first panel.
As you are aware, this is an investigative hearing, and it
is the practice of this subcommittee that when we hold
hearings, that the witnesses testify under oath. And I would
ask the two of you, do you have any difficulty testifying under
oath this afternoon?
Ms. Duke. No.
Mr. Smith. No.
Mr. Whitfield. I would also advise you that you do have the
right to counsel if you want counsel, and I am assuming that
neither one of you have legal counsel with you today. So in
that case, if you would please rise and raise your right hand,
I will swear you in.
[Witnesses sworn.]
Mr. Whitfield. Thank you.
I will proudly tell you, now you are officially sworn in.
And Dr. Duke, we will begin with you, and you may give your 5-
minute opening statement.
TESTIMONY OF ELIZABETH M. DUKE, ADMINISTRATOR, HEALTH RESOURCES
AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES; AND DENNIS SMITH, DIRECTOR, CENTER FOR MEDICAID
AND STATE OPERATIONS, CENTERS FOR MEDICARE & MEDICAID SERVICES,
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. Duke. Thank you very much, sir.
I would like to submit the longer statement for the record
and just give an abbreviated statement, if I may.
I want to thank you very much for having this hearing and
for allowing us to be with you this afternoon.
You know that the health centers, in 2004, served an
estimated 13.2 million people. That was about 3 million more
than they served in 2001. And they did that service at 3,650
service delivery sites, which represents an increase of 600 new
and expanded sites since 2001. In 2005, we plan to fund 153 new
or expanded health center sites and to serve almost 14 million
people.
The President's 2006 budget request includes an additional
$277 million to complete the President's 5-year health center
initiative by increasing the number of health center sites by
275 and significantly expanding 303 existing sites to increase
the number of people served by 2.4 million above the 2005 level
for a total of 16.3 million patients.
The President has also set a new goal to open a health
center or a rural health clinic in every poor county that can
support one. The budget includes a $26 million request to open
new health center sites in 40 of the Nation's poorest counties
and will support 25 planning grants as well. The goal of this
initiative is to leverage the success of the current program to
poor counties that can support a health center and provide
access to primary and preventive health care services,
particularly in poor counties that are medically under-served.
The distinguishing mission of the health center program is
to empower communities to solve their own local access problems
and to improve the health status of their under-served and
vulnerable populations by building community-based primary care
capacity and by offering case management, home visiting,
outreach, and other enabling services.
The program also addresses significant challenges facing
communities by targeting public housing, homeless, and migrant
health center development as well. Health centers can provide
access to high-quality, family oriented, comprehensive primary
and preventive care regardless of ability to pay.
Health center grantees, as a result of their receiving a
HRSA grant, under Section 330 of the Public Health Service Act,
are eligible for enhanced benefits, including Medicaid and
Medicare reimbursement, access to the Federal Tort Claims Act
program for malpractice coverage and access to the program for
discount drugs for patients under Section 340B of the PHS Act.
Under Section 330, a health center is required to provide
primary health services, including those related to family
medicine, internal medicine, pediatrics, obstetrics, or
gynecology, that are furnished by physicians and, where
appropriate, physicians assistants, nurse practitioners, and
nurse midwives. Additionally, they are required to have basic
health services, including diagnostic laboratory and
radiological services and services in preventive health.
To receive Section 330 grant funds, a clinic must meet a
number of statutory requirements. The health center must be
located in a federally designated medically under-served area
or serve a federally designated medically under-served
population. It must also be a public or a private non-private
health center, provide comprehensive primary health services,
referrals, and other services needed to facilitate access to
care, such as case management, translation, and transportation.
It must have a governing board, the majority of whose members
are patients of the health center, provide services to all in
the area regardless of their ability to pay, and offer a
sliding fee schedule that adjusts according to individual
family income.
Health centers are in all 50 States of the Union.
In conclusion, in administering grants for the health
center program, we take great pride in the high evaluation
given the program and by the bipartisan support of the
Congress, and we fully realize that the program works only as a
partnership with those extraordinary local primary care
providers providing indispensable, quality clinical service to
under-served Americans, their neighbors.
[The prepared statement of Elizabeth M. Duke follows:]
Prepared Statement of Elizabeth M. Duke, Administrator, Health
Resources and Services Administration
Mr. Chairman, Members of the Subcommittee, thank you for the
opportunity to meet with you today on behalf of the Health Resources
and Services Administration (HRSA) to discuss the Health Centers
Program.
I am so pleased to have the opportunity to address you regarding
the Health Centers program. I was here before the Health Subcommittee
of the Energy and Commerce Committee on August 1, 2001, to discuss the
reauthorization of this program. At that time, the funding for the
program was approximately $1.2 billion. We thank you for both your
efforts in reauthorizing the program and ensuring funding to expand
this worthwhile program to accomplish the President's Initiatives, with
a requested FY2006 funding level of approximately $2 billion, a $304
million increase.
Today, I am proud to update you on the success and growth of the
program to date. By any measure, we have been enormously successful
implementing the President's Health Center Expansion initiative--an
effort designed to establish or expand 1,200 health center sites and
serve an additional 6.1 million patients annually by the end of 2006.
This continues to be a priority because we know that 100 percent of
these funds go to provide direct health care services for our neighbors
who are most in need.
In 2004, the health center system served an estimated 13.2 million
people--about 3 million more than in 2001--at more than 3,650 service
delivery sites which represents an increase of more than 600 new and
expanded sites since 2001. In 2005, we plan to fund 153 new or expanded
health center sites and serve almost 14 million patients.
The President's FY 2006 budget request includes an additional $277
million to complete the President's five-year Health Centers Initiative
by increasing the number of health center sites by 275 and
significantly expanding 303 existing sites to increase the number of
people served by 2.4 million, above 2005 levels, for a total of more
than 16.3 million patients.
The President has set a new goal to open a health center or rural
health clinic in every poor county that can support one. The Budget
includes $26 million to open new health center sites in 40 of the
Nation's poorest counties and will support 25 planning grants as well.
The goal of the initiative is to leverage the success of the current
program to poor counties that can support a Health Center and provide
access to primary and preventive health care services particularly in
poor communities that are medically underserved.
Health Centers Program
The distinguishing mission of the Health Centers Program is to
empower communities to solve their own local access problems and to
improve the health status of their underserved and vulnerable
populations by building community-based primary care capacity and by
offering case management, home visiting, outreach, and other enabling
services. The program also addresses significant challenges facing
communities by targeting public housing, homeless, and migrant health
center development as well. Health Centers provide access to high
quality, family oriented, comprehensive primary and preventive health
care, regardless of ability to pay.
Health Center grantees, as a result of their receiving from HRSA a
grant under section 330 of the Public Health Service (PHS) Act, are
eligible for enhanced benefits including Medicaid/Medicare
reimbursement, access to the Federal Tort Claims Act (FTCA) program for
malpractice coverage and access to the program for discount drugs for
patients under section 340B of the PHS Act.
Under the section 330, a Health Center is required to provide
primary health services, including those related to family medicine,
internal medicine, pediatrics, obstetrics, or gynecology, that are
furnished by physicians and where appropriate, physician assistants,
nurse practitioners, and nurse midwives. Additional required basic
health services include diagnostic laboratory and radiologic services
and a series of preventive health services, including prenatal and
perinatal services; appropriate cancer screening; well-child services;
immunizations against vaccine-preventable diseases; screenings for
elevated blood lead levels; communicable diseases and cholesterol;
pediatric eye, ear, and dental screenings; voluntary family planning
services; and preventive dental services.
Health Centers Requirements
To receive section 330 grant funds, a clinic must meet a number of
statutory requirements. The Health Center must: be located in a
Federally designated medically underserved area (MUA) or serve a
Federally designated medically underserved population (MUP); be a
public or private nonprofit health center; provide comprehensive
primary health services, referrals, and other services needed to
facilitate access to care, such as case management, translation, and
transportation; have a governing board, the majority of whose members
are patients of the Health Center; provide services to all in the
service area regardless of ability to pay; and offer a sliding fee
schedule that adjusts according to individual family income.
The requirement that a majority of board members be Health Center
patients makes these clinics unique among safety net providers and is
designed to ensure that the centers remain responsive to community
needs. Under section 330, a Health Center applicant needs to
demonstrate the establishment of a governing board that has a 51
percent consumer majority, meets monthly, selects the Health Center's
services and hours, approves the Health Center's annual budget, selects
the Health Center's director, and establishes the Health Center's
general policies.
Health Centers are located in all 50 States, the District of
Columbia, and the territories. Currently the Health Center urban-to-
rural ratio is even.
Health Centers Awards Process
HRSA accepts, on a competitive basis, applications from eligible
organizations seeking a grant for operational support for new and
continuing Health Centers. Eligible organizations are public or
nonprofit entities including tribal, faith-based and community-based
organizations.
The largest category of grant awards includes new access points
encompassing both new clinic starts and satellites of existing clinics.
Other categories include the expansion of medical capacity at existing
locations and new service expansion activities such as enhanced oral
health and mental health/substance abuse services.
All eligible and responsive grant applications are referred to an
Objective Review Committee (ORC), comprised of experts in the delivery
of community health care services, for their independent review and
recommendations. When funding decisions are made, each applicant
receives a notification letter listing strengths and weaknesses of each
section of their application as noted by the ORC. This review approach
provides valuable technical assistance for improving future
applications for both awardees and those we were not able to approve
during a particular cycle due to funding limitations. The process is
very competitive and during many cycles, we are able to fund only 20%
of the applications submitted. This result reflects a very dynamic
program which is encouraging the development of community-based primary
health care clinics at a rate greater than we can provide monetary
support.
Technical Assistance
HRSA works directly with communities to develop needed resources
through the primary care associations in each State. These primary care
associations, funded by HRSA, provide ongoing technical assistance
involving guidance and options for organizations interested in applying
for Health Center grants and to existing Health Center grantees
interested in expanding their comprehensive primary care services.
In addition, HRSA assists applicants through grant-writing
workshops and other technical assistance activities, which are provided
through a contract with the National Association of Community Health
Centers. Such activities assist applicants to: demonstrate a high level
of need in the community; present a sound proposal to meet this need;
show that the organization is ready to rapidly implement the proposal;
display responsiveness to the health care environment in the service
area; and demonstrate collaborative and coordinated delivery systems
for the provision of health care to the underserved in their
communities.
Federally-funded health centers are similar to other health care
businesses. Like most businesses, at any point in time, approximately
4% of health centers are experiencing significant challenges to their
viability. HRSA, with assistance from interdisciplinary teams that may
include contractors, grantees and staff, provides intensive technical
assistance to grantees to address problems. At all times, continuity of
service for the affected population is the first priority under
consideration in addressing such challenges.
Health Centers Services
Health Centers offer ambulatory services that reflect the diverse
needs of the populations they serve. Because of the combination of low
incomes, linguistic barriers, and often poor health status, Health
Center patients require access to enabling services as well as
comprehensive primary care services.
Health Centers are unique among primary care providers for the
array of enabling services they offer, including case management,
translation, transportation, outreach, eligibility assistance, and
health education. Health Centers commit significant resources to
managing chronic conditions including diabetes, asthma, and
cardiovascular disease.
In 2003, Health Centers provided more than 49 million encounters,
220,000 mammograms, over 1.4 million pap tests, and 2.27 million
encounters for immunizations, as well as nearly 400,000 HIV tests and
counseling, perinatal and delivery care for 332,000 women, and
translation services to more than 3.5 million patients.
Health Centers are staffed by a combination of clinical, enabling,
and administrative personnel. They are typically managed by a chief
executive officer and a clinical director. Depending on the size of the
patient population, the clinical staff consists of a mixture of primary
care physicians, nurse practitioners, physician assistants, substance
abuse and mental health specialists, dentists, hygienists, and other
health professionals.
Health Centers Financing
Health Centers receive funding from a variety of sources. A
majority of Health Centers revenue comes from Federal resources
including Medicaid, Medicare, the 330 grant, SCHIP and other Federal
programs. On average nationwide, HRSA grants comprise 22 percent of
Health Center revenue, but as little as 15 percent depending on the
individual community and grant application. At 36 percent, Medicaid is
the largest source of revenue for Health Centers, followed by Federal
grants. Health Centers serve about 10 percent of all Medicaid enrollees
nationally, but in actual Medicaid dollars, this amounts to less than 1
percent of all Medicaid payments to all providers.
For Health Centers( revenues, in addition to Medicaid and the
section 330 Federal grant funding, Medicare accounts for 6 percent,
self-pay for 6 percent, other third-party payers 9 percent, other
State/local government or foundations account for 13 percent and the
remaining 6 percent from other sources.
Health Centers Background
The Consolidated Health Centers program has developed over 40 years
ago, beginning with the creation of the migrant health center program
and followed by the neighborhood health center demonstration projects
initiated in 1965 and first funded by Congress as part of the War on
Poverty. By the early 1970s, about 100 neighborhood health centers had
been established under the Economic Opportunity Act. These centers were
designed to provide accessible, dignified personal health services to
low-income families. Community and consumer participation in the
organization and a patient-majority governing board were features of
the Health Center model. With the phase-out of the Office of Economic
Opportunity in the early 1970s, the centers supported under this
authority were transferred to the Public Health Service. The mandate of
the centers was broadened so that comprehensive primary and preventive
services were provided to all who came through the doors. The Community
Health Center program, as authorized under section 330 of the Public
Health Service Act, was established in 1975. A reauthorization that
consolidated the separate authorities of the Community, Migrant,
Homeless and Public Housing Health Centers under section 330 took place
in 1996. Most recently, the Health Care Safety Net Amendments of 2002
reauthorized the Consolidated Health Centers Program through 2006. The
2002 Health Center reauthorization requires that grants be awarded for
FY 2002 and beyond in such a way that maintains the proportion of the
total appropriation awarded to migrant, homeless and public housing
applicants in FY 2001. In general, about 81 percent of funding is
awarded to community health centers, with the remaining 19 percent
divided across migrant, public housing, and homeless health centers.
Conclusion
Health Centers offer high quality, prevention-oriented, case-
managed, family-focused primary care services that result in
appropriate and cost-effective use of ambulatory, specialty and in-
patient services. Primary care is delivered for all life cycles, and
includes a full range of health services. In administering grants for
the Health Centers program, we take great pride in the high evaluation
given the program, and the bipartisan support of Congress, and fully
realize that the program works only as a partnership with those
extraordinary local primary care providers providing indispensable
quality clinical services to underserved Americans with few health care
alternatives.
Mr. Whitfield. Thank you, Dr. Duke.
And Mr. Smith, you are recognized for your opening
statement.
TESTIMONY OF DENNIS SMITH
Mr. Smith. Thank you, Mr. Chairman. And thank you, members
of the subcommittee, for inviting me today to talk with you all
on the role of community health centers as an important part of
America's health care system, and in particular, the
relationship of the Medicaid and Medicare programs to the CHCs.
I do have a full written statement for the record, and I
will try my best not to plow the same ground as the
administrator on our points.
But the majority of Medicare and Medicaid dollars that go
into the community health centers are through the federally
qualified health centers, or FQHCs. Over the years, Medicaid
spending has increased substantially. In 1991, Medicaid
spending through FQHCs totaled $45 million. Ten years later,
Medicaid expenditures in FQHCs had increased to $737 million.
Over the last 4 years, spending on FQHCs has nearly doubled to
an estimated $1.3 billion. This increased spending is due, in
large part, to the President's initiatives to expand community
health centers. Medicaid, indeed, is the largest single source
of revenues for FQHCs, accounting for 64 percent of patient-
related revenues.
Medicare, Medicaid, and SCHIP Benefits Improvement
Protection Act of 2000, or BIPA, established a prospective
payment system for FQHCs. This system, which has been in place
since January 2001, replaced the previous cost-based
reimbursement system for health centers under Medicaid. The
prospective payment system establishes a per-visit payment rate
for each FQHC in advance. And since fiscal year 2002, payments
made under this system have been adjusted annually for
inflation using the Medicare Economic Index.
States have the option of using an alternative payment
mechanism, provided that the payment rate is not lower than
what would have been paid under the new PPS. States have made a
variety of choices in how they want to set their reimbursement
rates--which system to use, the PPS or alternative
methodologies. I think it is very important to emphasize that
the FQHCs themselves must agree to the alternative
methodologies.
In addition, States are required to make supplemental
payments to FQHCs that provide care to Medicaid beneficiaries
when they are enrolled in a managed care plan to cover the
difference between the rates paid by managed care plans and the
FQHC's prospective payment rate. So again, Congress has been
very clear that FQHC's are an important part of the delivery
system. We want to make certain that those payments make the
FQHCs whole for the cost that they provide to beneficiaries.
Very briefly, in addition to Medicaid expenditures,
Medicare spends $265 million on services provided through
FQHCs. The Medicare reimbursement rate is based on an all-
inclusive per-visit payment amount based on reasonable costs as
determined through filing of a Medicare cost report. These are
subject to one of two upper payment limits, not the other upper
payment limits that we often discuss, but its own upper payment
limit, depending on whether the FQHC is located in an urban or
a rural area. For calendar year 2005, the upper payment limit
is $109.88 for urban centers, $94.48 for rural centers.
In conclusion, community health centers are an important
part of the Medicare and Medicaid network of providers.
Substantial growth in expenditures reflects the increase in
access to care at CHCs through President Bush's initiatives as
well as through the partnerships that have been formed over the
years between HRSA, CMS, the centers, the States, and the
managed care organizations.
I look forward to addressing the questions that you might
have, and thank you, again, for the opportunity to appear
before you today.
[The prepared statement of Dennis Smith follows:]
Prepared Statement of Dennis Smith, Director, Center for Medicaid and
State Operations, Centers for Medicare and Medicaid Services
Chairman Whitfield, Congressman Stupak, thank you for inviting me
to testify on the role of the Medicaid program in serving millions of
Americans who seek care through community health centers (CHCs). CHCs
are an important part of America's health care safety net, providing
comprehensive primary and preventive health care services to all who
seek care. They serve in rural areas or in inner-city neighborhoods,
places where too many people do not have the access to the quality
health care they require. CHCs exist in areas where economic,
geographic, or cultural barriers limit access to primary health care
for a substantial portion of the population; and, they tailor services
to the needs of the community. Services include primary and preventive
health care, prenatal services, dental care, and essential ancillary
services such as laboratory tests, X-ray, environmental health, and
pharmacy services. In addition, they provide services such as outreach
and health education, transportation, and translation services.
CHCS, STATE MEDICAID PROGRAMS, AND MEDICARE SERVE AMERICANS WITH
LIMITED INCOMES
The majority of Medicare and Medicaid dollars that go into CHCs are
through the Federally Qualified Health Centers (FQHCs). Congress
established the FQHC program in 1989 to respond to concerns that health
centers were using grant funds intended to support care for the
uninsured to supplement Medicare and Medicaid payments. FQHCs under
Medicare and Medicaid include three types of centers:
Community health centers that receive grants under section 330 of the
Public Health Service Act;
FQHC ``look-alikes''--centers that meet all of requirements for a
community health center under section 330 of the Public Health
Service Act, but do not receive such a grant, and that are not
owned, controlled or operated by another entity; and
Outpatient health programs or tribal facilities operated by a tribe
or tribal facility under the Indian Self-Determination Act or
by an urban Indian organization receiving funds under Title V
of the Indian Health Care Improvement Act for the provision of
primary health services.
Over the years, Medicaid spending through FQHCs has increased
substantially. As recently as 1991, Federal Medicaid spending on
services provided to Medicaid beneficiaries by FQHCs totaled $45
million. Federal Medicaid expenditures in FQHCs have increased since
then to $778 million in FY 2004. This increased spending is due in
large part to an increase of about 500 new health center sites under
the President's health center initiative. (These figures do not include
expenditures through managed care contracts or the state share of
Medicaid funding). Total Federal and State Medicaid spending total $1.3
billion in FY 2004.
According to HRSA, Medicaid is the largest single source of revenue
for the FQHCs. Medicaid accounts for 36 percent of total revenue of the
FQHCs.
CMS designates FQHC look-alikes based on the recommendation of
HRSA. When CMS receives a recommendation from HRSA, CMS notifies the
State Medicaid agency of a pending application for FQHC designation and
provides the state with an opportunity to comment on the application.
Once all issues are addressed, CMS notifies HRSA and the State Medicaid
agency that the application has been approved and HRSA notifies the
center of the approval. In CY 2004, CMS approved 26 applications.
Currently, six applications are under review.
MEDICAID COVERS FQHCS AS A MANDATORY BENEFIT
As mentioned earlier, FQHCs provide a package of primary and
preventive care services to Medicaid beneficiaries. These services
include physician, nurse practitioner, physician assistant, clinical
psychologist and clinical social worker, plus any other ambulatory
service that is covered in the state plan. FQHCs are paid under the
Medicaid program for services on a per visit basis, rather than billing
separately for each service provided when a patient visits a health
center.
The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA) established a prospective payment system
for FQHCs. This system, which has been in place since January 2001,
replaced the previous cost-based reimbursement system for health
centers under Medicaid. The prospective payment system establishes a
per visit payment rate for each FQHC in advance. The 2001 payment rate
was based on the average of each FQHC's reasonable costs per visit in
FY 1999 and FY 2000. Since FY 2002, payments made under this system
have been adjusted annually for inflation using the Medicare Economic
Index. Payments also are adjusted based on increases or decreases in
change in scope of services provided.
States have the option of using an alternative payment mechanism,
provided the payment rate is not lower than what would be paid under
the new PPS. For example, states may opt to establish an alternative
PPS or retain the original cost-based reimbursement system. CMS must
review and approve the payment system; and, the FQHC must agree to the
alternative methodology. Most states are using the PPS option
established under BIPA, while 15 states opted to use cost-based
reimbursement and eight states elected to implement an alternative PPS
to pay at least a portion of their FQHC costs.
In addition, states are required to make supplemental payments to
FQHCs that provide care to Medicaid beneficiaries enrolled in a managed
care plan to cover the difference between the rates paid by managed
care plans and the FQHC's prospective payment rate. FQHCs receive the
same payment rate from managed care plans that the plans pay to other
providers for similar services. This supplemental payment provision was
added as an incentive to FQHCs to participate in managed care plans.
FQHCs are guaranteed a PPS rate as a minimum to participate in a
managed care plan.
MEDICARE PAYMENTS BASED ON REASONABLE COSTS
FQHC services also are available to Medicare beneficiaries under
Part B. The Medicare FQHC benefit provides coverage for a full range of
primary care services (and services incident thereto) including
physician, physician assistant, nurse practitioner, and certain other
non-physician practitioner services such as clinical social worker and
clinical psychologist services. The benefit also covers a range of
preventive services as well as pneumococal and influenza vaccines. In
CY 2003, almost 900,000 Medicare beneficiaries received care at a
section 330-funded FQHC.
Medicare pays FQHCs an all-inclusive per visit payment amount,
based on reasonable costs as determined through the filing of its
Medicare cost report. The FQHC's all-inclusive per visit payment amount
is subject to one of two upper payment limits (UPL), depending upon
whether the FQHC is located in an urban or rural area. In CY 2005, the
UPL is $109.88 for urban centers and $94.48 for rural centers. In FY
2004, Medicare spent about $265 million on services provided by FQHCs.
To ensure payment rates are appropriate, CMS and HRSA are jointly
evaluating the current UPLs for Medicare FQHC services.
In addition, the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) establishes a wrap-around payment in
Medicare, similar to the supplemental payment in Medicaid. CMS will pay
FQHCs the difference between what a Medicare Advantage health care plan
pays the FQHC, and the reasonable cost payments the FQHC otherwise
would receive under Medicare fee-for-service. Medicare Advantage plans
must pay FQHCs the same levels and amounts they pay other providers for
similar services. This provision becomes effective for services
provided on or after January 1, 2006 and contract years beginning on or
after January 1, 2006.
ENSURING FQHCS PARTICIPATE IN THE MEDICARE PRESCRIPTION DRUG PROGRAM
HRSA and CMS have been working closely together on efforts to
implement the new prescription drug benefit under Medicare Part D, and
will be working to make sure health centers are a key part of that
effort, particularly with respect to outreach and education of low-
income Medicare beneficiaries who are eligible for the low-income
subsidy program and will be eligible for a comprehensive drug benefit
with minimal copayments. Also, health centers with pharmacies will be
able to participate in prescription drug coverage plans and Medicare
Health Plans with prescription drug coverage. In addition, the final
rule implementing the MMA provides that prescription drug coverage
plans and Medicare Health Plans may count FQHC pharmacies in meeting
the MMA pharmacy access standards, and this will give these plans
incentives to include FQHC pharmacies in their plan networks.
CONCLUSION
CHCs are an important part of the Medicare and Medicaid networks of
providers. The substantial growth in expenditures reflects the increase
in access to care at CHCs through the President's initiative as well as
partnerships that have been formed over the years between HRSA, CMS,
the Centers, the states, and managed care organizations.
Thank you again for this opportunity and I look forward to
answering any questions you might have.
Mr. Whitfield. Well, thank you all very much for your
testimony. We appreciate your taking the time to be with us, as
I indicated.
And Dr. Duke, I will begin the question period here.
And you mentioned in your testimony that one of your goals
is to be sure that 40 of the Nation's poorest counties each has
a community health center located within their boundaries. How
many of those 40 counties have a community health center today?
Ms. Duke. The initiative, as the President described it, is
to target high-poverty counties that have no health center or
rural health clinic in them today.
Mr. Whitfield. This 40 figure that you mentioned, so you
are talking about areas that do not have a center already?
Ms. Duke. Yes, sir; that is correct.
Mr. Whitfield. I thought that you were talking about that
it was an overall goal to be sure that the 40 poorest counties
had a center and that some of them already did have a center,
but that is not what you are talking about.
Ms. Duke. No, sir. The idea is that there are many, many
counties that do not have a rural health clinic or an FQHC.
Mr. Whitfield. Right.
Ms. Duke. And the goal would be to allow competition to
increase the number of poor counties that have a center.
Mr. Whitfield. Well, what role do States play in winning
these 330 grants? And I ask that question, because is there any
concern that some States just may be more adept at this than
others? I noticed, for example, that Alaska has, like, 21
grantees, and they have a population of about 670,000. A State
like Kentucky, and I just happen to be from Kentucky, has 4.5
million and we have 12. So do States play an important role in
being successful in the awarding of these grants?
Ms. Duke. The process by which these get awarded, perhaps
if I could talk about the process and then talk about the State
role in that, would that be helpful?
Mr. Whitfield. Yes. Right.
Ms. Duke. The process under which grants are awarded is a
competitive process. And the requirements are that to be
awarded a health center, it must be in a medically under-served
area----
Mr. Whitfield. Right.
Ms. Duke. [continuing] and that it must be a non-for-profit
or a public entity. And it is competitive. And it has been a
very competitive process. We receive far more applications than
we have capacity to fund. And the States do get engaged in this
activity, because we have initiated a strategic planning
process. And the primary care associations in each State work
to identify needs for health centers and provide technical
assistance to communities in building the foundation to be
actually able to compete. And some have been very, very engaged
in that process and others have been, perhaps, less engaged.
But interesting, you can actually see the results of the
way that activity has gone in the sense that intensive
strategic planning has produced increased numbers of awards to
States over the last 4 to 5 years.
Mr. Whitfield. And what are some of the States that are
most adept at that?
Ms. Duke. Well, I think the one that I took particular
attention to in the recent competition was Texas, which had a
high uninsured rate where the Primary Care Association and the
legislature put together a strategic plan, and in the last
competition, they achieved 10 health center awards in that last
competition.
Mr. Whitfield. And how many were granted nationwide?
Ms. Duke. In that round, I think it was 88.
Mr. Whitfield. So Texas received 10 of those?
Ms. Duke. Eighty-eight plus seventeen. I am sorry. It is 88
plus 17.
Mr. Whitfield. Okay. Now the Objective Review Committee,
who is a member of the Objective Review Committee, and how is
it decided who is a member of that committee?
Ms. Duke. Objective Review Committees are selected from
people who have expertise in community health delivery. And it
is our goal to have the members of the Objective Review
Committees cycle on and off so we don't have the same people on
all of the time. We have made a very aggressive campaign to
have more and more people involved in that process. We think it
is educational for them, and it certainly provides fairness for
the community. And we receive about 100 applications a month
for people to enter the ranks of serving on these objective
review panels.
So it is a widely diverse group.
Mr. Whitfield. And is there a set number of members on that
Objective Review Committee?
Ms. Duke. It is not a set number, but the goal is to have a
sufficient number that there can be dialog that they can carry
on the weight of the number of applications, because we get
hundreds of applications, and we break them down into a certain
number per panel. So they work very hard, and they do a great
deal of work, because each of these applications is about 80
pages long.
Mr. Whitfield. So do you appoint them, or who appoints
them?
Ms. Duke. I do not touch them. They are basically taken
care of in the routine process of our centralized grants
management process. We have a centralized grants management
process that sets up the Objective Review Committees. That is
to say it is separate from the program office that runs the
health center program. And it is separate from my office. It is
set up by people who do professionally grant administration.
And they are set up objectively, and then they have a scoring
process that is designed to get around the problem, which is
inherent in human nature, and, as we used to say in the school
world, some people are easy graders and some people are hard
graders, and so they set up a process to distinguish out the
outliners so that a fair score----
Mr. Whitfield. But they don't make the final decision?
Ms. Duke. No, sir; they don't make the final decision, but
their weighting is very significant.
Mr. Whitfield. Okay.
Ms. Duke. The final decision has to rest on addressing
other issues, like their financial viability.
Mr. Whitfield. I read an article for this hearing, and it
may have been somebody's testimony, I can't remember right now,
but it said that last year, 106 million visits were made to
hospital emergency rooms and that 58 percent of those really
were not necessary, it was not proper to be at a hospital, and
maybe going to a community health center would have been
better. Are you familiar with that statistic? And has your
agency conducted any studies on the relationship of savings by
these community health centers for hospital emergency rooms,
for example? Any sort of study like that that you conducted?
Ms. Duke. Sir, I could give you two. I am not familiar with
that particular statistic, but we could provide copies for you,
I am familiar with the results of one study that indicated that
by having patients have a medical home at a health center, that
that drives down the inappropriate hospitalizations by about 11
percent and drives down inappropriate use of emergency rooms by
19 percent. And we could provide that for you. The other thing
is that we have seen some communities that have come together
to compete for health center programs who have then networked
themselves together with the community health centers and
hospitals and private physicians and so forth to address this
question of the inappropriate use of very expensive emergency
room care. And we have seen in one instance where we provided a
grant for 3 years to support that kind of networking, and at
the end of the 3 years, the community sustained that approach
with the view that they were saving enough in the hospitals'
emergency rooms to support the networking costs associated with
it.
So it is a good investment.
Mr. Whitfield. Have you had any experience with a small
hospital, say a small rural hospital, that is a critical access
hospital, as an example, that was having such financial
difficulty that they decided they wanted to convert to become a
community health center with emphasis on primary care and
preventative care? Are you aware of an example of that
happening anywhere in the country?
Ms. Duke. I don't have a specific instance in mind, but
that is one of the things that we have seen is where hospitals
previously had run outpatient clinics and ultimately decided to
give up that line and a community board took over the
outpatient work and ultimately competed for and won a grant as
a federally supported FQHC.
Mr. Whitfield. Well, my time is expired, and I recognize
the gentleman from Michigan.
Ms. Duke. Thank you, sir.
Mr. Stupak. Thank you, Mr. Chairman, and welcome to our
witnesses.
Ms. Duke. Thank you.
Mr. Stupak. Mr. Smith, if I may ask you a question on
Medicaid here. The large Medicaid cuts are particularly hurting
our rural areas, as folks in rural areas are more likely to
receive Medicaid and to be uninsured, and 30 percent of the
children in rural areas have Medicaid or SCHIP coverage
compared to 19 percent in urban areas. Nearly 25 percent of
residents in rural counties are uninsured.
In my statement, I mentioned Michigan and how our
unemployment is at 7.5 percent and our demand on Medicaid is
unprecedented. We are covering a lot of people who are
employed. We have a job and can't afford insurance. So our
question is, we are having all of these people on here. We have
cuts coming to Medicaid. Where does Michigan go? Actually one
out of every four people now in Michigan are on Medicaid. So
who do we dump in Michigan if we don't have the funds to take
care of it? If you take a look at our Medicaid in Michigan, it
has gone up 30 percent but yet we have held our costs to less
than 5 percent. So I think Michigan has really done a good job,
but we are just at the point now where we have to start making
tough choices. So who do we dump? The senior in the nursing
homes? The children with disabilities? Or cut providers?
Mr. Smith. We are very pleased with the partnership we have
had with Michigan over the past several years. We have helped
Michigan expand health insurance coverage through the HIFA
waiver. We helped Michigan come up with one of the most
innovative cost containment proposals in the country by
starting the drug purchasing arrangements. Michigan was the
originator, but it has expanded to other States as well.
Mr. Stupak. Sure, but under that program, we are getting
penalized for being efficient.
Mr. Smith. I think that what we are finding in Michigan,
and other States as well, States are reconsidering new ways to
deliver services in more cost effective and innovative ways,
including in long-term care settings. A third of Medicaid's
spending is on long-term care. We are seeing States move more
into home and community-based services, expanding services for
people to stay in their own homes rather than go into
institutional care. We think this is part of the solution.
Mr. Stupak. Well, let me ask the question this way.
Medicaid was set up so that when unemployment goes up, Medicaid
would be there to take care of those people who lost their
insurance or can't afford it anymore. But yet what we are
seeing in Michigan, more and more people are going on Medicaid,
and our reimbursement, or help from the Federal Government, has
decreased, the exact opposite of the way it was supposed to be
when the program was passed by Congress. So how can we justify
increased caseloads in Michigan but yet less money? Something
has got to give. Who don't we cover any more?
Mr. Smith. In large part, when people become uninsured,
they are not eligible for Medicaid in the first place. For
example, if you are an unemployed single male, you are not
going to become eligible for Medicaid.
Mr. Stupak. But a lot of these are not unemployed single
males.
Let me ask you this question. The Energy and Commerce
Committee has been directed to find $15 to $20 billion in cuts
over the next 5 years. If you take a look at it, the
President's proposed Medicaid cuts, it is probably $8 billion,
but yet in the budget resolution, we are directed to come up
with $15 to $16 to $20 billion in cuts, and we have this
commission. Can you provide some specific ways Congress could
cut funding to Medicaid that were not included in the
President's budget proposal that CBO scored at $8 billion? And
this commission that is set up, wouldn't it be better if we had
them look outside the budget process on ways we can save money
as opposed to looking within the Federal budget process?
Mr. Smith. I think that the President's budget provides a
lot of guidance for how we think you can lower the rate of
growth in the Medicaid program. Medicaid over the next 10 years
is going to spend $5 trillion. And you mentioned Michigan's
rate of growth of being around 5 percent. In fact, Michigan has
been holding their rate of growth to below the national average
for each of the 5 years. So we know that States can adopt ways
to lower their rate of growth of spending and still deliver
quality services and, in the case of Michigan, expand coverage
as well. What we have----
Mr. Stupak. But rate of growth, to make sure we are on the
same page here, are you talking about spending, sir?
Mr. Smith. Yes, Mr. Stupak.
Mr. Stupak. Well, I am talking about rate of growth to
increase the people we have on here. I agree, the spending is
down, but the number of people on it are going up.
Mr. Smith. And as I said, and you stated as well,
Michigan's rate of growth is around 5 percent.
Mr. Stupak. Correct.
Mr. Smith. That is lower than the national rate of growth.
Mr. Stupak. And they have cut every possible way to keep
that less than 5 percent. They even came up with a new drug
program, and yet we are being penalized by the Federal
Government for doing that. We are going to lose money
underneath the program reimbursement. So how do we do it? I
mean, I am not wrong in my theory on why we have Medicaid, so
when unemployment goes up, Medicaid is supposed to go up and be
there to take care of the unemployed. When unemployment goes
down, Medicaid should go down, right? That is the theory behind
the program.
Mr. Smith. And that is the essential partnership that still
exists in the Medicaid program as well.
Mr. Stupak. The partnership exists, but the reimbursement
isn't there.
Mr. Smith. The Federal dollars follow State dollars, and
the States make the decisions beyond the Federal requirements
of eligibility and services. The States are the ones making the
decisions on who to cover, what services----
Mr. Stupak. But unlike the Federal Government, the States
have to balance their budget. The Federal Government does not.
And Michigan, as it balances its budget, is balancing a budget,
especially when we come to Medicaid when $1 out of every $4 is
on Medicaid, is either on seniors, on nursing homes, disabled
people, or the unemployed.
Let me just leave you with this thought. Hopefully this
commission will look at ways to modernize Medicaid outside the
budget process. I would hope you would encourage them to do
that. I would just look within this Federal budget, because I
think there are other ways of doing it, and Michigan would be
one good example, if you would take a look at it.
Let me ask Dr. Duke this question.
You said in your opening, and I found it pretty
fascinating, that about 2001 we had 10 million people on the
system, and your goal is to get, by the end of fiscal year
2005, 16.3 million. You know, we are putting more people on,
but the reimbursement isn't there, and you are bringing on new
centers and the centers now, as we will hear in the next panel,
don't have enough money to compete. So for putting on 60
percent more people than we did 5 years ago, we have more
health centers than we had 5 years ago, but we are not keeping
up with the reimbursement rates from the Federal Government the
same, so again, something has got to give. Either we have got
to cut back on providers, we have got to cut back on the
existing ones. We are going to have to find money elsewhere,
correct?
Ms. Duke. The health centers are supported by a variety of
funding sources. The grants under the Public Health Service Act
constitute about 22 percent of their funding. Medicaid is about
a third of their funding. But they also have funding that comes
in from the State and from private philanthropy, and in fact,
about 75 percent of their funding does not come through the
program that we conduct. They are locally funded as well. So I
don't want to just tie the public health centers to one source
of funding.
Mr. Stupak. Sure. Well, let me ask it this way. From just
the Federal Government, if you had 10 million people being
served, and I don't know how many centers there were back in
2001, but you had it in your testimony----
Ms. Duke. 3,200.
Mr. Stupak. 3,200. And in 2006, you are going to have how
many?
Ms. Duke. 4,400.
Mr. Stupak. Okay. Are the 3,200 going to get the same
amount of money in real dollars, not taking into account
inflation, what they got in 2001? Will they get that same
amount in 2006?
Ms. Duke. Well, there will be a different body of health
centers.
Mr. Stupak. Sure. We are expanding them.
Ms. Duke. There will be a different body of health centers,
and they will have different sources of funding. They will have
Medicaid. They will have our grant. They will have Medicare.
They will have private philanthropy----
Mr. Stupak. Well, that is the same thing they had in 2001.
The point being, how can we continue to expand a program if we
are not taking care of existing health centers now?
Ms. Duke. The health centers now have received, over the
last several years, grant money, and they have received base
adjustments, $31 million in 2005. In addition, they receive
sources of funding outside of the Federal Government.
Mr. Stupak. I agree with all of that. The Rural Flexibility
Grant Program, it is a great program. Let us zero it out this
year. How do we justify that? How about the Rural Health Reach
Grant Program? That is $28 million. It took a 70 percent cut
this year. So I mean, how do we make that stuff up?
Ms. Duke. The Rural Health Program is funded under a
different category, and the----
Mr. Stupak. Or not funded. But go ahead.
Ms. Duke. The reasoning behind that has been that the rural
areas are significantly benefited, about $25 billion, under the
Medicare Modernization Act, and the categorical programs that
were under our program were considered to be now not needed
since the funding would come through MMA.
Mr. Stupak. Do you really think any of the health care
centers are going to say we no longer need the Rural
Flexibility Grant Program or the rural outreach grants, that
they are no longer needed underneath your program? They still
need those programs, don't they?
Ms. Duke. The rural health centers and the variety of
recipients of those grants are in the process of just getting
used to the new act that is just coming into implementation.
Mr. Stupak. Getting used to no money? I mean, if you zeroed
out the program, they are just getting used to it.
Ms. Duke. The new act will come in in 2006, and that is the
2006 budget you are quoting.
Mr. Stupak. Right. Okay.
Mr. Walden [presiding]. The Chair now recognizes the
chairman of the full committee, Mr. Barton, for questions.
Chairman Barton. Thank you.
And I don't think I will take 10 minutes.
First, Dr. Duke, I want to thank you for your assistance in
helping make the decision to fund the health clinic in Tarrant
County at John Peter Smith. We appreciate that.
I guess my basic question is just kind of a general one.
How many counties and cities do we have that could use a rural
health clinic or a public health clinic that don't have them
right now? What percent of the truly eligible needy population
is not being served that could be served? Are we serving half
of the population, two-thirds of the population, a fourth of
the population?
Ms. Duke. Sir, I don't have an exact number to give you
there. We have a number of counties that have significant
populations at below 200 percent of poverty. The question is
some of them have a rural health clinic. Some of them have an
FQHC, so I don't exactly have the exact number to give you at
this moment.
Chairman Barton. Well, but give me some number. I mean, how
close are we to saying that we are generally meeting the need
that the program was designed to meet? I am not holding you to
any specificity, just generically. Are we----
Ms. Duke. I will just use the data I have myself. If I go
by the number of applications we receive versus the number of
applications are we are actually able to fund, that might be a
piece of data. We can fund about 20 percent of the grant
applications we receive, which means that four-fifths of those
that we receive, we can't fund.
Chairman Barton. And so all of those are qualified? They
are legitimate applications that meet the minimum requirements?
Ms. Duke. Yes, all of the grants that I am referring to
there were deemed to be eligible to compete and had
applications that could be reviewed by an objective review
committee.
Chairman Barton. Okay. So just kind of generally, we are
only meeting 20 percent, or one out of five, and it could be 1
out of 4 or 1 out of 3, but we can't say that we are meeting 7
out of 10. We are not at 70 percent or 80 percent. We are under
50 percent, not over 50 percent.
Ms. Duke. We have a base of 3,200 that we started with in
2001, and so given that as a base, which lays a foundation,
then on top of that, the competition is that we are funding
about one-fifth of our applications.
Chairman Barton. Okay. This application process, I mean, I
am familiar with it now, because I went through it in my home
county in my home District, do you consider that to be a fair
application process?
Ms. Duke. Yes, it is a fair application process. It has
many, many challenges. One of the challenges is ascertaining
need. Need exists in a variety of ways as you go across this
really very diverse, vast country. And need looks different in
Alaska than it looks in Florida. It looks different in Montana
than in Texas. And one of the things we did fairly early on was
to change the process to allow communities to tell us what need
looked like in their community and then tell us how they were
going to meet that need. And that need boils down to what are
the barriers to care in the area and what are the disparities
and health results that come from those barriers? So we have
just put on a Federal Register notice, and we have received
some answers back that we are in the process of having the
experts review. To get feedback from the communities as to the
adequacy of those criteria and also the percentage of weight
that should be put on need in both the first round of scoring,
which is just strictly on need, and then in the second round,
the percentage of need as related to how that need is going to
be met.
So we are constantly trying to assess that process, make
sure that it is fair, and make sure that it is getting a return
of good health care for the investment the taxpayers are
making.
Chairman Barton. My last question, Mr. Chairman, and I will
refer to this to Mr. Smith.
We are looking at Medicaid reconciliation and Medicaid
reform. We are going to do that in our Health Subcommittee
later this summer. Are these federally qualified health centers
an avenue that could be utilized more to get better quality
care for low income at a competitive price if we were to make a
few changes in the current Medicaid laws?
Mr. Smith. Mr. Chairman, I think that FQHCs in particular
are vitally important because of access in under-served areas,
and they are very important for that. In terms of reform or
generating a lower rate of growth----
Chairman Barton. No, I am talking about expanding them, not
contracting them, by taking the pressure off emergency rooms in
our central hospitals, could we get better quality at less cost
if we expanded the use of these federally qualified health
centers? That is probably a better way to phrase the question.
Mr. Smith. I think they are key players in under-served
areas. In terms of great impact on the overall program, as I
said, Medicaid reimbursement for FQHCs is about $1.3 billion
out of total Medicaid spending of well over $300 billion. They
are very important for local areas in giving access, but
nationally, FQHCs are a relatively small part of the program.
Chairman Barton. I am going to yield back. I yield to Mr.
Walden.
Mr. Walden. Thank you, Mr. Chairman.
I was just going to point out that as we have this
discussion about the size of the budget for the federally
qualified centers versus overall Medicaid, it is important to
go back to a comment made earlier and the work that is being
done to look at the savings that are achieved for Medicaid
because we have these centers in place. And it was pointed out
to me that a 1980 study looked at a set of Medicaid patients
who used community health centers back then and had a 30 to 65
percent lower hospitalization rate and used 12 percent to 48
percent less total Medicaid funds than a similar group of
Medicaid patients who did not use such centers.
So if these data hold true today, 25 years later or 20
years later, whatever it is, they are enormous savings. I mean,
it is just sort of logical that if you are not feeling well and
you can go to a health center in your community and get checked
out and sort of do the preventive end of things, you would
probably be more likely to do that, at least in this period of
time, than waiting if there is no clinic. That means I have got
to go to the hospital, and you wait and suddenly you just go to
the ER. And the most expensive portal of health care is open to
you. And so it just seems to me, logically, that if we could
encourage families and encourage these health care clinics----
Chairman Barton. Especially if only 20 percent of the
eligible population has one of these.
Mr. Walden. Yes. And that is why I think the President is
on track.
Chairman Barton. Expand this program and----
Mr. Whitfield. I might add, Mr. Chairman, that I have heard
some people make a comment, half seriously and half not
seriously, that we might be better of as a Nation, from a
health care perspective, if say half of the money spent on
Medicaid now was used to create additional community health
care centers, that that would be a greater savings, provide
better health care, in other words think outside the box a new
model.
Chairman Barton. Isn't it great to have these hearings so
we can talk to each other while you all watch?
Mr. Walden. Well, can I just finish up on----
Chairman Barton. Sure. I am going to yield the balance of
my time to Congressman Walden, the vice-chairman of the
subcommittee.
Mr. Walden. Thank you. I appreciate that, Mr. Chairman.
There is one question. I noticed today, in the Congress
Daily, Mr. Smith, you are quoted talking about----
Chairman Barton. This just means after he asks his
questions he can leave. He doesn't have to wait for another
hour. That is how sneaky he is.
Mr. Walden. Well, because I had to yield, when I was in the
chair, to you, because you are like senior and all and have the
big gavel.
So in the 43 seconds I have left on your time, I guess the
question is as we look for savings, one of the things that has
been identified recently is some pharmaceuticals that are given
to certain people, and specifically when it comes to things
like Viagra, for potential sex offenders through Medicaid. You
have spoken out on that. I mean, are there other things like
that that we need to be looking at when we look at how to
direct the money to the best place?
Mr. Smith. I think there are lots of areas in Medicaid to
look at. FQHCs show that when you have access, it is going to
lower costs for the total part of the system. We have talked,
and Chairman Barton held a hearing last December on how
Medicaid is overpaying for prescription drugs, finding ways for
Medicaid to be a better payer, and the extent to which Medicaid
can get to the under-utilization and the over-utilization by
improving service delivery. I think that is where the promise
really lies. And we have seniors who are on drugs that are
contraindicated for them individually. You go to a PACE program
and when I go in, I inevitably ask, ``What is the average
number of drugs a senior is on when they come into the
clinic?'' Once they have started, 6 months later, they are on
half of the number of drugs they were on when they started. So
I think there is a lot of over-utilization in the program and
by improving the way we deliver services we will also improve
health care and lower the rate of growth.
Mr. Walden. Well, the figure on these impotence drugs are
like $2 billion for Medicare and Medicaid combined. So we are
talking about billions around here. It adds up.
Mr. Smith. Yes, sir.
Mr. Whitfield. The gentleman's time has expired.
I might also just add that I had, myself, asked the General
Accounting Office to do a little more comprehensive study of
some of the savings to Medicaid and Medicare as a result of
having these community health centers, which touched on some
issues that Chairman Barton raised, and I am looking forward to
their getting back with us on that study.
At this time, I will recognize the gentlelady from
Wisconsin, Ms. Baldwin.
Ms. Baldwin. Thank you, Mr. Chairman.
My question is for Dr. Duke. I would like to get your
opinions on the sparsely populated area preference, which has
been in effect since 1995. And it is a provision that I would
say adversely affects my State, and as I understand, most
States in the Midwest, East, and South of our country.
Now let me just go through my understanding of this
preference before I ask your opinion.
My understanding is that a sparsely populated area is a
preference, which is unlike a priority designation, and that a
priority designation can add a few points to an applicant's
score, but a preference requires that an application that meets
minimal qualifications must be funded ahead of other
applicants, perhaps with significantly higher overall scores.
Thus, many sparsely populated area applicants that meet the
needs test cutoff and score well enough to be fundable are
allowed to really jump to the front of the funding line,
regardless of their overall comparative merit and score.
I represent part of the State of Wisconsin and much of
Wisconsin is quite rural. But none of the counties in Wisconsin
meet the very narrow criteria to be a sparsely populated area,
which, to my understanding, is a county with a population of
seven persons or fewer per square mile.
I think you previously testified that a few years back, in
2002, over $13 million was provided to 24 sparsely populated
applicants in eight States, yet 125 non-sparsely populated
applicants with higher scores than the lowest scoring sparsely
populated applicant were passed over for funding.
So I guess I would ask whether you would be supportive of
Congress making the sparsely populated applicants a priority
rather than a preference. And I would also be interested in
knowing what changes in the scoring process you would support
in order to make sure that rural applicants get their fair
share of these grants.
Ms. Duke. The legislation, as you describe it, sets up
certain categories of applicants, among them sparsely
populated, which, as you describe, is a requirement that has a
population number of seven----
Ms. Baldwin. Seven people or fewer per square mile.
Ms. Duke. [continuing] people or fewer per square mile, and
certain States fit that requirement.
One of the barriers to care that is part of the
consideration is the issue of geography and distance. And that
was the comment I made a bit back that America is an incredibly
diverse country. And so the barriers to care in one State may
look significantly different from the barriers to care in
another State or in a section of a State. So that was the
thinking of the Congress in putting that sparsely populated
provision in. There are also provisions for special treatment
of migrant health centers, public housing, and homeless health
centers as well. And the justification is, as I have indicated,
the administration does not have a position on changing those
designations at this point, but I will raise the issue.
Ms. Baldwin. Okay. And then for Mr. Smith, I am certainly
very supportive of the increases in funding for community
health centers. And in my State, centers have been able to use
additional funding to expand. In conversations with some of the
directors, it is my impression that CMS and HRSA have put a
large emphasis, and perhaps even a requirement, on build-out.
For example, if a clinic is expanding, they must also build
dental suites as part of that expansion. But what happens, it
seems that less emphasis is given to funding the actual health
care that would be provided in these build-outs. So I guess my
question is what kind of requirements are placed on centers
that are expanding? And is it appropriate to place such
emphasis on build-outs without a corresponding emphasis on the
services delivered?
Mr. Smith. I thank you for the question, but I think
actually the administrator would be better able to respond on
build-out.
Ms. Duke. I will have to get back to you for the record on
that. I need to check out what that issue is.
Ms. Baldwin. Okay.
Ms. Duke. I apologize. I need to follow up on that.
Ms. Baldwin. We would be happy to work with you to get some
more information.
Ms. Duke. Okay.
Ms. Baldwin. I do not have any further questions, and I
would yield back the remainder of my time.
Mr. Whitfield. Thank you, Ms. Baldwin.
At this time, we would recognize Mr. Walden.
Mr. Walden. Yes. Mr. Chairman, I had a couple minutes of
the other chair's time, and I know we have got votes coming up,
so I will yield to other members.
Mr. Whitfield. Okay. Mr. Burgess, you are recognized.
Mr. Burgess. Thank you, Mr. Chairman.
I will, too, try to condense this because of votes.
Dr. Duke, thank you for your commitment, the
administration's commitment to the community health centers
program, and thanks for your interest to work with Congress to
continue the expansion currently underway. The need for the
comprehensive services that these centers provide is on the
rise, based on the number of applications that your office
receives annually. And I see this need back home, where I am
very eager to have another health center established in Tarrant
County. Chairman Barton correctly pointed out that one was
placed in North Fort Worth just recently, but we very badly
need one in the southeast part of town.
Can you tell me how many applications you received last
year that were acceptable for funding? If there were no limits
on funding, how many would you have funded?
Ms. Duke. I think I am just going to have to report on one
round. I believe we received 330 some in the round, and we were
able to fund 76, I think, in that round, and it came back to
about 25 percent. But that is from memory. And what I would
rather do, frankly, is to share with you a table that would
have the accurate data rather than trying to do it from memory.
Mr. Burgess. Very well. If additional funding is coming
your way, what plans do you have for ensuring that the maximum
number of proposals are going to be accepted to receive
funding?
Ms. Duke. We have put together a strategic planning process
in each State that is led by the primary care association in
each State to identify where needs are and to give technical
assistance to communities to build those areas. What we are
doing right now is those plans are developed and the
applications that are coming in are extraordinarily good.
Basically, we follow the legislation, as I just mentioned to
Ms. Baldwin, and we follow the requirements for the set-asides
for the various categories. And then we take the available
money and we fund centers in order of their scores until we
have no more money. And so we have lots of applications that
are high-quality applications that we would continue to fund
and we believe that the strategic planning process will
continue to bring in good applications from deserving
communities.
Mr. Burgess. Very well. Thank you.
Mr. Smith, if I understand this correctly, Medicaid
reimbursement at a federally qualified health center or a look-
alike facility, is at the usual and customary rate as opposed
to the Medicare maximum allowable, is that correct?
Mr. Smith. There are a couple of different ways. The
payment methodologies can use a prospective payment system or a
cost-reimbursement system that is then indexed, or an
alternative that the FQHCs and the States can agree upon. So
there are really about three different ways you could
potentially pay. And then on top of that, if you are serving an
individual in Medicaid who is enrolled in managed care, the
managed care plan may be the payer, but the State would also
pay a supplemental rate at an FQHC site in order to make the
FQHC whole.
Mr. Burgess. Well, certainly I support the administration's
goal of providing more federally qualified health centers.
Given the chairman's discussion and Mr. Walden's discussion, I
just can't help but think there ought to be some way to pay
providers just a little bit better and have that network of
providers for that population without standing up a clinic with
walls. That is, there must be a network available in the
community already that would be willing to see those patients
and able to see those patients within existing facilities
without having to stand up the walls of a clinic and pay a
clinic administrator and all of the overhead associated with a
clinic. Is any work being done in that area to sort of
establish a federally qualified health center without walls?
Mr. Smith. I will ask the administrator to help me out. I
think part of----
Mr. Burgess. Well, clearly, Chairman Barton, if I could
just add to that, said this is a more cost-effective way of
delivering care. If we are able to keep the patient in the
doctor's office, whether it be a federally qualified health
center or a private office, it is cheaper than going to the
emergency room where you have the highest overhead on the
planet. So you know, maybe I am just more making an observation
rather than asking a question. It would seem to me that if you
can capture physician networks within a community that needs a
federally qualified health center but doesn't have one, and if
you just pay a little bit better, you are going to be able to
place those patients within private offices and, as Mr. Walden
pointed out, possibly save a ton of money in the process. I
just think back to my own days in private practice. No one ever
expects to make money on a Medicaid patient, and in fact, I
think we have been told that by the previous iteration of CMS
that was HCFA, we just expect you to go broke a little more
slowly. And I think that was sort of the business model where
this was set up.
But please feel free to respond to that, and again, it may
be more of an observation on my part than a question. It just
seems like when we are looking for a better way to do things,
this would be a better way.
Mr. Smith. A couple things. I think you are pointing out
that the solution is outside Medicaid in terms of getting more
Americans insured. And certainly, the President has offered a
number of proposals that expand insurance in the first place.
Within the Medicaid program, treating people and giving them
access to care in a clinic or an FQHC or in the doctor's office
instead of in the emergency room is a goal certainly we all
share. And I think that part of that is it is going to come in
a variety of different approaches. And as we have expanded
coverage, there have also been folks that want to know if
Medicaid is paying its share. I think Medicaid is paying its
share for the Medicaid recipients in the reimbursement system
that we presently have. As I stated, Medicaid accounts for 64
percent of total patient-related reimbursement to FQHCs.
So I think Medicaid is paying its share, and I think
Congress has made sure that Medicaid is paying its share in the
PPS system, the supplemental payments above the managed care
rates, et cetera. But the real goal everybody has is to expand
insurance so people are seeking care in the most appropriate
setting instead of in emergency rooms.
Mr. Burgess. Well, is there a subset of the population that
really just needs help buying insurance rather than the full
faith and credit of the Medicaid system behind them?
Mr. Smith. Again, I think what the President is proposing
is to be able to expand coverage through a variety of different
ways, whether it is through the employers, giving tax credits
to small businesses, forming purchasing pools, or tax credits
to help people meet the cost of care. They could take a variety
of approaches, and the President, in his budget, has increased
the Federal commitment to health care spending.
Mr. Burgess. Mr. Chairman, I have taken more time--I am
sorry. Did you have something you wanted to add, Dr. Duke?
Ms. Duke. I just could add that we do have some models
where centers have entered into partnerships with private
providers. In Salt Lake City, 600 private providers work with
the county, the hospitals, the doctors, and the health centers
to do what you are talking about in the sense that the services
are expanded by private contributions from doctors who take
uninsured patients and provide those services as part of their
commitment to the community.
Mr. Burgess. Thank you, Mr. Chairman. I have used more time
than I intended. I will yield back.
Mr. Whitfield. The gentleman from Washington, Mr. Inslee.
Mr. Inslee. Thank you.
I wonder if either or both of you could talk about the
clinics' experience with the Medicare prescription drug bill.
What percentage of folks are signed up for that? What are not?
What experience have you had with the bill that was adopted a
while back?
Mr. Smith. In terms of enrollment, there are a number of
people who will automatically be enrolled, people who are
presently eligible for Medicaid will be automatically enrolled
into a plan. I don't believe the MMA had a specific provision
about the role of the FQHCs, but certainly at CMS and HRSA, we
are encouraging PDPs and the plans to include FQHCs in their
network. FQHCs in particular play a very vital role in access
for individuals, and we are certainly encouraging that. For
enrollment of the rest of the Medicare population, we are on
the threshold of the Social Security Administration and CMS
doing great outreach efforts to encourage individuals to apply
for the low-income subsidy so that Medicare will pay the vast
majority of the cost of enrolling in the part D prescription
drugs. We are encouraging the plans to make the FQHCs a part of
their network. So we don't have statistics yet on actual
enrollment, because we are at the beginning of that for the
entire population.
Mr. Inslee. So can you give me any flavor at all? Are
people rushing to sign up on their first visits to the health
center, or is this a hard sell? Or can you give me any flavor
of what is happening out there?
Ms. Duke. I have just, within the last week, sent out a
letter to health centers to initiate this process, so we are
really at the very beginning, and I have no data on that at
this point. But as we get data, I will be glad to share it with
you.
Mr. Inslee. Have you had any feedback from the health
centers about the relative response to their constituents at
all to this effort?
Ms. Duke. No, I just sent the letter out within the last
week.
Mr. Smith. If I may add, I believe that with Social
Security's capabilities, we are going to have very
sophisticated analysis at the local level, by county, to be
able to identify the take-up rates. As we have said, we are at
the very beginning of that, but over time, those will be
targeted. We have teams around the country who will continue to
look at that data to make certain that the take-up rates are as
positive as possible.
So if we see that enrollment is lagging behind, we have
teams that will then provide outreach to sign up the
beneficiaries.
Mr. Inslee. So you haven't gotten calls from the health
centers that they are overwhelmed and you have got to put on
new help to get people clamoring to get on that? It doesn't
sound like it anyway.
Mr. Smith. We have a whole variety of different agencies
involved in the outreach including Social Security and SHIPs.
We have the area agencies on aging. The FQHCs are part of a
very large effort to do the outreach.
Mr. Inslee. Well, I suspect you won't be overwhelmed with
the needs of people to process this, so that probably won't be
a problem.
Thank you.
Mr. Smith. Thank you.
Mr. Whitfield. Ms. Blackburn, you are recognized for 10
minutes.
Ms. Blackburn. Thank you, Mr. Chairman.
And I am going to try to consolidate this as much as I can,
so that we get through everyone before we go to vote.
And Mr. Smith, you said something earlier that I think hits
the nail on the head with the centers that I have seen, and
that is that when you have the type of access that these
centers provide then you do have a lower cost. I think the
other thing that I have noticed in the centers is the
environment. And you create an environment where there is an
acceptance that it is okay to ask questions and to get some
education on how to deal with health care situations. And I
think that is a positive as we look for ways to better educate.
Mr. Smith, one more thing before I go to Dr. Duke.
The revenue stream, we have talked around that a couple of
times, and you mentioned 36 percent of the funding comes from
Medicaid payments, Medicare and Medicaid. If you will just in
writing for me later, break that stream down as to how most
centers arrive at their full funding.
And then I want to move on to my risk management liability
questions that I have.
And Dr. Duke, the HHSIG's report from February 2005 talks
about HSRA no longer performing onsite primary care
effectiveness reviews and that HSRA is developing a new
performance assessment protocol for all its grantees, including
the health centers. And what I would like to know is if this
has been developed and if it has not, when it is to be
developed and fully implemented.
Ms. Duke. We are in the process now of doing the first full
year of performance reviews for our grantees. The approach we
have taken is to do one review per grantee and to cover all of
the grants that they might have from us so that perhaps they
have a health center grant, they might have an HIV/AIDS grant,
so that we would not go back twice to the same grantee. We
would do them all at once.
Ms. Blackburn. So your new model will be one onsite review.
Ms. Duke. Yes.
Ms. Blackburn. Then the balance, are you planning to handle
that as a web-based review or information submission or what is
your template?
Ms. Duke. The approach we have taken is that the reviews
actually use both.
Ms. Blackburn. Okay.
Ms. Duke. That is to say there is a preparatory stage,
which is document reviews, web-based, and so forth, and then
there is an onsite, and then there is a feedback process, and
it has been received very well by grantees as positive.
Ms. Blackburn. Okay. Great. I will be interested in
following that. I think that is an important part of this
concept as we look at the care delivery, the cost-
effectiveness, and increasing the scope of the program.
In that vein, you have got 33 percent of the centers that
have received accreditation from the Joint Commission of Health
Care Organizations. Okay. And when do you think you are going
to have all current centers or your grant recipients receiving
accreditation?
Ms. Duke. We are working very closely in trying to move
that forward. We have a goal of having 100 percent coverage,
but we won't reach it this year.
Ms. Blackburn. Are all of the centers actively pursuing
accreditation or----
Ms. Duke. I don't believe I could say all of them are
seeking accreditation at this point. There are issues of cost
involved.
Ms. Blackburn. Okay.
Ms. Duke. And so I think at this point, people are
balancing many competing demands, but that is our goal is that
we will reach that. But we won't reach it this year.
Ms. Blackburn. Okay. Let us quickly talk about risk
management controls, because the Inspector General's report
notes that the risk management training is lacking. And I will
ask you to respond to this in writing, because we are in the
vote. I would like to know how the centers are conducting their
risk management training workshops and if you all have a
comprehensive agenda for covering that risk management.
And then my final question to you will be, and you can
respond in writing to this, too, just for the interest of time,
looking at the health center tort claims fund from which the
malpractice claims are paid. And I would like to know the
current status of that fund and what is the average amount of a
malpractice claim on one of the centers?
And with that, Mr. Chairman, I will yield back.
Mr. Whitfield. Thank you.
Mr. Stupak. Mr. Chairman, before we yield, you were asking
questions on the OIG report. Do you have that, and could you
put it in the record so we could have that?
Ms. Blackburn. Yes, I do have that, and I will be happy to
put it in the record.
Mr. Stupak. Okay. Thank you.
Mr. Whitfield. Without objection, so ordered.
Mr. Green, you are recognized.
Mr. Green. Thank you, Mr. Chairman, and I will try and be
brief, because I know we have a vote in a little over 2
minutes.
One, I want to thank you and the ranking member for
allowing me to be on the subcommittee. I serve on the Health
Subcommittee, and obviously community health centers are
important, and I want to thank HRSA for the ten for Texas and
we received five in the Houston area. We have identified,
through Dr. Sanchez, who used to be our Health Commissioner. I
don't know what we call him now since the State legislature
merged all of the agencies, identified community-based clinics
as a way that we can deal with it with the resources that we
don't have. But it brings it down to the local level oftentimes
that, for example, the one that was just awarded in Pasadena
had fund-raisers and we had both business and, in fact, one of
our for-profit hospitals convinced that over half their
emergency room contacts could be eliminated by having a
community health clinic. And our numbers, we think 57 percent
of the emergency room visits in Houston and Harris Counties are
people who could have been served by a community-based clinic.
And so I agree that we could look at lowering some of our other
costs if we do that.
One of the concerns I have is we have been looking at, in
the success we had, two of those five were in the District I
represent. And what I was trying to see, is it easier for FQHCs
to have amendments or look-alikes than it is to have another
free-standing one, because it seems like maybe they would have
better response from HRSA for expansion? So if we only have
five, for example, in the city of Houston and we are looking at
the next round to see what we can do, is it better to have just
expansions of clinics, additional sites that are in the needy
areas, or it seems like it is much harder to get a whole new
free-standing clinic with a new board?
Ms. Duke. The look-alikes often make very good candidates
for actual grant status in the sense that they already meet
many of the same requirements. And so I don't think that the
question is mutually exclusive. I think moving to look-alike
status has the advantage of providing care and getting some
benefits from the Federal Government and then being able to
compete very well. Look-alikes have competed very well for
those grants.
Mr. Green. Okay. The other issue for the one of the
clinics, I know the funding doesn't begin until later this
year, and I know in 2005, Congress provided $775 billion for
community health centers, and I know that several programs, the
Bureau of Primary Health Care, have it delayed during the
current fiscal year. And can you explain how the fiscal year
2005 funding for community health centers has been allocated or
is being allocated? It looks like the 330 grants are being
moved into the next budget year.
Ms. Duke. We have the costs of continuing the grantees we
already have, which is a number of about almost 3,700. And so
they continue to get grants to continue their operations. And
so the issue is the availability of funds to start new centers.
One of the issues, for me, or at least my sense, is that there
is a terrible cost for people that have to keep coming in to
compete over and over again. And so one of the things we have
tried to do was to identify the groups who had already competed
successfully and to identify them for funding in the next round
rather than go through another very costly grant process so
that we, in essence, have one leg up on the next cycle.
Mr. Green. And Mr. Chairman, my last statement is if we use
the cap program to put together these collaboratives for the
community, and I know the President is supporting community-
based clinics, but we also need the cap program to be able to
put together these collaboratives, particularly in areas that
we have to bring the community groups and the folks together
on.
But Mr. Smith, my last question for CMS is two of the FQHCs
in my District have expressed frustration with the process of
obtaining Medicaid provider numbers for Federal reimbursement.
There was a merger between two of our clinics, and it took 7
months to get a provider number. Is there some way that if you
have two clinics, for example, that may have separate numbers
that it could be fast-tracked on instead of the delay
sometimes?
Mr. Smith. Mr. Green, that is Medicare. Medicare is
enrolling the providers directly. I would be happy to get back
to you on that.
Mr. Green. Okay.
Mr. Smith. I just don't know off hand.
Mr. Green. I know our own experiences with our one in
Pasadena, we needed the number very quickly, and thank goodness
there is a Texan who I know is family who runs CMS, and we were
able to get that number quickly, but not everybody can call
their Member of Congress and get it done.
Mr. Smith. If you could give me their names, I will make
sure we check them.
Mr. Green. Okay. We can get that information to you.
Mr. Smith. Okay.
Mr. Green. In fact, when we run vote, my staff will be able
to share it.
Mr. Smith. We will be happy to follow up.
Mr. Green. And again, thank you, Mr. Chairman, for letting
me in. It is a great----
Mr. Whitfield. Thank you, Mr. Green.
We do have a series of four votes on the floor. We had a
lot of other questions for you, Dr. Duke, and Mr. Smith, but we
are not going to ask you to stay, because we have another panel
coming in. But we are going to submit some additional questions
in writing, particularly for you, Mr. Smith, and one being, for
example, should States be allowed to spend Medicaid dollars to
establish community health centers themselves, meeting the
guidelines? Just something to think about. And we will have
some additional questions for you.
And then Dr. Duke, one thing that I would like to ask you
all to provide us is 2003/2004 list of new grantees by
Congressional District. If you would do that, we would
appreciate it. And Mr. Stupak, do you have anything?
Mr. Stupak. Not at this time.
Mr. Whitfield. Okay. Okay. And like I said, we will submit
additional questions in writing.
And thank you all so much, and we look forward to continue
working with you as we strive to improve health care.
And with that, the first panel is dismissed.
For those of you on the second panel, as I said, we have
four votes. We are going to go cast those votes now. I imagine
we could be back here by about 4:35. And we will swear you in
at that point, and we will begin your panel.
So thank you very much.
With that, we are in recess.
[Brief recess.]
Mr. Whitfield. Okay. On our second panel, we have Mr.
Roderick Manifold, who is the Executive Director at the Central
Virginia Health Services, Incorporated; Mrs. Kim Sibilsky, who
is the Executive Director of the Michigan Primary Care
Association; Mr. Daniel Hawkins, who is the Vice-President of
the National Association of Community Health Centers; Dr.
Janelle Goetcheus, who is the Medical Director of Unity Health
Care; and Dr. Leiyu Shi, who is an Associate Professor at Johns
Hopkins School of Public Health. We welcome all of you.
And where is Mr. Manifold? Okay. Well, Mr. Stupak has just
come back from voting as well, and so as soon as we get Mr.
Manifold, we will go on and have you sworn in and you can begin
your testimony.
And we do genuinely thank you for being with us today, and
we look forward to hearing what you have to say.
I will tell you, if it is going to be 10 minutes, we will
go on and swear these in, and we will go on and start with your
testimony.
So I will call the meeting back to order. And you all are
aware that this is an investigative hearing, and it is the
practice of the Oversight Investigations Subcommittee that we
give testimony under oath. Do any of you have any difficulty
giving testimony under oath? And you also know that when you
give it under oath, if you want legal counsel, you have that
right. And assuming you do not have legal counsel, so if you
will stand, I will swear you in.
[Witnesses sworn.]
Mr. Whitfield. Thank you. Okay. You are now under oath, and
Mrs. Sibilsky, we will start with you. And be sure and turn
your microphone on and get it up close. And you may begin your
5-minute opening statement.
TESTIMONY OF KIM SIBILSKY, EXECUTIVE DIRECTOR, MICHIGAN PRIMARY
CARE ASSOCIATION; DANIEL R. HAWKINS, JR., VICE-PRESIDENT,
NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS; A. JANELLE
GOETCHEUS, MEDICAL DIRECTOR, UNITY HEALTH CARE; LEIYU SHI; AND
RODERICK V. MANIFOLD, EXECUTIVE DIRECTOR, CENTRAL VIRGINIA
HEALTH SERVICES, INC.
Ms. Sibilsky. Good afternoon. My name is Kim Sibilsky, and
I am the Executive Director of the Michigan Primary Care
Association.
On behalf of Michigan's federally qualified health centers,
I thank you for this opportunity to testify.
Representing community-based primary care centers, MPCA
provides a myriad of services, including health professional
recruitment, clinical support, technical assistance services,
education and training, as well as assisting organizations
becoming community migrant health centers or other primary care
delivery models. In short, we are a membership association of
FQHCs dedicated to educating for the medically under-served.
Mr. Chairman and members of the subcommittee, I believe the
most important job of a health center is to serve as a medical
home for medically under-served communities. In Michigan,
health centers serve as the medical home and are delivering
comprehensive primary care to more than 425,000 persons in more
than 140 communities and neighborhoods. Our 29 FQHC
organizations form an essential component of the State's safety
net for health care services. To that end, we are committed to
bringing high-quality, comprehensive health care to people and
communities in Michigan that desperately need them.
This job is getting tougher every day, however. Growing
health care costs coupled with increased uninsured and
underinsured people in Michigan and nationwide directly
contributes to the growing number of Medicaid-eligible people.
In Michigan, nearly 25 percent of the State's low-income
residents lack basic health insurance. And about 12 percent of
the overall State population is uninsured.
Seen another way, unless these people are fortunate enough
to live in a community with an FQHC or a free or a charity
clinic, they have few options, other than their local
hospital's emergency room, to receive care. And let me tell
you, there are consequences to this reality.
In 2001, Michigan looked at preventable hospitalizations,
those for which timely and effective ambulatory care can help
reduce the risks for common problems, such as asthma, diabetes,
or dehydration. High rates of preventable hospitalizations in a
community signal potential barriers to care, including lack of
sufficient primary care resources.
The review estimated that Michigan had over 240,000
preventable hospitalizations, which resulted in almost 1.3
million unnecessary inpatient days of care. But this does not
have to be the reality today. FQHCs strategically placed in
under-served communities increase access to early intervention
and improve the economic and physical health of Michigan's
communities.
Through the President's initiative, Michigan has expanded
access to care to over 56,000 residents in 28 communities. As
Michigan's uninsured population continues to grow, the State
also is experiencing record levels of enrollment in Medicaid as
the result of our slow economic recovery. Currently, Michigan's
Medicaid program covers one out of seven citizens. With such
high Medicaid enrollment numbers and low State revenues, the
pressure is on to identify cost savings.
Mr. Chairman, FQHCs stand ready to be a part of the answer.
In Michigan alone, 29 FQHC organizations currently care for 10
percent of all Medicaid enrollees for less than 1 percent of
the physician services budget. In other words, health centers
are saving the Medicaid program money.
This achievement is made possible largely because of
Congress' wise decision to support adequate Medicaid
reimbursement to health centers by creating the prospective
payment system for FQHCs. I am proud to say that the
implementation of the prospective payment system is a huge
success, and we applaud Congress for their support.
However, as Congress considers to Medicaid, it is critical
that it recognize the unique relationship between health
centers and Medicaid. In particular, lawmakers must appreciate
the changes in Medicaid that could be construed as minor could
actually have devastating impacts on health centers. For
example, the elimination of dental services for Medicaid adults
in Michigan in 2003 is still causing tremendous stress to the
system and to health centers. And to be sure, Michigan's
Medicaid adult benefit waiver program continues to threaten
FQHCs' abilities to protect Federal dollars for the uninsured
in the State. Lawmakers must be careful not to inadvertently
impact the mission of health centers during discussions on
Medicaid reform.
And I, along with the Michigan health centers, look forward
to working with Congress in this effort.
Thank you for this opportunity to talk with you. If there
are any questions, I would be pleased to answer.
[The prepared statement of Kim E. Sibilsky follows:]
Prepared Statement of Kim Sibilsky, Executive Director, Michigan
Primary Care Association on Behalf of the Michigan Primary Care
Association
Good Afternoon. My name is Kim Sibilsky and I am here representing
Michigan's Federally Qualified Health Centers (FQHC), which include
community, migrant, homeless health centers. I am the Executive
Director of the Michigan Primary Care Association (MPCA). The MPCA is a
nonprofit organization developed to promote, support and develop
comprehensive, accessible and affordable, quality primary health care
services to everyone living in Michigan. Representing organizational
providers and affiliates of community-based primary care centers in the
state, we provide a myriad of services, including health professional
recruitment, clinical support and technical assistance services,
education and training as well as helping organizations become a
Community/Migrant Health Center or other primary care delivery model.
Thank you for this opportunity to speak with you today.
Federally Qualified Health Centers (FQHC) provide medical homes to
residents of medically underserved communities. Michigan's health
centers deliver comprehensive primary care in more than 140 Michigan
communities and neighborhoods to more than 425,000 persons. Michigan's
29 FQHC organizations form an essential component of the state's safety
net for health care services. We are committed to providing high
quality, comprehensive health care services to federally designated
medically underserved areas and populations.
As FQHC organizations, we provide a comprehensive set of primary
care services and enabling services to all people, regardless of their
ability to pay. Our clinics not only provide care to families, they
also provide care to high risk and special populations including people
with changing insurance coverage and those with chronic conditions and
disabilities. Research has repeatedly shown that these groups cost the
system a disproportionate share of available resources and we are
committed to providing them with the best service in a cost-effective
manner.
To address the cost of health care, we must ensure that necessary
services are available, are delivered by the most appropriate provider,
and are accessible in the most cost-effective setting, at the right
time. By regulation, only communities lacking such access qualify for a
Federally Qualified Health Center. These regulations focus on two
different, but equally important issues: 1) a severe shortage of
primary care providers for the entire community; and/or 2) a severe
shortage due to primary care physicians refusing to provide essential
care to populations in need.
Research shows that you can reduce the cost of health care by
increasing access to preventive and primary care services. It follows
that a reduction in health care costs will result in a reduction in the
number of uninsured persons. Yet the cost of health care continues to
grow and the growing number of uninsured and underinsured people in
Michigan and across the country is directly contributing to the growing
number of Medicaid eligible people. This results in a burgeoning
Medicaid budget. Figures calculated from the Current Population Survey
and Claritas, a data clearinghouse, indicate that more than 250,000 or
24.7% of Michigan's low-income residents lack basic health insurance.
Looking at all income levels, 1.1 million or 12% of Michigan's
residents and 45 million or 15.6% nationally are uninsured.
Unless an uninsured person is fortunate enough to live in a
community with an FQHC or a free/charity clinic, they have few options
other than their local hospital's emergency room. Reports indicate that
58% percent of the 106,000,000 annual visits to hospital emergency
rooms across the country are described as inappropriate. In a new study
published in Health Services Research; entitled, ``ailability of Safety
Net Providers and Access to Care of Uninsured Persons'' Hadley J. and
Cunningham P., October 2004) finds that FQHCs are more cost effective
because they improve access to primary care for the uninsured and
underinsured and reduce emergency room visits and hospital stays.
Michigan completed a study in 2001 which looked at preventable
hospitalizations, those for which timely and effective ambulatory care
can help reduce the risks for common problems such as asthma, diabetes
or dehydration. High rates of preventable hospitalizations in a
community signal potential barriers to care including lack of
sufficient primary care resources. The review estimated that we had
over 240,000 preventable hospitalizations which resulted in almost 1.3
million unnecessary inpatient days of care.
Michigan's Medicaid program covers 1 out of 7 citizens. We continue
to experience record levels of enrollment as a result of our slow
economic recovery. With such high Medicaid enrollment numbers and low
state revenues, the pressure is on to identify cost savings. FQHCs
stand ready to be a part of the answer. Several studies have
demonstrated that health centers save the Medicaid program more than
30% in annual spending per beneficiary due to reduced specialty care
referral and fewer hospital admissions and FQHCs save by helping to
prevent unnecessary usage of the emergency room. Studies have indicated
that Medicaid beneficiaries who sought care at health centers were 22%
less likely to be hospitalized for potentially avoidable conditions
than beneficiaries who obtained care elsewhere. Michigan's 29 FQHC
organizations currently care for 10% of all Medicaid enrollees for less
than 1% of the physician services budget.
Federally Qualified Health Centers (FQHC) applaud the work of
Congress to protect the federal funds provided to help care for the
uninsured and underinsured. From the beginning, Congress recognized
that without mandating a payment system that provided sufficient
resources to the FQHCs to care for Medicaid clients, federal dollars
may be shifted away from the uninsured. Previously, this meant cost-
based reimbursement. On January 1, 2001, the Prospective Payment System
outlined in the Medicare and Medicaid Beneficiaries Improvement and
Protection Act of 2000 was implemented across the country. This was a
historic moment in our program's history. For Michigan FQHCs, not only
did this allow them to plan for the future with a predictable budget,
it created incentives to innovate and implement cost-saving programs
such as the 340(b) drug pricing program. FQHCs welcomed and continue to
support efforts to maximize the use of limited tax dollars at both the
state and federal levels. The Prospective Payment System is key to
these efforts.
Under the Prospective Payment System, each FQHC is assigned a
prospective payment amount calculated from their reported 1999-2000
costs. While states have implemented the system in slightly different
ways, they all are required to adjust the rates annually by at least
the Medicare Economic Index (MEI). These adjustments have averaged
around 2.7% over the last four years, way below the medical inflation
rate. Even with these modest adjustments, Michigan FQHCs view the
implementation of the Prospective Payment System as a huge success and
support efforts by our State Medicaid Agency to act as a guardian on
behalf of the public good. We have to work within a budget and we
understand that both the State and federal government have to do the
same.
The Prospective Payment System reimburses the FQHCs and FQHC
``look-alikes'' on an encounter basis. FQHC encounters combine the cost
of the face-to-face visit with a provider and the cost of ancillary
services such as immunizations, on-site lab and x-rays, translation,
and nutritional counseling provided during the visit into one payment.
People not directly involved in the FQHC program often mistakenly
believe that we are paid higher rates for office visits than private
physician offices. In reality, private physician offices usually do not
provide the scope of services we do and when they do provide some of
these ancillary services, they often do not incorporate these services
into their practice without a means to receive payment.
Michigan would like to draw your attention to how crucial the
Prospective Payment System is to FQHCs. We recognize that through the
waiver process, states regularly request the ability to waive their
obligation to provide FQHCs with payment according to the Prospective
Payment System. This waiver activity has the potential to jeopardize
the entire system. For example, when the State Children's Health
Insurance Program was created, recognition of our payment system was
not included. At the time of development, we anticipated that the
enrollees would be relatively inexpensive to care for given that they
were children. To our surprise, Michigan created a SCHIP waiver program
for childless adults with incomes below 35% of the federal poverty
level. This program is referred to as the Adult Benefits Waiver. As you
can imagine, this is a very different population than the one we, and
we believe Congress, envisioned. Adults enrolled in this program often
have multiple conditions including chronic illness, substance abuse,
and mental health issues. Many of them are very transient, moving from
shelter to shelter or reside on the street. Without recognition of our
Prospective Payment System, programs such as Michigan's Adult Benefit
Waiver threaten the FQHCs' ability to protect the federal dollars for
the uninsured persons in our communities. Because of the demographics
of the target population, most private providers do not wish to enroll
in these provider networks. As a result, more than half to two-thirds
of the Adult Benefit Waiver program enrollees are patients of FQHCs.
Recognition of our payment system would protect the financial viability
of our nation's health centers and the federal funds provided for the
uninsured.
I would like to ask for your assistance as you and your colleagues
begin to evaluate the Medicaid program to remember the Federally
Qualified Health Centers. Changes that could be construed as minor
could have devastating impacts on our system. For example, the State of
Michigan elected to eliminate dental services for Medicaid adults on
October 1, 2003. This saved relatively little general fund dollars
($9.2 million) and would impact few providers given the relatively
small number of private dentists enrolled in the program. What they did
not understand is that the Federally Qualified Health Centers accounted
for the majority of dental care currently being provided to the
Medicaid adults. The elimination of Medicaid adult dental is still
causing tremendous stress to our system since the need did not
disappear, just the payment.
Everyone is struggling with how to pay for our Medicaid system. We
must remember the interplay between publicly-funded coverage and the
uninsured. When you restrict enrollment in public programs, the cost of
providing care does not disappear and the savings are not absolute.
People will eventually receive the care they need. It may not be in the
best and most cost-effective location, at a time when the progression
of illness can be headed off and the most expensive care prevented, but
in the end, anyone can walk into a community hospital and receive some
level of care. Our goal as providers is to squeeze any waste out of the
system that we can. We believe a sizeable amount of waste exists simply
from the vast amount of paperwork required of health care providers,
the lack of connections between different components of the health care
delivery system, and the mobility of our population. I would like to
talk to you today about two opportunities that Michigan's FQHCs have
embraced to help us address some of these challenges--the chronic
disease collaboratives and technology.
Federally Qualified Health Centers are uniquely positioned to
embrace change. Our administrators are particularly adept at stretching
dollars, our clinicians are mission-oriented and employed by the
centers, our Boards of Directors are made of a majority of users of the
clinics and therefore personally committed to their continuation, and
the federal government is an important partner with resources that go
beyond the financial. With the support of the Bureau of Primary Health
Care, the FQHCs have undertaken a major shift in how chronically ill
patients are cared for and given the responsibility for their own
health. Many positive changes have occurred as a result of the Chronic
Disease Collaboratives. Some of these are listed below:
Michigan Health Centers in the Chronic Disease Collaboratives have
experienced drastic reductions in the severity of diabetes
among their patients. The Hemoglobin A1c, a lab measurement
used to gauge the severity of diabetes, has increased by 26%
from the when the centers began to implement the model in 1999
to April 2005.
Presently there are over 5,463 Michigan patients being tracked
related to cardiovascular disease. The Chronic Disease
Collaborative aims to reduce blood pressure which leads to
reduction in complications associated with cardiovascular
disease. To date, despite an influx in the number of new
patients enrolled, the program has demonstrated a 5% overall
increase in the number of patients with a blood pressure less
than 140/90.
In addition to tracking diabetes and cardiovascular disease, the
Michigan health centers are spreading the care model to other
chronic diseases including cancer, depression, asthma and a
perinatal pilot project.
As a State Primary Care Association, we are working to educate our
state policymakers about this program and in fact have a proposal
pending with the State of Michigan that will draw many different
provider types into providing care using the chronic care model
including Critical Access Hospitals, community hospitals, independent
and provider-based Rural Health Clinics, private physician offices,
Medicaid Health Maintenance Organizations, and community-based coverage
programs. This model has tremendous potential that is just beginning to
be broadly appreciated such as improvements in patients' depressive
symptoms, percentage increases of patients receiving appropriate
treatment for chronic conditions and the ability to track measurable
improvement in meeting nationally accepted guidelines. We are committed
to providing assistance and sharing our lessons learned in order to see
the impressive results in improvement of health status and reduction of
health disparities in Michigan that we have experienced in health
centers nationally.
Finally, in light of the national interest in moving health care to
the electronic age, I'd like to speak with you concerning Michigan
health centers' innovation in information technology supported by the
Bureau of Primary Health Care of HRSA, VirtualCHC. VirtualCHC is an
Application Service Provider (ASP) designed by MPCA which delivers
application functionality and computer services to many users via the
Internet or a private network. VirtualCHC houses software appropriate
to health centers, including a number of choices of practice
management, general ledger, Microsoft Office Suite and many others,
making them available to health centers via the Internet.
As I mentioned earlier, electronic health records represent an
opportunity. They are key to our efforts to improve the quality of care
through better and more regular monitoring of patient/provider
adherence to clinical guidelines and to eliminate duplication of
services/testing/treatment. Implementing electronic health records is a
large front-end expense for centers purchasing the software, equipment,
training and lost productivity. VirtualCHC provides a way to help
minimize that initial investment by giving them a viable alternative to
developing and implementing complex systems themselves. Finally,
because VirtualCHC is Internet based, there are no geographic
limitations in health centers selecting or being supported by
VirtualCHC. As a result, VirtualCHC has serviced health center clients
in Michigan, Missouri, Massachusetts, Alaska and the Virgin Islands.
With Community Health Centers, the future really IS now.
Thank you for this opportunity to talk with you. If there are any
questions, I would be pleased to answer them at this time.
Mr. Whitfield. Thank you.
Mr. Hawkins, you are recognized for 5 minutes.
TESTIMONY OF DANIEL R. HAWKINS, JR.
Mr. Hawkins. Thank you, Mr. Chairman.
Good afternoon to you and members of the subcommittee. My
name is Dan Hawkins, and on behalf of America's health centers
and their 15 million patients, thank you for the opportunity to
speak with you this afternoon about the Federal health centers
program and to share their success stories.
Mr. Chairman, I have personally seen the power of health
centers to transform the health and well being of under-served
people and communities as a VISTA volunteer back in the 1960's.
I helped a community in a small, rural south Texas town to
startup a health center and then served as its initial
Director. That center is still in operation today, no thanks to
me. It serves more than 40,000 people a year.
Conceived in 1965 as a bold experiment to bring health care
services to our Nation's neediest communities, the health
center program has a 40-year record of success, providing an
enduring model of primary care delivery for the country.
Health centers have used community empowerment, what we
like to call patient democracies, to produce improved health
outcomes and quality of life. Dr. Duke has already pointed out
the stellar record of achievement of the health centers. NAC,
and all health centers, are deeply grateful to Congress for its
support of the health centers program and for expanding its
reach. The $566 million increase in appropriations provided
since fiscal year 2002 has enabled more than 700 communities to
secure a new or expanded health center, adding 4 million new
patients over the last 4 years.
Program funds are rewarded nationally on a competitive
basis, thus ensuring high-quality projects. Thankfully,
Congress has also provided additional funding for existing
centers, all of which face growing uninsured patient rolls and
rising costs. We appreciate the President's historic request, a
$304 million increase for next year. It can't come soon enough,
as the numbers show. As you have heard earlier today, last
year, over 430 applications were submitted for a new health
center site, and only 91 of them received funding.
We are delighted the President has announced a second
health center initiative to place a new health center in every
poor county that currently lacks one. We recently released a
study showing 929 such counties, including 69 in Kentucky and
11 in Michigan, several in your District, Mr. Chairman, and
several in Mr. Stupak's District.
We look forward to working with the President and Congress
to help this program reach every community in need. As my
colleague, Kim Sibilsky has already noted, NAC and State
primary care associations have long recognized that the success
of the program and the current expansion initiatives will
depend on the ability of health centers to meet all
requirements and performance standards and expectations. With
this in mind, we have significantly enhanced our training and
technical assistance activities for health centers focused on
financial management, clinical practice, and board governance,
among others. We continue to assist hundreds of communities to
successfully apply for new health center funding.
As you know, the health centers program is scheduled for
reauthorization next year. Over the years, Congress has
consistently reaffirmed and strengthened the core elements of
the health centers program, including community governance,
location in under-served communities, open-door policy
regardless of health status, insurance coverage, or ability to
pay, and focus on community-wide health. We believe these core
statutory requirements provide the crucial framework for the
success of the program. It simply would not be where it is
today without them, and we commend the committee for
consistently safeguarding these requirements over the years.
I want to turn, for a moment, to the Medicaid program.
Medicaid health centers have long enjoyed a special
relationship as twin pillars of a broad strategy to improve
health care for the poor, minority, and under-served Americans.
Today, that unique relationship continues with health centers
caring for nearly 6 million Medicaid recipients, more than one
of every ten Medicaid beneficiaries for less than 1 percent of
all Medicaid dollars, while Medicaid serves as their single
largest revenue source. Recognizing the importance of this
relationship, Congress, in 1989, made health center services a
guaranteed Medicaid benefit and required that its payments
cover the cost of care for Medicaid patients so that their
Federal grant funds could be dedicated to care of the
uninsured. Since that time, health centers have doubled the
number of uninsured people served to 6 million because Medicaid
paid its fair share. And in 2000, this committee led Congress
to reaffirm the importance of adequate Medicaid payments to
health centers by creating a prospective payment system for
them.
Today, health centers continue to deliver significant
savings to all payers, and especially to Medicaid. They control
health care costs by providing primary care and preventive
services, reducing the need for more costly hospital care down
the road. Dozens of studies have found that health centers save
the Medicaid program 30 percent or more in total spending
compared to other providers.
As Congress considers Medicaid reforms, we stand ready to
work with the committee to ensure that any such reforms
preserves Medicaid's crucial coverage for those who need it
most and recognizes the key role of health centers in both
caring for Medicaid recipients and the uninsured.
Thank you, once again, for this opportunity, and I would be
happy to answer any questions.
[The prepared statement of Daniel R. Hawkins, Jr. follows:]
Prepared Statement of Daniel R. Hawkins, Jr., Vice President, Federal,
State, and Public Affairs, National Association of Community Health
Centers
Mr. Chairman and Members of the Subcommittee, my name is Dan
Hawkins and I am Vice President for Federal, State, and Public Affairs
for the National Association of Community Health Centers. On behalf of
America's Health Centers and the 15 million patients they serve, I want
to express my gratitude for the opportunity to speak to you today about
the federal Health Centers program. NACHC and health centers appreciate
the unwavering support that this Subcommittee and the entire Committee
has given to carry out their mission and we look forward to continuing
to work with you to further strengthen the program to serve medically
underserved communities. As the Committee that oversees not just the
authorization of the Health Centers program, but also the entire
Medicaid program, we appreciate the opportunity to appear before you
today.
Mr. Chairman, I have personally seen the power of health centers to
lift the health and the lives of individuals and families in our most
underserved communities. As a VISTA volunteer assigned to south Texas
in the 1960s, the residents of our town asked me to work on improving
access to health care and clean water in our community. We decided to
apply for funds through a relatively new, innovative program--the
Migrant Health program. I stayed on and served as executive director of
the health center from 1971 to 1977. The health center is still in
operation today, and has expanded to serve over 40,000 patients
annually. The community empowerment and patient-directed care model
thrives today in every health center in America and I am honored to be
here to share with you their success story.
Background and History of the Health Centers Program
Conceived in 1965 as a bold, new experiment in the delivery of
health care services to our nation's most vulnerable populations, the
Health Centers program has a 40-year record of success that serves as
an endearing model of primary care delivery for the country. The Health
Centers program began in rural Mississippi, and in inner-city Boston in
the mid-1960s, to serve rural, migrant, and urban individuals who had
little access to health care and no voice in the delivery of health
services. In the 1980s and 1990s, the Health Care for the Homeless and
Public Housing health centers were created. In 1996, the Community,
Migrant, Public Housing and Health Care for the Homeless programs were
consolidated into a single statutory authority within the Public Health
Service Act (PHSA).
Congress established the program as a unique public-private
partnership, and has continued to provide direct funding to community
organizations for the development and operation of health systems that
address pressing local health needs and meet national performance
standards. This federal commitment has had a lasting and profound
affect on health centers and the communities and patients they serve in
every corner of the country. Now, as in 1965, health centers are
designed to empower communities to create locally-tailored solutions
that improve access to care and the health of the patients they serve.
This blueprint has stood the test of time, and has allowed health
centers to serve hundreds of millions of people since the inception of
the program. Health centers proudly accept this responsibility in
return for the investment made by the American taxpayers in the form of
PHSA grants. However, this overwhelmingly poor, uninsured, and
medically underserved patient mix creates unique challenges for health
centers that are not necessarily confronted by other health care
providers.
Current Statistics
Indeed, America's Health Centers serve an estimated 15 million
people in every state and territory. Health centers provide care to 10
million people of color, 6 million uninsured individuals, 700,000
seasonal and migrant farmworkers, and 600,000 homeless individuals.
Over 1,000 health centers are located in 3,600 rural, frontier, and
urban communities across the country. The communities served by health
centers are in dire need of improved access to care, and in many cases
the centers serve as the sole provider of health services in the area,
including medical, dental, mental health, and substance abuse services.
Patients can walk through the doors of their local health center
and receive one-stop health care delivery that offers a broad range of
preventive and primary care services, including prenatal and well-child
care, immunizations, disease screenings, treatment for chronic diseases
such as diabetes, asthma, and hypertension, HIV testing, counseling and
treatment, and access to mental health and substance abuse treatment.
Health centers also offer critically important enabling services that
ensure that health center patients can truly access care, such as
family and community outreach, case management, translation and
interpretation, and transportation services.
Delivery of High-Quality, Cost-Effective Care
Because of the unique model of patient empowerment, what we like to
call ``patient democracies'', health centers have produced improved
health outcomes and quality of life. Health centers provide preventive
services to vulnerable populations that may not otherwise have access
to certain services such as immunizations, health education,
mammograms, and Pap smears, as well as colorectal, glaucoma, and other
screenings. Health centers have also made significant headway in
preventing anemia and lead poisoning.
Additionally, health centers have distinguished themselves in the
management of chronic illness, meeting or exceeding nationally accepted
practice standards for treatment of these conditions. In fact, the
Institute of Medicine and the General Accounting Office have recognized
health centers as models for screening, diagnosing, and managing
chronic conditions such as cardiovascular disease, diabetes, asthma,
depression, cancer, and HIV/AIDS.
HHS' Health Resources and Services Administration (HRSA) has also
helped improve the provision of quality care at health centers through
the Health Disparities Collaboratives initiative. At the end of 2004,
more than two-thirds of all health centers had initiated this effort,
and an additional 150 health centers have started a Collaborative this
year. I like to think of the Collaboratives as clinical demonstrations
for health centers, designed to improve the skills of clinical staff,
and strengthen caregiving through the development of extensive patient
registries that improve clinicians' ability to monitor the health of
individual patients, and effectively educate patients on the self-
management of their conditions. More than 75,000 people with chronic
diseases have been enrolled in elective registries for cancer,
diabetes, asthma, and cardiovascular disease. Health centers
participating in the Collaboratives almost unanimously report that
health outcomes for their patients have dramatically improved.
As a result of health centers' focus on the provision of preventive
and primary care services and management of chronic diseases, low-
income, uninsured health center users are more likely to have a usual
source of care than the uninsured nationally. 99% of surveyed health
center patients report that they were satisfied with the care they
receive at health centers. Communities served by health centers have
infant mortality rates between 10 and 40% lower than communities not
served by health centers, and the latest studies have shown a continued
decrease in infant mortality at health centers while the nationwide
rate has increased. Health centers are also linked to improvements in
accessing early prenatal care and reductions in low birth weight.
This one-stop, patient-centered approach works. The Health Centers
program has been recognized by the Office of Management and Budget as
one of the most effective and efficiently run programs in the
Department of Health and Human Services (HHS). Numerous studies have
also pointed to the success of health centers in reducing health
disparities and improving the health status of vulnerable populations
who receive care at their sites. Indeed, a major report by the George
Washington University found that high levels of health center
penetration among low-income populations generally results in the
narrowing or elimination of health disparities in communities of color.
Historic Expansion of Access Through the Health Centers program
While health centers have had four decades of success, there has
been no brighter moment in the life of the program than now. NACHC and
health centers are deeply grateful to Congress for its support of the
Health Centers program. In Fiscal Year (FY) 2005, Congress appropriated
$1.7 billion in overall funding for the Health Centers program, a $566
million increase in funding over FY 2002.
These increases have enabled hundreds of additional communities to
participate in the Health Centers program and to deliver community-
based care to more than 4 million people in the past 4 years. We are
also very grateful that Congress has provided additional funding for
base grant adjustments for existing health centers, which have seen
unexpected increases in the number of uninsured patients coming through
their doors at the very same time they continue to battle the
continuously rising cost of delivering health care in their
communities. These base grant adjustments have allowed health centers
across the country to stabilize their operations and continue to
provide care to their existing patients, while also looking for ways to
expand access to necessary care.
We also appreciate the President's strong support for the program
and his historic request for a $304 million increase in FY 2006, which
would bring overall health center funding to $2 billion. This year we
expect health centers to serve nearly 16 million people in every state
across the country. This would be a tremendous boost for those lacking
care in their communities and we wholeheartedly support the
Administration's request, which would meet the 5-year goal of the
President to serve an additional 6.1 million patients at 1,200 new
health centers.
Despite the expansion of the program, the demand for health centers
is at record highs--in 2004, we estimate that there were over 430
applications for new access points, only 91 of which received funding--
a 21 percent success rate, making health centers' funding on the same
level with other competitively awarded grant programs under HHS. Indeed
the application process is rigorous, and it should be. Health center
program funds are awarded on a nationally competitive basis, ensuring
that the highest possible quality projects receive approval.
Organizations can apply for new access point funding (which is for new
starts and new sites), or for expanded medical capacity funding to
serve additional patients at existing sites, or to make new services
such as dental or mental health services available to patients.
Given the increasing need for health centers, we are extremely
grateful that the President has committed to continue the growth of
program by announcing a continuation of his Health Center Initiative
into the future. This new announcement will focus on placing new health
centers in poor counties that currently lack a health center site, a
very ambitious goal. To begin this effort, the President has requested
$26 million in FY 2006 to fund 40 new access points in high need
counties.
Given the President's new initiative, we have also examined the
need in poor counties. NACHC and the George Washington University
estimate that there are approximately 929 poor counties in need of a
health center, from Kentucky to Michigan. Through this continued
expansion, we believe that millions of additional patients would have
access to care at a health centers. We commend the President for his
continued support of the Health Centers program and we look forward to
working with Congress to ensure it reaches every community in need.
Authorization of the Health Centers program
As we look forward in the life of this 40-year experiment in
community health empowerment, I note that the Health Centers program
was last reauthorized in 2002, as a part of the Health Care Safety Net
Amendments Act. The program is scheduled for reauthorization next year.
Health centers are grateful to the Committee for its leadership role in
strengthening and improving the Section 330 statute in 2002, further
modernizing it to serve millions of new patients. Most importantly, in
reauthorizing the program the Committee and Congress reaffirmed its
four core elements, as it has consistently over the entire life of the
program. These core elements, which have greatly contributed to its
continued success, require that health centers: 1) be governed by
community boards a majority of whose members are current health center
patients, to assure responsiveness to local needs; 2) be open to
everyone in the communities they serve, regardless of health status,
insurance coverage, or ability to pay; 3) be located in high-need
medically-underserved areas; and 4) provide comprehensive preventive
and primary health care services.
In reauthorizing these bedrock requirements, Congress sent a clear
message that it sees patient involvement in health care service
delivery as key to health centers' success in providing access and
knocking down barriers to health care. Active patient management of
health centers assures responsiveness to local needs. This begins with
community empowerment, through the patient-majority governing board
that manages health center operations and makes decisions on services
provided, and leads to the fulfillment of the other core elements of
the program.
Through the direction and input of these community boards, health
centers can identify their communities' most pressing health concerns
and work with their patients, providers, and other key stakeholders to
address these issues. This has been particularly valuable as health
centers address and work to eliminate health disparities in their
patient population. Board members with unique and direct community
connections determine the best approach for removing barriers to health
care, helping health centers to meet their patients where they are, not
where they want them to be. The critical, distinguishing feature of the
health center model of community empowerment is that the community has
been directly involved in virtually every aspect of the centers'
operations, and, in turn, each health center has become an integral
part of its community, identifying the most pressing community needs
and either developing or advocating for the most effective business or
public policy solutions.
I also want to expand on the other core features of the Section 330
program, each of which has played a key role in the continued success
of the Health Centers program. First, health centers are unique among
health providers and systems in its statutory requirement that they be
open to all in the community regardless of ability to pay. Like the
community board requirement, this element is what links health centers
the local neighborhoods they serve. There is no cherry picking at
health centers; everyone--the uninsured, underinsured, those on
Medicaid and Medicare, and those who have private coverage can receive
quality health care at health centers. Consequently, health centers
have a very diverse payor mix, in which the federal grant constitutes
approximately 25% of center revenues. Medicaid and SCHIP make up 40% of
revenue, private insurance constitutes 15%, and Medicare approximately
6%. Health centers are interested in addressing health needs on a truly
community-wide basis, and the requirement that they be open to all in
the areas they serve allows them to do just that.
Second, health centers are required under the statute to be located
in high-need, medically-underserved areas. In reauthorizing the
provision in 2002, Congress sought to ensure that much-needed, precious
resources are allocated to the communities most in need of the services
of a health center. Location of health centers in MUAs prevents the
duplication of services, and establishes health centers in newly
identified communities or expands the work of existing centers where
there are well-documented gaps in care.
Third, health centers are distinctive in the broad range of
required and optional primary and preventive health and related
services they provide under Section 330. This also includes a range of
enabling services that ensure optimal access to care. In 2002, Congress
not only reauthorized this requirement, but added to the list by
including appropriate cancer screenings and specialty referrals as
required services and behavioral health, mental health, substance
abuse, and recuperative care treatment as optional services that health
centers may provide.
We believe that these core statutory requirements provide the
crucial framework for success of the Health Centers program. The
program simply would not be where it is today without these critical
elements, and we commend Congress for safeguarding these requirements
in every reauthorization of the Section 330 since its inception.
Need for Construction Assistance
While health centers greatly appreciate the ongoing effort of the
federal government to expand the reach of the program, we must
acknowledge the growing need for support for facility construction,
renovation, and modernization. Currently, we estimate that over two-
thirds of health centers need to upgrade, expand, or replace their
facilities. Approximately 30% of health center buildings are more than
30 years old and 65% operate in facilities that are more than 10 years
old. The average cost of a facility project is estimated to be $1.8
million, but projects can range in size from a small $400,000 project
to a major $20 million effort. NACHC estimates that the current unmet
need among health centers for capital projects is approximately $1.2
billion.
We strongly believe that the delivery of quality care to patients
at health centers hinges greatly upon the quality of the facilities
where care is provided. Prior to 1996, health centers could use a small
portion of their grant funding for construction, renovation, and
modernization of their facilities; elimination of this authority during
the 1996 reauthorization and the failure to restore it during the 2002
process has severely undermined health centers' ability to successfully
address their most pressing capital needs. As just one example, wiring
a health center for high-speed IT systems or secure wireless networks,
which will be crucial as we move to electronic health records, is not
an allowable grant cost today.
Given this limited access to capital resources, health centers were
very pleased that the Bureau of Primary Care Loan Guarantee Program was
revised as part of the 2002 reauthorization to allow health centers to
use loans not only for the development of managed care networks, but
also for the purchase of equipment and to refinance existing loans
previously made for facility construction. However, these funds still
cannot be used for capital projects, and the guarantee covers only 80%
of the value of the loan. Consequently, health centers participation
has been limited, as many centers find it difficult to cover 20% of
initial loan value, because of very slim financial margins as non-
profit organizations serving low-income, underserved populations.
Despite this, health centers have worked hard to leverage resources
to participate in other federal programs that offer capital assistance.
Health centers in rural areas have been very successful in obtaining
funding for facility improvement from the Department of Agriculture's
Rural Housing Administration programs, which provide loan guarantees up
to 90% of loan value. Health centers have had more limited success in
accessing facility assistance through the Department of Housing and
Urban Development (HUD) programs. If health centers were able to access
HUD's loan guarantee and mortgage insurance, they would have an
important tool with which to address facility concerns. We look forward
to working with Congress to ensure that health centers are given the
tools to expand, modernize and, when needed, to build new facilities in
order to serve additional patients.
Above all, we stand ready to assist the Committee as you move
forward next year to reauthorize the Section 330 Health Centers program
and its core elements.
The Importance of Health Centers and Medicaid
I want to turn for a moment to the importance of Medicaid to the
Health Centers program. Since their creation back in 1965, Medicaid and
health centers have enjoyed a special relationship, as twin pillars of
a broad strategy whose goal was to dramatically improve health care for
poor, minority, and underserved Americans. Today, that unique
relationship continues: just as health centers rely on Medicaid
revenues, Medicaid beneficiaries rely on health centers for their care.
Health centers are major providers of primary and preventive care
services in Medicaid today, caring for nearly six million Medicaid
recipients. In fact, Medicaid is currently the single largest
beneficiary of health center services, as well as health centers'
single largest source of financing. Keenly recognizing the importance
of health center services to Medicaid beneficiaries, Congress in the
Omnibus Budget Reconciliation Act of 1989 made the services of a
Federally Qualified Health Centers (FQHCs) a guaranteed Medicaid
benefit offered to beneficiaries in every State Medicaid program. Most
important, Congress recognized and acknowledged that Medicaid
reimbursement to FQHCs must be sufficient to assure that health centers
were paid their full reasonable costs for serving Medicaid patients (so
that they would not have to use their Public Health Service Act grant
funds to subsidize low Medicaid payments). In the accompanying
Committee report, lawmakers wrote:
``The Subcommittee on Health and the Environment heard
testimony that, on average, Medicaid payments to Federally-
qualified health centers cover less than 70 percent of the
costs incurred by the centers in serving Medicaid patients. The
role of the programs funded under sections 329, 330, and 340 of
the PHS Act is to deliver comprehensive primary care services
to underserved populations or areas without regard to ability
to pay. To the extent that the Medicaid program is not covering
the cost of treating its own beneficiaries, it is compromising
the ability of the centers to meet the primary care needs of
those without any public or private coverage whatsoever.''
(U.S. Congress, 1989, p. 415).
In the 16 years since enactment of the FQHC Medicaid requirement,
health centers have increased their capacity for uninsured care by 3
million people--double the number of uninsured patients served in 1990,
a rate of growth that is more than twice that for the nation's
uninsured population. Alternatively stated, the Congress has received a
higher rate of return on its annual appropriations investment in health
centers because Medicaid cost-based reimbursement was in place.
In 2000, under the leadership of former Republican Congressman (now
Senator) Richard Burr and his Democratic colleague Congressman Edolphus
Towns, and with the support of the overwhelming majority of the Energy
and Commerce Committee, Congress reaffirmed the continued importance of
adequate Medicaid reimbursement to health centers by creating a
prospective payment system for FQHCs that (1) assures continued access
to care for Medicaid patients, (2) protects Federal grant funds to
provide care for the uninsured, and (3) gives state Medicaid agencies
greater flexibility in designing their Medicaid programs and
predictability in the cost of payments to health centers.
Today, health centers continue to deliver significant savings to
all payers, and especially to Medicaid. They control health care costs
by providing primary and preventive services, reducing the need for
more costly hospital care down the road. In South Carolina, for
example, the state health department analyzed their annual costs for
patients who have diabetes as a primary or secondary diagnosis. They
found that patients of CareSouth, a health center system that had
participated in the Diabetes Collaborative, had annual health costs of
$343.00 per patient, while patients of other providers had a cost of
$1,600 and specialists had a cost of $1,900. The health center had
produced those results by reducing the average blood sugar level of
their diabetic patients from 11 to 8--a 3 point drop (a 1 point
decrease translates into a 17% decrease in mortality, an 18% decrease
in heart attacks, and a 15% decrease in strokes) (Health Resources and
Services Administration, 2003).
In addition, according to another study, communities served by
health centers had 5.8 fewer preventable hospitalizations per 1,000
people over three years than other medically underserved communities
not served by a health center (Epstein, 2001). Another study found that
Medicaid beneficiaries who seek care at health centers were 22 percent
less likely to be hospitalized for potentially avoidable conditions
than beneficiaries who obtained care elsewhere (Falik, 2001) Several
other studies have found that health centers save the Medicaid program
more than 30 percent in annual spending per beneficiary by successfully
managing their patients' care in ways that reduce the need for, and use
of, specialty care referrals and hospital admissions (Braddock, 1994:
Duggar, 1994a; Duggar, 1994b; Falik, 2001; Starfield, 1994; Stuart,
1995; Stuart, 1993).
Growing Challenges
Beyond paying its fair share for health center services provided to
beneficiaries, Medicaid plays an important role by providing its
beneficiaries access to comprehensive services beyond those available
at health centers. However, as the health care needs of low-income
individuals continue to grow, so do the challenges to health centers in
sustaining their ability to provide quality care to Medicaid
beneficiaries and other patients.
Undoubtedly, one of the greatest of these challenges is the
increasing number of states in the past few years that have sought to
limit the scope and the breadth of services provided to enrollees in
their state Medicaid programs as well as implementing so-called ``cost-
containment'' measures. Cutbacks in Medicaid eligibility levels or
benefits, caps in enrollment, or forgone expansion plans naturally are
presenting significant difficulties for health centers. What's more,
these actions are occurring at the same time as employers are either
shifting more of the rising cost of health insurance onto their workers
or to dropping the coverage altogether. As other health care providers
have begun cutting back on the uncompensated or charity care they
provide, the result is that health centers are serving an ever-
increasing number of uninsured individuals who previously were covered
under Medicaid or through their employers.
Compounding this challenge is the increasing level of discretion
being provided to the states in the operation of their Medicaid
programs through HHS' issuance of Section 1115 waivers--under which
State Medicaid agencies are permitted to reduce benefits, increase cost
sharing requirements, and adjust reimbursement rates. Health centers
have already experienced the impact of this increased state flexibility
in some fifteen states during the 1990s. In most cases, the ability of
health centers to care for both their Medicaid and their uninsured
patients during this period was negatively impacted when their Medicaid
payments were reduced below the cost of providing care. In many of
those states, other providers decided not to participate or limited
their care to only a few Medicaid patients, leaving health centers as
one of the few remaining sources of primary and preventive care to this
population.
While these and other changes in the health care system have put a
tremendous strain on the overall Health Centers program, health centers
remained committed to providing access to care for everyone that walks
through their doors, regardless of their health status, insurance
coverage, or ability to pay for services. Put simply, health centers
will continue to provide care for those whom other providers cannot or
will not serve.
Health Centers and Medicaid Reform
As Congress moves forward on considering ways in which to reform
Medicaid, it is critical that it keep in mind the important role health
centers play in their communities and the unique relationship between
these centers and the Medicaid program. Indeed, as the Kaiser Family
Foundation points out, ``[t]he fundamental interrelationship between
Medicaid and health centers . . . suggests, by extension, that dynamics
in one domain are bound to have important impacts in the other.'' It is
therefore imperative that lawmakers working on Medicaid reform consider
the impact of any changes in that program on the ability of health
centers to fulfill their public policy mission.
All health care providers must seek to cross-subsidize when
payments from a third party source are insufficient. However, unlike
most physician practices that have paid for indigent care services by
cross-subsidies from their commercial payers, health centers do not
have a substantial commercially insured patient base from which to
draw. Evidence abounds that the traditional response by physicians and
other providers to reduced Medicaid or Medicare payments has been to
restrict or reduce the number of publicly-insured patients they serve,
often accompanied by a reduction in the amount of indigent care they
provide as well.
Because of the shortage of commercial payments, health centers have
three options if Medicaid, their largest third party payer, does not
cover the cost of providing care to its beneficiaries. They can (1)
reduce health care services or reduce the number of health care access
points, (2) close their doors entirely--likely resulting in communities
having little or no access to primary health care services--or (3)
cover Medicaid shortfalls with their PHSA grants intended to defray the
cost of caring for the uninsured.
Ensuring the adequacy of payments under Medicaid, regrettably, is
not a new issue for health centers. It in fact has been an ongoing
concern since the 1990s, during which the relationship between health
centers and Medicaid experienced significant challenges as a result of
the increased use of Section 1115 waivers in many states. In most cases
throughout this period, the ability of health centers to care for
Medicaid and uninsured patients was severely damaged when Medicaid
payments were cut to only a fraction of the cost of providing care.
Moreover, in many of those states, other providers refused to
participate or limited their care to only a few Medicaid patients,
leaving health centers as one of the few remaining sources of primary
and preventive care to this population.
One of the states in which health centers were most impacted during
this period was Tennessee. In 1998, the certified public accounting
firm of Goldstein, Golub, Kessler and Company (GGK) examined the impact
of low-Medicaid payments on health centers in the state under the
TennCare program. In GGK's study they found that, while the number of
TennCare visits to health centers increased, the gap between revenues
and costs per TennCare visit widened, resulting in significant revenue
losses for health centers.
By 1996, Tennessee's health centers were losing almost $28 per
TennCare patient visit. This created an unfunded gap in reimbursement
that forced health centers to cover these losses out of their PHS Act
grants. The result was a reduction in the number of uninsured persons
receiving care at Tennessee's health centers, and the virtual
elimination of all ``supplemental'' services, including health and
nutrition education, parenting classes and community outreach--all of
which have been proven highly effective in improving the overall health
of patients.
Increasingly, health centers today continue face many of the same
challenges with 1115 waivers as they did in the 1990s. Originally
created to allow states to try innovative health care approaches, many
recently approved waivers have instead been used to limit benefits,
increase cost sharing, and reduce enrollment. In some cases, Medicaid
provider payments have been cut dramatically, causing other providers
to severely limit or end their participation in Medicaid, and leaving
health centers--whose mandate is to serve everyone regardless of
ability to pay--as one of the few remaining sources of primary and
preventive care to this population. If states are permitted to cut
Medicaid payments to health centers under these waivers, their ability
to care for both Medicaid-covered and uninsured patients would be
severely damaged. For these reasons, health centers believe strongly
that Medicaid waivers should be approved only if they ``promote the
objectives of'' Medicaid, and do not erode the program's ability to
provide comprehensive services to beneficiaries.
As Congress begins to consider reforms to Medicaid, it will be
important for lawmakers to appreciate the integral role of health
centers and other core safety net providers in Medicaid, and ensure
that these providers are adequately paid for the reasonable costs of
health care they provide to enrollees. We look forward to continuing to
work with Congress in these efforts.
The Importance of Ensuring Future Health Centers Success
Health centers have successfully stood the test of time over the
past four decades, not only because they are rooted in the communities
they serve, but because of their attention to continuous quality
improvement and technical assistance. Since 2002, health centers have
expanded to serve an additional 4 million people, adding approximately
3,000 clinicians and several thousand other staffers at centers across
the country. With hundreds of new health centers, staff and patients,
it is imperative that health centers, whether brand new or established,
receive the technical assistance and training required to successfully
expand to provide high quality care.
NACHC and State and Regional Primary Care Associations (S/R PCAs)
remain fully committed to and engaged in technical assistance
activities with health centers. We have long recognized that the
success of the program--and current and future expansion initiatives--
depends on the ability of health centers to carry out the requirements
of the statute and program expectations.
While HRSA has restructured the availability of technical
assistance through its project officers, and decreased funding
available for on-site assistance for many new centers, HRSA has been
able to help health centers plan and implement effective expansion
strategies through a cooperative agreement with NACHC and grants to S/R
PCAs,. NACHC and the PCAs also conduct trainings for health center
staff regarding financial management, clinical practice guidelines,
regulatory and legal requirements and consumer board trainings. NACHC
also assists communities seeking to apply for new health center funding
to meet the federal requirements of the grant.
I am very pleased to report that, over the past few years, NACHC
has dramatically increased the frequency and types of education,
training and technical assistance it provides. Indeed, since the
beginning of the expansion initiative, NACHC has conducted 44 health
center grant proposal trainings, some in cooperation with the Bureau of
Primary Health Care, PCAs and other organizations, and involving over
3000 individuals interested in starting a health center. In addition to
onsite trainings conducted at our two annual conferences, NACHC has
also conducted trainings in 12 states. We average 300 technical
assistance calls a month. We have also held six onsite orientations for
new health centers, and six new start teleconference sessions,
providing training for approximately 1100 individuals who are on the
staffs and boards of the newly-funded health centers in their
communities.
Additionally, NACHC has conducted 35 new health center medical
director orientation sessions, providing intensive training to over
1100 medical directors representing 1000 health centers, since 2001.
Over this same period of time, our clinical team has also conducted
quality management trainings for approximately 720 health centers and
their clinicians. NACHC also provides trainings and technical
assistance on other key aspects of health center operations, including
board governance, financial management, corporate compliance, and
strategic business planning. We stand ready to continue our activities
in all of these areas to ensure that health centers can build on their
record of success over the past 40 years and in this current expansion
effort.
Conclusion
Health centers appreciate the unwavering support of Congress for
the program over the past four decades. In the past 40 years, health
centers have produced a return on the federal investment in the
program, by providing access to care and a health care home to millions
of patients in medically-underserved communities across the country.
Because Congress has continued to reaffirm the core elements of the
program; that health centers are open to all, run and controlled by the
community, located in high need medically-underserved areas, and
provide comprehensive primary and preventive services, the program has
successfully faced challenges posed by our ever-changing health care
system. On behalf of health centers across the country, their staffs,
and the patients they serve, we stand ready to work with you to ensure
that health centers continue to provide a health care home for everyone
who needs their care. Thank you once again and I would be happy to
entertain questions from the committee.
Mr. Whitfield. Thank you, Mr. Hawkins.
And Dr. Goetcheus, you are recognized for your opening
statement. And be sure and turn your microphone on.
TESTIMONY OF A. JANELLE GOETCHEUS
Ms. Goetcheus. Thank you for holding these hearings. Thank
you for the opportunity to share today.
I am Janelle Goetcheus. I am the Medical Director of Unity
Health Care, which is a federally qualified health center here
in Washington. Unity operates a large number of community
health centers throughout DC, last year seeing over 55,000
individual patients, representing 240,000 patient visits.
Unity began in 1985 as a health care for the homeless
project. And a lot we did here in DC was to place health
services directly in the shelters. One of those shelters is
just a few blocks away from here at 2nd and D. I think some of
the committee members have been there to visit, and we would
welcome any others who would want to. A thousand people in one
building. We have a health service that runs 6 days a week. It
is constantly busy. We have another outreach van with a medical
team that goes along Pennsylvania Avenue and some of the parks
in the adjacent area looking for homeless folks who need access
into health care.
But through the years, we have spread into community health
centers throughout the District. And what we have known is it
was more than just a doctor's office visit that we needed to
provide. We needed to provide a comprehensive set of services,
wrap-around services, and so we include mental health and
dental and pharmacy. And one of the most important ones is
social work. I often say, as a physician, I could never
practice without social workers with me. For example, this
week, I was with a person who came in who had cancer and was
also mentally ill. And I needed to work with a social worker
myself to try to get Medicaid for that person in order that I
could get chemotherapy for them.
I guess, if anything I would like to share today, and I
have heard it here today, is in terms of the quality of the
health care that happens in these community health services. I
really do think it is equal to any care that you would get in
any other place of choice. One of the things that has helped
has been these collaboratives, and you have heard some mention
of that today.
We participate in a diabetic collaborative. What that means
is if a patient comes in to see me who has diabetes, they don't
just see me as a primary care provider, they also see the nurse
care manager who sits with the patient, teaches them about
their illnesses, and helps them set goals for themselves. And
we have, and the Bureau of Primary Health Care, has the
outcomes related to these initiatives and really can show that
we have decreased hospitalizations, decreased emergency room,
and decreased all of the complications that diabetes can bring,
the early amputations, the early dialysis.
Another great source of help has been the National Health
Corps, and I think you would hear this from all of us at the
table. We have, for instance, in some of the poorest areas here
in DC, we have six health services out there. All of them have
National Health Corps physicians. Two of those have been out
today making home visits in some of the housing projects,
accessing elderly people who otherwise never would have health
care.
We also multiply. We take the Federal dollars and we
multiply them in various ways. For example, United Health Care
this year gave us a $1 million grant, and it will be a multi-
year grant to establish improved care at some of our community
health centers in these areas. NIH has also been a great
partner. They provide care not only on our specialists but also
access patients into their own campus. Volunteers also help us.
We look forward to hopefully further legislation that would
allow the Federal tort to cover volunteer physicians,
especially specialists that we often have a great deal of
difficulty finding.
We face lots of challenges. You have heard today in terms
of the base funding issues, we have benefited by the expanded
grants that have come. What we have done from one of our grants
is we have gone into the jail, because here in DC, there are
over 50 people a day who are coming out of DC jail into the
community and another 2,400 that are coming from Federal
prisons around the Nation and coming back into the District,
and we are trying to connect those folks into ongoing primary
health care.
But I think most of all what we do is bring hope to people,
not only good primary care, but we bring hope. One of those I
think most often of is my friend Robert who I met not very far
from here one night, a very cold night, and they were standing
around a barrel. And they had built a fire with just some
papers to try to keep warm, a group of men. He had a blood
pressure of 190 over 135, which is dangerously high, and he is
a 54-year-old gentleman. He had worked day labor most of his
life and had gotten to that age and couldn't do the heavy
lifting anymore, and so he was homeless. But now, instead of
around that fire barrel, he was able to move into his own
apartment. So I think these community health centers bring good
primary care, but they bring hope and they bring hope to many,
many Roberts around this Nation.
Thank you.
[The prepared statement of A. Janelle Goetcheus follows:]
Prepared Statement of A. Janelle Goetcheus, Chief Medical Officer Unity
Health Care, Inc.
Good afternoon, my name is Dr. Janelle Goetcheus, Chief Medical
Officer of Unity Health Care, Inc. (Unity), Washington, D.C., a
Federally Qualified Health Center (FQHC) that operates a large network
of health centers which provided health care services to 55,500 patient
in 2004, generating over 240,000 patient encounters.
It is a privilege to testify before this Sub-Committee and I thank
you Mr. Chairman for the opportunity to do so.
I have over 20 years of experience serving the medically
underserved in Washington, D.C., and I wish to speak to you today about
the unique value of a community health center in addressing the health
care needs of the medically underserved. Let me first tell you about
Unity, and the people we serve. Unity began as a private non-profit
with funds from the Robert Wood Johnson/Pew Charitable Trust providing
health care services to homeless persons. In 1987 we were one of the
first federally funded programs under the Stewart B. McKinney Homeless
Assistance Act. Over time we expanded our services to include provision
of health services in neighborhood/community settings. Today we are the
recipient of federal grants under the Community Health Center
Consolidated Act, with grants to serve fixed populations in community
health centers, homeless persons and we also receive a school based
health grant.
Unity provides primary health care services, mental health
services, case management, pharmacy, dental, WIC and HIV/Hep-C services
throughout the eight (8) wards of the District of Columbia. We do this
in fixed sites, homeless shelters, and outreach mobile vans. We have a
total of 31 access points throughout our Citywide network.
Of the approximately 55,500 persons served by Unity in 2004 over:
75% of them were at 200% or lower of the Federal Poverty Level, most
of them were actually 100% or below,
74% were uninsured
16% were recipients of Medicaid
10% Medicare and other
of our total population served 21% were homeless (on the streets or
in shelters)
Of the homeless persons we see approximately:
36% are substance abusers
19% have mental health issues; much higher percentage for women
16% are dually diagnosed
20% are veterans, and
12% are person living with HIV/Aids.
The ethnic make up of Unity's population is as follows:
77% are African American
18% are Latino
4% other
21% are best served by a language other than English.
I share these statistics only to point out that health centers are
adept at cultural competence, able to recognize the unique needs of
their patients, address them in their own language and culture, and
thus remove barriers to care that are often present when serving a
mixed racial, ethnic and low income population.
It is important to recognize that health centers provide
comprehensive primary health care. This federal requirement to provide
comprehensive services enables patients to have the majority of their
health care needs addressed in a one stop setting. The comprehensive
nature of the care provided goes far beyond a doctors visit. My role as
a provider in the health process is important, but I could not practice
medicine without the support of a myriad of other providers/services
that go into this healing process. Patients we serve have a host of
problems, beyond chronic illness. Social workers are an essential part
of the provision of health care in a community health center. They
assist the provider with arranging for entitlements, and in some cases
housing, since over 20% of our patients are homeless, or living in
shelters, and many of them suffer from chronic illnesses. As a primary
care provider, I often rely on the psychiatrist or mental health worker
on staff to link that patient to them so that they can begin to address
underlying problems that often go much deeper than the initial
presenting symptom. Our patients experience trauma, domestic violence,
a family facing eviction, a person with a cocaine addition, a grieving
mother; all of these issues can be addressed in a comprehensive manner
within a community health center setting.
As the Bureau of Primary Health Care (BPHC) increasingly encourages
health center grantees to participate in the Disease Collaboratives,
the role of comprehensive health care, and coordinated care management
is further emphasized. The Disease Collaboratives are a model of care
that places the patient at the center of the care, and he/she is
supported in their goal of self-management by a Care Management Team
often consisting of a nurse care manager, a social worker, the
provider, and other support personnel as needed, such as mental health
therapist, pharmacist and speciality providers, i.e. ophthalmologist,
podiatrist, in the case of diabetes.
The Chronic Disease Collaboratives nationally have shown that even
an indigent and hard to manage population can still generate good
health outcomes and improve health status if the care is provided in a
coordinated manner. The community health center is the ideal location
for the implementation of these Disease Collaboratives because most of
the services are on site and the support offered by the overall care
team goes far beyond the type of care that an individual physician
could provide alone. The clinical data collected through these Disease
Collaboratives substantiates the effectiveness of this model of care.
Patients who participate in this model of care have expressed their
satisfaction with it, and many for the first time are taking ownership
of their health status and realize that their own self involvement, and
reliance on support from the care management provided between physician
appointments plays a crucial role in their health status.
Unity Has in addition, to the care management structure outlined
above, launched its own initiative called ``open access'' or ``same day
appointment''. This process again calls for a radical re-design of the
traditional doctors office visit. A pilot program, with guidance from
the Institute for Health Care Improvement (IHI), Unity staff and
providers are accommodating patients within 24 hours of their request
for care. Traditionally patients requesting care would call up and
unless it was an emergency, would be given an appointment on the next
available opening which could be weeks or months away. The theory
behind ``same day access'' is to ``do today's work today'', to address
the needs of the patient immediately, and to reduce waste and lost time
both for the patient and the staff of the health center. This
initiative is now operative in three (3) of Unity's major sites with
plans to expand it to the whole network over time.
I point this initiative out as another example of the creativity
and adaptability of health centers in addressing the needs of their
community, as well as pointing out that health centers are in the
forefront of the provision of state of the art health care.
Health Centers are extremely creative in their ability to generate
revenues to address the ever increasing number of uninsured and working
poor who are coming through their doors. We multiply the Federal
dollars made available through the federal grant.
Unity like all other Community Health Centers faces this challenge
on a daily basis. We must constantly insure that our ability to survive
as a private non-profit is essential, so that we can continue to remain
faithful to our mission, a mission ``to provide health care to all
regardless of ability to pay''. Unity currently participates in a
District of Columbia sponsored Alliance program, which is essentially a
local sponsored uncompensated care pool for uninsured patients under
200% of poverty. We rely on Medicaid, and a vital component of the
Medicaid program for us, and for all health centers is the Prospective
Payment System (PPS). The PPS system is a method which enables health
centers to be compensated for the care they provide to Medicaid
patients at a reasonable rate of reimbursement. In a time of budget
crunch at the Federal and State levels it is important that the PPS
system remains in place for the viability of health centers.
While we are extremely grateful for the President's Five Year
Initiative to expand access to care through Community Health Centers it
is also important to point out that Unity's base grant has remained
stagnant for almost five (5) years. The President's Initiative
increases access through ``new starts'' and ``new access points'' but
does not provide for any base adjustment to existing grantees like
Unity, whose numbers of uninsured are rising. Unity like most health
centers is creative in building partnerships with other entities,
hospitals, health care institutions and corporations to support the
strategic interests of their mission. One such partnership of which
Unity is extremely proud is our partnership with United Health Care
(United), Minnesota. This joint venture results in an annual investment
of $1,000,000 over several years by United to one of Unity's health
centers to develop a ``Center of Excellence'' where the model of care
management can be implemented in treating several chronic diseases,
such as diabetes, cardio-vascular, and asthma, as well as the
development of systems to insure improved outcomes in the area of pre-
natal care. This ``Center of Excellence'' drawn from many of the
concepts of the Institute for Health Care Improvement (IHI) will serve
as a model for further expansion of the concept throughout Unity.
Without the financial support of United Health Care, Inc. Unity could
not from its existing revenue undertake such a broad based initiative.
For over twenty years it has been my privilege to serve the
patients who come to our health centers. I am grateful for how they
challenge us, and for the trust they place in us. I have also been
privilege to work alongside a committed group of health care
professionals, physicians, nurse practitioners, physician assistants,
specialists, nurses and social workers. Their commitment to Unity and
indeed to the health center movement nationwide is the soul of our
success. Many of these professionals come to us through the National
Health Service Corps (NHSC) or the Corps Loan Re-Payment Program. This
is a vital cog in the machine of recruitment and retention for our
health centers. At Unity we witness young African American physicians
returning to their neighborhoods giving back to the very people who are
their neighbors. Their willingness to come to Unity, often for salaries
much less than could get in the commercial market, is another example
of the unique role that health centers play in the community, because
of their ability to attract such dedicated, committed professionals.
I thank you again for allowing me to testify before you Sub-
Committee and I am available to answer any questions.
Mr. Whitfield. Thank you, Dr. Goetcheus.
And Mr. Manifold, thank you for joining us. As you can
tell, our schedule is so chaotic around here, we do appreciate
your coming in. I introduced you earlier, but I am going to
call on Dr. Shi to go on and make his statement, and then we
will go back to you.
Would you turn your microphone on?
TESTIMONY OF LEIYU SHI
Mr. Shi. Thank you, Mr. Chairman. Thank you, members of the
subcommittee for inviting me to testify at your hearing, a
review of community health centers: issues and opportunities.
My name is Leiyu Shi. I am a faculty member of the Johns
Hopkins Bloomberg School of Public Health. I am also co-
director of the Johns Hopkins Primary Care Policy Center for
the under-served populations.
For the past 15 years, I have conducted research related to
various aspects of community health centers. Today, I would
like to share with you some of my and our team's research work
related to the role of health centers in improving health care
access, quality, and outcome for the Nation's vulnerable
populations, particularly the uninsured and racial/ethnic
minorities.
Due to time constraints, I will highlight the findings in
my presentation and the PowerPoint slides provide the specifics
of the findings. Data from which these studies were conducted
come from a variety of sources, including that regularly
submitted by the federally qualified health centers, regular
surveys targeting health centers, new data collection by myself
or our research team, and also existing national surveys. The
published studies are listed at the end of the handouts and are
available upon request.
I would like to start by highlighting the profile of health
center patients. Those are in part one of the handouts.
Health center patients are predominantly racial/ethnic
minorities. Over 64 percent of those are minorities. Health
centers rely heavily on Medicaid funding. Indeed, Medicaid is
the single most important funding for health centers for the
past 14 years. Health centers are primary care safety net
providers for the uninsured, as over 41 percent of health
center users are uninsured. They are also primary care safety
net providers for the poor, as over 65 percent of health center
users are below the Federal poverty line.
Health center patients are sicker than patients seen in any
other settings in the country, except emergency rooms. I would
like to give some examples of research comparing access to
primary health care between health center patients and patients
seen in other settings. Those are in part two of the power
point handouts.
Among the uninsured patients, those seen by health centers
are more likely to have usual source of care than those seen in
any other places, 97.5 percent versus 64.9 percent. Health
center uninsured patients also have more doctor visits than
uninsured patients seen elsewhere, 56 percent versus 33.3
percent with four or more visits per year. Health center
patients even outperform nationally privately insured patients
on certain access indicators. For example, 97.4 percent health
center uninsured and 99.3 percent health center Medicaid
patients have usual source of care compared to 91.2 percent
nationally privately insured with usual source of care. Over 54
percent of health center uninsured and 65 percent health center
Medicaid patients have four or more visits per year compared to
55 percent of nationally privately insured patients with four
or more doctor visits per year.
I would like to now provide examples of research comparing
access to preventive health care between health center patients
and patients seen elsewhere. Those are in part three of the
handouts. In terms of cancer screening, pap tests among health
center females remain significantly higher than females below
200 percent Federal poverty line in the Nation. Mammography
screening among health center females remains significantly
higher than the females below 200 percent Federal poverty line
in the Nation. Health center diabetic patients use more
preventive services, including eye exam, foot exam, flu shot,
than diabetic patients nationwide. Health center uninsured and
Medicaid adults are more likely to receive health promotion
counseling, including smoking, alcohol, exercise, diet, drugs,
STDs, than U.S. Medicaid and uninsured patients seen elsewhere.
Let us turn to examples of research comparing quality of
health care between health center patients and patients seen
elsewhere. Those are in part four of the slides. Health center
Medicaid patients are significantly less likely to be
hospitalized for potentially avoidable conditions than those
obtaining care elsewhere. Health centers patients receive
comparable or even better quality primary care services than
managed care HMO patients, especially in the comprehensiveness
of services provided and the continuity of care.
Finally, I would like to summarize that the above examples
of research indicate that health centers provide better access
to and quality of care for the Nation's uninsured and low-
income minorities than elsewhere for the same vulnerable
groups. Their continuous support is critical to the Nation's
uninsured and low-income individuals. Providing basic primary
health care services to all is a valued national health policy
objective.
Thank you very much.
[The prepared statement of Leiyu Shi follows:]
Prepared Statement of Leiyu Shi, Co-Director, Johns Hopkins Primary
Care Policy Center for Underserved Populations, Johns Hopkins
University Bloomberg School of Public Health
Distinguished representatives, dear ladies and gentlemen, thank you
for inviting me to testify at your hearing titled ``a review of
community health centers: issues and opportunities.''
My name is Leiyu Shi. I am a faculty member from the Johns Hopkins
Bloomberg School of Public Health. I am also Co-Director of the Johns
Hopkins Primary Care Policy Center for the Underserved Populations. I
have a doctorate in public health and masters in public administration
and business administration. For the past 15 years, I have conducted
research related to various aspects of community health centers. Today
I would like to share with you some of my and our team's research work
related to the role of health centers in improving access, quality, and
outcome for the nation's vulnerable populations particularly the
uninsured and racial/ethnic minorities. Due to time constrain, I will
highlight the findings in my presentation. The attached power point
slides provide the specifics of the findings. Data from which these
studies were conducted come from a variety of sources including data
regularly submitted by federally qualified health centers (e.g., the
Uniform Data System), regular surveys targeting health centers (e.g.,
Health Center User/Visit Survey), new data collection by myself or our
research team (e.g., Sentinel Centers Network Project, numerous surveys
of health centers), and existing national surveys (e.g., National
Health Interview Survey). The published studies are listed at the end
of the slides and are available upon request. Further questions,
comments, or discussions can be directly to me through e-mail at
[email protected].
I'd like to start by highlighting the profile of health center
patients (see Part I of the power point slides). Health center patients
are predominantly racial/ethnic minorities (64%). Health centers rely
heavily on Medicaid funding (33%). Health centers are primary care
safety-net providers for the uninsured (41%) and the poor (65% below
FPL). Health center patients are sicker than patients seen in other
settings.
I'd like to give some examples of research comparing access to
primary health care between health center patients and patients seen in
other settings (see Part II of the power point slides). Among the
uninsured patients, those seen by health centers are more likely to
have usual source of care than those seen elsewhere (97.5% vs. 64.9%).
Health center uninsured patients also have more doctor visits than
uninsured patients seen elsewhere (56% vs. 33.3% with 4 or more visits
per year). Health center patients even outperform nationally privately
insured patients on certain access indicators. For example, 97.4%
health center uninsured and 99.3% health center Medicaid patients have
usual source of care compared to 91.2% nationally privately insured
with usual source of care. Over 54% of health center uninsured and
64.6% of health center Medicaid patients have 4 or more doctor visits
per year, compared to 54.9% of nationally privately insured patients
with 4 or more doctor visits per year.
I'd like to provide examples of research comparing access to
preventive health care between health center patients and patients seen
elsewhere (see Part III of the power point slides). In terms of cancer
screening, pap tests among health center females remain significantly
higher than females below 200% FPL in the nation. Mammography
screenings among health center females remain significantly higher than
the females below 200% FPL in the nation. Health Center diabetic
patients use more preventive services (including eye exam, foot exam,
flu shot, pneumovax) than diabetic patients nationwide. Health center
uninsured and Medicaid adults are more likely to receive health
promotion counseling (including smoking, alcohol, exercise, diet,
drugs, STDs) than U.S. Medicaid and uninsured patients).
Let's turn to examples of research comparing quality of health care
between health center patients and patients seen elsewhere (see Part IV
of the power point slides). Health center Medicaid patients are
significantly less likely to be hospitalized for potentially avoidable
conditions than those obtaining care elsewhere. Health centers patients
receive comparable or even better quality primary care services than
managed care (HMO) patients especially in the comprehensiveness of
services provided and the continuity of care.
Finally, I'd like to share examples of research comparing outcomes
of care between health center patients and patients seen elsewhere (see
Part V of the power point slides). Babies born to health center mothers
enjoy lower rates of low birth weight than those born elsewhere. There
is significantly less racial disparity in low birth weight rate within
health centers than within the nation as a whole (3.25 times vs. 5.6
times). Had the health center program become available to all the low-
income blacks in this country, 17,107 fewer low birth weight incidences
would result annually.
In conclusion, I would like to emphasize that the above examples of
research indicate that health centers provide better access to and
quality of care for the nation's uninsured and low-income minorities
than elsewhere for the same vulnerable groups. Their continual support
is critical to the nation's uninsured and low-income individuals if
providing basic primary health care services to all is a valued
national health policy objective.
Mr. Whitfield. Thank you, Dr. Shi.
And at this time, Mr. Manifold, as you are aware, this is
an investigative hearing, and I would like to swear you in for
your testimony.
[Witness sworn.]
Mr. Whitfield. Thank you very much, and you may proceed
with your opening statement.
TESTIMONY OF RODERICK V. MANIFOLD
Mr. Manifold. Thank you for your indulgence, Mr. Chairman,
members of the committee.
Thank you for inviting me to testify before you today about
Central Virginia Health Services, our community health center
in central Virginia. I am Rod Manifold, and I am the CEO of
CVHS. Our health center really got started back in 1968 when a
lady named Buelah Wiley slumped down in a chair at the local
Community Action Program offices and said, ``We should not have
to drive an hour and a half one way to take a child to see the
doctor.'' From that moment, community activities began that
culminated in the establishment in 1970 of Central Virginia
Community Health Center, now called Central Virginia Health
Services.
Today, our health center is a 10-site family of health
centers serving 18 counties and cities that are located from
the northern neck of Virginia to the city of Petersburg, south
to the North Carolina State line and west as far as Albemarle
County and Charlottesville. Central Virginia Health Services is
the oldest community health center organization in Virginia and
is celebrating its 35th year of operation in 2005. Last year,
Central Virginia served over 34,000 people, and it is still
operated as it was in 1970 by a board of directors made up of
community members that are committed to its mission. In fact,
63 percent of our board members are users of our services. This
community representation tempered with the responsibility for
the mission of the entire health center is one of the hallmarks
of the health center movement.
As in the 1970's, poverty and lack of access to care are
still primary reasons for the existence of Central Virginia and
the many other health centers around Virginia and around the
country. Lack of income, racial disparities, and lack of access
are all reasons why health centers are needed in central
Virginia. In the Central Virginia Health Services sites in
2004, more than half of our patients were minorities, 30
percent were below the Federal poverty guideline, and 31
percent were completely uninsured.
As you may know, community health centers do charge fees to
all of these patients. These are not free clinics, because
Congress in its wisdom set them up to collect fees on a sliding
scale basis from each and every one of our patients. All
consumers of our services participate in funding their
community health center based upon their ability to pay. It
gives them a kind of ownership of the health center in their
community, and it clearly states to them that these services
have a value.
In recent years, under the President's initiative to expand
health centers, Central Virginia, like many other health
centers around the country, has been able to expand services
and add additional access points for care in many communities.
We competed for and received a grant for a new access point in
Charles City County that has helped create a totally new health
center with medical, dental, and behavioral health services in
a county that previously had one part-time doctor serving the
community only three half-days per week and no dentist or
psychologist. Additionally, we receive grants to expand medical
capacity in two existing health centers, and we also received a
grant to add dental services in a health center that was
previously providing only medical services. All of these
additional services and sites would not have been possible
without the HRSA grants awarded under the President's
initiative.
In addition to thanking this subcommittee for its support
of the expansion of the program, I would be remiss if I didn't
also discuss the critical importance of the Medicaid program to
our health center. We respect that your committee has a very
difficult challenge in looking at reductions in the Medicaid
program. That being said, we do want to make one thing very
clear. The prospective payment system that Congress has given
to health centers because of our unique place in the safety net
is very important to health centers. We know that our patients
in that safety net will be our patients regardless of what sort
of payment methodology is created here. Obviously, if the PPS
was tinkered with, health centers could suffer greatly. In
addition, if Medicaid primary care benefits are reduced, our
patients will still need those services. We will just have to
use the Federal grant, which is designed to serve the many
uninsured patients in our centers, to subsidize the Medicaid
program and its patients.
In conclusion, Mr. Chairman and members of the
subcommittee, I appreciate the opportunity to discuss our work
at Central Virginia Health Services, and we appreciate the
recent expansion opportunities provided to all health centers.
We also stand ready to work with you as you debate changes in
the Medicaid program that may have a significant impact on our
operations and the patients we serve.
Thank you for your time, and I am happy to answer any
questions you may have.
[The prepared statement of Roderick V. Manifold follows:]
Prepared Statement of Roderick V. Manifold, Executive Director, Central
Virginia Health Services, Inc.
In 1968 a staff member named Beulah Wiley of the Community Action
Program in Cumberland County, Virginia returned from taking a child to
the doctor at the University of Virginia Medical Center. She reportedly
slumped down in a chair at the CAP offices and said, ``We should not
have to drive an hour and a half, one way, to take a child to see the
doctor.'' From that moment community activities (and I emphasize that
word community) began that culminated in the establishment in 1970 of
Central Virginia Community Health Center, located in Buckingham County
and serving three counties.
Today that health center has grown to a ten-site family of health
centers serving 18 counties and cities that are located from the
Northern Neck of Virginia to the city of Petersburg, south to the North
Carolina state line and west as far as Albemarle County and
Charlottesville. Central Virginia Health Services, as it is called
today, is the oldest community health center organization in Virginia
and is celebrating its 35th year of operation in 2005. Last year
Central Virginia served a diverse population of over 34,000 people in
rural and urban sites across its many community service areas. It is
still operated, as it was in 1970, by a board of directors made up of
community members that are committed to its mission. In fact, as many
of you may know, at least 51% of the board members of a community
health center must be consumers of the health center's services. Last
year, 63% of our board members were users of our services. This
community representation tempered with responsibility for the mission
of the entire health center is one of the hallmarks of the health
center movement. Being patients as well as leaders of the policy-
setting board makes our members the best possible representatives of
their communities and of the thousands of patients we serve.
As in the 1970's, poverty and lack of access to care are still
primary reasons for the existence of Central Virginia and the many
other health centers around Virginia and around the country. The high
poverty rate, severe health care disparities, and the lack of access to
the health care system are all reasons why health centers are needed in
central Virginia. In the Central Virginia Health Services sites in
2004, for example, more than half (51%) of our patients were
minorities, 30% were below the federal poverty guideline, and 31% were
completely uninsured. These numbers of high need are not unusual for a
community health center. In fact, in one of our urban centers, over 50%
of our patients are uninsured and fully 70% are below the federal
poverty guideline.
As you may know, community health centers do charge fees to all of
these patients. These are not free clinics, because Congress in its
wisdom set them up to collect fees on a sliding scale basis from each
and every one of our patients. All consumers of our services
participate in funding their community health center based upon their
ability to pay. It gives them a kind of ``ownership'' of the health
center in their community, and it clearly states to them that these
services have a value. Last year Central Virginia Health Services
collected from our various payer sources (not including the federal
grant we receive to assist the uninsured patients), 24% of our patient
income from private insurance companies, 30% from Medicaid, 20% from
Medicare, and 26% directly from patients' payments. As an example of
those patient payments, we have a collection rate of over 95% from our
Medicare patients for the services they receive from our providers.
While these numbers are not the same in every health center, virtually
all health centers work to develop a broad spectrum of payer sources,
in addition to the HRSA grant.
In recent years, under the President's initiative to expand health
centers, Central Virginia, has been able to expand services and add
additional access points for care in many communities. We competed for
and received a grant for a new access point in Charles City County, a
jurisdiction with a minority population of over 75%. This grant helped
to create a totally new health center with medical, dental and
behavioral health services in a county that previously had one part-
time private doctor serving the community only three half days per week
and no dentists or psychologists. Additionally we received grants to
expand medical capacity in two existing health centers, and we also
received a grant to add dental services in a health center that was
previously providing only medical services. All of these additional
services and sites would not have been possible without the HRSA grants
awarded under the President's Initiative and funded by Congress. And
these grants have stimulated private foundations to provide funding for
additional services to be provided in several of our existing health
centers.
Of perhaps even more compelling interest to this subcommittee and
your full committee, are some issues related to Medicaid and Medicare.
Frankly, as a community health center director, I worry about these two
major payer sources for our patients. Remember that we health centers
are the true safety net providers of primary care for many of our
nation's most vulnerable citizens. And I mean, we really are working in
the frayed bottom of that safety net. We live day to day, and we get
very concerned when Congress begins to discuss cuts to the Medicaid
program. We respect that your committee and the Medicaid Commission
have a very difficult challenge in looking at reductions in the
Medicaid program. That being said, we do want to make one thing very
clear: the prospective payment system (PPS) that Congress has given to
health centers because of our unique place in the safety net is very,
very important to health centers. We know that our patients in that
safety net will be our patients regardless of what sort of payment
methodology is created here. Obviously, if the PPS was tinkered with,
health centers could suffer greatly. In addition, if Medicaid primary
care benefits are reduced, our patients will still need those services.
We will just have to use the federal grant, which is designed to serve
the many uninsured patients in our centers, to ``subsidize'' the
Medicaid program and its patients. Furthermore, if Medicaid eligibility
limits are lowered, and more patients are moved off the Medicaid rolls,
we in health centers will still serve those patients, only they will
then join the ranks of the uninsured. Reductions in benefits and/or
eligibility levels for Medicaid will be a real double whammy to health
centers and their patients, and could well bring about drastic
reductions in programs and services--exactly the opposite of the goal
for the President's Initiative. At Central Virginia, our providers and
staff know these patients very well, and we know that they will look to
us for their care, regardless of whether they have Medicaid or not.
Also of interest to this subcommittee, of course, is the Medicare
Part D program. The provision of pharmaceuticals to Medicare patients
will be the largest contributor to better health outcomes for our
health center Medicare patients since the inception of the Medicare
program itself. We look forward to 2006 and we hope that the
development of training and orientation programs and materials for
seniors and for us caregivers of seniors will come in time for every
Medicare recipient to benefit fully from this new service. We know that
CMS and other agencies are working to meet the deadline set by Congress
for the initiation of this program. Please know that we in community
health centers will do everything possible to assist in this monumental
effort, because we truly know how important it is to the health of our
individual patients.
I would like to tell you about another part of the community health
center story in one of our communities: Farmville and Prince Edward
County, Virginia. In the mid-1980's the Piedmont Health District
serving these two localities and the surrounding counties had one of
the highest infant mortality rates in the Commonwealth of Virginia. In
1985 Central Virginia Health Services, the Virginia Department of
Health, and the federal government collaborated to open the Women's
Health Center in Farmville. This OB-Gyn practice started small with one
physician and a tiny group of support staff. The Health Center for
Women and Families, as it is called today, now provides the only
obstetric services in this rural community. Our center there has two
full time OB-Gyn physicians, one full time family practice physician,
and one part time nurse midwife doing deliveries in the local hospital
and, along with a full time nurse practitioner, they also provide
virtually all of the prenatal care for the community. This is a real
success story for Farmville and the surrounding area. While several
community hospitals in Virginia have recently closed down their labor
and delivery service due to skyrocketing malpractice insurance and
other factors, Southside Community Hospital, with our assistance, has
been able to not only keep its community obstetric program, but to make
it grow and thrive. By the way, the infant mortality rate has gone down
over the past twenty years and the community and its families are all
the better for that positive outcome.
I would like to close with a story about the first community health
center patient in Virginia. Dr. Mike Shepherd, a University of Virginia
physician and the first physician of Central Virginia Community Health
Center, recounts this story of opening day on the Friday after
Thanksgiving in 1970. I have told it many times because I believe it
illustrates why health centers are an absolute necessity in many
communities around our country. A woman in her eighties was brought to
the center by her family on that first day. She was being interviewed
by the nurse taking her health history. The nurse asked the woman when
was the last time she was seen by a doctor. The woman thought for a few
moments and finally said, ``Nineteen and twenty-three.'' And that is
why health centers are needed. Here was woman who was not seen by a
doctor for nearly 50 years. And, while we don't find many patients
these days with such a long time between visits, we do know that we
serve people who need us and who would not be seen if it were not for
the health center in their communities.
Mr. Whitfield. Thank you, Mr. Manifold.
And I would ask all of you, are any of you familiar with
some community health centers over the last couple of years
that have gone into bankruptcy or have gone out of operation?
Are any of you aware of any that have gone out of business?
Mr. Hawkins. On a national level, Mr. Chairman, what I can
tell you is I have not seen data for the last couple of years,
but I have no reason to suspect it is different from the data I
have seen for the previous 10 years. In any given year, three
to five health centers will have their grant pulled. They will
be defunded. They will be folded into another center. An effort
is always made by, I am going to call them the feds, HRSA to
keep the services going when an existing health center runs
into trouble. But that is three to five out of 1,000. So that
is a failure rate of less than 1 percent. I have never seen it
exceed 1 percent.
Mr. Whitfield. And they are basically folded in with
another when that occurs?
Mr. Hawkins. Most often. I think it is quite rare when HRSA
has pulled the resources completely out of the community, but
they do insist that centers be well managed.
Mr. Whitfield. Right. Now patients pay on a sliding scale.
Some do not have to pay anything, and others pay full price.
Those of you who operate a center, could you tell me the range
of prices that are paid per visit by a patient? From zero to
what?
Mr. Manifold. Well, we established these sets of charges
based on the statute that basically sets it at the cost of
doing business the usual and customary in the community. So you
could be, in some communities, as much as $50 or $60 or $70 a
visit for someone who is able to pay the full charge.
Mr. Whitfield. So if I come in and I am over the poverty
level, and say I am at 200 percent of the poverty level, and I
come in Petersburg, Virginia to the clinic, what would I be
expected to pay per visit?
Mr. Manifold. If you are over 200 percent of the poverty
level?
Mr. Whitfield. Yes.
Mr. Manifold. You would pay the full charge, whatever it is
in that particular community.
Mr. Whitfield. So it would be, maybe, $50 or $60?
Mr. Manifold. It could be, yes. I can't tell you right off
the top of my head what it is. Part of it depends on your
health and what sort of services you receive at that time.
Mr. Whitfield. Okay. So it does depend on the service? It
is not just the one fee.
Mr. Manifold. Just like any other health care institution,
yes.
Mr. Whitfield. Okay. Now I have heard some discussion about
the President's budget and even though he is requesting more
money for the centers, people are concerned that because each
center receives a grant each year, that even though more money
being available and wanting to create more new centers that the
existing centers are a little bit concerned about whether or
not they are going to continue to receive their grant each
year. Is that a concern or is that not a concern?
Mr. Hawkins. Nationally, I think, Mr. Chairman, every
health center must go through a competing grant renewal process
every, what is it, Rod, 3 years or 5?
Mr. Manifold. Yes, three to five.
Mr. Hawkins. Three to 5 years depending on how good their
record is and how well they are operated. The best operated
ones perhaps every 5 years. They do have to submit
documentation and annual audits, et cetera, every year. I will
let the actual health center folks answer, but I will tell you
what we have heard from health centers is not so much that they
are concerned about losing their current grant, it is that the
grant doesn't keep pace with the increased costs.
Mr. Whitfield. Okay.
Mr. Hawkins. Health center cost increases on a per-patient
basis are among the lowest in the health care system, usually
about 4 percent a year, and that is over the last 8 years.
Mr. Whitfield. And what is the maximum grant that one can
receive?
Mr. Hawkins. There is no ceiling on that. Although not on a
formula basis, it is done often related to per-patient cost or
per-uninsured patient----
Mr. Whitfield. Well, what grants do you all receive? The
ones here.
Mr. Manifold. Well, at Central Virginia, we have added
various sites over the years from that original site in 1970.
Mr. Whitfield. Right.
Mr. Manifold. And so each time that we have been able to
add a site, we have been able to get additional funding for
that site, which then stays with it?
Mr. Whitfield. How much?
Mr. Manifold. Well, I can tell you that in 1995, we were
getting $250,000 per year to start a new health center site.
Now you must provide more services. You must provide dental,
behavioral health----
Mr. Whitfield. But do you have an overall figure of what
your center receives?
Mr. Manifold. What Central Virginia receives?
Mr. Whitfield. Yes.
Mr. Manifold. We receive $5.2 million in Central Virginia.
Mr. Whitfield. Okay. Okay.
Mr. Manifold. It is about 34 percent of our operation----
Mr. Whitfield. Okay. What about you, Ms. Sibilsky, in
Michigan?
Ms. Sibilsky. I am a primary care association.
Mr. Whitfield. Right.
Ms. Sibilsky. We are not a health center, specifically.
Mr. Whitfield. Oh, you are not?
Ms. Sibilsky. No.
Mr. Whitfield. So----
Ms. Sibilsky. We are a Statewide association that works
with health centers.
Mr. Whitfield. So you don't receive any grants?
Ms. Sibilsky. We do receive a grant to do technical
assistance and support to health centers as well as going to
communities to help them get ready to be able to provide that
primary care.
Mr. Whitfield. How much is your grant that you receive?
Ms. Sibilsky. We receive about $625,000 for the technical
assistance component.
Mr. Whitfield. Okay. Okay. And what about you, Dr.
Goetcheus?
Ms. Goetcheus. I was just getting the answer to that, $6.4
million is what we----
Mr. Whitfield. $6.4 million.
Ms. Goetcheus. [continuing] receive.
Mr. Whitfield. Okay.
Ms. Goetcheus. Just in regard to what was asked as far as
the base funding, we do get concerned. The health care costs
for insurance for our folks go up----
Mr. Whitfield. Right.
Ms. Goetcheus. [continuing] as well as just basic expenses,
so we do get very concerned about base funding.
Mr. Whitfield. Now I have heard different answers on this
question. Can you or can you not spend money on capital
projects from the grant money?
Mr. Hawkins. On acquisition and lease, yes; on
construction, modernization, renovation, no.
Mr. Whitfield. But on acquisition and lease, yes.
Mr. Hawkins. Yes.
Mr. Whitfield. But for renovation and modernization, no.
Mr. Hawkins. Any bricks and mortar. If you need to put in
an elevator to make the facility ADA compliant, no go.
Mr. Whitfield. Okay.
Mr. Hawkins. If you need to wire the facility for
electronic health records, no.
Mr. Whitfield. Right.
Mr. Hawkins. If you need to paint the interior of the
facility, you may not use the grant dollars for that purpose.
It is prohibited.
Mr. Whitfield. Okay.
Mr. Hawkins. That was stripped from the statute 10 years
ago.
Mr. Whitfield. Okay. Okay. Now someone made the comment
that community health centers provide care for 10 percent of
the Medicaid population at a cost of only 1 percent of the
total Medicaid dollars. Is that correct?
Mr. Hawkins. That is correct, Mr. Chairman. Six million
people, it is less than $3 billion. The last number I have is
$2.5 billion in total Medicaid payments to health centers for
approximately 6 million Medicaid recipients. That is under $500
per patient per year for the four visits that Dr. Shi
mentioned.
Mr. Whitfield. And some of you may have heard in my opening
statement I made the comment we have people on Medicare, we
have people on Medicaid, and then we have a lot of uninsured
who are working who have jobs, but their employer does not
provide their health insurance. They are paying taxes for
Medicare and taxes for Medicaid, but they can not afford to buy
their own health insurance and they maybe do not have a
community health center area to visit. So I would ask the
question, do you believe that community health centers have the
capacity with the right resources available to be the primary
health and preventive care providers for the country for the
uninsured, let us say? Or is that capability not----
Ms. Sibilsky. It would be a wonderful model with limitless
resources to be able to provide. I believe in the model I
worked with modeled for 26 years, comprehensive, primary care,
prevention, and community based. It is also a wonderful part of
a whole system of care, and that is the way I think we have to
look at it, because there are not limitless resources. It is a
tremendous model, especially in under-served communities.
Mr. Hawkins. It is a model for primary care, Mr. Chairman.
I have been in it for 35 years, and I don't know that even I,
in my ideal world vision, would see health centers even as the
primary care provider for all Americans, although there are
those who would say that they would only wish that they could
get primary care for their family like they have seen delivered
at a health center. But for uninsured, for low-income, both
publicly insured and uninsured, for isolated rural, for inner
city communities, for those working people that you talk about,
with or without insurance coverage, every American needs, and
Dr. Shi can speak to this, two things for good health, and plus
their own thing, and that is insurance coverage to make the
care affordable and a health care home, a family doctor who is
the organizer of their care. I don't see health centers doing
specialty care, doing inpatient hospital, or long-term care,
but primary care and being the care manager for each
individual, organizing referrals, et cetera, down the road.
Mr. Shi. I just want to add that I do believe that the
community health centers are a very well suited model for
community-based primary care for all Americans. And many
physicians' offices are not equipped to provide enabling
services and culturally sensitive care that community health
centers are able to provide.
Mr. Whitfield. Right. Okay. And you studied them quite a
bit. So thank you.
Mr. Shi. Yes.
Mr. Whitfield. My time is expired, so I recognize Mr.
Stupak.
Mr. Stupak. Thank you, Mr. Chairman, and thank you all for
being here and doing what you do. I have quite a few health
centers in my District, and I am always amazed at the work they
do on a very, very thin dime.
Why was the brick and mortar stripped out 10 years ago? You
said that. Was it alleged abuse within the program or what
happened? Because I mean, it seems to be a big issue with
health care centers.
Mr. Hawkins. It is a cautionary tale, and what can happen
some time when something is inadvertent and unintentional. In
the process of stripping out language that related to the Davis
Bacon wage and hour law, which had been in the statute since
1978, the Congress inadvertently, we believe, and certainly
even those who were involved in it told us they never intended
to strip out the authority for construction, only the language
that related to the Davis Bacon law. Unfortunately, what was
stripped was all of the construction modernization and
expansion language. And attempts to restore that since that
time have not been successful.
Mr. Stupak. Is there opposition from others for----
Mr. Hawkins. No one opposes restoring the construction
authority. The authority for health centers to use even a small
portion, no one believes that a big part of the health center
funding should go for bricks and mortar. It is patient care
dollars. But no one opposes restoring the authority for some
portion of that to be used for bricks and mortar. The divide,
Mr. Stupak, is literally over whether to restore it without
Davis Bacon or with Davis Bacon, and there, unfortunately,
quite frankly, I don't think it is a divide up here. It is a
divide out there.
Mr. Stupak. Well, let me ask this question. There are a
number of health care centers that have increased significantly
in the last few years, and there is an increased likelihood
that centers will be located in areas where they are in
competition with other health centers and private
practitioners. With resources being stretched, what safeguards
are used, if you know, in the grant review process, this is
really a question I had for HRSA, but I never got to it, to
ensure that placement of health centers are in the proper
location so that agency gets the best bang for its buck, its
Federal dollars? How do you do that? I mean, actually some
folks have said we don't want health centers where we have
other private practitioners. And is that part of the problem
here?
Mr. Hawkins. It may be in some communities. I remember in
south Texas 35 years ago a grave concern among the local
private practice physicians at the startup of our health
center, they all understood that there was a population that
they didn't have the resources to care for. And they were happy
to have the health center care for that population. They were
deeply concerned about that center then being a place that
might encourage people with private insurance to go.
Mr. Stupak. I see.
Mr. Hawkins. As time went on, I think all of the private
practitioners, in fact, they all donated their time to the
facility, they came to see, and I will defer to my colleagues
who are out there today.
Mr. Stupak. Sure, I would be interested to what Dr.
Goetcheus thought on that one.
Mr. Hawkins. They came to see it much more as a benefit
than not.
Ms. Goetcheus. In terms of DC, the need is so great that
two of the new starts that have just come are within a few
blocks of one of our health services. The need is so great; we
are all very busy. I think----
Mr. Stupak. Do specialists, though, not want you in the
area because you may detract from their patients? Specialists?
Ms. Goetcheus. Specialists are hard to obtain, and they are
very hard to obtain in terms of accepting Medicaid or here in
the District, trying to find those specialists who will accept
that kind of insurance. That is why we have brought specialists
to our sites. One of the limiting factors has been in terms of
the Federal tort for them. For example, we have so many HIV
patients, so we have hired two infectious disease physicians to
be a part of our staff, because trying to find access otherwise
for them with Medicaid or no insurance is very hard.
Mr. Stupak. It is very difficult. Sure.
Mr. Chairman, if I may, with your permission, the
reinstatement of oral health benefits for Medicaid adults, I
think every one of our witnesses here this afternoon mentioned
adult oral health care and the benefits thereof, and this
actually happens to be from Ms. Sibilsky's group. It is a
three-page document, and if you don't mind, I would like to
place it into the record and--well, it is already in the
record. Okay. Great.
But Kim, could you just mention some of the highlights you
found? I found this really fascinating. Michigan did it for the
first time, and then unfortunately we have to cut it out after
being so successful because there is no money there. But you
have all mentioned it, and I just want to----
Ms. Sibilsky. Yes. For a $9.2 million savings in general
fund for the State budget, we have done an assessment of
inappropriate care in the emergency room, which begins to
approach that $9.2 million. When you then look at the Medicaid
managed care billings that are addressing the issues that would
appropriately be handled within the health centers in their
dental component, you get very, very close to the $9.2 million
savings. And that doesn't even address how ill people get when
they have that primary infection in their mouth: heart disease,
diabetes, perinatal health is just directly impacted. I think
that it is a service that has been seen to be not a primary
care service, but is now being looked at and sadly being looked
at so closely because we are in such big trouble with it. I
would hope that some day it is seen to be a mandatory service
under Medicaid and not an optional service, because it is such
a critical need.
Mr. Stupak. And then I am a little confused, and maybe you
can help me on this. From what I have read, the Surgeon General
of the United States keeps saying that we don't need this
service, the oral health care for folks, or do I have that
right? He encourages or discourages it?
Ms. Sibilsky. I can't speak to that, Mr. Stupak. I am
sorry.
Mr. Stupak. Okay. So in Michigan now, are they getting
dental care, the patients?
Ms. Sibilsky. At this point, under the Medicaid program,
only emergency care is being delivered and paid for. For any
dental services beyond that to adults that are being delivered
in the health centers is being subsidized by the Federal grant
as uninsured. So you have Medicaid-covered adults categorized
as uninsured for dental services. So the grant is subsidizing
Medicaid on those services.
Mr. Stupak. Okay. I talked about, earlier, rural programs,
and I didn't get to ask all of my questions, because I was
concerned about the nursing act. I was concerned about the huge
cut that we saw in the funds to try to lure specialists to our
rural areas or under-served areas. And in those two programs, I
think one was cut like $100 million this year and then next
year it is going to be $11 million and then that just about
wipes about that program. That is the program to attract
specialists to our areas. And if we don't fund these programs,
what is going to happen to bring your specialists in? You all
talk about collaborative efforts you have with other people.
Are these specialists volunteering their time, or do they
expect some kind of reimbursement, because I just don't see how
we are going to continue to do what you are doing as we are
expanding the number of health care centers when the programs
we have to provide rural health and to recruit physicians and
everything else is being severely cut? I mean, Dr. Burgess
talked about we need, for doctors, higher reimbursement, but
you have got to have doctors there first before you have to
worry about reimbursements, and we are not getting the doctors.
Am I wrong?
Ms. Sibilsky. I would like to cite the large amount of
volunteerism that is actually happening within the State of
Michigan right now. Physicians went into health service for
altruistic reasons, and when they feel the intensity of the
problem the way that they are feeling it today, they do
volunteer. And that is why the Federal torts claims act
coverage for free clinics has been very helpful and why
extending that into health centers is going to be even more
important. The training programs are under siege with the State
budgets. For them to be under siege with the Federal budget
puts us, once again, right in the middle of the fire. This is
not a simple Medicaid issue that we are dealing with. We are
under duress on every side. And so the programs you asked
about, for example, the rural health outreach program that has
helped communities innovate in order to attempt to invent
themselves out of these problems through collaborative efforts
and outreach efforts. To have those zeroed out is also a very
big problem for rural communities.
Mr. Stupak. Yes, it is about a 70 percent cut.
Mr. Manifold, how about the rural flexibility grant
programs? Have you used that? Has that helped? Michigan, right
now we have got some high unemployment. We are having some
tough times in Michigan, but Virginia seems to be doing a
little bit better from what I read in the local papers.
Mr. Manifold. We do not use that program in Virginia, that
I know of, not in the health center arena, so I can't speak to
that issue.
Mr. Stupak. That is interesting.
Mr. Manifold. Unless I am not understanding the
terminology.
Mr. Stupak. Well, the rural flexibility grant program
actually helps our hospitals in northern Michigan go into the
critical access hospitals, which are the smaller hospitals that
provide critical access in really remote rural areas, and they
get a pretty good reimbursement. And that program actually is
one of those that has really been a great help to us, and we
see it zeroed out in the budget, so I thought you just might
have the same thing.
Mr. Manifold. Yes. Because the critical access hospitals in
Virginia are few and far between, many in southwest Virginia, I
can't say that our particular arena of health centers in
Central Virginia has any connection directly with any critical
access hospitals in Virginia.
Mr. Hawkins. Mr. Stupak, if I could add, though.
Mr. Stupak. Sure.
Mr. Hawkins. Across the country, we have heard from health
centers who have worked very closely with critical access
hospitals in their communities. Health centers help those
hospitals keep their doors open. They staff them, especially in
the taking evenings and weekends, et cetera, and they have
reported. I mean, the affiliation is in partnerships that have
developed across the country between health centers and
hospitals and especially in rural communities where they are so
crucial to one another. They are interdependent. It is
heartening to see, because each is helping to keep the other in
business for the benefit of the community.
Mr. Stupak. Sure. One more, if I may.
Dr. Shi, you mentioned in your oral testimony that health
center patients receive ``comparable or even better quality
primary care services than managed care HMO patients,
especially in the comprehensiveness of service provided and the
continuity of care.'' When I was asking Mr. Smith the questions
there, and even Dr. Duke, they kept talking about other sources
of funding. The only other sources of funding I have really
seen being pushed is probably managed care or, as you all do,
private fundraising to keep you guys open. If we continue to
move toward HMOs or managed care, do you feel there will be a
decline in the quality of service provided to our patients?
Mr. Shi. Compared to community health centers, I agree.
Yes, it is on my page 36 of the handouts. I have the details of
that study.
Mr. Stupak. Okay.
Mr. Shi. It compares HMO with health center patients in
terms of the primary care they received from the doctors. And
we look at various domains of primary care using our primary
care assessment tool. We find that----
Mr. Stupak. There it is.
Mr. Shi. Yes. If you look at comprehensiveness of services,
health centers are rated much higher than HMOs, and the
continuity of care, they are also rated higher than HMOs. On
the other indicators of primary care quality, they are
comparable. And the overall primary care score is also higher
among health center patients than among HMOs.
Mr. Stupak. Thank you. Thank you for the time.
Mr. Whitfield. There are a number of areas I want to get
into in just a minute here.
On the managed care issue, I know there was some testimony
that because managed care pays so little on reimbursement, that
the State, I believe, has to make up that difference in the
reimbursement to the community health center in most States or
all States, is that correct?
Mr. Hawkins. All States.
Mr. Whitfield. Okay. Okay. And so Dr. Shi is making the
argument that the managed care, we are underpaying but they are
not providing the quality of health care. But on Michigan just
a minute, the dental program in Michigan was dropped. That was
a decision that the State of Michigan made, and it sounds like
it was a short-sighted decision, because they are saving $9.2
million by dropping it, but maybe infection rates have gone up
and health care has gone up and so overall Medicaid costs have
probably escalated. Is that right?
Ms. Sibilsky. We are seeing symptoms of that.
Mr. Whitfield. Okay. Now I know that there are some loan
guarantee programs out there for the community health centers.
And maybe you, Ms. Sibilsky, have even made the argument during
the 1980's that some changes were made to the community health
center program that gave you the flexibility of running it more
as a business than as a government entity and that sort of
freedom provided you with some innovative opportunities. Would
you expand on that a little bit for us?
Ms. Sibilsky. I believe that much of the value of health
centers has been displayed in its ability to be a business and
be viable and be managed accordingly. It has spurred innovation
to keep us viable. It has also helped us, I believe, to become
a bipartisanly supported program.
Mr. Whitfield. Right.
Ms. Sibilsky. Communities, as Mr. Manifold says, and I will
yield to him, want to participate in something that they can
pay for and receive value.
Mr. Whitfield. Right.
Ms. Sibilsky. And I believe very strongly in those precepts
in our program.
Mr. Whitfield. Well, you know, one of the frustrating
things for me, having been elected to Congress in 1994, we have
been talking about trying to address the uninsured program, and
I know people go in and out of uninsured status, but we have
some areas of the country that have wonderful community health
centers, like your area, Mr. Manifold, where more and more
people are going to those centers. And then we have other
centers that the taxpayers don't have anything. And so we have
some people paying taxes, and they have a tremendous program,
and others are paying taxes that have nothing. And that is why
I was asking this question about using this as a model to be
the primary care for the Nation. And I think the consensus was,
among this group at least, that you would probably agree with
that.
Now let me ask this question. Would you agree if State
Medicaid programs individually could use their Medicaid dollars
to expand community health centers? I mean, they are already
paying a lot of health care providers. Maybe they could get a
group together and say won't you provide this service under the
community health center umbrella. Would you support that kind
of a concept?
Mr. Hawkins. Mr. Chairman, if it were an allowable use of
Medicaid dollars. Although, I suppose, under administrative
cost expenses, and I assume what you are talking about is the
startup costs for establishing and getting a health center
going.
Mr. Whitfield. Right. Right.
Mr. Hawkins. The one big question, then, that would come up
is the Federal grants that Mr. Manifold receives, that Dr.
Goetcheus' center receives really, if you look at how a health
center budget breaks out, and then the patient population by
payer source, the Federal grants really truly go to cover care
for the uninsured. So I guess the only question left would be,
then, would Medicaid be paying for the uninsured? They don't at
health centers today.
Mr. Whitfield. Right.
Mr. Hawkins. And there is always a concern. We have heard
that from Medicare and Medicaid. We are happy to pay for care
for our beneficiaries, but we don't want to be paying for
others.
Mr. Whitfield. Right. Well, just kind of discussing things
here, I read an article not too long ago that General Motors is
now paying more for its health care costs than it is for its
material for the car or the vehicles that they produce. What
would you think about if General Motors could put money into
establishing a community health center under all of the Federal
guidelines with all of the drug discounts, the tort claim
liability protection and whatever, but they had to put the
money into it to expand it to make it available to more people?
Is that a concept that would be totally ridiculous, or is that
one that you would be willing to maybe explore?
Mr. Hawkins. I don't think it is ridiculous at all, Mr.
Chairman. The same day that the CEO of GM came out and made
that statement about the sheer cost of health care there was an
article in the Wall Street Journal, and I will be happy to get
you a copy of it for the record. A company named Quad Graphics
in Wisconsin, it is a printing company, and it does business
with Mars Bars and M&M and places all over the country. It
makes the wrapper paper. The article pointed out that Quad
Graphics is a relatively small employer. It has got printing
plants around the country. It was fed up with its increasing
health insurance costs, and it opened up a primary care center
in its main printing plant in Wisconsin and watched its total
health care bill drop like a rock.
Mr. Whitfield. Really?
Mr. Hawkins. Yes. Saving 15 percent or more in health care
spending. They are, obviously, a self-insured plan. So they
reap the benefits of the investment in that primary care
center. It is a measure for the ages, because it is not just
any kind of primary care when you have organized primary care
with a focus on, through the collaboratives, providing quality
care, the kind of standards that health centers must operate
under. And then I would argue, the strong community oversight
that ensures that that center responds to the real local
problems, that is the measure for success.
Mr. Whitfield. Right.
Mr. Hawkins. And I think that Quad Graphics got it right,
as one business.
Mr. Whitfield. Would you give us a copy of that?
Mr. Hawkins. I would be glad to do so, sir.
Mr. Whitfield. All right. Provide that for us.
Do you have any questions, Mr. Stupak?
Mr. Stupak. Mr. Chairman, I want to ask Ms. Sibilsky this.
You all do a great job, and I am seeing this. I am really
concerned about this expansion on community health centers and
how we are going to get reimbursed. It just seems to me, and I
tried to get more out of Mr. Smith that during these difficult
economic times, while Michigan is having it, and I am sure
other parts of the country are, too, that Medicare
reimbursement should be going up as you are seeing more and
more people. And I think I pointed to Michigan with a 30-
percent increase but yet we have been able to hold the cost at
about 5 percent.
Ms. Sibilsky. Right.
Mr. Stupak. And when I was trying to ask these questions, I
kept hearing about other sources of funding and all of that.
And the only other sources of funding that I really know or see
is your great job in getting private contributions into the
system. And it certainly helps out a lot. And you mentioned
this in your written testimony about the prospective payment
system gives community health centers a higher fee per office
visit than a private physician would receive, and you explained
that at a center might include other services not included in
an office visit with a private doctor. Could you explain that a
little bit more just to clarify it for me?
Ms. Sibilsky. Right. An encounter is the terminology we
use, and an encounter is all of the services delivered to an
individual in a day at a health center for medical. Now since
we have gone into mental health and substance abuse services
and dental care, you could actually have three encounters a
day. But if you are talking about the medical encounter, it can
include lab, it can include x-ray, it can include education,
our whole bundle, pharmacy. It is the whole bundle of services
delivered to an individual in 1 day is one encounter.
Mr. Stupak. So the reimbursement is for that one encounter?
Ms. Sibilsky. Correct.
Mr. Stupak. Okay. So if I go in and I have got a bad knee
and I want you to look at it, but you might talk to me about--
--
Ms. Sibilsky. Your weight.
Mr. Stupak. What is wrong with it?
Ms. Sibilsky. Excuse me. I am sorry. I have no intention
of----
Mr. Stupak. I am only teasing. I am only teasing.
Ms. Sibilsky. I am sorry, Mr. Stupak.
Mr. Stupak. No, no, no. I am only teasing.
Ms. Sibilsky. But one person's weight.
Mr. Stupak. How about my blood pressure being here in
Congress?
Ms. Sibilsky. Okay. Blood pressure.
Mr. Stupak. So that is the difference. So if I went to a
doctor's office, I would get multiple bills, then, would I not,
for the service, but not for the encounter of the day?
Ms. Sibilsky. Yes, you would. Absolutely.
Mr. Stupak. I see. I see.
Ms. Sibilsky. Absolutely. And so when we were talking about
it is the benefit of prospective payment to our health centers
allowing us to be able to budget, we know, on a prospective
basis, what we are going to be receiving from Medicaid.
Mr. Stupak. Okay.
Ms. Sibilsky. And so we can project what we can spend.
Mr. Stupak. Sure.
Ms. Sibilsky. And it forces us to economize and to
creative, in the legal sense of the term, work.
Mr. Stupak. Okay. But then in your testimony you also
talked about how the waiver program may threaten the
prospective payment system.
Ms. Sibilsky. Yes.
Mr. Stupak. Okay. Explain that.
Ms. Sibilsky. Well, for example, with the SCHIP program,
when it came into Michigan, we were very supportive of that
program, of course. And we are not concerned especially about
receiving the FQHC prospective payment assurances under SCHIP,
because it was going to be for kids.
Mr. Stupak. Right.
Ms. Sibilsky. And kids are lower cost. However, under the
Michigan adults benefit waiver, as you recall, that is an SCHIP
waiver that covers childless adults up to 35 percent of
poverty. These are people who have been out of health care,
except perhaps through a voucher, for years. And so what it
does is it gives the SCHIP payment for adults who are terribly
complicated. I mean, Dr. Goetcheus sees these people. They are
on the streets. They are dual diagnosis: mental health and
substance abuse, and they are expensive. So waiver programs, we
believe that population should be served, and we are seeing
half to two-thirds of those folks within our clinics, but
actually at about 85 percent of fee for service, which is,
itself, at about 60 percent of reasonable cost.
Mr. Stupak. Well, but 60 percent. What are you actually
getting paid, then, for these adults? Because SCHIP, it is not
very large reimbursement at all.
Ms. Sibilsky. No, it is probably between $25 and $30 for an
encounter.
Mr. Stupak. For everything for that day?
Ms. Sibilsky. For everything, because all of the people who
we serve receive the same types of services, the FQHC bundle of
services.
Mr. Stupak. And obviously the sliding scale doesn't help
you, because there is nothing there.
Ms. Sibilsky. Thirty-five percent of poverty is about $260
a month.
Mr. Hawkins. In Medicaid or SCHIP, you can't bill for any
underpayment. That would be balance billing. It would violate
the Federal statute.
Ms. Sibilsky. Right.
Mr. Stupak. Okay.
Mr. Whitfield. Dr. Goetcheus, one question I just want to
ask you.
You mentioned something about 2,400 individuals are coming
from prison back to DC. Is that per year?
Ms. Goetcheus. Per year.
Mr. Whitfield. Is that right?
Ms. Goetcheus. And they are scattered all over the United
States.
Mr. Whitfield. Each year.
Ms. Goetcheus. For instance, in Rivers, North Carolina,
there are 1,000 District residents in that prison. What we have
set up is some telecommunication so we can try to have, even in
groups and individuals, to try to talk with them about when you
get back into the District, you need your medications. This is
where you come. If you are coming to a homeless shelter,
because a lot of them end up in homeless shelters, this is the
shelter we want you to come to, because we have a health
service there and we want you to come in. And we have social
workers there, and we will try to get you jobs. And but it is
2,400 a year coming from the prisons around the United States
back into the District and 50 a day coming out of DC jail back
into the community.
Mr. Whitfield. Per day?
Ms. Goetcheus. Per day.
Mr. Stupak. I found this statement intriguing and the
theory. Mr. Hawkins, I think you mentioned it. For 1 percent,
you are providing for 10 percent of the people, right?
Mr. Hawkins. That is correct, Mr. Stupak.
Mr. Stupak. So in theory, if we gave you 2 percent, could
you provide for 20 percent?
Mr. Hawkins. In theory, yes.
Mr. Stupak. Could you go 10 percent at 100 percent?
Mr. Hawkins. For 100 percent?
Mr. Stupak. No, no, no, 10 percent for 100 percent.
Mr. Hawkins. Well, and keep in mind, please, that that is 2
percent of total Medicaid spending, which includes hospital and
nursing homes.
Mr. Stupak. Sure.
Mr. Hawkins. But about 25 percent of Medicaid goes for
physician services. And so by dint of that, your math is good.
For 10 percent of Medicaid spending, or about half of what is
spent on physician services today, yes, we could provide the
care for 100 percent of Medicaid beneficiaries. Certainly, for
the 40 million who are non-disabled, non-aged. You know, we do
have health centers that provide care to frail elderly and
disabled individuals, but those who need to be
institutionalized in a nursing home or what have you, you know,
we do the visits, inpatient visits. I don't know that we could
do the long-term care. That is a huge expense. But for the 40
million Medicaid beneficiaries who are adults, children mostly,
and relatively non-disabled adults, yes, we could do it. And we
would save, just as we do now, Medicaid more money today than
all of the money that Medicaid pays health centers. In effect,
they get that care for free, and we still give them a further
return on investment. The savings exceed the $2.5 billion that
Medicaid pays health centers today compared to any other
providers. That is what the record shows. So for 10 percent of
the dollars, we would give you 100 percent of the patients and
give you an even greater return. Lower hospitalizations, fewer
specialty referrals, most importantly, a healthier population.
Mr. Stupak. Sure. Someone said, you know, that they feel
that health care is a right and not necessarily a privilege in
this country. If we did the uninsured population and gave them
the option, if you will, of moving either into a CHIPs program,
a Medicare program, or a Federal health employees benefit
package, in your opinion, would it be--I am trying to find a
way to ensure, you know, everyone who doesn't have health care
coverage, and we are actually working on some legislation to do
this, to give them an option. If you are child is on the SCHIP
program, or in Michigan we call it ``My Child'', why can't
that, usually a single parent, get on the program, too? Or
going through the Medicaid program, why can't people under 65
buy into the Medicare system sooner? Why can't those who fall
in between come into the Federal employees' health benefit
package, because I am sure you must see Federal employees at
some of your clinics, because we are in remote areas? I am just
trying to find a way to find coverage and at the same time keep
the costs reasonable for everybody. Comments on that crazy
utopian idea?
Mr. Hawkins. No, no, not necessarily.
I think two things, too. I mean, the question you want to
ask is for the 6 counties in your District and for the 16 in
yours, Mr. Chairman, that don't have a health center today and
our poor county. Their low-income population is above the
national average. Why can't they have a health center? You
asked that earlier of the appropriate authorities.
Mr. Stupak. Right.
Mr. Hawkins. I wish I could answer it. If only we had it. I
think in an ideal world, something like that, giving people a
choice but giving them an option of coverage, would be
incredibly important.
I just want to say one other thing. I am no Ellen
Greenspan, but I think there is a business argument to be made
for the fact that we are not competitive in this global
environment, because of the costly fragmented health care
system we have today with multiple payers, each of whom plays
games and tries to push the cost off on somebody else.
Mr. Stupak. Sure.
Mr. Hawkins. I think there is a good business argument to
be made for a system, and I don't understand why America's
businesses, GM included, they are the first ones to be speaking
out. They are picking up 50 percent of the tab today. I don't
understand why they are not demanding change for this. But I am
not in that part of the business world.
Mr. Stupak. Thank you, Mr. Chairman.
Mr. Whitfield. Thank you.
I just want to ask one brief question, and then we will
conclude.
On this issue of physicians, we touched on it a little bit,
but how difficult is it to find physicians, and what are the
retention issues? And would you all comment on that, those of
you involved?
Mr. Manifold. I will make a comment on that.
We have had awfully good luck at Central Virginia over the
years. Now one of the reasons why we have that luck, and it is
not luck in that sense, is because of the support systems, for
example the National Health Service Corps has helped us to
recruit. But we have also had good relationships with the two
teaching institutions in Virginia, the Medical College of
Virginia and the University of Virginia. And with those
arrangements, we actually, in our particular situation, and I
know there are other health centers that do this, we actually
teach residents at our site. Medical residents come out. We
even have had dental students over the years. And now we have
psychology students coming out to our sites and being taught.
And that helps us to get to know them. They get to know us.
Those kind of arrangements like that, where we have a good
teaching kind of relationship, does help us to find good
providers along the way, and we have even had people who said,
``Gosh, I came out here to your health center. I learned
something. I don't want to be a primary care doctor. I am going
into surgery.'' You know. ``This is not what I want to do.''
Mr. Whitfield. Right.
Mr. Manifold. So you have both sides of that coin, and that
is a good thing, because had that gentleman come to us at work
and then said, ``Wait a minute here. I don't like this,'' the
connection with the teaching institution is very strong.
Mr. Whitfield. Ms. Sibilsky?
Ms. Sibilsky. Yes, I would like to support what Mr.
Manifold said. I would also like to cite an example of that
where 100 percent of the fourth year dental students at the
University of Michigan are rotating through community health
centers, and as a result, the recruitment rates have just
escalated beautifully because they have learned that they are
valued organizations and in good communities. Also, the Area
Health Education Center, the AHEC program, funded to the Bureau
of Health Professions, which we were just funded for in
Michigan about a year ago, is starting to develop those kinds
of relationships for us. Also, the waiver program has been a
real benefit. And we have found amazing acceptability of those
providers within rural and remote communities. So thank you.
Mr. Shi. I just want to add that in addition to physicians,
non-physician primary care providers also are the backbone in
community health centers. Those include nurse practitioners,
physician assistants, and other advanced nurses. And we did
studies showing that they provided comparable quality care to
primary care physicians in most of the primary care services.
Mr. Whitfield. Right. Good point. Good point.
Dr. Goetcheus?
Ms. Goetcheus. I would just echo the same. We have
relationships with all of the medical schools. There are three
here in DC that have students and residents, have four family
practice fellows that spend clinical time with us has been a
wonderful way to recruit, but the most important way has been
because of National Health Corps. And one of the things I
always say is that because many of the physicians who have come
to us are minority. And some of them have grown up in these
very neighborhoods where they have been out east of the river,
and what a wonderful witness that is to that community. So I
don't know, we could not, in terms of recruitment, do it. It
would be much more difficult without National Health Corps. I
am just, every day, grateful for it.
Mr. Hawkins. I would just say nationally that one thing
health centers have learned over the last 40 years is there are
three strategies to recruit and keep your staff. No. 1, get
your staff involved with teaching hospitals. They are part of
that system. They are not renegades and mavericks and lone
rangers. They are actually mainstream. No. 2, expose those new,
soon-to-be doctors to the experience of working in a health
center, and you will, more often than not, have someone who is
very interested in coming to work for you down the line. And
the third successful strategy that many health centers have
employed is grow your own. Find young people in your community
who have the promise and the hope and who look like the people
you serve and help send them off to get an education, a medical
education, a dental education, a nursing education, and they
will come back. They will come back and serve the community
that grew them.
Ms. Sibilsky. I would like to give Mr. Stupak an example of
that. I was the administrator of the health center in Alcona
County, which is one of yours, and I think this was about 20
years ago. I was administering that clinic, and a young medical
student came in, and he said to me, ``Do you think you will be
recruiting doctors in about 10 years when I come out of medical
school and residency program?'' I said, ``I venture to say we
would be delighted to have you, and I would almost give you a
guarantee of hire.'' He came back in 10 years and was also
married to a doctor, and we got two out of that one.
Mr. Stupak. That is great. You know, you mentioned doctors,
but what about nurses? One of the questions I was going to ask
earlier, you know, we had the nurse reinvestment act on this
committee, and I think we all supported it. And back last time
we had a nurse shortage I think was in the mid 1970's or so.
Back then, Congress put in like $150 million to help nurses, to
recruit them and pay for their education. Well, I think it was
actually $153 million. This past year, we only put in $150
million. I mean, in 30 years, if my math is right, we haven't
increased the funding for the program, but yet the demand is
just as great. I mean, in the 1970's, we had it for a while and
then it went away. Now it is back again, because we have this
shortage. Do you recruit and use nurses? And you must, in your
fields all of the time, right?
Ms. Goetcheus. It is one of our most difficult people to
recruit is to get nurses. It is very, very difficult. And as we
are talking about the collaboratives and the importance of
education and care management, the nurses are key here. And so
at least for us, it has been very, very difficult to recruit
nurses.
Mr. Stupak. And the nurses we talked to, they say at $150
million, which was 30 years ago, like 98 percent of them are
rejected for any financial aid, even though we have this great
need for nurses. I mean, I just can't figure this one out other
than we need some more bucks here just to help them out. I
mean, they are not asking for a lot, just a little help with
their schooling and come work in your clinics and centers. It
would be of great help to us all.
Mr. Hawkins. Health centers are up against shortages in any
number of areas. Nursing is one. Dentists. The number of
dentists are declining in the dental school. We actually
started, we, the National Association, working with a medical
school to help start a dental school, because the need is so
great. Primary care physicians, pharmacists, and mental health
counselors are all in significantly short supply.
Mr. Stupak. Thank you.
Mr. Manifold. We have six dental sites in our Central
Virginia family, and four of the positions are filled right now
and two are not filled. And we have a mighty strong effort. We
have gotten some changes to Virginia law that helps to allow
for more dentists to come into the State. And it is still
virtually a nightmare for us, because we have the money, we
have the chairs, we have everything we need, and it is still
very, very difficult to find those dentists.
Mr. Whitfield. Well, I want to thank you all so much for
your testimony. We really enjoyed spending Wednesday afternoon
with you, and I am sure Mr. Stupak and I both would say that we
look forward to maintaining contact with you as we move forward
to try to address some of these issues. So thank you for your
time and your testimony.
And I will say that we will keep the record open for 30
days, and we are going to ask members to submit any questions
that they have for the record within the next 7 days.
And with that, the hearing is adjourned.
[Whereupon, at 6:03 p.m., the subcommittee was adjourned.]
[Additional material submitted for the record follows:]
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