Change is hard. Moving our health care system forward to both improve quality and reduce costs is the primary focus of the Affordable Care Act. Much of the press surrounding this is focused on large medical systems such as Hopkins or Mayo Clinic. Look a little deeper and you’ll see that there’s another type of care model well poised to advance this goal: Community Health Centers.
Community health centers (CHC) take care of the uninsured, poor and underserved. If our patients do have insurance it’s usually Medicaid or a state sponsored plan that offers a minimal set of benefits to go along with a minimal and inadequate payment. Between the uninsured and the minimal payments from state plans we don’t make enough to cover our costs. To make up the shortfall, CHCs have a large federal grant which we supplement with grants from state, local and private entities. Generally, over 50% of our funding comes from grants and so our services are geared towards meeting our grant obligations which focus on quality measures and range and depth of services.
As Medicaid expansion comes into effect it’s changing how we look at ourselves and the work we do. Within a few years our main source of income will be reimbursements from insurance, not grants. We’ll have to devote greater effort to expanding the volume of patients we serve in addition to the quality and depth of services we provide to each patient. This shift is the mirror image of what the majority of primary care practices who accept private insurance are seeing: that their payments are starting to be tied to quality now in addition to volume.
Balancing quantity and quality is challenging and we struggle with how to reach a new equilibrium on a daily basis. Providers who are used to seeing people for as long as is needed to get as much done as possible are now being asked to see more patients while maintaining quality.
Much like every sector of health care there is slack in the system. One area for improvement is that no show rates at CHCs are generally in the 30% range. Utilizing this dead time is critical to expanding access to patients. Making it happen is much harder since it’s impossible to predict beforehand who’s not going to show up. Do you double book patients to make up for no-shows knowing that both patients in a given time slot can show up? Do you have a list of walk-in patients ready to be seen who have to sit around and wait until a spot opens up? Do you use a whole new scheduling system where you only give out appointments the day before? The list of possible changes goes on and on but what they all share in common is that in increasing access for patients they also make the day more unpredictable for providers. For us Type A folk, not knowing how your day is going to unfold is a hard pill to swallow. But these changes are necessary to both increase access for patients and to ensure that we are financially viable to continue our mission in the years ahead.
CHCs have demonstrated over time that they provide high quality care while keeping costs down. This is the main reason that the Affordable Care Act directs billions of dollars to the expansion of CHCs. Also in the ACA is money to expand the National Health Service Corps which helps health professionals who work in CHCs pay off their student loans. This workforce expansion will increase the capacity of CHCs to accommodate the new influx of insured patients who will begin flooding the system on January 1, 2014.
Not all CHCs will navigate this changing environment successfully but those that do will strengthen their position in their communities. More importantly, these CHCs will be the leaders in increasing quality while bringing costs down. You should keep an eye on us over the next few years