BOSTON, Mass. (September 11, 2007)--Uninsured patients in publicly funded community health centers face significant obstacles accessing specialty services outside of these centers, a new study finds. What's more, this is even the case after a doctor has determined that the patient does in fact need these services. Conversely, community health center patients with private insurance have a relatively easier time accessing services.
"Often times, people think that community health centers act as a kind of safety net for the uninsured, but these findings present a far more problematic picture," says Nakela Cook, a research fellow in the Health Care Policy Department, and the lead author on the paper that will be appearing in the September/October edition of the journal Health Affairs.
According to Bruce Landon, associate professor in Harvard Medical School's Health Care Policy Department and senior author, "Community health centers work well for primary care services provided on site. The breakdown occurs when an uninsured patient needs to see a specialist, or needs some sort of high-tech service, or to be admitted to a hospital. Uninsured patients, and to a lesser extent Medicaid patients, have a much harder time than insured patients."
Community health centers serve approximately 15 million people nationwide, most of whom are low income and either lack insurance altogether or rely on programs like Medicaid. While these centers often provide adequate primary on-site services, many question how successfully they can refer patients to other more specialized services, even when a patient has a potentially life-threatening condition.
In order to investigate this, a research team led by Cook sent surveys to the directors of all federally qualified community health centers in the United States. Fifty-four percent of the medical directors responded.
The surveys focused on seven primary areas, and in each of them, uninsured patients requiring outside services were at a major disadvantage when compared to their insured counterparts. Patients with Medicaid, while faring better than the uninsured, also faced significant obstacles.
For example, community health centers are typically not able to perform diagnostic tests on site. The surveys reported that when a physician deemed a particular diagnostic test necessary, uninsured patients faced major difficulty in accessing the test 21 percent of the time, versus only 1 percent for insured patients. Those numbers were the same for medical-specialist referrals. The most dramatic discrepancy involved accessing high-tech services such as cardiac catheterizations. Here, 52 percent of the time, medical directors reported difficult access for uninsured patients, versus 10 percent for insured patients. Directors reported about 16 percent of the time that Medicaid patients confronted significant barriers in accessing these same services. Other examples include the following:
- Specialized services (e.g., chemotherapy): 30% of the time medical directors reported difficult access for uninsured patients, 4% for insured patients, and 6% for Medicaid
- Hospital admissions: 33% uninsured, 7% insured, 11% Medicaid
- Mental health services: 42% uninsured, 10% insured, 21% Medicaid
- Substance abuse services: 52% uninsured, 18% insured, 30% Medicaid
The authors suggest two ways that new policies might improve this situation.
First, the federal government could provide additional resources for outside services that require up-front payment. "Paying up-front is a major barrier for the uninsured, many of whom are low income," says Cook. "Earmarking additional funds for this would really help alleviate this particular obstacle."
Second, policy makers should encourage affiliations between CHCs and medical schools or hospitals. According to Landon, centers with such affiliations had higher success rates with helping the uninsured access outside services. "These kinds of affiliations really help to build locally integrated referral networks," says Landon.
Uninsured patients who receive their primary health care in publicly funded community health centers face significant obstacles accessing specialty services outside of these centers, even after a physician has deemed them necessary. While Medicaid patients, to a lesser extent, also face obstacles, insured/Medicare patients have a far easier time accessing needed services.
More than 1,000 federally qualified community health centers nationwide serve more than 15 million people.
Nakela Cook, health services research fellow at Harvard Medical School and Harvard School of Public Health and fellow in clinical cardiology at Massachusetts General Hospital
Bruce Landon, associate professor of health care policy at Harvard Medical School and an associate professor of medicine at the Beth Israel Deaconess Medical Center.
Health Affairs, Volume 26, Number 5, September/October 2007
This research was supported by the Harvard Medical School Office for Diversity and Community Partnership Bridge Award.
Health Affairs, Volume 26, Number 5, September/October 2007
"Access to specialty care and medical services in community health centers"
Nakela L. Cook, LeRoi S. Hicks, A. James O'Malley, Thomas Keegan, Edward Guadagnoll, and Bruce E. Landon
Harvard Medical School (www.hms.harvard.edu) has more than 7,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 18 Harvard teaching hospitals and research institutes. Those Harvard hospitals and research institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, The CBR Institute for Biomedical Research, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System