Detailed Information on the
Health Centers Assessment

Conducting national survey of Health Center users, in collaboration with the National Center for Health Statistics, in order to expand and update information on program performance and impact.

Implementing program-wide collection of core quality of care and health outcome performance measures, including hypertension and diabetes-related outcomes, from all grantees by 2009.

Working with Congress to reauthorize the Health Centers program.

Measure: : Number of patients served by health centers (in millions)

Explanation:This measure focuses on increasing access to care by extending the reach of the program. Patients are defined as individuals who have at least one health center encounter during the year. Encounters are defined to include a documented, face-to-face contact between a patient and a provider who exercises independent professional judgment in the provision of services to the individual. To be included as an encounter, services rendered must be documented. Each patient is counted once even if s/he received more than one type of service. Data for this measure comes from the Uniform Data System.

Measure: Rate of births less than 2500 grams (low birth weight) to health center prenatal patients compared to the national low birth weight rate. (Health Center Rate - National rate/ National rate).

Explanation:This measure reflects both on quality and health outcomes for health center women of child-bearing age, a key population served by the program. The measure is benchmarked to the national rate to demonstrate how health center performance compares to performance of the nation overall. The measure is calculated by dividing the difference between the health center low birth weight rate and the national low birth weight rate by the national low birth weight rate. Data comes from the Uniform Data System and the National Center for Health Statistics. In 2005, 7.3 percent of Health Center patients had low birth weight infants as opposed to 8.2 percent nationwide. The goal is to achieve a rate 11% lower than the nationwide average. While the measure seeks to maintain the current ratio in the next five years, it is ambitious because health centers serve a higher risk population for low birth weight than nationally. In addition, over the past years, national low birth weight rates have gotten worse (continuously increased) while health center averages remained relatively stable. In the past few years, health center low birth rates have started following national trends and have gotten slightly worse. This makes maintaining the existing ratio a particular challenge.

Measure: Percentage of adult patients with diagnosed hypertension whose blood pressure is under adequate control (less than or equal to 140/90).

Explanation:This measure reflects the quality of care and improved health outcomes for hypertension, one of the most prevalent chronic conditions facing health center patients. Clinical evidence indicates that controlling blood pressure (hypertension) can reduce the health risk associated with the conditions such as heart disease and stroke. An adult patient with blood pressure under adequate control is defined as a patient 18 years of age or older diagnosed with hypertension with a last systolic blood pressure measurement ???? 140 mm Hg and diastolic blood pressure ???? 90 mm Hg during the measurement year. The measure is calculated by dividing the number of health center adult patients diagnosed with hypertension with blood pressure under adequate control by the total number of health center patients diagnosed with hypertension. The current source of data is reports by grantees participating in the Health Center program's Health Disparities Collaboratives (19% percent of health centers). Given that the 2006 actual performance is a single data point from collaborative data on a limited sample of patients, and that for the previous two years the performance percentages are flat, the targets are set to reflect a reasonably ambitious progression toward the 2014 target for this medically challenging chronic condition. The Program has moved to collect this data from UDS the Uniform Data System in 2009.

Measure: Percentage of adult patients with type 1 or 2 diabetes with most recent hemoglobin A1c (HbA1c) under control (???? 9%). (UNDER DEVELOPMENT)

Explanation:This measure will focuses on quality of care and improved health outcomes for one of the most prevalent chronic conditions facing health center patients, diabetes. (In 2005, 6.8 percent of Health Center patients had a primary diagnosis of type 1 or 2 diabetes). Clinical evidence indicates that controlling blood glucose benefits people with either type 1 or type 2 diabetes. Currently data on a similar measure (average HbA1c value) are reported by grantees participating in the Health Disparities Collaboratives. Future data will be collected from all grantees through the Uniform Data System in 2009.

Measure: Percentage of pregnant patients beginning prenatal care in the first trimester.

Explanation:This measure supports the long-term low-birth weight measure by focusing on a process that is associated with improving birth outcomes. Identification of maternal disease and risks for complications of pregnancy or birth during the first trimester can help reduce the risk of low birth weight. The measure is calculated by dividing the number of female patients who began prenatal care in the first trimester by the number of female patients who entered prenatal care during the measurement year. Data is reported through the Uniform Data System

Measure: Efficiency Measure: Percent increase in cost per patient served at health centers. (Health Center growth rate /Target: 20% below the National growth rate)

Explanation:The program's efficiency measure focuses on maximizing the number of patients per dollar by keeping cost increases below annual national health care cost increases. Total cost includes all financial costs (excluding donations) for: Medical, Lab and X-Ray, Dental, Mental Health, Substance Abuse, Pharmacy and Enabling Services (translation, transportation, case work, outreach, etc.). The measure is calculated by dividing total Health Center costs (excluding donations) by the total number of patients served in the calendar year. Data comes from the Uniform Data System and the benchmark used for targeting future costs comes from the Center for Medicare and Medicaid Services' National Health Expenditure Projections (http://www.cms.hhs.gov/NationalHealthExpendData) which forecast health spending. Given recent performance of the program, the benchmark is 20 percent below forecasted national rates.

Is the program purpose clear?

Explanation: The purpose of the Health Center program is clear. The program is designed to increase access to comprehensive primary and preventive health care and improve the health status of underserved and vulnerable populations. Health center grants support a variety of community-based public and private nonprofit organizations that provide required primary health services to a population in an area with a shortage of personal health services, regardless of ability to pay. Health Centers include a variety of organizations covered by the authorizing legislation, including organizations funded to serve migrant and seasonal agricultural workers, the homeless, and residents of public housing.

Evidence: Federally supported health centers have served as a primary care safety net for underserved rural and urban populations since the 1960s. The Health Centers Consolidation Act of 1996 authorized the current Health Centers Program (section 330 of the Public Health Service Act). The authorization specifies that the purpose of the program is to provide primary medical and enabling services to medically underserved populations. The agency's program expectations are outlined in Policy Information Notice 1998-23. Agency regulations (42 CFR; Part 51c and 42 CFR Part 56) specify the population to be served and the specific services to be provided. The program is administered by the Health Resources and Services Administration (HRSA).

Does the program address a specific and existing problem, interest, or need?

Explanation: The program addresses the specific and ongoing problem of lack of access to high quality, comprehensive, and cost-effective primary health care. Major barriers to quality health care include poverty, lack of health insurance, lack of nearby health facilities, availability of health care professionals, limited English proficiency, and other cultural barriers. Populations face different problems and have varying needs. Homelessness continues to be a pervasive issue throughout the U.S. Migrant and seasonal farm workers also have specific health needs and face specific barriers to care, including rigorous work schedules, lack of transportation, financial, linguistic, and cultural barriers. The Health Center program addresses these problems by serving as a medical home that provides regular access to comprehensive primary and preventive health care, regardless of patients' ability to pay. The program targets the nation's neediest populations and geographic areas. In addition, the program provides translation, case management, transportation, and other enabling services for patients.

Evidence: Nearly one in five Americans lack ready access to a "medical home"?? a regular and usual source of quality primary care. (The National Association of Community Health Centers (NACHC) and the Robert Graham Center: "Access Denied: A Look at America's Medically Disenfranchised." 2007). Nearly 45 million people, 15.3% of the US population, lacks health insurance (U.S. Census Bureau: "Income, Poverty, and Health Insurance Coverage in the United States: 2005"). At the same time, the proportion of physicians serving existing Medicaid and uninsured patients and willing to accept new Medicaid or uninsured patients has declined. (Cunningham and May: "A Growing Hole in the Safety Net: Physician Charity Care Declines Again." Center for Studying Health System Change, Tracking Report, 2006), (Cunningham: "Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997-2001." Center for Studying Health System Change, Tracking Report No. 6, 2002). Additionally, disparities related to race, ethnicity, and socioeconomic status continue to pervade the American health care system. (Agency for Healthcare Research and Quality: "National Healthcare Disparities Report." 2006) There are more than 3 million migrant and seasonal farm workers, most of whom lack access to health care. (National Center for Farmworker Health: "Facts About Farmworkers," 2002.) It is estimated that 2 to 3 million people are homeless over the course of a year. (Homelessness Research Institute of the National Alliance to End Homelessness: "Homelessness Counts: Research Reports on Homelessness." 2007.)

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The program is unique in that it is designed to expand access to health care for underserved populations by providing organizations with revenue that is not tied to individual patients. While populations served by the program could seek care in emergency rooms, they are unlikely to get comprehensive, continuous and preventive care. The program fills major gaps where there are no existing programs or resources. For example, it is the only Federal health care program available to non-elderly, non-disabled, low-income men. (The program serves 2.9 million males between the ages of 20 and 64.) The program also complements other Federal and State programs. For example, the Federal government and States broaden access to health care through financing streams such as Medicaid, Medicare, and SCHIP. Through the provision of services, health centers ensure access to care for the populations covered by these funding streams. Unlike other Federal programs, funding and eligibility for health center services is not tied to individual patient characteristics (e.g. only women or infants as in the Maternal and Child Health Block Grant) or health conditions (e.g. only HIV/AIDS as in the Ryan White CARE Act). The program is also designed with a number of safeguards to ensure that it is neither redundant nor duplicative of any other Federal, State, local or private efforts, Grantees must collaborate appropriately with other health care and social service providers in their area to gain access to critical assistance and support (e.g. housing, food, jobs). In addition, grantees must assure that health center funds supplement but do not supplant other funding received by the health center. The program also works to limit the redundancy in the allocation of health center resources through the examination of the potential overlap of service areas between health centers.

Evidence: The Health Centers Consolidation Act of 1996 (section 330 of the Public Health Service Act) specifies that the purpose of the program is to provide primary medical and enabling services to medically underserved populations regardless of ability to pay. The agency's program expectations are outlined in Policy Information Notice 1998-23. Agency regulations (42 CFR; Part 51c and 42 CFR Part 56) specify the population to be served and the specific services to be provided. Per its authorizing statute, regulations and program expectations, health centers must collaborate appropriately with other health care and social service providers in their area to ensure the most effective use of limited health center resources, provide a comprehensive array of services for clients, and gain access to critical assistance and support (e.g. housing, food, jobs). In addition, health center applicants must describe how it plans to coordinate and integrate project activities with the activities of other Federally funded, as well as State and local, health services delivery projects serving the same population. Specifically, as required by 42 C.F.R. 51c.305, in reviewing applications, HRSA considers to what extent an applicant plans to maximize all sources of revenue through an appropriate and reasonable budget which includes non-grant resources to support the proposed project. Policy and Process: Policy Information Notice 2007-09 describes policies in place to limit redundancy in the allocation of health center resources through its examination of the potential overlap of service areas between health centers. Health centers receive roughly 21% of their total funding from this program. An additional 47% of health center's revenue comes from Medicaid (state and Federal combined), Medicare, SCHIP and other Federal grants. The remaining 32% comes from state, local, third party and self-pay collections.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: The Health Center program has no major design flaws that prevent it from meeting its defined objectives and performance goals. There is no evidence that another approach or mechanism would be more efficient or effective. Eligibility and program requirements ensure that health centers are placed in high need areas and that health center patients have access to comprehensive preventive and primary care services. Every project receiving Federal Health Center funds must: (1) Be located in or serve a high need community, i.e. "medically underserved areas" or "medically underserved populations;" (2) Provide comprehensive primary care services (as defined in statute) as well as supportive services such as translation and transportation services that promote access to health care; (3) Make services available to all residents of their service areas, with fees adjusted according to patients' ability to pay; (4) Be governed by a community board with a majority of members being health center patients; and, (5) Meet other performance and accountability requirements regarding their administrative, clinical, and financial operations. A variety of health center data and independent evaluations demonstrate that the program design is achieving its objectives.

Evidence: The authorization directs the program to provide grants for primary medical and enabling services to medically underserved populations. The agency's program expectations are outlined in Policy Information Notice 1998-23. Agency regulations (42 CFR; Part 51c and 42 CFR Part 56) specify the population to be served and the specific services to be provided. Over 91 percent of health center patients are at or below 200 percent of the Federal poverty level, approximately 64 percent are from racial/ethnic minority groups, and almost 40 percent are uninsured. Health Centers receive only about a fifth (21%) of their total funding from the Federal Health Center grant, an amount that has continued to decline over time, indicating that health centers are successfully leveraging non-Federal resources. (Uniform Data System: Data on revenue sources, financial costs.) Having a regular source of primary health care has been shown to have a significant effect on health status disparities. Health center uninsured patients are far more likely to have a usual and regular source of care than uninsured patients who obtain care elsewhere--98% vs. 75%. (Starfield and Shi: "The Medical Home, Access to Care, and Insurance: A Review of Evidence." Pediatrics 113, 2004, Carlson et al: "Primary Care of Patients without Health Insurance by Community Health Centers." Journal of Ambulatory Care Management 24, 2001) Since health center patients are also more likely to be from racial/ethnic minority groups, having a regular and usual source of care contributes to the reduction and elimination of disparities in health status. (Shi et al: "America's health centers: Reducing racial and ethnic disparities in perinatal care and birth outcomes." Health Services Research 39, 2004.) In addition to providing timely and comprehensive health services, health centers manage patients with chronic diseases such as diabetes. (HRSA Health Disparities Collaboratives National Reporting and GPRA Reporting, 2005.) Health center low birth weight rates also continue to be lower than national averages for all infants. The health center African American low birth weight disparity is nearly 20 percent less than the African American rate observed nationally. (Shi et al: "America's health centers: Reducing racial and ethnic disparities in perinatal care and birth outcomes." Health Services Research, 39 2004). By addressing health disparities by race, ethnicity, poverty status, and geographic location, health centers significantly reduce disparities.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The Health Center program design effectively targets resources to meet the program's purpose and reach intended beneficiaries. The program design ensures that resources are being used effectively to support the program's intended purpose by providing funds directly to health centers that in turn provide direct service delivery to the target population of underserved and vulnerable individuals. The authorizing legislation and program regulations require grant funding go to areas and/or populations designated by the Federal government as medically underserved. Grantees are required to provide a specific scope of comprehensive primary and preventive care services to patients, regardless of ability to pay. Funding is distributed via a competitive grant process and awards are based on merit. In addition, there are no unintended subsidies as grantees must assure that health center funds supplement but do not supplant other funding received by the health center.

Evidence: The authorization directs the program to provide grants for primary medical and enabling services to medically underserved populations. The agency's program expectations are outlined in Policy Information Notice 1998-23. Agency regulations (42 CFR; Part 51c and 42 CFR Part 56) specify the population to be served and the specific services to be provided. Program data demonstrates that the correct beneficiaries are being targeted. In calendar year 2005, 954 Health Center grantees at 3,745 sites served 14.1 million people. The program provides care to over 12% of the nation's uninsured, over 14% of the nation's population below 200% of the Federal poverty level, and an estimated 20% of the 48 million underserved in areas lacking access to primary care providers. Of those served, 91% are at or below 200% of poverty, over 39% are uninsured, and 64% are racial or ethic minorities. HRSA-funded health center programs serve more than one quarter of all migrant and seasonal farm workers in the US, and the Health Care for the Homeless program is a major source of care for homeless persons throughout the US. Health centers receive roughly 21% of their total funding from this program. An additional 47% of health center's revenue comes from Medicaid (state and Federal combined), Medicare, SCHIP and other Federal grants. The remaining 32% comes from state, local, third party and self-pay collections.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program's four long-term measures focus on the purpose of the program: assuring access to care, improving quality of care, and improving health status among health center patients. All four of the program's long-term performance measures have five year time-frames. The program's first long-term measure (#1) focuses on access to care through the number of patients served. While this is an output measure, it is a meaningful performance measure because it focuses on the program's central mission of delivering care to underserved and vulnerable populations. Increasing the number served through the program reflects progress toward the outcome of expanding access to care. The second long-term measure (#2) focuses on outcomes by examining the rate of low birth weight babies born to health center patients compared to national low birth rate. Appropriate prenatal care management can have a significant effect on the incidence of low birth weight. Improvements in infant birth weight can contribute significantly to reductions in infant mortality rates. In addition, young mothers and African American mothers are at greater risk of having low birth weight infants. Patients with these risk factors are served at a higher rate at health centers than at other health providers, predisposing health center births to higher risk for low birth weight and adverse birth outcomes. Benchmarking the measure to the national low birth rate takes into account national trends in low birth weight while demonstrating if the program is improving clinical outcomes. The third long-term measure (#3) is also an outcome measure and addresses hypertension, one of the most prevalent chronic conditions facing health center patients. Clinical evidence indicates that controlling blood pressure (hypertension) can reduce the health risk associated with the conditions such as heart disease and stroke. The fourth measure (#4) is under development and focuses on the outcome of diabetes care. The prevalence of diabetes is higher among health center patients than among the overall population. The low birth weight, hypertension, and diabetes measures are meaningful outcome measures because they capture both quality and health outcomes for key populations served by the Health Center program.

Evidence: The program's long-term measures are: 1) Number of patients served by health centers. 2) Rate of births less than 2500 grams (low birth weight) to health center prenatal patients compared to the national low birth weight rate. 3) Percentage of adult patients (18 years and older), with diagnosed hypertension whose blood pressure is under adequate control (less than or equal to 140/90). 4) Percentage of adult patients with type 1 or 2 diabetes with most recent hemoglobin A1c (HbA1c) under control (≤ 9%).

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has targets and ambitious timeframes for most of its long-term measures. The target for measure 1) is to serve 4.3 million more patients by 2014. This target is ambitious as it proposes to increase the number of patients served irrespective of resource levels. The five-year time frame is also ambitious given that the increase over the previous five years (2001-2005) was 3.9 million patients. The target for measure 2) is to ensure that the health center low-birth weight rate is at least 11% below the national rate. While the measure seeks to maintain the current ratio in the next five years, it is ambitious because health centers serve a higher risk population for low birth weight than nationally. In addition, over the past years, national low birth weight rates have gotten worse (continuously increased) while health center averages remained relatively stable. In the past few years, health center low birth rates have started following national trends and have gotten slightly worse. This makes maintaining the existing ratio a particular challenge. The target for measure 3) is 45.0 percent of adult patients with diagnosed hypertension whose blood pressure is under adequate control. This measure is ambitious given that in the past two years, performance has remained stagnant at 42.7 percent. This target will be difficult to achieve because improvements in a chronic condition require treatment with both lifestyle modifications, usually as the first step, and, if needed, with medication. The program is developing measure 4) a diabetes measure for which it will begin collecting data in 2009. Consequently, it does not yet have targets.

Evidence: The target for the measure #1 (the number of patients served by health centers) is 18.4 million patients in 2014. The 2005 baseline is 14.1 million patients served. The target for measure #2 (the rate of low birth weight births to health center prenatal patients compared to the national low birth weight rate) is 11% below the national rate. The 2005 baseline is 11% below the national rate. (In 2005, 7.3 percent of infants born to Health Center patients were low birth weight, compared to 8.2 percent of births nationally.) The target for measure #3 (the percentage of adult patients with diagnosed hypertension whose blood pressure is under adequate control) is 45 percent. The program expects to have baseline data and targets for its diabetes measure #4 in 2009.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The program has three annual performance measures that are discrete and quantifiable and can demonstrate progress toward the desired long-term programmatic goals of assuring access and improving quality of care and health status for health center patients. The first annual (#1) is the same as long-term measure #1 and is an output measure that focuses on the number of patients served with intermediate annual targets. Measure #1 is discussed in more detail in Question 2.1. The second annual measure (#2) looks at the percent of pregnant patients beginning prenatal care in the first trimester While this measure is an output measure, it contributes to long-term outcome measure #2, as early entry into prenatal care reduces the risk of low birth weight. The third annual measure (#3) is the same as the long-term outcome measure #3 and focuses on hypertension with intermediate annual targets. Measure #3 is discussed in more detail in Question 2.1.

Evidence: The program annual measures are: #1) Number of patients served by health centers; #2) Percentage of pregnant patients beginning prenatal care in the first trimester; #3) Percentage of adult patients (18 years and older), with diagnosed hypertension whose blood pressure is under adequate control (less than or equal to 140/90).

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The program has baselines and ambitious targets for all of its annual measures. The target for measure #1) is to serve 2.5 million more patients in 2009 over the 2005 baseline. This target is ambitious as it proposes to increase the number of patients served irrespective of resource levels. Targets for measure #1 are discussed in more detail in Question 2.1. The target for measure #2) is to increase the percent of pregnant patients in prenatal care in their first trimester by 2 percentage points over the 2005 baseline. This target is ambitious as health centers serve a higher risk prenatal population (migrant and homeless, teenage, racial/ethnic minority women) than is seen nationally. In addition, the target proposes to continue the rate of improvement for women beginning first trimester prenatal care consistent with historical trends despite the fact that national trends for first trimester entry into prenatal care have improved much more gradually over time (National Vital Statistics System - Natality (NVSS-N), CDC, NCHS ). The target for measure #3) is to increase the percent of hypertension patients with blood pressure levels under control by 0.3 percent over the 2005 baseline. This is ambitious given that in the past two years, the actual performance has been stagnant. Targets for measure #3 are discussed in more detail in Question 2.1.

Evidence: The annual target for measure #1 (the number of patients served by health centers) is 16.6 million in 2009. The baseline is 14.1 million served in 2005. The annual target for measure #2 (percent of pregnant patients in prenatal care in their first trimester) is 62.4 percent in 2009. The baseline is 60.4 percent in 2005. The annual target for measure #3 (the percentage of adult patients with diagnosed hypertension whose blood pressure is under adequate control) is 43.0 percent in 2009. The baseline is 42.7 percent in 2005.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: All grantees and other partners are committed to supporting the overall goals of the program. In program applications, grantees commit to assuring access to care, improving quality of care and improving health status among health center patients. All grantees are required to report on the program performance measures??persons served, low birth weight, trimester of entry into prenatal care, total cost??or will be required to report??hypertension and diabetes??annually as a term of grant award. Additionally, all grantees are required to focus on three areas of performance measurement as part of the Office of Performance Review (OPR) process: persons served, financial viability, and a clinical measure. These measures are reviewed during OPR site visits to assess national program and individual grantee performance and impact, identify performance trends, help individual grantees improve performance, and inform national program policy and guidance development. In instances where partners fail to contribute to the goals, the program provides additional oversight or technical assistance to improve performance.

Evidence: Program and reporting requirements are described in Health Center Program Expectations (Policy Information Notice 1998-23). Expectations on individual grantee performance are detailed in the Health Center Notice of Grant Award. OPR reports and action plans identify how health centers are performing on selected performance measures and ways to improve performance.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: A variety of evaluations of quality and sufficient scope are conducted on an ongoing and regular basis by unbiased, independent researchers. Evaluations are published in peer-reviewed journals and employ study design and sampling methodologies that ensure adequate size and representation as well as control for appropriate factors such as population and provider characteristics as applicable. Methods of statistical analysis included chi-square comparisons, multiple linear regression and multivariate logistic regression. These evaluations cover a variety of topics that reflect the entire scope of the program and evaluate effectiveness and support program improvements. Recent evaluation topics include: the impact of health centers on access to care for the uninsured; access to care for health center Medicaid patients; quality of chronic disease care in health centers and reductions in related health disparities; and comparisons of health center performance against results in the private sector. In addition, the Government Accountability Office (GAO) evaluated HRSA's process for assessing health centers need for services, the geographic distribution of health centers, and HRSA's monitoring of health center performance. At the grantee level, many grantees are evaluated through the accreditation process of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as through other independent national accreditation organizations. These accreditations confirm health center self-reports. The program uses evaluations to make program improvements. For example, a recent evaluation found that health centers do not participate in a national reporting system that is transparent and standardized to evidence-based measures of clinical quality and patient satisfaction. In response, HRSA established a set of core clinical performance measures, aligned with those of national quality measurement organizations such as the Ambulatory Care Quality Alliance and the National Quality Forum, to be reported on by all health centers through its new Quality and Data strategy (see Question 2.8).

Evidence: On average, more than one evaluation or study on health centers is published annually in a peer-reviewed journal. Examples of recent evaluations are "Comparative Effectiveness of Health Centers as Regular Source of Care." Falik M. et al, Journal of Ambulatory Care Management, 2006; "Availability of Safety Net Providers and Access to Care of Uninsured Persons" Hadley and Cunningham, Health Services Research, 2004; "Access to care for U.S. Health center patients and patients nationally: how do the most vulnerable populations fare?" Shiand and Politzer, Med Care, 2007; "The Quality of Chronic Disease Care in US Community Health Centers." Hicks et al., Health Affairs, 2006; and "Measuring Health Centers against Standard Indicators of High Quality Performance: Early Results from a Multi-Site Demonstration Project" Shin and Rosenbaum, United Health Foundation, 2006. GAO reported in 2005 on HRSA's selection and evaluation process of grantees (Health Centers: Competition for Grants and Efforts to Measure Performance Have Increased). Nearly 29% percent of health center grantees are accredited through JCAHO or other independent national accreditation organizations. Uses of health center performance measures are detailed in the Health Disparities Collaborative Report, GAO and Shin and Rosenbaum.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: The program does not have budgeting in place that defines the relationship between annual and long-term performance targets and resources. The program does not have integrated budget and performance presentation that makes clear the impact of funding on expected performance or provides evidence on how the requested performance resource mix will enable the program to meet performance goals. The program does report on indirect costs.

Evidence: The budget justification for the Health Center program is included in the Health Resources Administration Fiscal Year 2008 Justification of Estimates for Appropriation Committees.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The Program is currently implementing a Quality and Data strategy. As part of this strategy, a select set of core clinical performance measures is being introduced (including the hypertension and diabetes measures) for reporting across the lifecycle, for chronic conditions, and for primary and preventive care screening. Data resulting from this effort will be used to provide more effective technical assistance, and identify best practices within health centers. Health centers will benefit from improved information and feedback to respond to changing conditions in the health care market.

Evidence: New measures resulting from the Quality and Data strategy include measures tracking clinical outcomes on hypertension and diabetes management discussed in Question 2.1.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The program regularly collects performance information from grantees and uses it to manage and improve individual grantee and overall program performance. Performance data is used to set baselines and establish performance targets. All health centers report annually through the Uniform Data System (UDS). Federal program managers and individual grantees use UDS data to compare centers' demographics, financial status, and performance. The program ensures data quality through an extensive validation process. On a regularly scheduled basis, HRSA grantees are also comprehensively reviewed by the Office of Performance Review (OPR). OPR works collaboratively with grantees and program managers to measure performance, analyze the factors affecting performance, and identify effective strategies to improve performance, with a particular focus on outcomes. Grantees report on progress of overall program objectives (covering financial, health care, and management performance) through their annual grant applications. Program managers have access to additional fiscal information through grantees' required annual A-133 audit and to quarterly reports on the drawing down of Federal funds through the Payment Management System and annual Financial Status Reports (FSR). Program managers use this combination of annual and quarterly information from the UDS, applications, OPR reviews and financial reports to make decisions about continued funding, grant conditions, and corrective actions or improvements and to provide general monitoring and assistance for grantees throughout the year. For example, during a recent review of a renewal application, a health center was found to have significant deficits and a declining current ratio, which posed threats to the organization's financial viability. The health center was placed on drawdown restriction of funds. In addition, HRSA requested the grantee submit a financial recovery plan that addressed revenue enhancement and cost reduction activities and described corrective actions that would be taken to improve the operational efficiency and financial status of the organization. The grantee's performance will be monitored against the recovery plan. Once their operations stabilize, the drawdown restriction will be removed.

Evidence: Performance data and targets are discussed in Section 2. UDS data collection tracks a variety of information, including user demographics, services provided, staffing ratios and productivity, utilization rates, costs and revenues, managed care penetration, and clinical indicators ( http://www.bphc.hrsa.gov/uds/manual/default.htm). UDS data is available at the grantee, state, regional, and national levels. The UDS contractor and trained editors check data for consistency, including checks for missing data and outliers and checks against history and norms. A 2005 Government Accountability Office (GAO) report found that the program "has increased the role of performance measurement in its monitoring of health centers and has improved its collection of data that could help measure overall program performance." (Health Centers: Competition for Grants and Efforts to Measure Performance Have Increased GAO-05-645 July 13, 2005.) The FY 2008 Service Area Competition and Budget Period Renewal Application describes the data grantees must submit in their renewal applications. HRSA Office of Performance Review Protocol describes the OPR process.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: The program identifies managers and staff who are responsible for achieving results. Program staff is held accountable for program performance through the HHS Performance Management Plan (PMP) system. Program managers are held accountable by the direct relationship between their individual performance rating and the program's cost, schedule, and performance results. For example, the Associate Administrator for Primary Health Care's PMP includes the goal of increasing the number of patients through the Primary Health Care programs (i.e. Health Centers) that can be supported by the final appropriation level. Additionally, program performance criteria included in the executive performance plan of senior management are cascaded into the performance plans of first line managers and staff. Grantees are held accountable through the OPR review process. OPR works with each health center grantee to select three to five measures that reflect the specific needs of the center's community and patient population, and then to ascertain the health center's current performance on each measure. OPR identifies ways to improve health centers' operations and performance. The program requires that grantees develop an action plan to improve the performance in response to the OPR findings. The action plan describes the specific steps the grantees plans to take to improve performance on each measure and provides estimated completion dates. For example, an item included in a recent action plan was to survey patients on whether travel and/or parking arrangements created an impediment to receiving services at a specific site. Grantees are also held accountable for cost, schedule, and performance results through annual applications, audits, and Financial Status Reports. This data is used to make decisions about continued funding, grant conditions, and corrective actions or improvements. Grantees found to have performance issues may be placed on drawdown restrictions of program funds until deficiencies are corrected.

Evidence: Program managers' contracts detail performance standards as they relate to the performance of the Health Center program. OPR reports identify quantifiable performance targets for Health Center grantees. Grantees must develop action plans related to these reports with a timetable of quantifiable performance improvement actions. Annual applications, audit reports, and Financial Status Reports give additional information on grantee performance.

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: Program funds are obligated in a timely manner throughout the fiscal year in accordance with agency approved grants and procurement spending plans. HRSA reports program awards promptly and accurately on FAADS. All program funding is obligated by the end of each fiscal year. There are no large unobligated balances at the end of the fiscal year. Grantees submit proposed budgets in their annual applications and the program compares these with actual reports/retrospective data (i.e. UDS reports, FSR, audits). Award recipients undergo annual audits and report on planned and actual expenditures and provide a cash transaction report indicating the drawdown of funds and balances on a quarterly basis. Project scopes are monitored for compliance with financial, grant, and program requirements. Grantees are required to complete a Financial Status Report (FSR) on the status of funds. In addition, an OMB A-133 audit is required to be completed and submitted to HRSA, which ensures that funds are spent for allowable purposes and consistent with program requirements. Grantees who receive qualified opinions may be placed on restriction for drawdown of funds until material weaknesses are corrected.

Evidence: At the end of FY 2006, 100 percent of program funds were obligated. Proposed grantee budgets for 12 months of operations are included in annual applications. Each year grantees submit Financial Status Reports (FSR), a cash transaction report on the drawdown of funds. 100 percent of grantees were audited in FY 2006. Of the most recent audits currently on file, 97 percent of grantees received an unqualified opinion. While only a small percentage of Health Center grantees receive a qualified opinion, every grantee's audit is analyzed in depth by the program to ensure financial viability and gain additional information on the grantee's fiscal status.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The program has procedures in place to achieve efficiencies. The program regularly monitors grantee costs at the cost per encounter and cost per patient level. The program offers technical assistance to grantees to help control costs and generate additional revenue as part of a financial recovery plan. The program has one efficiency performance measure with a baseline and targets. The measure focuses on maximizing the number of patients per dollar. The program aims to keep cost per patient increases at least 20 percent below annual national health care cost increases, as forecasted by the Center for Medicare and Medicaid Services' National Health Expenditure Projections. By benchmarking the health center efficiency to national per capita health care cost increases, the efficiency measure takes into account changes in the health care marketplace while demonstrating if the program delivers services at a more cost-effective rate. At the administrative level, HRSA is increasing efficiencies as it transitions to fully electronic programmatic and grants management functions. The program also regularly outsources the provision of technical assistance and the production of its electronic, web-based program and grants management system.

Evidence: The program's efficiency measure is: "Percent increase in cost per patient served at health centers." The baseline is 2.1 percent increase in 2005. The national cost increase in health expenditures was 6.9 percent. The target for 2009 is 5.8 percent increase. This is 20 percent below the projected national growth rate of 7.3 percent. The program is increasing its electronic grants management functions. In FY 2006, nearly 21 percent of grant applications (both competing and non-competing) were received electronically, up from 4 percent in FY 2005. To date in FY 2007, nearly 97% of applications have been received electronically. The program has contracts with outside contractors to provide technical assistance and for its electronic, web-based program and grants management system.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program coordinates and collaborates with related Federal, State, local, and private programs. The program has interagency cooperative agreements with the following Federal agencies: (1) Agency for Health Care Research and Quality (AHRQ) to develop the Health Information Technology (HIT) Community Portal for health centers; (2) the Centers for Disease Control and Prevention (CDC) to address Migrant Stream Farmworker issues and HIV prevention initiatives; (3) National Institutes of Health (NIH) on issues related to cardiovascular health in the US/ Mexico Border region and issues related to Public Housing Primary Care Program Health Centers; (4) the Environmental Protection Agency (EPA) to address pesticide exposure among persons living on the US/Mexico border; and (5) the Department of Labor to conduct a future migrant enumeration study. In addition the program coordinates with the Centers for Medicare and Medicaid Services (CMS) to jointly review section 1115 Medicaid Demonstration Waivers to address any concerns for health centers within the State. The program also works closely with the Department of Justice on the Federal Tort Claims Act (FTCA) program, which provides medical malpractice liability protection to Section 330 supported health centers. The program has developed ongoing partnerships with State, regional, and national organizations to provide technical assistance to, or in support of, health centers. An example of the benefits provided by these partnerships is the extensive community development activity provided by HRSA partners.

Evidence: The program has documented collaborative agreements with the AHRQ, CDC, NIH, EPA, and the Department of Labor. National cooperative agreements organizations include: National Conference of State Legislatures, National Academy for State Health Policy/Center for Health Policy Development, National Association of County and City Health Officials, Association of State and Territorial Health Officials, National Association of Community Health Centers, National Rural Health Association, and the Institute for Healthcare Improvement (Health Disparities Collaboratives). Additionally, cooperative agreements with organizations that focus specifically on the needs of special populations include: The Association of Asian/Pacific Community Health Organizations, Farmworker Health Services, Inc., National Assembly on School Based Health Care, Migrant Health Promotion, National Health Care for the Homeless Council, Migrant Clinicians Network, Inc., National Center for Farmworker Health, Inc, North American Management (Public Housing Primary Care)

Does the program use strong financial management practices?

Explanation: In its 2006 audit, HHS received a material control weakness for its financial management systems and reporting. Specifically, HHS had trouble producing timely and reliable financial statements. Substantial manual procedures, significant adjustments to balances, and numerous accounting entries outside HHS's general ledger system were necessary. The Health Center Program, though HRSA, uses the financial management systems that contribute to this material internal control weakness. In FY 2006, HRSA replaced its existing accounting system with the Unified Financial Management System (UFMS), which should improve compliance with the Federal Financial Management Improvement Act (FFMIA). However, auditors found difficulties with the UFMS conversion process. It is expected that these errors will go away in FY 2007 when the conversion process is complete. In addition to the material weaknesses identified in the HHS audit, internal control weaknesses in HRSA led to the re-obligation of prior year funds, which may not be in compliance with accounting requirements.

Evidence: Since 2003, HRSA has been included in a consolidated HHS audit. In a 2006 audit of HHS, Price Waterhouse Coopers found a material weakness in HHS financial management systems and reporting. HHS's financial management systems are not FFMIA compliant. In particular, the 2006 audit found that HHS continues to experience significant challenges in resolving issues related to the UFMS conversion and implementation. Despite the implementation of UFMS, HHS recorded more than 1,000 manual entries during the year, more than of $10 billion to correct conversion balances, correct opening balances, and record financial transactions in order to complete the financial reporting process. HHS expects that the need for manual entries will disappear once the UFMS conversion process is complete. The Inspector General of HHS is in the process of investigating potential violations of accounting requirements at HRSA.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: HRSA has recently taken steps to address identified internal control deficiencies. HRSA is centralizing the control of prior year funds within the office of the HRSA CFO. HRSA's program offices will no longer have funds control authority for prior year funds. Instead, the Division of Financial Management, Budget Execution Branch maintains the funds control for all prior year funds.

Evidence: Under this new procedure, a program office wishing to use prior year funds must obtain a funds availability signature (or electronic approval) from a trained budget analyst in the Budget Execution Branch who would have the knowledge to make determinations about the legitimate use of prior year funds and who would also have the support of attorneys in the HHS Office of General Counsel when an unusual circumstance might call for legal advice. The UFMS accounting system is also structured to support this new approach, because in the UFMS system HRSA will assign the funds control role for available prior year funds only to specific users in the Budget Execution Branch.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: 100 percent of grants are awarded based on a clear and competitive process that includes a qualified assessment of merit. Program applications are announced nationally through Grants.gov for competitive grant cycles. For each grant opportunity throughout the fiscal year, HRSA announces and convenes a conference call to provide a summary overview of the application guidelines and an opportunity for a question and answer session. Additional information regarding application materials, due dates, and review schedules is made available on the HRSA website. All grant applications are reviewed by objective review committees. Review committees are composed of experts who are qualified by training and experience in particular fields or disciplines related to the program. Each reviewer is screened to avoid conflicts of interest and is responsible for providing an objective, unbiased evaluation based on the standardized review criteria announced publicly in the application guidance. The committee provides expert advice on the merits of each application to program officials responsible for final selections for award. Funding decisions are made based on committee assessments, relative need, announced funding preferences and program priorities. In addition, health centers are required to compete for their existing service areas at the completion of every project period (generally every 3 to 5 years).

Evidence: Funding opportunities for the Health Center program are posted on the Grants.Gov Website: http://www.grants.gov/applicants/apply_for_grants.jsp . Procedures and criteria for grant applications are described in HRSA-07-067 New Access Points in Programs Funded under the Health Centers Consolidation Act of 1996, HRSA-08-005 FY 2008 Service Area Competition Guidance, and HRSA-06-054 Expanded Medical Capacity Competition. The HRSA Division of Independent Review (DIR) Review Manual describes the independent review process.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The program has oversight practices that provide a high level of understanding of grantee activities. There are numerous reporting systems in place to document grantee activities including health centers' annual grant applications, annual independent (A 133) financial audits, UDS data, quarterly Payment Management System reports, and OPR site visit reports. Project Officers track actual expenditures to verify that funds are used for their intended purpose. OPR and Project Officers responsible for oversight of grantees also visit grantees for technical assistance and monitoring purposes on a regular basis.

Evidence: Over 200 health center grantees are comprehensively reviewed annually by an OPR review team. Project Officer data analysis tools include UDS Grantee Feedback Report, Application Review and Recommendation (ARR), Mid-Year Review (MYR), Audit Analysis (based on financial audit), Performance Analysis (based on UDS data), reviews conducted by JCAHO (not done for all health centers), Performance Reviews conducted by OPR, and analysis of funds drawn and remaining in the Payment Management system (PMS).

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The program collects grantee performance data on an annual basis through UDS and makes it available to the pubic. All health center grantees are required to report UDS data annually. Annual performance data are summarized at the national, regional and state levels and made available upon request through the agency web site. Data is expected to be available directly on the website in the near future, once ADA web-compliance issues are resolved. Performance data are also presented at conferences and other public presentations by the HRSA Administrator and other HRSA staff. Performance data are also included in the annual Congressional Justification and in GPRA reporting, which are available on the HRSA website.

Evidence: Data on Health Center grantees is available through the UDS Data Webpage: http://www.bphc.hrsa.gov/uds/. In addition, data is also available at the HRSA GPRA Webpage: http://www.hrsa.gov/about/perplan/default.htm

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The program has demonstrated some progress on three of its four long-term performance goals. From 2002 to 2005, the number of patients increased steadily. While the program exceeded its target for the number served in 2005, it slightly missed its targets in previous years. From 1999 to 2005, the program showed significant improvement in the low-birth weight rate compared to the national rate. The program has also demonstrated some improvement in hypertension, although improvement has stagnated in the last two years. The program has no data on the diabetes measure.

Evidence: In 2005, 14.1 million patients were served by health centers, which is 100,000 more persons than the 14.0 million target. The program missed its 2003 and 2004 target by 100,000 patients. In 2005, the low birth weight rate to health center prenatal patients was 11 percent below the national low birth weight rate. This is equal to the 2014 target. The low birth weight rate was 2.6 percent below the national rate in 1999. The percent of adult patients with hypertension whose blood pressure is under adequate control increased from 39.5 percent in 2002 to 42.7 percent in 2005. The target is 45 percent in 2014. The program will begin collection data on its diabetes measure in 2009.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The program has demonstrated some progress in achieving all three annual performance goals. The program met its 2005 goal of number of patients served. The program shows progress on the percent of pregnant patients who begin prenatal care in the first trimester. The program made progress on its hypertension measure in 2004, but remained level in 2005.

Evidence: In 2005, 14.1 million patients were served by health centers. This is 100,000 more than the 14.0 million target. The program missed its 2003 and 2004 target for persons served by 100,000 patients. The program missed its 2002 target for persons served by 500,000 patients. The percent of pregnant patients that began prenatal care in the first trimester grew steadily from 57.8 percent in 2000 to 60.4 percent in 2005. The percent of adult patients diagnosed with hypertension whose blood pressure is under adequate control was 39.5 percent in 2002 and 42.7 percent in 2004 and 2005.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The program demonstrates improved efficiencies. Since 2002, Health Center cost increases have remained at least 20 percent below the national cost increases. By keeping costs increases below national health care cost increases, the program delivers services at a more cost-effective rate. At the administrative level, HRSA is increasing efficiencies as it transitions to fully electronic programmatic and grants management functions. As part of this effort, the program has increased the number of applications it receives electronically.

Evidence: From 2002 to 2005, the program met its efficiency measure. In 2005, the average cost per patient served at health centers grew by 2.1 percent. This is about 70 percent below the 6.9 percent growth in national health expenditures. Given that total cost for health centers amounted to over $ 7.2 billion in 2005, health centers achieved significant cost avoidance by remaining 70% below the national growth rate. In the past 4 years, cost increases at health centers have been at least 20 percent below national cost increases. In FY 2006, nearly 21 percent of grant applications (both competing and non-competing) were received electronically. This is an increase over the 4 percent received in FY 2005. To date in FY 2007, nearly 97% of applications have been received electronically.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: The program compares favorably to other programs that serve similar populations and have similar goals. Studies comparing health centers to other health care providers have found that the program compares favorably on such relevant indicators as having a usual source of care, reducing inappropriate hospitalizations for primary care treatable conditions, and improving quality of care for chronic conditions. For example, a recent study found that health center patients received care comparable to or better than that of other providers serving vulnerable populations. Several studies of Medicaid beneficiaries found that those who obtained care at health centers had lower hospitalizations and emergency room use, lower annual Medicaid costs and less expensive chronic disease and disability than those who obtained care elsewhere.

Evidence: Researchers found the quality of care delivered by Health Centers was comparable to and sometimes better than the quality delivered in other settings for the underserved. For example, Health Center' patients rates of blood pressure control were better than hospital-affiliated clinics, the Veterans Affairs health system, or in commercial managed care populations. (Hicks LS. et al: "The Quality of Chronic Disease Care in U.S. Community Health Centers" Health Affairs 25, 2006.) Medicaid beneficiaries receiving care from a health center are less likely to be hospitalized than Medicaid beneficiaries receiving care elsewhere. (Falik M. et al: "Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers." Medical Care 39(6), 2001). Another recent study found that health center Medicaid patients are 11 percent less likely to be inappropriately hospitalized and 19 percent less likely to visit the emergency room inappropriately than Medicaid beneficiaries who had another provider as their usual source of care. (Falik M. et al: ??Comparative Effectiveness of Health Centers as Regular Source of Care." Journal of Ambulatory Care Management 29, 2006.). Medicaid patients who use health centers have lower annual costs. (McRae and Stampfly: "An Evaluation of the Cost Effectiveness of Federally Qualified Health Centers (FQHCs) Operating in Michigan." Institute for Health Care Studies at Michigan State University, 2006, Proser: "Deserving the Spotlight: Health Centers Provide High-Quality and Cost-Effective Care." Journal of Ambulatory Care Management 28. 2005),

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: Independent evaluations of sufficient scope and quality published as peer reviewed research articles indicate that that the program is effective and achieving results. Peer-reviewed literature and major reports document that health centers successfully improve access to care, improve patient outcomes for traditionally underserved patients, and are cost effective. Studies have found that health centers are associated with higher utilization of preventive services, improved outcomes as well as earlier and more accurate diagnoses, fewer unmet needs, fewer hospitalizations and emergency room visits, lower costs, and increased patient satisfaction. Access to primary care is also particularly important for narrowing disparities among low income and minority communities.

Evidence: Studies have shown that health centers facilitate the use of preventive care, especially among minority and low income patients. Health center uninsured patients are more likely to have a usual source of care than the uninsured nationally (98% vs. 75%)., (Carlson et al: "Primary Care of Patients without Health Insurance by Community Health Centers." Journal of Ambulatory Care Management 24, 2001, Starfield and Shi: "The Medical Home, Access to Care, and Insurance: A Review of Evidence." Pediatrics 113, 2004). Health centers provide continuous and high quality primary care and reduce the use of costlier providers of care, such as emergency departments and hospitals. (Proser: "Deserving the Spotlight: Health Centers Provide High-Quality and Cost-Effective Care." Journal of Ambulatory Care Management 28(4), 2005). Additionally, uninsured people living within close proximity to a health center are less likely to have an unmet medical need. (Hadley J and Cunningham P. "Availability of Safety Net Providers and Access to Care of Uninsured Persons." Health Services Research 39(5): 2004). Health centers are also improving access to care for Medicaid patients. Medicaid patients of health centers are more likely to report having access to care than Medicaid patients nationally. (Shi L, Stevens GD, and Politzer RM: "Access to care for U.S. Health center patients and patients nationally: how do the most vulnerable populations fare?" Medical Care 45(3): 2007). Health Centers have also been found to reduce racial and ethnic disparities in health care. (O'Malley AS, et al. "Health Center Trends, 1994-2001: What Do They Portend for the Federal Growth Initiative?" Health Affairs 24(2): 2005, Shin P, Jones K, and Rosenbaum S. Reducing Racial and Ethnic Health Disparities: Estimating the Impact of High Health Center Penetration in Low-Income Communities. 2003, Shi, L., J. Regan, R. Politzer, and J. Luo.. "Community Health Centers and Racial/Ethnic Disparities in Healthy Life." International Journal of Health Services 31(3): 2001). A recent article reported health center quality of care was comparable to or better than care delivered elsewhere, as measured by reduced hospitalizations and emergency department visits, higher vaccination rates, and higher cancer screening rates. (Hicks LS, et al. "The Quality of Chronic Disease Care in US Community Health Centers." November/December Health Affairs 25(6): 2006). Health center low birth weight rates also continue to be lower than national averages for all infants. The health center African American low birth weight is lower than the African American rate observed nationally (10.7% vs. 14.9% respectively). (Shi et al: "America's health centers: Reducing racial and ethnic disparities in perinatal care and birth outcomes." Health Services Research, 39 2004). Health centers also demonstrate success in chronic disease management. A high proportion of health center patients received appropriate diabetes care. (Maizlish et al: "Glycemic Control in Diabetic Patients Served by Community Health Centers." American Journal of Medical Quality 19(4), 2004.). Medicaid patients relying on health center incurred lower total costs per month than Medicaid patients seen elsewhere, even after controlling for age and disability status. (McRae and Stampfly: "An Evaluation of the Cost Effectiveness of Federally Qualified Health Centers (FQHCs) Operating in Michigan." Institute for Health Care Studies at Michigan State University, 2006.).