Primary Health Care

Health Centers

Notes:

1. The National data for low birth weight (1.II.B.2) in FY 2006 is preliminary.
2. DNA = Data not available for 1.II.B.3 due to change in data source for this measure.  Previous data were collected from Health   Disparity Collaboratives.  In FY 2009 the data will be available from the Uniform Data System.
3. DNA = Data not available.  Due to modifications in data collection, data will not be available for 2007-2009. For FY 2008 and FY 2009 the previously published target was 64%.

INTRODUCTION

Health Centers are community-based and patient-directed organizations that serve populations lacking access to high quality, comprehensive, and cost-effective primary health care.  The Health Center Program’s performance measures help the Program track progress in reaching Health Resources and Services Administration’s (HRSA) Strategic Plan goals of improving access to care, improving the quality of care, improving health outcomes and eliminating health disparities.  The more specific HRSA objectives the Program aims to achieve include: increase the utilization of preventive health care and chronic disease management services, expand the availability of health care, and expand the capacity of the health care safety net.  The Health Center Program has funded new and expanded Health Center organizations as a major strategy to reaching performance goals relating to the numbers of patients served and their demographic mix.  Efforts to achieve other performance goals involve strategies that include:  sharing best practices so that health centers learn from one another what works in improving quality and performance; providing technical assistance and training on issues such as quality improvement and risk management; enhancing health information technology assistance; and support of a unique model of health care delivery that emphasizes prevention, health-related enabling services, outreach, follow-up, and cultural competency services.

DISCUSSION OF RESULTS AND TARGETS

Long-Term Objective:  Increase the utilization of preventive health care and chronic disease management services, particularly among underserved, vulnerable, and special needs populations. 

1.II.B.2.  Rate of births less than 2500 grams (low birth weight) to prenatal Health Center patients compared to the national low birth weight rate.

Appropriate prenatal care management can have a significant effect on the incidence of low birth weight (LBW) which is the risk factor most closely associated with neonatal mortality.  In turn, improvements in infant birth weight can contribute significantly to reductions in infant mortality rates.  This measure reflects both on quality of care and health outcomes for Health Center women of child-bearing age, a key group served by the program. 

This measure is benchmarked to the national rate to demonstrate how Health Center performance compares to performance of the Nation overall.  The goal is to achieve a rate that is 11% below the national average even as Health Centers continue to serve a higher-risk prenatal population than represented nationally in terms of socio-economic status, health status and other risks factors that might predispose Health Center patients to higher risk for low birth weight and adverse birth outcomes. 

In 2006, 7.7% of Health Center patients had low birth weight infants, a rate that was 7.2% lower than seen nationally (8.3%, 2006 national low birth weight rate).  (See section below on “Targets Substantially Exceeded or Not Met.”)  In addition, Health Center low birth weight rates have continued to follow a steady pattern at about 7%, unlike increases observed in the National rate.  As indicated above, the FY 2009 target is to achieve a rate of 11% below the National rate, as previously achieved in 2005. 

1.II.B.3.  Percentage of adult Health Center patients with diagnosed hypertension whose blood pressure is under adequate control (less than or equal to 140/90).

Health Center patients, including low-income individuals, racial/ethnic minority groups and persons who are uninsured, are more likely to suffer from chronic diseases such as hypertension and diabetes.  Clinical evidence indicates that access to appropriate care can improve the health status of patients with chronic diseases and thus reduce or eliminate disparities.

This measure focuses on quality of care and improved health outcomes for one of the most prevalent chronic conditions facing Health Center patients, hypertension.  Clinical evidence indicates that controlling blood pressure (hypertension) can reduce the health risk associated with the conditions such as heart disease and stroke.  An analysis of billing data reported in the Uniform Data System (UDS) over a five year period from 2001-2006, indicates a steady increase in the percentage of patients with a primary diagnosis of hypertension during the reporting year (13.9% to 15.3%). 

In 2004 and 2005, 42.7% of hypertensive Health Center patients had their blood pressure under control.  In 2006, the figure was 44.4%, exceeding the target of 42.7%.  The FY 2008 and FY 2009 targets are 42.9% and 43%, respectively.  The Program proposes to demonstrate improvements in a chronic condition that requires treatment with both lifestyle modifications, usually as the first step, and, if needed, with medications.  Lifestyle factors to treat high blood pressure include weight control, exercise, healthy diet, limiting alcohol use, and other lifestyle modifications that are often challenging interventions that improve only slowly over time.  National data supports this as according to CDC data for 1999-2002, only 32% of adults demonstrated adequate high blood pressure control.  The 2009 target is slightly below the most recent actual performance because this single data point is not enough information upon which to base a new projection, and because there will be a change in the data source for this measure as noted below.

This measure replaces a previous, related measure in which control of hypertension was self-reported via the periodic Health Center User Survey last conducted in 2002.  Previously, data for this measure was reported by a subset of grantees participating in the Health Disparities Collaboratives.  Future progress on the measure will be reported annually by all grantees via the UDS beginning in 2009. 

1.II.B.4.  Percentage of adult Health Center patients with type 1 or 2 diabetes with most recent hemoglobin A1c (HbA1c) under control.

This measure also focuses on quality of care and improved health outcomes for one of the most prevalent chronic conditions facing Health Center patients, diabetes.  An analysis of billing data reported in the UDS over a five year period from 2001-2006, indicates a steady increase in the percentage of patients with a primary diagnosis of diabetes during the reporting year (5.6% to 7.1%). 

Uncontrolled diabetes can lead to non-traumatic amputations, blindness, end-stage renal disease, and hospitalizations for diabetes-associated cardiovascular disease.  These and other health problems associated with diabetes contribute to an impaired quality of life, substantial disability among people with diabetes and resulted in an estimated $92 billion in direct costs nationally in 2002.

Clinical evidence indicates that controlling blood glucose through such activities as chronic care management provided in Health Centers benefits people with either type 1 or type 2 diabetes.  In general, for every 1% reduction in results of A1C blood tests (e.g., from 8.0% to 7.0%), the risk of developing eye, kidney, and nerve disease is reduced by 40%.

This measure is developmental and future progress will be monitored and reported annually by all grantees via the UDS beginning in 2009.  The FY 2009 target will be established after the collection of baseline data. 

Long-Term Objective:  Expand the capacity of the health care safety net.

1.I.A.1.  Number of patients served by Health Centers.

Monitoring the number of patients served annually by Health Centers is key to assessing the program’s performance in increasing access to care for underserved and vulnerable populations.  Not only do Health Center patients gain access to care, they gain access to a comprehensive health care home (also referred to as medical home).  A health care home is a regular/usual, continuous, and patient-centered source of primary care, such as that offered by Health Centers.  A health care home prevents sickness, manages chronic illness, and reduces the need for avoidable, costlier care such as emergency room visits and hospitalizations.  This is key as an estimated 56 million Americans lack access to a health care home because they live in communities where there is an acute shortage of primary care providers.  The lack of such physicians is associated with higher mortality rates and health care disparities (The National Association of Community Health Centers (NACHC) and the Robert Graham Center: 2007).

The number of patients served by Health Centers reached 15 million in 2006 and 16.1 million in 2007.  The 16.1 million patients served by Health Centers in 2007 met the projected Program target and is over one million additional patients than served in 2006.  Health Centers are projected to serve 16.75 million patients by the end of 2008 and reach 16.85 million patients by the end of 2009.

1.D.I.A.2.  Total number of new or expanded sites.

The Health Center Program supported a total of 337 new and expanded sites in FY 2007 and 61 new and expanded sites in FY 2008.  The Program has accomplished its goal of establishing 1,200 new or expanded sites since 2002, with a total of 1,297 new or expanded sites created from FY 2002 through FY 2008. 

Long-Term Objective:  Increase the utilization of preventive health care and chronic disease management services, particularly among underserved, vulnerable, and special needs populations.

1.II.B.1.  Percentage of pregnant Health Center patients beginning prenatal care in the first trimester.

Monitoring timely entry into prenatal care assesses both quality of care as well as Health Center outreach efforts and focuses 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.  Results over the past few years demonstrate improved performance as the percentage of pregnant Health Center patients that began prenatal care in the first trimester grew from 57.8% in 2000 to 61.3% in 2007, slightly less than the target of 61.9%.

The Health Center program anticipates increasing the percentage of pregnant patients beginning prenatal care in the first trimester to 61.5% in 2008 and 61.6% in 2009.

Long-Term Objective:  Expand the availability of health care, particularly to underserved, vulnerable, and special needs populations.

1.II.A.1.  Percentage of Health Center patients who are at or below 200% of poverty.

To improve the health status of the Nation’s underserved communities and vulnerable populations, safety-net programs must target access to care for people of low income.  According to 2006 UDS Health Center data, nearly 92% of patients were at or below 200% of the Federal Poverty Level.  In 2007, the figure was 91.4%, which exceeded the Program target of 86%.  The FY 2009 target will continue to be 86%, due, in part, to factors outside the control of the Program such as fluctuations in the economy that impact poverty levels, unemployment, and insurance levels. 

1.II.A.2.  Percentage of Health Center patients who are racial/ethnic minorities.

To improve the health status of the nation’s underserved communities and vulnerable populations, safety-net programs must target access to care for people of racial/ethnic minority groups.  According to UDS Health Center data, in CY 06 the population served was 23.0% African American (AA), 36.1% Hispanic, and 4.5% Asian/Other for a rounded total of 64%, meeting the target.  These percentages represent almost twice the percentage of African Americans and almost two and a half times the percentage of Hispanics reported in the overall U.S. population.  It is currently estimated that the percentage of minority patients will hold steady at about two-thirds of all patients served.  Due to modifications in data collection, data will not be available for 2007-2009. 

1.II.A.3.  Percentage of Health Center patients who are uninsured.

To improve the health status of the Nation’s underserved communities and vulnerable populations, safety net programs must also target access to care for people who are uninsured.  According to UDS Health Center data, in 2006 that population served included almost 6 million uninsured individuals comprising 40% of the health center patient population, which was just below the target.  In 2007, the health center population served included 6.24 million uninsured individuals, which was nearly 40% of the client population - just slightly below the target.  The FY 2009 Program target is 41%.

In 2007, UDS Health Center data showed that:

• One quarter of the children served by Health Centers are uninsured.
• Almost one half of adult Health Center patients are uninsured.
• About three quarters of Health Center patients are either uninsured or Medicaid recipients.

In comparison, nationally, research reveals that caseloads of private physicians in the primary care specialties include 4% uninsured and 7% Medicaid for a total of 11% (National Ambulatory Medical Care Survey: 2001), down from the 19% in the previous study (National Ambulatory Medical Care Survey: 1998).  Additional reports note that:

• The percentage of physicians providing any free or reduced cost care decreased to 68.2% in 2004-05 from 71.5% in 2000-01.
• Their overall number of charity care hours per 100 uninsured people also declined from 7.7 hours in 1996-97 to 6.3 in 2004-05, an 18% decline (Cunningham P and May J,  Center for Studying Health System Change: 2006).

At the same time, the number of uninsured in the Nation has increased steadily from 38.7 million in 2000 to nearly 46 million or 15.3% of the U.S. population in 2007 (U.S. Census Bureau).      

Long-Term Objective:  Expand the capacity of the health care safety net.

1.I.A.2.  Percentage of grantees that provide the following services either on-site or by paid referral:  Pharmacy, Preventive Dental Care, and Mental Health/Substance Abuse.

Access to pharmacy, oral health, and mental health/substance abuse (MH/SA) services is critical to ensuring overall health and well-being of Health Center populations.  Inadequate access to pharmacy services often leads to problems with drug interactions, inappropriate doses, and failure to adhere to prescribed therapy.  Lack of access to oral health care services is the primary reason for significant disparities in oral health status among vulnerable populations.  MH/SA disorders, such as depression and abuse of alcohol are prevalent among underserved populations, and treatment is not accessible in many local communities.

Of the grantees reporting in 2006, 83% provided pharmacy services, 83% provided preventive dental care, and 79% provided mental health/substance abuse services either on-site or by paid referral.  For 2007, of the 1,067 grantees reporting, 82% reported that they provided pharmacy services either on-site or by paid referral, virtually meeting the target of 83%.  The figures for dental care and mental health/substance abuse services were 83% and 80%, respectively.  The percentage of Health Centers providing dental and MH/SA services on-site or by paid referral exceeded their respective 2007 targets.  The FY 2009 targets are: 83% for pharmacy services, 82% for dental services, and 74% for mental health services.

1.E.  Percentage increase in cost per patient served at Health Centers.

This efficiency measure focuses on maximizing the number of Health Center patients served per dollar.  It also monitors Health Center performance in keeping cost increases below annual national health care cost increases while maintaining access to high quality services.  The efficiency measure also utilizes a metric that speaks to the program as a whole.  By looking at growth in total cost per patient, the full complement of services that make Health Centers a “health care home” are captured.  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.).

In 2006, health center costs grew at a rate of 4.6%, which not only met but was under the target growth rate of 5.4%.  This was 31% below the actual growth rate for national health expenditures in 2006, which was 6.7%.  In 2007, health center costs grew at a rate of 4.5%, which surpassed the program goal of keeping the cost growth rate at or under 5.3%.  By restraining increases in the cost per individual served at Health Centers below national per capita health care cost increases, the Health Center Program has served a volume of patients that otherwise would have required additional funding to serve and demonstrates that it delivers its high quality services at a more cost-effective rate.  Given recent performance of the program, annual targets in growth are set at 20% below forecasted national rates.  Successful restraint of the cost per individual served at Health Centers below national per capita health care cost increases may, in part, be related to the Health Centers’ strategic use of a multi- and interdisciplinary team model of care that treats the “whole patient,” with a focus on continuity of primary care and enabling services.

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

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

FY 2006 target:  11.0% below national low birth weight rate
FY 2006 result:  7.2% below national low birth weight rate

This measure is benchmarked to the national rate to demonstrate how Health Center performance compares to performance of the Nation overall.  In 2005, 7.3% of Health Center patients had LBW infants, a rate that was 11% lower than seen nationally (8.2%, 2005 national LBW rate).  While the incidence of LBW rates increased for the Health Center prenatal patients and prenatal patients nationally in 2006, separation between the Health Center’s rate and the national rate was only 7.2% (8.3% -2006 preliminary national LBW rate). 

The Program serves a prenatal care population at higher risk than that seen nationally.  With the extensive expansion of health center services since 2002 through the development of new health center sites, more high risk prenatal patients who were previously underserved are being served, thus impacting the level of this rate.  While the Program addresses LBW through the implementation of preventive prenatal health care in new organizations, there will be a delay before the benefit of these efforts is realized.  The Program will take the following to address this issue:

• Technical assistance to health centers on the delivery of quality health care through State Primary Care Associations.
• Outreach to patients to encourage timely entry into prenatal care, and patient education on healthy behaviors that can impact birth weight.
• Information to clinicians to help them in the identification of maternal disease and risks for complications of pregnancy or birth during the first trimester.

Despite the recent slight increase in LBW, results over the past few years demonstrate that Health Center patients have continued to follow a steady LBW pattern at about 7%, unlike increases observed in the national rate (Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2006.  National vital statistics reports; vol. 56, no. 7.  Hyattsville, MD: National Center for Health Statistics, 2007).  The Program will continue its effort to remain below the national LBW rate, while serving a higher-risk prenatal population than seen nationally.