PRIMARY
HEALTH CARE
Programs
included in this section are:
Health
Centers
# |
Key
Outcomes |
FY
2004 Actual |
FY
2005 Actual |
FY
2006 |
FY
2007 |
FY
2008
Target |
FY
2009
Target |
Out-Year
Target |
Target |
Actual |
Target |
Actual |
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 [Baseline – 2005] |
-13.2% |
-11.0% |
-11.0% |
-7.2% |
-11.0% |
Nov-08 |
-11.0% |
-11.0% |
2014:
11.0% |
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) [Baseline
– 2005] |
42.7% |
42.7% |
42.7% |
44.4% |
42.8% |
Aug-08 |
42.9% |
43.0% |
2014:
45.0% |
1.
II.B.4 |
Percentage
of adult Health Center patients with type
1 or 2 diabetes with most recent hemoglobin
A1c (HbA1c) under control (less than or
equal to 9%) [Baseline – 2008]. (Developmental)
|
|
|
|
|
|
|
Aug-09 |
Aug-10 |
TBD |
# |
Key
Outputs |
FY
2004 Actual |
FY
2005
Actual |
FY
2006 |
FY
2007 |
FY
2008 Target/ Est. |
FY
2009 Target/ Est. |
Out-Year
Target/ Est. |
Target/
Est. |
Actual |
Target/
Est. |
Actual |
Long-Term
Objective: Expand the capacity of the health
care safety net. |
1.
I.
A.1 |
Number
of patients served by Health Centers (in
millions) [Baseline – 2005] |
13.1 |
14.1 |
14.62 |
15.0 |
16.1
a |
Aug-08 |
16.75 |
17.05 |
2014:
18.8 |
1.
D.1.
A.2 |
Total
new or expanded sites |
129 |
158 |
121 |
122 |
302
a |
337 |
62 |
40 |
|
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 |
60.9% |
60.4% |
61.4% |
61.3% |
61.9% |
Aug-09 |
61.5% |
61.6% |
|
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
(number
in millions) |
91.1%
11.96 |
91.5%
12.93 |
86%
12.57 |
91.9%
13.81 |
86%
13.85 |
Aug-08 |
86%
14.4 |
86%
14.6 |
|
1.
II.
A.2 |
Percentage
of Health Center patients who are racial/ethnic
minorities
(number
in millions) |
63.5%
8.34 |
64%
9 |
64%
9.35 |
64%
9.57 |
64%
10.3 |
Aug-08 |
64%
10.7 |
64%
10.9 |
|
1.
II.
A.3 |
Percentage
of Health Center patients who are uninsured
(number in millions) |
40.1%
5.3 |
40%
5.6 |
41%
5.99 |
40%
5.99 |
41%
6.6 |
Aug-08 |
41%
6.86 |
41%
6.9 |
|
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:
a) Pharmacy |
84% |
85% |
83% |
83% |
83% |
Aug-08 |
83% |
83% |
|
b)
Preventive Dental Care |
82% |
84% |
82% |
83% |
82% |
Aug-08 |
82% |
82% |
|
c)
Mental Health/Substance Abuse |
75% |
77% |
74% |
79% |
74% |
Aug-08 |
74% |
74% |
|
Efficiency
Measure |
1.E |
Percentage
increase in cost per patient served at Health
Centers |
5.3% |
2.1% |
5.4% |
4.6% |
5.3% |
Aug-08 |
5.6% |
5.8% |
|
blank |
Appropriated
Amount
($ Million) |
$1,617.9 |
$1,734.8 |
|
$1,785.0 |
|
$1,988.0 |
$2,065.0 |
$2,091.8 |
|
Notes:
a FY 07 target differs from that shown
in the FY 08 Congressional Justification due to a
higher than expected continuing resolution funding
level. The FY 07 target may differ from that shown
in budget narrative tables. Whereas budget narrative
tables are continually updated, performance reporting
guidelines do not permit (except as noted above) changing
a previously established target for the “reporting”
year.
b FY 08 and 09 targets differ from those
established during the FY 07 OMB PART reassessment
to reflect expected budget levels.
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 HRSA’s
Strategic Plan goals of improving access to care,
improving the quality of care, and improving health
outcomes. 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 Centers 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 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.
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
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 percent of Health Center patients had low
birth weight infants, a rate that was 7.2 percent
lower than seen nationally (8.3 percent 2006 national
low birth weight rate). 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 09
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 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.
The FY 08 and FY 09 targets are 42.0% and 43%, respectively.
Targets for the measure are particularly ambitious
as they propose 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.
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. Currently data for this new measure is 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 Uniform
Data System (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 Uniform Data System (UDS) beginning in 2009.
The FY 09 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
13.1 million in 2004 and 14.1 million in 2005. The
15 million patients served by Health Centers in 2006
exceeds the target by over 380,000 patients and is
almost 1 million additional patients than served in
2005. The growth in number of patients served has
been fueled by the President’s Health Centers
Initiative which was designed to impact communities
across the Nation through the support of new access
points and significantly expanded sites. Based on
final FY 07 appropriation amounts, Health Centers
are projected to serve 16.1 million patients by the
end of 2007 and reach 17.05 million patients by the
end of 2009.
1.D.I.A.2.
Total number of new or expanded sites
As
a result of FY 07 activities, Health Center patients
were served through 4,033 comprehensive primary care
delivery sites. The Health Center Program supported
a total of 122 new and expanded sites in FY 06 and
337 new and expanded sites in FY 07, exceeding the
targets. The Program has accomplished its goal of
establishing 1,200 new or expanded sites since 2002.
The program anticipates supporting 40 new and expanded
sites in FY 09.
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 percent
in 2000 to 61.3 percent in 2006, virtually meeting
the target.
It
should be noted that Health Centers serve a higher
risk prenatal population than seen nationally and
targets for this measure propose an ambitious steady
increase in the percentage of women beginning first
trimester prenatal care. Specific characteristics
more prevalent in the Health Center population that
are also associated nationally with late entry into
prenatal care include serving a higher proportion
of:
-
Transient populations such as migrant and homeless
women;
-
Teen prenatal patients (19% of Health Center prenatal
patients are teens as compared to
10% nationally); and
-
Racial and ethnic minorities that nationally also
often have late or no entry into prenatal
care programs (3rd trimester entry is highest in
Black/African American (6%) and
American Indian or Alaska Native (7.7%) populations)
as compared to non-Hispanic
Whites (2.1%) (Martin JA, Hamilton BE, Sutton PD,
et al. National Center for Health
Statistics: 2006)
Based on appropriation amounts, 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 percent of the Federal Poverty Level. The total
number (13.81 million) of individuals at or below
200 percent of poverty served in 2006 is nearly 10%
above the target (12.57 million). The percentage of
patients at or below 200% of poverty has risen for
the eleventh year for which UDS data have been collected.
The FY 09 target is to serve at least 86% of Health
Center patients at or below 200% of poverty.
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 percent Hispanic, and
4.5 percent Asian/Other for a rounded total of 64%,
meeting the target. These percentages represent almost
twice the percentage of African Americans and over
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.
The FY 09 target is 64%.
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 CY 06 the population served included almost
6 million uninsured individuals, which was nearly
40% of the client population served, just slightly
below the target.
- Over
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 percent in 2004-05 from
71.5 percent 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 percent decline
(Cunningham P and May J, Center for Studying Health
System Change: 2006).
-
Physicians also limited the number of new Medicaid
and uninsured patients in their practice. In 2001,
approximately one-fifth of physicians were not accepting
any new Medicaid patients, and 16 percent were not
accepting any new uninsured patients (Cunningham
P, Center for Studying Health System Change: 2002).
At
the same time, the number of uninsured in the nation
has increased steadily from 38.7 million in 2000 to
nearly 47 million or 15.8% of the US population in
2006 (U.S. Census Bureau). In 2004- 2006, 40% of Health
Center patients were uninsured, falling slightly below
the targets of 41%. The FY 09 target is 41%.
At
Health Centers, efforts to increase SCHIP enrollment
through outreach have shifted a major portion of uninsured
children to the publicly-insured. Nearly 37% of all
Health Center patients are children and the percentage
of uninsured children has decreased from 35% in 1999
to approximately 26% in 2006. However, the program
is still committed to continuing to increase the number
of uninsured served proportional to Health Center
growth. Indeed, while the number of uninsured Health
Center patients increased by only 150,000 per year
between 1998 and 2001, it increased by nearly 500,000
in 2003, by nearly 400,000 in 2004, by over 350,000
in 2005, and by more than 365,000 in 2006.
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
1002 grantees reporting in 2006, 83% reported that
they provided pharmacy services either on-site or
by paid referral. The figures for dental care and
mental health/substance abuse services were 83% and
79%, respectively. The percentage of Health Centers
providing these services on site or by paid referral
met or exceeded their respective 2006 targets. The
FY 09 targets therefore reflect maintaining current
levels of these 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
2005, the average cost per patient served at Health
Centers grew by only 2.1 percent and in 2006, while
costs grew at a slightly higher rate (4.6%), performance
not only met but was under the target growth rate
of 5.4%. This is about 33 percent below the 6.8 percent
projected growth rate for national health expenditures
in 2006. In fact, in the past 4 years, cost increases
at Health Centers have been at least 20 percent below
national cost increases. 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 percent 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 06 target: 11.0% below national low birth weight
rate
FY 06 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 percent of Health
Center patients had LBW infants, a rate that was 11
percent lower than seen nationally (8.2 percent -
2005 national LBW rate). While the incidence of LBW
rates fell slightly for health center prenatal patients
in 2006, separation between the Health Center’s
rate and the national rate was only 7.2 percent, (8.3
percent -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 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 percent, unlike increases
observed in the national rate (Source: 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.
Free
Clinics Medical Malpractice
# |
Key
Outcomes |
FY
2004 Actual |
FY
2005 Actual |
FY
2006 |
FY
2007 |
FY
2008
Target |
FY
2009
Target |
Out-Year
Target |
Target |
Actual |
Target |
Actual |
Long-Term
Objective: Expand the capacity of the health
care safety net |
2.I.A.1
|
Increase
the number of volunteer free clinic health care
providers deemed eligible for FTCA malpractice
coverage. [Baseline - 2005] |
|
657 |
1,350 |
1,657 |
1,950 |
Nov-08 |
2,500 |
3,100 |
|
2.1 |
Patient
visits provided by free clinics sponsoring volunteer
FTCA-deemed clinicians. Developmental |
|
|
|
|
|
|
TBD |
TBD |
TBD |
# |
Key
Outputs |
FY
2004 Actual |
FY
2005
Actual |
FY
2006 |
FY
2007 |
FY
2008 Target/ Est. |
FY
2009 Target/ Est. |
Out-Year
Target/ Est. |
Target/
Est. |
Actual |
Target/
Est. |
Actual |
Long-Term
Objective: Expand the capacity of the health
care safety net |
2.I.A.2
|
Number
of free clinics operating with FTCA-deemed volunteer
clinicians. [Baseline - 2005] |
|
38 |
55 |
65 |
70 |
Mar-08 |
85 |
105 |
2011:135 |
2.I.A.3
|
Percent
of volunteer FTCA-deemed clinicians who meet certification
and privileging requirements. [Baseline - 2005] |
|
100% |
100% |
100% |
100% |
Mar-08 |
100% |
100% |
|
Efficiency
Measure |
2.E |
Administrative
costs of the program per Federal Tort Claims Act
(FTCA) -covered volunteer[Baseline – 2004] |
|
$221 |
$281 |
$331 |
$204 |
Mar-08 |
$195
a |
$190 |
|
Appropriated
Amount
($ Million) |
$4.8 |
$.099 |
|
$.040 |
|
$.041 |
$.040 |
$.040 |
|
Notes:
a FY 08 target differs from that shown
in the FY 08 Congressional Justification as it has
been adjusted to include the projected need for additional
quality assurance resources.
INTRODUCTION
The
Free Clinics Program encourages health care providers
to volunteer their time at free clinics by providing
medical malpractice protection at sponsoring health
clinics, thus expanding the health care safety net,
which is a HRSA strategic objective. The Program’s
performance measures track progress in achieving this
objective. The program uses the data from its annual
measures to track and assess program expansion. The
data include the locations of Free Clinics that have
applied for FTCA-deemed volunteer clinicians. The
key strategy used to meet performance targets is to
determine areas with few for no applications and then
target these areas for outreach about the program.
DISCUSSION OF RESULTS AND TARGETS
Long-Term
Objective: Expand the capacity of the health care
safety net
2.I.A.1.
Number of volunteer free clinic health care providers
deemed eligible for FTCA malpractice coverage.
This
measure examines program participation by volunteer
health professionals. In 2005, the first year that
the program began covering providers, 657 providers
were successfully deemed eligible for FTCA coverage.
This number more than doubled in the second year of
the program, exceeding the target by deeming over
1,600 volunteer providers in 2006. The program aims
to deem 3,100 volunteer health care providers by the
end of 2009.
2.1.
Patient visits provided by free clinics sponsoring
volunteer FTCA-deemed clinicians. (Developmental)
This
developmental measure tracks the volume of visits
performed by volunteer clinicians at free clinics
that choose to sponsor these health professionals
for FTCA coverage as an indicator of increased patient
capacity. The program is currently revising its application
materials to collect these data from free clinic applicants
and anticipates having data available in 2009.
Long-Term
Objective: Expand the capacity of the health care
safety net
2.I.A.2.
Number of free clinics operating with FTCA-deemed
volunteer clinicians.
This
measure demonstrates the extent to which free clinics
are participating in the program. In 2005, the first
year that the program began deeming providers, 38
free clinics were operating with FTCA-deemed volunteer
clinicians. In 2006, performance exceeded the target,
with 65 clinics operating with FTCA-deemed volunteers.
By 2009, the program anticipates having 105 clinics
operating with FTCA-deemed volunteers.
2.I.A.3.
Percent of volunteer FTCA-deemed clinicians who meet
certification and privileging requirements.
This
indicator reflects the quality of services provided
by the deemed health professionals volunteering at
participating free clinics as measured by the percentage
meeting licensing and certification requirements.
Performance continues to meet the target with 100%
of FTCA-deemed clinicians meeting appropriate requirements.
The FY 09 target is 100%.
2.E.
Administrative costs of the program per Federal Tort
Claims Act (FTCA)-covered volunteer
By
restraining the annual Federal administrative costs
necessary to deem each provider, the program will
be able to provide an increasing number of clinicians
with malpractice coverage, thus building the free
clinic workforce capacity nationwide and increasing
access to care for the
vulnerable populations served by these clinics. In
2005, the first year that program began deeming providers,
the cost per provider deemed was $221.
The
2006 target included a projected one-time increase
due to new contractor costs, substantial redeeming
application activities, increased technical assistance,
potential claims administration and outreach assistance.
The actual cost per provider deemed in FY 06 of $331
was higher than projected. The size of this increase
in cost is estimated to be a one-time occurrence and
future targets reflect the program's projection of
steady and ongoing increases in efficiency. The FY
09 target is $190.
NATIONAL HANSEN'S DISEASE
PROGRAM
# |
Key
Outcomes |
FY
2004 Actual |
FY
2005 Actual |
FY
2006 |
FY
2007 |
FY
2008
Target |
FY
2009
Target |
Out-Year
Target |
Target |
Actual |
Target |
Actual |
Long-Term
Objective: Expand the availability of health
care, particularly to underserved, vulnerable,
and special needs populations |
3.II.A.1 |
Prevent
increases in the level of Hansen's Disease-related
disability and deformity among patients
treated and managed by the National Hansen’s
Disease Program (NHDP) (Percentage of patients
at grades 1 and 2).
[Baseline – 2002] |
56% |
51% |
50% |
Nov-08 |
50% |
Nov-09 |
50% |
50% |
2013:
50% |
Long-Term
Objective: Promote effectiveness of health
care services |
3.III.A.1 |
Develop
an animal model for the full spectrum of
clinical complexities of human Hansen’s
Disease.
[Baseline – 2006] |
|
|
BRM-1 |
BRM-1 |
BRM-2CM-1 |
Mar-08 |
BRM-3CM-2,3 |
BRM-4CM-4 |
2013:
Produce relevant animal model |
Notes:
BRM = biological response modifiers; CM = cell markers
(CM).
# |
Key
Outputs |
FY
2004 Actual |
FY
2005
Actual |
FY
2006 |
FY
2007 |
FY
2008 Target/ Est. |
FY
2009 Target/ Est. |
Out-Year
Target/ Est. |
Target/
Est. |
Actual |
Target/
Est. |
Actual |
Long-Term
Objective: Expand the availability of health
care, particularly to underserved, vulnerable,
and special needs populations |
3.II.A.2. |
Number of private sector physicians who
have received training from the NHDP.
[Baseline – 2004] |
23 |
12 |
35 |
35 |
40 |
135 |
45 |
50 |
|
3.II.A.3. |
Continue to provide outpatient care for
Hansen’s Disease patients through the National
Hansen’s Disease Program.
[Baseline – 2003] |
3,000 |
3,000 |
3,000 |
3,000 |
3,000 |
Nov-08 |
3,000 |
3,000 |
|
Efficiency
Measure |
3.E |
Maintain increases in the cost per patient
served in the outpatient clinics to below
the medical inflation rate. |
|
$1,456 |
$1,526 |
$1,366 |
$1,599 |
Mar-08 |
$1,676 |
$1,756 |
|
Appropriated
Amount a
($ Million) |
$19.6 |
$19.5 |
|
$18.2 |
|
$18.2 |
$17.8 |
$18.2 |
|
Notes:
a The “Appropriated Amount”
differs from that shown in the CJ budget narrative,
because the CJ table includes amounts for the Hansen’s
Disease Center and excludes Payment to Hawaii and
Buildings and Facilities. This appendix table includes
amounts for the Hansen’s Disease Center, Payment
to Hawaii and Buildings and Facilities.
INTRODUCTION
The
Hansen’s Disease Program is the only dedicated
provider of expert Hansen’s disease treatment
services in the United States, a crucial source of
continuing education for providers dealing with the
identification and treatment of the disease, and a
major source of research on Hansen’s disease.
The Program’s performance measures reflect the
major activities of the program and are linked to
the broader HRSA strategic objectives of expanding
the availability of health care, particularly to underserved,
vulnerable, and special needs population; and promoting
the effectiveness of health care. Strategies for achieving
the program’s performance goals include ongoing
support for ambulatory care clinics that focus on
case management and patient compliance, and the identification
of opportunities for training groups of private physicians
in the geographic areas most impacted by the disease
on the diagnosis and management of Hansen’s
disease.
DISCUSSION
OF RESULTS AND TARGETS
Long-Term
Objective: Expand the availability of health care,
particularly to underserved, vulnerable, and special
needs populations
3.II.A.1.
Level of Hansen's Disease-related disability and deformity
among patients treated and managed by the NHDP.
Hansen’s
Disease is a life-long chronic condition which left
untreated and unmanaged will usually progress to severe
deformity. As this deformity is generally irreversible,
both the annual and long-term measure track the impact
of the program’s case management efforts as
well as patient compliance on the prevention of further
deterioration to a higher grade of disability/deformity.
Through
this annual and long-term measure the program will
monitor its efforts to prevent an increase of the
percentage of Hansen’s Disease patients with
grades 1 or 2 disability/deformity. Disability/deformity
is measured based on the World Health Organization
scale, which ranges from 0-2. Patients graded at 0
have protective sensation and no visible deformities.
Patients graded at 1 have loss of protective sensation
and no visible deformity. Patients graded at 2 have
visible deformities secondary to muscle paralysis
and loss of protective sensation. In 2004, 56 percent
of patients had grades 1 or 2 disability/deformity.
It is expected that both the program’s existing
case management efforts as well as its activities
to train more private sector physicians to recognize
Hansen’s Disease and initiate treatment earlier,
will help prevent further increases in the level of
disability/deformity among Hansen’s patients.
Long-Term
Objective: Promote effectiveness of health care services
3.III.A.1.
Development of the armadillo as an animal model for
the full spectrum of clinical complexities of human
Hansen’s Disease
The
National Hansen’s Disease Program (NHDP) seeks
to prevent and manage Hansen’s Disease (leprosy)
through both clinical care and scientific research.
As an annual and long-term measure, this indicator
monitors advances in scientific knowledge related
to the early diagnosis, treatment, and prevention
of Hansen’s Disease and the NHDP’s performance
in achieving breakthroughs in genomic and molecular
biology.
The measure focuses on the development of an animal
model (the armadillo) for the full spectrum of clinical
complexities of human Hansen’s Disease. This
is the only other species besides man to naturally
acquire Hansen’s Disease and currently, no such
model for human leprosy exists. Once the animal model
is developed, potential advances in scientific knowledge
related to questions associated with pathogenesis,
early diagnosis, vaccine development, and transmission
of Hansen’s Disease can be further explored.
The
annual measure specifically tracks development of
six protective biological response modifiers (BRMs)
and six white blood cell subtype markers (CMs) that
are important in host resistance to Hansen’s
Disease and will ultimately permit development of
the full animal model for human Hansen’s Disease.
In 2006, the program met its target and developed
the first of the 12 reagents needed to produce a relevant
animal model (armadillo). The targets are to develop
BRM-3 and CM-2,3 in FY 08 and BRM-4 and CM-4 in FY
09.
Long-Term
Objective: Expand the availability of health care,
particularly to underserved, vulnerable, and special
needs populations
3.II.A.2.
Number of private sector physicians who have received
training from NHDP.
Early
diagnosis and treatment helps reduce Hansen’s
Disease-related disability and deformity. This can
only be achieved if there are enough healthcare providers
in the U.S. with knowledge of the disease and access
to the support provided by NHDP though its function
as an outpatient clinic, training education, and referral
center for Hansen’s Disease patients. Increasing
knowledge about Hansen’s Disease in the U.S.
medical community should lead to earlier diagnosis
and intervention, resulting in a decrease in Hansen’s
Disease-related disabilities.
In
2007, the NHDP exceeded its program performance target
of 40, and trained 135 private sector physicians.
The FY 08 target is 45 and the FY 09 target is 50,
reflecting the current assessment of training opportunities.
A national promotion effort targeted at physicians
whose practice may include individuals with Hansen’s
Disease (e.g., dermatologists) is underway, as well
as training healthcare providers in targeted areas
where clusters of newly diagnosed cases are appearing.
3.II.A.3.
Continue to provide outpatient care for Hansen’s
Disease patients through the National Hansen’s
Disease Program.
The
National Hansen’s Disease Program includes a
regional outpatient clinic program. The HD population
in the U.S. is approximately 6,000. Currently there
are an estimated 3,000 patients cared for through
the National Hansen’s Disease Program through
outpatient clinics in the area in which they live.
Actual performance for FY 05 met the target. The FY
08 and FY 09 target is 3,000.
3.E. Maintain increases in the cost per patient served
in the outpatient clinics to below the medical inflation
rate.
Hansen’s Disease outpatient care supports treatment
protocols for multi-drug therapy, diagnostic studies,
consultant ancillary medical services, clinical laboratory
analysis, hand and foot rehabilitation, leprosy surveillance,
and patient transportation for indigent patients.
The National Hansen’s Disease Program is committed
to improving overall efficiency through controlling
the cost of care at all of its outpatient clinics
by keeping increases in the cost per patient served
at or below the national medical inflation rate.
By
restraining increases in the cost per individual served
by the Ambulatory Care Program Clinics and at the
National Hansen's Disease Program outpatient center
below the national medical inflation rate, the Hansen's
Disease Services Program can continue to serve a volume
of patients that otherwise would have required additional
funding to serve in the fiscal year. In 2006, the
cost per patient served through outpatient services
was $1,366 and was below the target of expected growth
in cost per patient served. This can be partially
attributed to certain one-time cost decreases as well
as some reductions in certain contract requirements.
As these were one time reductions, targets for FY
07 - 09 remain appropriate.
TARGETS
SUBSTANTIALLY EXCEEDED OR NOT MET
Measure:
Number of private sector physicians who have received
training from the NHDP.
FY 06 target: 40
FY 06 actual: 135
In
2007, the NHDP exceeded this performance target due
to an expansion of the training program to include
an outreach Hansen’s Disease (HD) awareness
seminar and 3 on-line video HD clinical pathological
conferences.
In
response to a changing dynamic in immigrant relocation
in the U.S., the new outreach HD awareness training
initiative is a needed expansion of our training mission.
It is premature, however, to change the target for
this measure.
The
main topic of our outreach seminars is to bring awareness
to physicians of the cardinal signs of HD and whether
a HD diagnosis must be considered when treating immigrant
patients from countries where HD is endemic. Increased
awareness of HD by physicians should lead to earlier
diagnosis of the disease with consequent easier management
and fewer disabling manifestations of HD. This impact
of increased training may take 10 or more years to
become apparent.
|