Fiscal Fitness: How States Cope
Community health centers having trouble making specialty referrals
The nation's community health centers (CHCs) provide primary health care services to more than 15 million people, many of whom are members of racial or ethnic minorities, have low income, are uninsured, or have coverage through Medicaid. But a Commonwealth Fund study says there are concerns that CHCs don't have adequate capacity to provide a full range of services to their patients, and in particular have difficulty obtaining off-site specialty services, including referrals to medical specialists, diagnostic testing, and mental health and substance abuse treatment. The problem is especially acute for CHC patients who are covered by Medicaid or are uninsured, the study found.
The Commonwealth Fund report, "Access to Specialty Care and Medical Services in Community Health Centers," was developed by surveying 814 medical directors of federally qualified CHCs focusing on two issues1) the relationship between access to specialty medical and mental health services and patient insurance status; and 2) other factors associated with access to off-site specialty services for uninsured and Medicaid patients.
Lead author Nakela Cook of Massachusetts General Hospital and Harvard Medical School says CHC medical directors told her some 25% of CHC visits result in medically necessary referrals for services not provided by the centers, regardless of patient insurance category.
She found that getting specialty medical care outside the CHC usually posed little problem for patients with Medicare or private insurance. But access to off-site specialty services was difficult for patients who were uninsured or were covered through Medicaid and was even more challenging for patients needing off-site mental health or substance abuse services. Such access was difficult for uninsured patients, she says, even if the CHC was affiliated with a medical school or a hospital. Access to off-site mental health services was found to be somewhat easier if the CHC had on-site mental health services.
The medical directors said the most common barriers to care were providers who are unwilling to take patients with specific types of insurance, patients who could not pay up front as required, and patients lacking full coverage for needed services. "The effect of these barriers varied significantly by insurance status," Ms. Cook says.
Frequent need for specialized care
Despite the frequent need for specialized medical and mental health services, CHC medical directors reported major problems obtaining them for uninsured and publicly insured patients. "Given that federal policies expanding the number of CHC sites have not led to a substantial increase in the availability of many on-site specialty services, the problem of difficult access for services may increase if additional resources and planning are not devoted to assuring access to outside specialty services or bringing a greater array of services into CHCs," Ms. Cook says.
One potential solution she sees is for some federal funds to be earmarked for providing such services and requiring off-site facilities to deliver a defined amount of specialty care to patients referred from CHCs. Recognizing that centers affiliated with medical schools or hospitals, and those with on-site mental health services, reported greater access to specialty services, Ms. Cook and her colleagues also suggest that policy-makers encourage CHCs to seek such affiliations. Additional research is needed to explore other aspects of CHCs associated with referral success, they say.
"If policy-makers plan to extend access to primary care for the uninsured by increasing the number of CHCs, they must also address the problem of access to secondary and tertiary levels of care," Ms. Cook says. "Because CHC patients are disproportionately minority and low income, these improvements could go a long way in correcting disparities in health outcomes across racial and socioeconomic groups."
Ms. Cook tells State Health Watch there are differences among CHCs across the country in terms of the numbers and types of services they have available on-site. "There are a lot of community health centers that don't have in-house services and have to refer out to specialists, labs, etc.," she says. "Many do have mental health services. We found that if they have some services available on-site, they are more likely to be able to get referrals."
According to Ms. Cook, the report from CHC medical directors that, on average, 25% of their patients need specialist care was higher than the researchers had expected. "We found that a lot of people need services but couldn't get them," she says. "A lot of providers won't accept patients who don't have insurance or who are covered through Medicaid."
Ms. Cook says the solution to the program is through a broader effort to persuade more doctors to accept other payments or people with no insurance or even require that physicians provide some level of service to the uninsured and Medicaid patients. "It's difficult to promote that idea among providers," she adds.
It may ultimately be better, Ms. Cook says, if more effort goes into enhancing services that are offered through existing CHCs rather than increasing the number of CHCs. It also would be important, she says, to find ways to put more specialists on-site at CHCs and to set up referral networks. But she also says she recognizes that some areas of the country, especially rural areas, need CHCs, although the focus still should be on providing full service.
Ms. Cook tells SHW additional research could help clarify the issues facing CHCs. She would like to see research into CHCs that have referral networks that work well and what the factors are that make them work for uninsured patients. She also would like to see researchers look at the role CHC organizational structure plays in being able to obtain referrals and what role any affiliation with an academic medical center or hospital plays in obtaining referrals.
Contact Ms. Cook by e-mail at [email protected]. Access the study from Health Affairs at http://healthaffairs.org.
The nation's community health centers (CHCs) provide primary health care services to more than 15 million people, many of whom are members of racial or ethnic minorities, have low income, are uninsured, or have coverage through Medicaid.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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