Challenge 1: thin margins, marginalized populations

Most FQHC patients are insured by Medicaid or by state-level child health insurance programs, or are uninsured and pay for their care on a sliding scale (Ku et al., Reference Ku, Richard, Dor, Tan, Shin and Rosenbaum2010). Here’s how the math works at one FQHC, serving a largely uninsured patient population in northwestern New Jersey, one of the wealthiest states in the nation.

The cost of a primary care ‘encounter’ at this FQHC is $165. If the patient is on Medicaid, the FQHC will be paid $140 for this encounter. If the patient is uninsured, the patient will be asked for a co-pay of about $20. The FQHC will be paid $101 for the care of this patient from New Jersey’s uncompensated care fund, making the total ($131) about the same as a Medicaid reimbursement. Some states offer no uncompensated care fund at all, and there is wide variation in reimbursement rates among the states that do (Silow-Carroll and Alteras, Reference Silow-Carroll and Alteras2004). New Jersey’s program is among the more generous in the nation.

The difference between this FQHC’s costs and what one state’s public insurance, plus patients’ co-pays, will cover is made up through federal grants administered through the Health Resources and Services Administration in support of health care for vulnerable populations. While FQHCs accept private insurance, they are usually paid far less to treat those patients: this FQHC would be reimbursed only $50 by a private insurer. Under the ACA, health care plans offered through the new health insurance ‘marketplaces’ are required to contract with safety-net providers in the community, but they are not required to provide the enhanced Medicaid rate described above.

FQHCs aim to offer comprehensive primary care, including dental care and behavioral health services. Most low-income patients would have little or no timely access to this range of services if FQHCs did not provide them, as they would not be able to find other local providers willing to take Medicaid or to be paid on a sliding scale. In addition to offering these additional clinical services, FQHCs offer care coordination, transportation, mobile health care sites and patient education, to make it possible for their patients to receive needed medical care in a single location that is close to where they live or work. They do this because of the reality of their patients’ lives. FQHC patients who work and are uninsured are unlikely to have paid time off for medical appointments; indeed, they may risk losing their jobs if they miss work. Low-income patients may travel to medical appointments on foot or via public transportation.

FQHCs are highly vulnerable to Medicaid cuts, as their vision of good care and their service-intensive model of delivering care are based on Medicaid reimbursements and on a payer mix that includes mostly Medicaid patients. While most health care organizations operate on thin margins, FQHCs face the double challenge of limited, precarious revenue streams and few opportunities to diversify their sources of income beyond reimbursements and program-related grants. The federal mandate that at least 51% of the members of an FQHC’s board of directors be ‘consumers’ – that is, low-income members of the community – means that these not-for-profits have a built-in constraint on their ability to raise funds through board members, a common strategy for most not-for-profits.

To maximize reimbursable ‘encounters,’ FQHCs could hire more physicians. More patients could be seen, even if less time is spent with each patient. However, this vision of primary care falls short not only of what FQHCs expect of themselves, but also what the federal government expects from FQHCs: comprehensive primary care for patients who lack access to health care as a condition of their lives – a hard reality – and who may need more than medical services.

FQHC leaders are now confronting severe state-level cuts to Medicaid reimbursement rates and uncertain federal level support for Medicaid. The expansion of Medicaid in 25 states under the ACA may result in greater demand for FQHC services – as newly-enrolled Medicaid recipients are directed to FQHCs from hospital emergency rooms or social service agencies, for example – while funding for these services is being cut or is always at risk (Thompson and Gusmano, 2014). At what point will FQHC leaders and clinicians perceive that their vision of good (or even adequate) care for the population they serve is being compromised by longer waits for dental care, or reduced hours, with the risk that patients will not be able to get in, or will not come back?

The roll-out of the ACA is introducing related challenges for FQHC leaders who are trying to balance the books and maintain a reliable structure for front-line clinicians. On the one hand, the ACA requires that they recruit a minimum proportion of safety-net providers in a community. Furthermore, the law defines ‘safety net’ broadly, so plans do not have to contract with a local FQHC. Even if FQHCs are included in plan networks, will newly insured patients bring their insurance to an FQHC, or look elsewhere for primary care now that they have a choice? Should FQHCs seek to serve newly insured patients, who may like the comprehensive primary care the FQHC offers, or refocus on the Medicaid and uninsured populations who have the fewest options?

The resource limitations FQHC leaders routinely grapple with, and the uncertain consequences of these limitations for the delivery of care, are challenges reformers must expect to face in coming years of tight budgets. Insuring more patients is a huge accomplishment. It is not at all the same as ensuring that patients will be able to get care, and that the true cost of good care will be covered.

Challenge 2: policy shifts, identity follows?

FQHCs are accustomed to running lean operations in the best of times. As they must keep responding to policy shifts and public health trends at federal and state levels, they are highly adaptive and politically astute organizations. However, the pressure to adapt constantly (and to secure grants) makes it hard for an FQHC to plan for its own future and to determine which local activities are a good investment of its limited resources.

FQHCs and hospitals share some features. Both types of organizations have long fulfilled federal mandates to ensure access to basic health care. Federal law requires FQHCs to provide comprehensive primary and preventive care to patients regardless of ability to pay [Health Centers Consolidation Act of 1996, Section 330 of the Public Health Service Act, Title 42 USC§ 254b(b)(1)(A), P.L. 104-299]. The federal law known as Emergency Treatment and Active Labor Act (EMTALA) requires any hospital that provides emergency services and accepts Medicare to provide patients who come to their emergency department with appropriate medical screening regardless of ability to pay to determine if they are suffering from an emergency medical condition (including active labor) (EMTALA 42 U.S.C. § 1395dd, part of the Consolidated Omnibus Budget Reconciliation Act of 1986, Pub.L. 99-272, 100 Stat. 82). If a patient is determined to be in need of emergency medical care, the hospital must provide treatment until the patient’s condition has been stabilized. If the patient’s condition cannot be stabilized at this hospital, the patient must be transferred to a hospital that can provide the needed emergency care. Federal law does not currently require either FQHCs or hospital emergency rooms to determine a patient’s citizenship status as a condition of receiving care under these statutes.

Beyond the limited obligations imposed by EMTALA, not-for-profit hospitals must provide ‘community benefits’ to qualify as tax-exempt. The definition of ‘community benefit’ is broad, but would include providing charitable care and operating an emergency department that is open to the public. Efforts to define and enforce these obligations more precisely have included community-led monitoring projects supported by the not-for-profit consumer advocacy group Community Catalyst, which released a report in 2010 critical of how some hospitals defined charitable care (Lenihan, Reference Lenihan2009; Pryor et al., Reference Pryor, Rukavina, Hoffman and Lee2010). Defining a hospital’s uncollected debt as charitable care, for example, or failing to provide the public with information about free care or financial assistance, fell short of planned efforts to allocate health care benefits within a community in a transparent way.

One longstanding community goal of FQHCs is to reduce non-emergency utilization of EDs. A May 2011 report by the General Accounting Office (GAO) on strategies to reduce use of EDs described the relationship between these two health care settings as a given: ‘the nationwide network of health centers’ are ‘like emergency departments’ in that both are safety-net providers for patients who are uninsured, underinsured or lack access to health care for other reasons (Draper, Reference Draper2011). The GAO report, which was based on interviews and other survey data from community health centers and networks, sought to identify what these organizations were doing to reduce ED use for primary care needs. It described three strategies: FQHC collaboration with hospitals on patient education, aimed at directing primary care visits to the FQHC rather than the ED; care coordination by FQHCs, aimed at identifying and addressing health problems to reduce emergencies; and expanded access to FQHC services through evening and weekend hours and same-day and walk-in appointments, so that FQHCs are seen to be nearly as accessible as EDs.

FQHCs and hospitals in the same community have a common patient population: the Medicaid or uninsured patient in different states of health. FQHCs aim to offer comprehensive primary care to patients who might otherwise turn up at the ED with non-emergent problems. If these strategies succeed, ED clinicians can focus on emergency care. How, then, should hospitals reciprocate by supporting FQHC as organizations? What is the nature of the relationship between these organizations, apart from privileging FQHC physicians at local hospitals? Should FQHCs and hospitals collaborate to identify common problems in their common patient population, and if so, what venues are available for collaboration between organizations of unequal size and authority within a community? These are continuing practical questions with ethical and also legal dimensions (Rosenbaum et al., Reference Rosenbaum, Zakheim, Leifer, Golde, Schulte and Margulies2011).

Challenge 3: access to specialty care

The blurring of boundaries between ‘primary’ and ‘specialty’ care, and between health care services that can be provided in the primary care setting and those that require collaboration with an outside entity, further complicates the picture for FQHCs today and for policymakers tomorrow as ACA rolls out. The GAO report on the role of FQHCs in reducing demand for ED services describes FQHCs as providers of “comprehensive primary health care services – preventive, diagnostic, treatment and emergency services, as well as referrals to specialty care – without regard to a patient’s ability to pay” and also as providers of “enabling services, such as case management and transportation, which help patients access care” (Draper et al., 2011). This is a vision of primary care that anyone can embrace – who wouldn’t want all these services under one accessible roof? However, can FQHCs do all this, given their current and projected revenue sources, the demand for their services, and also the difficulties of outside collaboration? This is the biggest ethical and practical challenge FQHC leaders and clinicians face, if they do not have some existing and reliable arrangement, usually with an academic medical center, for making specialty care referrals for low-income patients.

As primary care providers, FQHCs aim to help patients maintain their health, resolve health problems and manage chronic conditions. Some FQHC clinicians, such as pediatric nurse-practitioners or certified nurse midwives, are specialists within their professions. The scope of services they offer, within the boundaries of licensure and skill, may be broader if they work in a FQHC than in another setting. For example, compared with private physician offices, FQHCs often provide more so-called ‘wrap-around’ services: physicians and nurses in FQHCs are more likely to spend time collaborating with staff social workers and with community social service providers to remove barriers to a patient’s continued access to health care.

Specialty medical care usually requires collaboration with an outside provider. Local specialists may volunteer at an FQHC one day a week: for example, a urologist can provide prostate exams. Others donate pro bono services, such as colonoscopies, at their own facilities. The details of care coordination fall to the FQHC: to take advantage of donated colonoscopies, for example, the FQHC staff must provide transportation for patients. The GAO report on the efforts of FQHCs to reduce non-emergency ED visits noted that these care coordination services characteristic of FQHCs are usually not fully covered by any third-party payer.

Referrals introduce discontinuities into patient care and can work against the goal of access, if it is difficult for a patient to follow-up on a referral. Certain services associated with primary care, such as blood work, also may not be covered by an FQHC’s available funding streams. An FQHC may then have to refer patients who need blood work to the local ED, a practice that conflicts with the FQHC’s goal of reducing non-emergency use of ED services. FQHCs with few options for specialty referrals may be mandated to offer community outreach and screenings, such as prostate-specific antigen testing for prostate cancer, for conditions that they cannot treat. What happens to the low-income patient whose test results are suspicious?

Sometimes, an FQHC patient presents with bothersome symptoms of potentially life-threatening illness. Some illnesses, such as HIV/AIDS and tuberculosis, can be managed in the primary care setting following diagnosis, the establishment of a treatment plan, and support for the patient who must manage a chronic illness. Other conditions demand specialty care. For example, an FQHC patient’s symptoms may indicate cancer, and the urgent need for an oncology consultation. In a 2002 survey, FQHC medical directors reported that while they were able to find specialists willing to accept referrals for patients with insurance (usually, Medicaid), only 60% were reliably able to find specialists for uninsured patients (Gusmano et al., Reference Gusmano, Fairbrother and Park2002). Recent studies suggest that publicly-insured patients who are not seriously ill but who need outpatient specialty care may have great difficulty obtaining this care on their own in a timely fashion (Bisgaier and Rhodes, Reference Bisgaier and Rhodes2011).

Who is accountable, ethically and financially, for the continuing and often costly health care needs of an uninsured patient who is initially seen in an FQHC and who is diagnosed with a serious, treatable condition? Who is responsible for coordinating the care of a patient who is both seriously ill and has difficulty gaining access to health care of any type, even if this patient has public insurance? For such patients, obtaining outpatient specialty care seems impossible without someone to work the system, to identify willing local specialists and sources of charity care, as well as to help navigate the system.

A ‘net’ or a ‘home’?

‘Navigation’ is a metaphor as well as an activity. A ‘patient navigator’ is a health care worker responsible for guiding a patient safely through a health care system, typically cancer care. This metaphor is also used in some community health centers, which employ patient navigators to help patients, particularly patients who do not speak English, gain access to needed health care beyond the FQHC itself; two other metaphors for safety are prominent in FQHCs. Community health centers are classic ‘safety-net’ organizations. Like hospital EDs, they are federally mandated to serve as providers of last resort for patients who cannot afford to pay for the health care they need. However, unlike hospital EDs, FQHCs may also identify themselves as ‘medical homes’ for individuals and families. Definitions of medical homes emphasize well-coordinated care, professional teamwork and attentiveness to patient’s health-related needs beyond the clinical encounter, with the assumption that the primary care medical home can serve as the patient’s destination for most health care. This is a different concept of safety than that of the safety net, which catches someone who is already falling to prevent them from falling further. Another practical challenge for FQHCs, then, concerns how to organize themselves as long-term medical homes while maintaining their safety-net mandate. For example, the FQHC as medical home needs ways to pay for lab work, radiology and other features of primary care. It may also need better access to specialists, not all of whom will be able or willing to volunteer their services, and stronger commitments to charity care on the part of other health care organizations in the community.

Collaborations between FQHCs and academic medical centers that offer new physicians opportunities to complete part of their residency in a community health center, in exchange for loan repayment, are part of the solution to one challenge for all primary care organizations in the United States: the lack of primary care physicians (Mullan, Reference Mullan2009). Providing early-career physicians with opportunities to learn about community health care and the needs of medically underserved populations is a great idea. What is unclear is how many of these new primary care physicians will stick with FQHCs once their loans are repaid. This may not matter so much to FQHCs, which already rely on teams that include physicians, nurse-practitioners and physician assistants as primary care providers. As a profession, nurse-practitioners have a strong orientation toward primary care: 70–80% of them go into primary care, compared with 16–18% of new physicians (Council on Graduate Medical Education, 2010; Naylor and Kurtzman, Reference Naylor and Kurtzman2010). What FQHCs need is the funding to keep a health care team together, mindful that scarce physicians are reimbursed at the highest rate.