Hope Medical Center, Estancia, New Mexico / 31 Fresno County Medical Society-Firebaugh and Mendota East Jacksonville Neighborhood Health Center, Jacksonville, Florida / 34 Lafayette County Health Center, Lafayette County, Florida / 37 South Central Multipurpose Health Services Center, Los Angeles, California / 38 University of Miami Projects, Miami, Florida / 40 Brooklyn-Cumberland Medical Center, New York, New York / 41 East Harlem Triangle Community Health Project, New York, New York / 43 Samaritan Health Service, Phoenix, Arizona / 45 Surgicenter, Phoenix, Arizona / 46 Mission Neighborhood Health Center, San Francisco, California / 47 Presbyterian Medical Services, Santa Fe, New Mexico / 48 Remote Area Health Project, Santa Fe, New Mexico / 50 Wakita Health Center, Wakita, Oklahoma / 51 Upper Cardozo Health Center, Washington, D.C./52 George Washington University Medical Center Delivery System, National Medical Association Foundation, Washington, D.C. / 56 A Task Force of the Committee on Community Health Care, composed of designated members of the Committee and staff, conducted a series of site visits to selected community health delivery programs. Initially, data were gathered on neighborhood health centers; however, the Task Force soon recognized that a study limited only to neighborhood health centers would be inadequate since the intent was a study of representative types of community health programs. The Task Force expanded its study to include satellite clinics, ambulatory surgical facilities, closed-panel prepaid group practices, and a number of experimental and innovative programs. In a majority of the visits, the Task Force utilized a multipage data form to secure uniform information on the many aspects of the projects visited. Visits were made to 30 programs (see Section II) which were selected on the basis of geographic location, sponsorship, information from local medical societies and other health groups, innovative approaches to problems, and receptiveness of program administrators to inclusion in the study. In addition to the site visits, data were obtained by mail survey from other community delivery programs. Although there was no effort to have this study include a statistically valid sample of programs, the Task Force arrived at some conclusions formed as a result of the information gathered. This report summarizes the information obtained, includes a brief analysis of the data, and presents recommendations for involvement by physicians and medical societies that are intended to help improve community health programs. SPONSORSHIP AND FINANCING The programs were sponsored by a variety of groups, including medical societies, medical schools, medical society foundations for medical care, private *Submitted as Council on Medical Service Report B and adopted by the AMA House of Delegates, December 1971. foundations, health insurance and prepayment organizations, religious organizations, other private sources, local health departments, and the federal government. The federal funding agencies included the Office of Economic Opportunity (OEO), Comprehensive Health Planning, Maternal-Infant and Children-Youth Programs, Housing and Urban Development-Model Cities, Regional Medical Programs, National Institute of Mental Health, and the Migrant Health Branch-Division of Health Care Service-Community Health Service. None of the projects visited has a single source of financing. All of the projects had multiple sources of financial support, although 80 percent of the programs had one principal source of support supplemented by smaller amounts from several sources. Six programs received relatively equal financial support from three or more sources. In five programs there were some qualifying limitations on patient registration depending on residence and source of payment. Twenty-five programs accepted any residents of their service area, including those who were covered by Medicare, Medicaid. Blue Cross-Blue Shield, or private insurance. Success in securing reimbursement from these sources of financing varied widely and depended on the established policy, philosophy, degree of effort exerted in attempting collection, and on how well the program was organized administratively, especially the accounting and billing functions. Because of the multiple sources of funding, the health centers had difficulty in establishing a unified program to provide comprehensive health care to all patients. The categorical restrictions placed on the use of these funds, particularly federal funds, often caused fragmentation and inefficiency in the organization, administration, and operation of the program with the result that some patients could not be provided with the health services that they needed. The custom of annual appropriation of funds, with the resulting lack of assured continuity of program operation, caused serious problems in recruiting top quality personnel. Ten projects visited were identified as OEO neighborhood health centers since their principal funding source was OEO at that time. These programs had been operational longer than most others and were the larger-funded neighborhood health centers. The OEO grants ranged from approximately $1 million to $6 million, with the bulk of these funds being used for personnel expenses in operating the health program. Using the total budget divided by the number of people served in the target area, the cost of the operation of these OEO programs ranged from about $70 to about $200 per year per individual enrolled. This substantial variance in per patient cost was due to several factors, including a wide difference in the range of services offered including those of a nonmedical nature, as well as the low volume of enrolled patients during prolonged start-up periods for these programs. Besides the ten OEO health programs, financing sources among the other programs were diverse, consisting of direct grants from private individuals and foundations, third party payments (Medicare, Medicaid, Blue Cross-Blue Shield, private insurance), and individual out-of-pocket payments. Total program budgets ranged from $25,000 in the case of one store-front clinic to $6 million for a sophisticated community health program. A few clinics relied heavily on volunteer staff services, donated drugs and equipment, and contributions from patients. The impact of all these contributions on the financial operations of these programs had not been fully considered by anyone and thus it was difficult to assess whether they could ever become economically self-sustaining. The patient payment mechanisms for services rendered in the 30 health programs varied from free care, or no patient-payment, to a single form of payment or a combination of methods, including fixed fee-for-service schedules, a sliding scale according to the patient's ability to pay, and capitation. Capitation per person for a family varied according to scope of services covered; however, the average subscription rate was usually over $50 per month per family of three or more. Exact determination of costs could not be made due to the many factors discussed above, but a figure of approximately $35 per facility visit was frequently offered. However, in examining this cost figure, it must be understood that it includes a large number of medical and health-related services, such as physicians' services, nursing services, laboratory, x-ray, pharmacy, dental, nutrition counseling, health education, community health worker training and Outreach services, and transportation. It was therefore not possible to make direct comparison between these costs and the costs of providing services in other delivery methods. Half of the programs visited appeared to have been initiated by and were being sustained by large federal contracts. These programs were almost totally dependent on heavy financial subsidization; even though the programs had received federal approval for long-range operation, they were still subject to annual appropriation of funds and contract renewal and thus subject to changes in policies and regulations that might modify plans for the future. At least nine programs reported that they expect to become self-sustaining within three to five years. Five of these more highly developed projects had been initiated through private funding and had some reasonable assurance of long-term operation. AREA AND PEOPLE SERVED Twenty-three of the projects visited were considered to be in an urban or suburban setting. Seven projects were in rural locations, primarily in the South or Southwest. Sixteen of the urban programs dealt with an inner-city population of mostly black or Spanish-speaking persons. These urban poor areas were typical of the inner-city ghetto with a high majority of the people unskilled, unemployed, or retired, and with family incomes near or below the poverty level. A substantial number of the inner-city populations served by these health programs were dependent upon public and charitable agencies for food and clothing. These ghetto residents were characterized by rates of mental and physical illness that were among the highest in their respective cities. The effect of the increased incidence of acute and chronic illness, malnutrition, and accidents in these ghetto areas was clearly visible in higher morbidity and mortality rates than in other areas of the same city. The seven rural areas visited had health programs serving migrant MexicanAmericans, poor whites, and poor blacks. Problems in these areas were accentuated by problems of transportation, isolation, and mental illness. In 22 of the 30 programs visited, the population served was poor, or near poor. Of the remaining eight programs, only three appeared to be serving a representative cross section of the population. The other five programs were largely privately financed and served only a limited number of poor people. Social, educational, and economic factors appeared to be important determinants in an individual's ability to obtain health and medical care. MEDICAL AND HEALTH SERVICES The range of medical and health services offered by the community centers varied considerably. Twenty-four of the programs, including all of the OEO and CHP (314e) neighborhood health center projects, were attempting to provide comprehensive ambulatory care including a wide range of preventive, diagnostic, and therapeutic services for the entire family. Most of the community health programs offered primary care or initial care for entry into the health care system. Sophistication of medical care operations ranged from a skeleton store-front clinic with a very limited health care capability to a comprehensive health service program providing a wide range of services, including annual complete physical examinations, early disease detection through screening, and complete hospitalization with specialty hospital backup from several hospitals. In other programs the care consisted largely of crisis management with little evidence of attention to total needs of the patients. Twelve of the programs reported that they offered ambulatory dental services for prevention and treatment. A key feature of many of the programs was that they sought to use the occasion of delivery of episodic care to introduce to the patient the concept of health maintenance and ideas for basic, broader changes in the physical and social milieu that contribute to the cycle of ill health and poverty. Such ideas were new to the individual and offered him further opportunity to improve his basic way of life. However, any in-depth evaluation of these program efforts was felt to be premature at this time because of the long-range process of measuring such environmental and socioeconomic change. The availability and accessibility of backup facilities for patient referral and inpatient care were reviewed. In 12 urban programs and one rural program, adequate backup facilities were immediately adjacent or in close proximity to the community health center. In these cases, patient referral procedures had been well established and a high percentage of the medical staff had hospital privileges. The remainder of the programs had some arrangements for backup facilities, but accessibility was complicated by time and distance factors (from 15 to 75 miles), with resultant transportation difficulties. Also, patient referral procedures appeared to be more loosely defined and only a portion of the medical staff had hospital privileges. Those programs without firm linkages for adequate backup facilities and services did not appear to be meeting the needs of their patients for continuing care. Home visits were provided by most programs, usually by nursing and community outreach personnel. House visits by physicians were provided in at least two programs, but usually only after a screening of the need by allied health personnel. Most of the community health centers were open during regular business hours with some of the centers having evening clinics two or three days a week. These centers were usually open five or six days a week with a few open every day. Some types of emergency services were provided by every program with most of them having emergency service available on a 24-hour basis either by clinic visit, telephone consultation, or referral. Those programs that did not directly provide such emergency service usually had arrangements with nearby facilities to provide emergency care to program area residents. Appointment systems were in use in all programs. The success of the appointment system varied greatly. In the program with the highest percentage, slightly more than half the patient load were seen by appointment. The appointment system was utilized to establish personal family-physician relationships in order to foster the concept of bringing patients back to the same physician |