foreword The American Medical Association Committee on Community Health Care, through its Task Force consisting of designated Committee members and AMA staff, made a series of site visits to 30 selected community health delivery systems. The site visits were begun in February 1969 and completed in the early fall of 1971. They were designed to study a broad range of new or alternative patterns and systems of community health delivery programs. This publication is an outgrowth of the Task Force's efforts and is presented in two sections. The first section is the report adopted in December 1971 by the House of Delegates of the American Medical Association. This report consists of a brief analysis of the collected data, summary and conclusions, and recommendations for physician involvement, either directly or indirectly, in community health programs. The second section includes individual narratives about the community health programs visited by the Task Force. Included is information concerning geographic location, administration, finance, demographic structure of the area served, medical and health services provided, manpower utilization, and physical facilities used. All descriptions of individual programs are based on information that was current at the time of the site visits, and some changes have probably occurred in many of the programs since then. Some program narratives highlight aspects of the program that their representatives perceived as innovative and that were thought to have promise for use in other locations in alleviating some of the basic problems of health care delivery at the community level. The AMA has for many years supported the concept that there is no single approach-no single master plan-that can suit the needs of every community. The diversity of community approaches to meeting the needs of varying communities presented herein emphasizes the merits of continuing to have a multiplicity of patterns of health care delivery. Copyright© 1972, Revised 1973 American Medical Association 535 North Dearborn Street Chicago, Illinois 60610 All rights reserved PD-210-1804-1380:2M5C:135-J:4/73 For additional copies write to: Department of Community Health AMERICAN MEDICAL ASSOCIATION 535 North Dearborn Street Chicago, Illinois 60610 !!! table of contents Foreword/ iii SECTION II--NARRATIVES ON COMMUNITY HEALTH PROGRAMS VISITED BY TASK FORCE Community Health Programs Visited by Task Force, Feb/69-Sept/71 Atlanta Southside Comprehensive Health Center, Atlanta, Georgia / 14 East Baltimore Medical Plan, Baltimore, Maryland / 15 Bunker Hill Health Center, Boston, Massachusetts / 17 Harvard Community Health Plan, Boston, Massachusetts / 18 Health, Incorporated, Boston, Massachusetts / 20 Tufts-Columbia Point Health Center, Boston, Massachusetts / 21 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 |