Back to Table of Contents | February 2010

Cover Story

Community Service

Although they’ve quietly served the poor for decades, community clinics are emerging as the health care model to emulate.

By Kate Ledger

From the street, the squat, brick building that houses the University of Minnesota’s Community-University Health Care Center (CUHCC) looks modest, even inauspicious, on its corner in the Phillips neighborhood of Minneapolis. But the bustle inside the warm, homey waiting room is a clear sign of how vitally important this place is. Most mornings, it’s standing-room only as patients check in. In some cases, entire families wait together to accompany one relative to an appointment.

At the reception desk, you can hear the hushed ripples of several languages: English, Spanish, Somali, Lao, Hmong, Cambodian, Vietnamese, and Thai. Although CUHCC serves an exceptionally diverse patient population, what it offers is similar to the care available at Minnesota’s 14 other government-funded community health centers. Known as Federally Qualified Health Centers (FQHCs), these clinics are a critical piece of the state’s health care safety net, offering services to some of the neediest patients in impoverished and underserved areas. (In addition, one community clinic in the state is a “lookalike”; it provides similar services but doesn’t get federal grant money to cover the uninsured.) What the clinics provide, however, is much more than what a typical doctor’s office might. To be eligible for federal funding, each clinic must offer medical, mental health, and dental care. And it must provide services to make care accessible to all patients, whether they have insurance or not.

The challenge these clinics face is providing high-level care to patients who have complicated health conditions—and doing so at minimal cost. “Our clinics operate on a very tight margin,” acknowledges Walter Cooney, executive director of the Neighborhood Health Care Network, a nonprofit that assists the state’s community clinics with services such as tech support and joint purchasing.

Community clinics rely on federal grants, as well as grants from the state, foundations, and organizations for support. They also depend to some extent on insurance reimbursement and on fees from patients who don’t have insurance but pay according to their income. Securing funding has proved more difficult as the competition for grant money has ramped up as a result of the current economic downturn. At the same time, more people have lost jobs and, subsequently, their health insurance, and are turning to the clinics for affordable care.

Despite the slimmed budgets, community clinics are doing a remarkable job addressing widespread health problems such as diabetes, sexually transmitted diseases, and infant mortality. And many are taking note. In December, President Barack Obama announced he was committing $600 million to 85 community health centers in the country, affirming their approach to care. “It’s an exciting time for the community health centers,” says Rhonda Degelau, executive director of the Minnesota Association of Community Health Centers, which provides advocacy for community clinics. In fact, at a time when the state and nation are discussing how to improve health care delivery, community health centers may have much to offer.

Care for the Whole Patient

What community clinics have already put into action is the health care home model, in which care is interdisciplinary and services are well-coordinated. Clinic visits often include much more than a brief meeting with a primary care provider. The patients who go to FQHCs often have severe life circumstances and few resources, Degelau notes: Sixty-five percent of FQHC patients in the state have incomes less than 100 percent of the poverty level; approximately 40 percent have no insurance at all. It’s not uncommon for a patient’s primary care visit to also include a meeting with a mental health professional or help with housing or legal issues.

At CUHCC, the clinic’s electronic health record flags patients who are due for a screening or dental exam, so those can be scheduled during the visit. Dovetailing appointments can be critical, explains Christopher Reif, M.D., the center’s director of clinical services. “It’s frequently difficult for the patients we see to come back a few days or a week later,” he says. “We run the risk that they won’t make another trip.”

Providing coordinated care is especially important for those patients who have serious, persistent mental illness and are at high risk of dying if their other medical needs are not met. One middle-aged man in the waiting room at CUHCC has an appointment to see a therapist. A recovering drug addict, he’s been working hard to stay on top of the depression that has fueled his substance abuse. But before he leaves, he’ll also stop in down the hall to have his blood pressure checked; he learned at a recent visit it’s running high, and he has started on medication.

In a trailer alongside the clinic, where community-based mental health programs are housed, case managers and adult rehab workers offer patients who have mental illness a wide range of services. They might help a patient fill out MinnesotaCare or Medicaid forms. Or they might help patients who are dealing with sexual abuse and the court system get connected with pro bono legal services. Although insurers don’t pay for such services, “all these aspects of care are germane to good health,” notes Reif, recalling one patient he saw recently whose blood sugar level was elevated. During the appointment, Reif learned the patient had lost his apartment and was living on the streets. With the help of a case manager at the clinic, the patient was able to find better living conditions, “which was really the underlying cause of the diabetes going bad,” he says.

In addition, some of the clinics’ health initiatives go beyond their walls. Reaching some patients involves going into the community to connect with them, says Terry Hart, M.D., who has served as interim director of West Side Community Health Services, a busy center in St. Paul with two medical clinics that conduct more than 120,000 patient visits a year. In addition to providing in-house care, West Side outreach workers hold walk-in clinics at a local homeless shelter and at a mission. “We need to go to the places where people congregate,” Hart says. At the Fremont Community Health Clinic in northeast Minneapolis, workers have come up with novel ways to reach out to community members, particularly low-income African Americans, who are at risk for heart disease and diabetes. They’ve conducted blood pressure screenings in churches, hair salons, barbershops, and at public housing facilities.

A Formula for Value

By a number of accounts, the clinics’ approach to care is working. According to Minnesota Community Measurement, last year the state’s community clinics were more successful than other medical groups in achieving a range of health standards. When it came to the appropriate treatment of children with upper respiratory infections, 93 percent of children got the right care at a community clinic, as opposed to 87 percent statewide. In giving children the appropriate tests for sore throats, the clinics scored 93 percent, as opposed to 86 percent across the state. The clinics reached 60 percent of adult female patients for chlamydia screening, while the state average was 49 percent. And in treating adults with bronchitis, the clinics were on target in terms of appropriately prescribing antibiotics 47 percent of the time, while the state average was 19 percent. Even compared with national community clinic averages, the Minnesota clinics do better. They had fewer low-birth-weight babies, conducted higher rates of Pap smears, and did a better job of controlling blood glucose levels in diabetes patients, according to Cooney. And, he says, patients are happy with the care they receive. A 2008 survey found patient satisfaction in Minnesota’s community clinics was 90 percent.

In addition to offering a broad range of services and high-quality care, the clinics pay close attention to health care costs, both for the system and their patients. Physicians are careful about ordering expensive procedures and tests and work hard to find affordable alternatives. They are aware that for patients who struggle to afford a copay for a clinic visit, having an X-ray or CT scan at a partnering hospital might well be out of the question. Instead, they might have a discussion about other tests that are available. Patients can then ask about the potential benefits and costs involved in order to make a decision. “If there’s a reason for great concern, sometimes we have to encourage patients to put health concerns first, and we prepare them for how they’ll arrange payment with the hospital,” Reif says. Another way physicians work to keep patient costs low is by prescribing generic rather than brand-name pharmaceuticals. The clinics have access to them at a low cost through a government drug-pricing program. Some clinics also have established arrangements with local pharmacies, which then sell the drugs at rock-bottom prices. And some keep medications, from insulin to Zoloft, on site to disburse to patients who can’t otherwise pay for them.

Because physicians are salaried (ranging from $110,000 to $135,000 in cities and up to $165,000 in rural outposts), their compensation isn’t tied to the number of patients they see or procedures they do. Moreover, like military physicians, they can’t be sued by patients. A person with a grievance needs to sue the federal government under the federal tort claim act. “The good news is that we have had very little problem with that over time. Outcomes are excellent and patient satisfaction is high,” says Ron Jankowski, M.D., a family physician and medical director of Fremont Community Clinics, three clinics in north and northeast Minneapolis.

Many of the ideas for initiatives and services come from the people the clinics serve. One critical characteristic of an FQHC is that at least 51 percent of its board of directors must be volunteers from the patient population. This can be “rocky,” acknowledges West Side’s Hart, because members may have a range of experience and a limited amount of time to dedicate. It also can be a boon in “assuring community members have a major role in governance,” he says, and in orchestrating health programs that are effective and culturally sensitive.

Even though community clinics provide care to those who have trouble affording it, the patient base is more varied than one might expect. “We see an incredible mix of people,” Jankowski says. About a third of those who visit one of Fremont’s three sites are uninsured and living at or below 200 percent of poverty, another third are covered by federal or state programs, and another third have standard insurance. In terms of lifestyle, he says, patients range from “homeless people to physicians.”

Having a range of patients may be essential to keeping a clinic afloat. This year, Open Door Health Center in Mankato became the southern-most FQHC in the state, drawing more than 3,000 patients from 11 neighboring counties. Some of those patients make the trip to the clinic site from 45 minutes away, says executive director Sarah Kruse. Long before attaining eligibility to receive federal grants, the clinic had depended on an array of creative funding sources, including some state grants as well as donations from foundations, local businesses, and even other health care facilities (the building where the center is located came by way of a donation). “You need a broad base of resources to get the dollars to cover all the program expenses,” Kruse says.

With its new source of federal dollars, Open Door will make updates to the building. It recently hired a full-time physician (the staff physician had been seeing patients four days a week) and a social worker. It plans to add a physician assistant this spring. Kruse is pleased to note Open Door has held onto longtime patients with standard health insurance. “Some of those patients developed a relationship with us during a period of time when they didn’t have insurance,” she says. “Now, they find they want to stay with the clinic in order to have continuity with their provider.”

In the Spotlight

During his second term in office, President George W. Bush successfully pushed to expand the number of community health centers nationwide. Today, more than 1,400 FQHCs receive federal grants under section 330 of the Public Health Service Act to cover uncompensated care. “Community clinics have long been a bipartisan effort,” notes Colleen McDonald, director of development and programming at CUHCC. “We’ve seen support come from both sides of the aisle.” Most recently, the Obama administration has moved to increase the base funding given to clinics, a monetary amount that hadn’t changed in several years. With recent stimulus money—CUHCC received an additional $800,000 this year—clinics are able to invest in technology such as electronic medical record systems and make much-needed capital improvements.

But even with increased federal money, the clinics continue to operate on a shoestring. They make use of community volunteers, and even physicians and nurses from the surrounding neighborhoods are known to donate time. McDonald’s job, writing grant applications for CUHCC, also involves ferreting out new funding sources, like the grant it recently received from the Minnesota Department of Health to provide family planning services to the uninsured. She raises between $2.5 and $3 million a year in order to support projects or services that are not billable, including nursing care, care coordinators, and interpreters.

By all counts, the clinics are facing additional financial stressors these days. As the recently unemployed lose their health insurance coverage, community clinics are seeing a dramatic increase in new patients. Among clinics in the Neighborhood Health Care Network, patient visits jumped to 492,000 last year, an 18 percent increase over the number of visits four years earlier. CUHCC had the state’s largest bump as it took on 1,400 new patients in 2009, an unprecedented one-year increase of 11 percent. The clinic now accommodates more than 60,000 patient visits a year.

Another blow was the announcement last spring that Gov. Tim Pawlenty intended to cut General Assistance Medical Care (GAMC), the state health insurance program for some of the poorest Minnesotans. Because the program covers approximately 32,000 impoverished adults during any given month and the reimbursement provides nearly $6 million to community clinics, they were duly concerned. Although GAMC funding represents only one source of money for community clinics, “it’s a significant chunk,” Jankowski says.

Budget challenges aside, finding doctors to practice in community clinics has been difficult in parts of the country. To attract candidates, some clinics have increased salary offerings. Others have initiated loan repayment programs. In some areas, international medical graduates have received special visa status for working in community health centers. But lately in the Twin Cities, Jankowski feels he’s seen more physicians finding the option attractive. In the last year, he says, he’s had at least 10 inquiries from doctors interested in working at the clinics. “They could be making more money working other places, but they come here because they’re not feeling fulfilled and want to make a difference in the health of their patients and their community,” he says.

Their interest may signal the beginning of a new respect for community clinics. President Obama announced in December that he would establish a program to evaluate the benefits of community clinics, particularly their use of the health care home model. In Minnesota, one group of community clinics is signing up with the Institute for Clinical Systems Improvement to share what they’ve learned. Reif believes community clinics have much to offer in discussions about reforming health care delivery: They’ve shown how health care costs can be trimmed and how treatment can be made available to everyone who needs it, and they’ve figured out how to involve patients in their own care. “We’re bringing voice of community health into those discussions,” he says. Given the recent spotlight shown on community clinics by the president and others, it’s likely many will be listening. MM

Kate Ledger is a freelance writer in St. Paul and a frequent contributor to Minnesota Medicine.