A Sketch of Community Health Centers. Chart Book 2012

Transcription

1 A Sketch of Community Health Centers Chart Book 2012

2 National Association of Community Health Centers, 2012 For more information, Cover picture provided courtesy of Codman Square Health Center in Boston, Massachusetts. This publication was supported by Grant/Cooperative Agreement Number U30CS16089 from the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA/BPHC.

3 Table of Contents Preface Sources and Methodology Section I: Who Health Centers Serve Figure 1.1: Health Centers Serve Figure 1.2: Health Center Patients Are Predominately Low Income Figure 1.3: Most Health Center Patients are Members of Racial and Ethnic Minorities, 2010 Figure 1.4: Most Health Center Patients are Uninsured or Publicly Insured Figure 1.5: Health Center Patient Mix Is Unique Among Ambulatory Care Providers Figure 1.6: Health Centers Serve Patients Throughout the Life Cycle Figure 1.7: Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-Insured, 2010 Figure 1.8: Health Center Patients are Disproportionately Racial/Ethnic Minorities, 2010 Figure 1.9: Health Centers Are More Likely to Treat Patients with Chronic Illnesses Compared to Other Primary Care Physicians Section II: Health Center Growth Figure 2.1: The Number of Health Centers Receiving Federal Health Center Grants Has Increased Dramatically Figure 2.2: The Number of Health Center Patients Continues to Increase Figure 2.3: The Number of Health Center Patient Visits Continues to Increase Figure 2.4: The Number of Uninsured and Medicaid Health Center Patients Continues to Grow at Faster Rate than Other Patients Figure 2.5: The Number of Health Center Low Income* Patients Is Growing Faster than the Number of Low Income Nationally, Figure 2.6: The Number of Health Center Medicaid Patients Grew Faster than the Number of Medicaid Beneficiaries Nationally, Figure 2.7: The Number of Health Center Uninsured Patients Grew Faster than the Number of Uninsured Nationally, Figure 2.8: The Numbers of Patients with Chronic Conditions Is Rapidly Rising at Health Centers, Figure 2.9: The Number of Chronic Condition Visits at Health Centers Has Increased,

4 Section III: Access to Care Figure 3.1: Health Centers Have Higher Rates of Accepting New Patients Regardless of Insurance Coverage Compared to Other Primary Care Providers Figure 3.2: Health Center Uninsured Patients Are Half as Likely to Go Without Care as the Uninsured Nationally Figure 3.3: Health Center Uninsured and Medicaid Patients are More Likely to Have a Usual Source of Care than the U.S. Privately Insured Figure 3.4: Health Center Uninsured Patients are Twice as Likely To Get the Care They Need than Uninsured Nationally Figure 3.5: Percent of Low Income, Uninsured Served by Health Centers, 2010 Figure 3.6: The Percent of Medicaid Beneficiaries Served by Health Centers, 2008 Section IV: Preventive Services Figure 4.1: Health Centers Provide a Broad Array of Services Figure 4.2: Health Centers Have Experienced Tremendous Growth in the Number of Patients and Visits for Medical, Dental, and Mental Health Care, Figure 4.3: Health Centers Provide More Preventive Services than Other Primary Care Providers Figure 4.4: Health Center Patients with Hypertension Are More Likely to Receive Counseling About Diet, Exercise, and Taking Medications than Their National Counterparts Figure 4.5: Health Center Patients with Hypertension are More Likely to Comply to Counseling About Diet, Exercise, and Taking Medications than their National Counterparts

5 Section V: High Quality Care and Reducing Health Disparities Figure 5.1: Health Centers Reduce Disparities in Access to Mammograms Figure 5.2: Health Centers Also Reduce Disparities in Access to Pap Tests Figure 5.3: Health Centers Also Reduce Disparities in Access to Colorectal Cancer Screening Figure 5.4: Health Center Patients Have Lower Rates of Low Birth Weight than the U.S. Average Figure 5.5: Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts Figure 5.6: More Health Center Patients Prefer to Be Served in Languages Other than English Every Year Section VI: Cost-Effective Care and Economic Impact Figure 6.1: Health Centers Save $1,263 Per Patient Per Year Figure 6.2: Community Health Centers Economic Impact by State, 2009 Figure 6.3: Health Center Economic Impact by State, 2009 Figure 6.4: Large urban health center generates a total economic impact of $21.6 million for its local community, while the average small rural health center generates about $3.9 million Figure 6.5: Health Centers Could Save Over $18 Billion Annually By Preventing Avoidable ER Visits

6 About this Chartbook This chartbook includes data from Health Centers who meet the Community, Migrant, and Public Housing Health Center grant requirements and receive federal funding from the Bureau of Primary Health Care. Therefore, unless otherwise noted, this chartbook does not always include data from a category of Health Centers that does not receive these funds, known as Look-Alikes. Data reflected in this chartbook may consequently underreport the volume of health care delivered by health centers. There are approximately 100 Look-Alikes across the United States.

7 Preface The National Association of Community Health Centers (NACHC) is pleased to present A Sketch of Community Health Centers, an overview of the federal Health Center Program and the communities they serve. Health Centers began over forty years ago as part of President Lyndon B. Johnson s declared War on Poverty. Their aim then, as it is now, is to provide affordable, high quality and comprehensive primary care to medically underserved populations, regardless of their insurance status or ability to pay. A growing number of health centers also provide dental, behavioral, pharmacy, and other needed supplemental services. No two health centers are alike but they all share one common purpose: to provide primary health care services that are coordinated, culturally and linguistically competent, and communitydirected. Health centers play a critical role in the health care system as the health care home to over 20 million* people. Across the country health centers produce positive results for their patients and for the communities they serve. They stand as evidence that communities can improve health, reduce health disparities, and deal with a multitude of costly and significant health and social problems including substance abuse, HIV/AIDS, mental illness, and homelessness if they have the resources and leadership to do so. The Health Center Program has been very successful over the years in providing vital health care services to those in need. However, the program faces many looming challenges. Rising costs, narrowing revenue streams, and steady increases of newly uninsured and chronically ill patients threaten health centers ability to meet growing need. Federal and state support is critically important to keep pace with rising costs and escalating health care needs. Who health centers serve, what they do, and their impressive record of accomplishment in keeping communities healthy, is represented in the following charts. *Includes patients of federally-funded health centers, non-federally funded health centers (health center look-alikes ), and expected patient growth for 2012.

8 Section I: Who Health Centers Serve

9 Figure 1.1 Health Centers Serve 1 in 7 Medicaid beneficiaries 1 in 7 uninsured persons, including 1 in 5 low income uninsured 1 in 3 individuals in poverty 1 in 4 minority individuals in poverty 1 in 7 rural Americans Source: NACHC, Includes patients of federally-funded health centers, non-federally funded health centers, and expected patient growth for 2012.

10 Figure 1.2 Health Center Patients Are Predominately Low Income Over 200% 7% % 7% % 14% 100% and below 72% *Please refer to sources and methodology at the end for more information Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Federal Poverty Level (FPL) for a family of three in 2010 was $17,600. (See Based on percent known. Percents may not total 100% due to rounding.

11 Figure 1.3 Most Health Center Patients are Members of Racial and Ethnic Minorities, 2010 Race Ethnicity More than One Race 4% Black/African American 26% White 64% Hispanic/ Latino(a) 34% American Indian/ Alaska Native 1% Asian/Hawaiian/ Pacific Islander 5% Non- Hispanic/ Latino(a) 66% *Please refer to sources and methodology at the end for more information Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Based on percent known. Percents may not total 100% due to rounding.

12 Figure 1.4 Most Health Center Patients are Uninsured or Publicly Insured Other Public 3% Private 14% Medicare 7% Uninsured 38% Medicaid/ SCHIP 38% Other public may include non-medicaid SCHIP and state-funded insurance programs. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Percents may not total 100% due to rounding.

13 Figure 1.5 Health Center Patient Mix Is Unique Among Ambulatory Care Providers % 5% 9% 90% 14% 80% 70% 60% 50% 40% 30% 20% 10% 0% 8% 38% 39% 4% 61% 17% 13% 37% 14% 9% 31% Health Centers Private Physicians Hospital Outpatient Depts. Other/Unknown Private Insurance Medicare Uninsured Medicaid Notes: Other public includes non-medicaid SCHIP and other state-funded insurance programs. Sources: Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System. Hing E, Uddin S. Visits to primary care delivery sites: United States, NCHS data brief, no 47. Hyattsville, MD: National Center for Health Statistics

14 Figure 1.6 Health Centers Serve Patients Throughout the Life Cycle Ages 65+ 7% Under 5 11% Ages % Ages % Ages % Ages % Ages % Note: Percents may not total 100% due to rounding. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

15 Figure 1.7 Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-Insured, % Health Centers U.S. 72% 38% 39% 40% 16% 16% 21% Uninsured Medicaid At or below 100% of Poverty Under 200% of Poverty Note: Health Center: Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System. U.S.: Kaiser Family Foundation, State Health Facts Online, Based on U.S. Census Bureau 2009 and 2010 March Current Population Survey. U.S. Census Bureau,Table POV46. Poverty Status by State, August 2010, Annual Social and Economic Supplement, 2010 Current Population Survey.

16 Figure 1.8 Health Center Patients are Disproportionately Racial/Ethnic Minorities, % Health Centers US 35% 34.4% 30% 25% 25.8% 20% 15% 16.3% 12.6% 10% 5% 0% Hispanic/Latino(a) Black/African American 4.6% 5.0% Asian/Hawaiian/Pacific Islander 1.4% 0.9% American Indian/Alaska Native Sources: Based on 2010 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. U.S. Census Bureau, Census 2010 data. Table: Race and Hispanic or Latino Origin: 2010, 2010 Census Summary File 1.

17 Figure 1.9 Health Centers Are More Likely to Treat Patients with Chronic Illnesses Compared to Other Primary Care Physicians Percentage of Physician Visits Involving Patients with Common Chronic Conditions Percent age of Physician Visits Involving Patients with the Specified Chronic Condition 28% 25% 18%*** Health Centers Private Physician Offices 14% 11%* 15%*** 11% 8% 8%** 6% Health Centers Physician Offices Depression Diabetes Asthma Hypertension Note: Statistical significance measures compared to value for private physician offices; *** p <.01, ** p <.05, * p <.10 Common chronic conditions include visits where the primary diagnosis listed for the visit is an ICD-9-CM diagnosis code for hypertension, asthma, diabetes, heart disease, and selected psychotic conditions and other psychoses. Excludes visits classified as pre/post surgical, all visits to non-primary care physicians, and any visits where the patient did not see a physician. Source: Based on George Washington University analysis from Kaiser Commission on Medicaid and the Uninsured. Community Health Centers: The Challenge of Growing to Meet the Need for Primary Care in Medically Underserved Communities.. (march 2012.)

18 Section II: Health Center Growth

19 Figure 2.1 The Number of Health Centers Receiving Federal Health Center Grants Has Increased Dramatically 106% growth since ,002 1,067 1,080 1,131 1, Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

20 Patients in Millions 25 Figure 2.2 The Number of Health Center Patients Continues to Increase 103% growth since Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

21 Patient Visits in Millions Figure 2.3 The Number of Health Center Patient Visits Continues to Increase % growth since Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

22 Patients in Millions Figure 2.4 The Number of Uninsured and Medicaid Health Center Patients Continues to Grow at Faster Rate than Other Patients Uninsured Medicaid Private Medicare Other Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

23 Figure 2.5 The Number of Health Center Low Income* Patients Is Growing Faster than the Number of Low Income Nationally, Percent Increase 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 93% Health Center Low Income 27% Low Income Nationally * Patients under 200% of poverty. Sources: U.S. Census Historical Poverty Tables. ( ). Table 5. Percent of People By Ratio of Income to Poverty Level. NACHC analysis. (2010) Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

24 Figure 2.6 The Number of Health Center Medicaid Patients Grew Faster than the Number of Medicaid Beneficiaries Nationally, Percent Increase 140% 120% 100% 133% 80% 60% 58% 40% 20% 0% Health Center Medicaid Medicaid Nationally Sources: Bureau of Primary Health Care, Health Resources and Services Administration, DHHS and 2010 Uniform Data System. Kaiser Commission on Medicaid and the Uninsured. Medicaid Enrollment: December 2010 Snapshot.

25 Percent Increase Figure 2.7 The Number of Health Center Uninsured Patients Grew Faster than the Number of Uninsured Nationally, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 89% Health Center Uninsured Sources: U.S. Census Bureau. Historical Health Insurance Tables. Table HIB-2. Health Insurance Coverage Status and Type of Coverage-All Persons by Sex, Race, and Hispanic Origin: 1999 to 2010." NACHC analysis. (2012) Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS, 26% Uninsured Nationally

26 Percent Increase Figure 2.8 The Numbers of Patients with Chronic Conditions Is Rapidly Rising at Health 180% Centers, % 140% 154% 147% 120% 100% 103% 80% 60% 40% 20% 0% Total Patients Patients with Diabetes Patients with Hypertenison Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

27 Figure 2.9 The Number of Chronic Condition Visits at Health Centers Has Increased, Visits in Millions Asthma Depression Diabetes Hypertension Note: Only includes visits by primary diagnosis and therefore likely underestimates the true volume of care provided by condition. Source: NACHC analysis of Bureau of Primary Health Care, HRSA, DHHS, 2006, 2007, 2008, 2009, 2010 Uniform Data System

28 Section: III Access to Care

29 Figure 3.1 Health Centers Have Higher Rates of Accepting New Patients Regardless of Insurance Coverage Compared to Other Primary Care Providers Health Center Other Primary Care Providers 100% 80% 60% 40% 20% 98% 97% 96% 97% 93% 66% 76% 89% 0% New Patients New Medicaid Patients New Medicare Patients New Uninsured Source: Hing E, Hooker RS, Ashman JJ. Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health Nov 3 epublished.

30 Figure 3.2 Health Center Uninsured Patients Are Half as Likely to Go Without Care as the Uninsured Nationally 120% 100% 80% 60% 96% Health Center Uninsured 60% US Uninsured 82% 68% 40% 20% 0% Has Usual Source of Care At least 1 Primary Care Visit in the Past Year Source: Shi, L and Stevens, GD. The Role of Community Health Centers in Delivering Primary Care to the Underserved. April-June 2007 JACM 30(2):

31 % Reporting They Have a Usual Source of Care Figure 3.3 Health Center Uninsured and Medicaid Patients are More Likely to Have a Usual Source of Care than the U.S. Privately Insured 100% 96% 99% 80% 60% 55% 40% 20% 0% Health Center Uninsured Health Center Medicaid US Privately Insured Sources: Health center data from Shi, L and Stevens, GD. The Role of Community Health Centers in Delivering Primary Care to the Underserved. April-June 2007 JACM 30(2): National data from Kaiser Commission on Medicaid and the Uninsured analysis of 2010 NHIS data. Found in 5 Basic Facts on the Uninsured (2012)

32 Figure 3.4 Health Center Uninsured Patients are Twice as Likely To Get the Care They Need than Uninsured Nationally 60% Health Center Uninsured 55% Uninsured Nationally 40% 20% 25% 16% 30% 12% 24% 0% Delayed Care Due to Cost Went Without Needed Care Could Not Fill Rx Source: Politzer, R., et al. Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care Medical Care Research and Review 58(2):

33 Figure 3.5 Percent of Low Income, Uninsured Served by Health Centers, % 25% 52% 21% 26% 40% 34% 21% 32% 19% 21% 22% 26% 9% 11% 27% 37% 44% 26% 30% 15% 29% 24% 17% 27% 34% 19% 14% 17% 57% 15% 22% 18% 22% 21% 11% 29% CT: 32% DC: 58% DE: 20% MA: 61% MD: 12% NH: 30% NJ: 23% RI: 48% VT: 40% 12% 16% 40% 50% 0% to 19% 19% to 26% 26% to 37% 37% to 62% 20% Note: Under 200% of poverty. Source: National data from: Kaiser State Facts. Distribution of the Nonelderly Uninsured by Federal Poverty Level, 2010, Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System.

34 Figure 3.6 The Percent of Medicaid Beneficiaries Served by Health Centers, % 19% 15% 10% 7% 15% 11% 4% 12% 15% 11% 12% 11% 8% 10% 7% 14% 28% 7% 9% 6% 11% 15% 6% 21% 13% 9% 10% 21% 10% 9% 5% 9% 12% 7% 5% 11% CT: 31% DC: 30% DE: 7% MA: 17% MD: 15% NH: 10% NJ: 20% RI: 27% VT: 19% 6% 7% 18% 25% 0% to 9% 9% to 11% 10% 11% to 18% 18% to 31% Source: 2010 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation, State Health Facts Online. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2009 MSIS, Kaiser Family Foundation, State Health Facts Online.

35 Section IV: Preventive Services

36 Figure 4.1 Health Centers Provide a Broad Array of Services Behavioral Health 8% Dental 12% Enabling 7% Medical Care 73% Vision 1% Total = 77 million encounters in 2010 * Encounters for enabling services include visits to case managers and health educators. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

37 Percent Increase, Figure 4.2 Health Centers Have Experienced Tremendous Growth in the Number of Patients and Visits for Medical, Dental, and Mental Health Care, Dental Mental Medical 433% 406% % 207% % 89% million million Patients million million million Patient Visits million 37 Source: UDS, HRSA. Note: Mental health does not include substance abuse.

38 Figure 4.3 Health Centers Provide More Preventive Services than Other Primary Care Providers Source: Shi L, Tsai J, Higgins PC, Lebrun La. (2009). Racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients compared with non-health center patients. J Ambul Care Manage 32(4): Shi L, Leburn L, Tsai J and Zhu J. Characteristics of Ambulatory Care Patients and Services: A Comparisonof Community Health Centers and Physicians' Offices J Health Care for Poor and Underserved 21 (4): Hing E, Hooker RS, Ashman JJ. (2010) Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health Nov 3 epublished. Patient Visits to Other Providers Asthma Education for Asthmatic Patients Tobacco Cessation Education for Smoking Patients Pap Smears in least 3 years Immunizations for 65 years and older Health Education Health Center Patients Visits 15% 24% 19% 33% 37% 51% 65% 70% 81% 85% 0% 20% 40% 60% 80% 100%

39 Figure 4.4 Health Center Patients with Hypertension Are More Likely to Receive Counseling About Diet, Exercise, and Taking Medications than Their National Counterparts 100% 80% 60% 40% 20% 91% 82% 84% 84% 75% 67% 69% 64% 0% Diet* Salt* Exercise* Taking Medication* Health Center Patients Low Income Nationally *p<0.05 Source: Health Resources and Services Administration, Primary Health Care Patient Survey. Based on data for adults, aged 18 64, from 2009 BPHC Patient Survey and National Health Interview Survey, 2008.

40 Figure 4.5 Health Center Patients with Hypertension are More Likely to Comply to Counseling About Diet, Exercise, and Taking Medications than their National Counterparts 100% 80% 88% 72% 94% 83% 86% 93% 95% 60% 58% 40% 20% 0% Diet* Salt* Exercise* Taking Medication Health Center Patients Low Income Nationally *p<0.05 Source: Health Resources and Services Administration, Primary Health Care Patient Survey. Based on data for adults, aged 18 64, from 2009 BPHC Patient Survey and National Health Interview Survey, 2008.

41 Section V: High Quality Care and Reducing Health Disparities

42 % Receiving Mammogram Figure 5.1 Health Centers Reduce Disparities in Access to Mammograms 100% 80% 81% 81% 66% 66% 78% 63% 63% 60% 45% 40% 20% 0% Hispanic African American Medicaid Uninsured Health Centers Low Income Nationally Note: Rates calculated for women over the age of 50 receiving a mammogram over the last 2 years. All categories are statistically significant at the p < 0.05 level. Source: Health Resources and Services Administration, Primary Health Care Patient Survey. Based on data for adult women, aged 50-74, from 2009 BPHC Patient Survey and National Health Interview Survey, 2008.

43 Figure 5.2 Health Centers Also Reduce Disparities in Access to Pap Tests 100% 80% 89% 92% 93% 79% 81% 80% 79% 70% 60% 40% 20% 0% Hispanic African American Medicaid Uninsured Health Centers Nationally Note: Rates calculated for pap smear screening in last 3 years. Health Center rate significantly lower at the p < 0.05 level. Source: Health Resources and Services Administration, Primary Health Care Patient Survey. Based on data for adult women, aged 21 64, from 2009 BPHC Patient Survey and National Health Interview Survey, 2008.

44 Figure 5.3 Health Centers Also Reduce Disparities in Access to Colorectal Cancer 100% Screening 80% 60% 40% 31% 29% 57% 44% 49% 35% 32% 20% 18% 0% Hispanic African American Medicaid Uninsured Health Centers Low-Income Nationally Note: Health Center rate significantly lower at the p < 0.05 level except for Hispanic where there is no significance. Source: Health Resources and Services Administration, Primary Health Care Patient Survey. Based on data for individuals, aged 50-74, from 2009 BPHC Patient Survey and National Health Interview Survey, 2008.

45 % Low Birth Weight Figure 5.4 Health Center Patients Have Lower Rates of Low Birth Weight than the U.S. Average 9.0% US Health Centers 8.5% 8.0% 8.3% 8.2% 8.2% 8.2% 8.1% 7.5% 7.7% 7.8% 7.6% 7.3% 7.4% 7.0% 6.5% Source: U.S. rates from National Center for Health Statistics (NCHS) Based on Bureau of Primary Health Care, HRSA, DHHS, Uniform Data System.

46 Figure 5.5 Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts Source: Shi, L., et al. America s health centers: Reducing racial and ethnic disparities in prenatal care and birth outcomes Health Services Research, 39(6), Part I,

47 Number in Millions Figure 5.6 More Health Center Patients Prefer to Be Served in Languages Other than English Every Year % Increase Since Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

48 Section VI: Cost-Effective Care and Economic Impact

49 Figure 6.1 Health Centers Save $1,263 Per Patient Per Year $6,000 $5,306 $5,000 $4,000 $3,000 $2,000 $1,000 $4,043 Hospital Emergency Department Hospital Inpatient Ambulatory Other Services $0 Health Center Users Non-Health Center Users Source: NACHC analysis based on Ku L et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.

50 Figure 6.2 Community Health Centers Economic Impact by State, 2009 Less than $119,000,000 Between $120,000,000 and $229,000,000 Between $230,000,000 and $400,000,000 More than $400,000,000 Puerto Rico Source: The Economic Impact Analysis was prepared by Capital Link with MIG, Inc. IMPLAN Software Version 3.0, 2008 structural matrices, 2008 state-specific multipliers, and data from 2009 Uniform Data System.

51 Figure 6.3 Health Center Economic Impact by State, 2009 Alabama $ 194,609,172 Kentucky $ 228,231,869 North Dakota $ 21,923,285 Alaska $ 209,528,820 Louisiana $ 169,256,482 Ohio $ 347,083,172 Arizona $ 436,393,978 Maine $ 172,912,011 Oklahoma $ 112,356,701 Arkansas $ 107,631,335 Maryland $ 345,217,498 Oregon $ 470,409,290 California $ 3,434,654,244 Massachusetts $ 1,096,120,443 Pennsylvania $ 544,215,885 Colorado $ 579,408,724 Michigan $ 566,912,895 Rhode Island $ 130,325,455 Connecticut $ 385,499,939 Minnesota $ 214,818,705 South Carolina $ 272,548,491 Delaware $ 37,343,728 Mississippi $ 197,819,426 South Dakota $ 46,549,870 District of Columbia $ 140,081,354 Missouri $ 422,506,377 Tennessee $ 278,364,074 Florida $ 877,608,818 Montana $ 73,144,140 Texas $ 949,460,539 Georgia $ 245,580,795 Nebraska $ 58,310,063 Utah $ 106,489,982 Hawaii $ 180,088,619 Nevada $ 59,248,521 Vermont $ 104,009,011 Idaho $ 97,513,472 New Hampshire $ 77,280,715 Virginia $ 220,404,799 Illinois $ 1,082,732,035 New Jersey $ 382,432,656 Washington $ 934,705,298 Indiana $ 232,248,623 New Mexico $ 295,497,470 West Virginia $ 308,218,227 Iowa $ 132,659,924 New York $ 1,269,493,264 Wisconsin $ 379,544,478 Kansas $ 87,455,193 North Carolina $ 331,842,618 Wyoming $ 21,280,348 United States $ 19,669,972,831 Source: NACHC & Capital Link, Community Health Centers Lead the Primary Care Revolution, For more detailed explanation of methodology, see Appendix B in NACHC, Access Granted: The Primary Care Payoff,

52 Figure 6.4 Large urban health center generates a total economic impact of $21.6 million for its local community, while the average small rural health center generates about $3.9 million. Large Urban Health Center Total Economic Impact Employment (Full Time Equivalents) Small Rural Health Center Total Economic Impact Employment (Full Time Equivalents) Direct $ 12,252, $ 3,333, Indirect $ 2,273, $ 261,600 3 Induced $ 7,114, $ 287,124 4 Total $ 21,640, $ 3,882, Note: Total Economic Impact includes Value-Added Impact. Actual health center with an annual budget of $12.3 million (large) and $3.3 million (small), based on Capital Link s financial information database. Each Full Time Equivalent (FTE) denotes one full time employee. Total FTEs denote total workforce generated by health centers. For more information see the full report at Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007,

53 Figure 6.5 Health Centers Could Save Over $18 Billion Annually By Preventing Avoidable ER Visits Annual Wasted Expenditures on Avoidable Emergency Department Visits, 2006 Alabama $ 319,400,854 Kentucky $ 353,798,163 North Dakota $ 41,491,015 Alaska $ 32,732,965 Louisiana $ 354,757,738 Ohio $ 932,659,694 Arizona $ 311,438,714 Maine $ 105,902,573 Oklahoma $ 208,230,028 Arkansas $ 189,500,122 Maryland $ 320,407,972 Oregon $ 179,035,367 California $ 1,829,345,794 Massachusetts $ 401,458,842 Pennsylvania $ 790,754,728 Colorado $ 238,246,230 Michigan $ 726,928,960 Rhode Island $ 61,807,552 Connecticut $ 207,348,610 Minnesota $ 256,913,897 South Carolina $ 265,008,761 Delaware $ 47,497,790 Mississippi $ 252,769,055 South Dakota $ 36,418,180 District of Columbia $ 55,797,643 Missouri $ 429,712,468 Tennessee $ 476,285,058 Florida $ 1,061,420,739 Montana $ 54,444,985 Texas $ 1,233,549,349 Georgia $ 537,867,735 Nebraska $ 94,243,689 Utah $ 152,152,368 Hawaii $ 55,098,405 Nevada $ 112,928,929 Vermont $ 38,015,757 Idaho $ 88,713,842 New Hampshire $ 79,046,610 Virginia $ 452,375,606 Illinois $ 853,731,297 New Jersey $ 438,047,852 Washington $ 354,817,611 Indiana $ 441,019,299 New Mexico $ 132,027,370 West Virginia $ 180,480,840 Iowa $ 183,880,125 New York $ 1,126,031,176 Wisconsin $ 272,179,576 Kansas $ 159,038,693 North Carolina $ 548,645,880 Wyoming $ 36,360,931 United States $18,445,991,718 Source: NACHC and Association of Community Affiliated Plans, The Impact of Health Centers and Community-Affiliated Health Plans on Emergency Department Use, April 2007,

54 Section VII: Health Centers Financial Health

55 Figure 7.1 Health Center Costs of Care Grow Slower than National Health Expenditures, % 70% 60% 50% 40% 30% 20% 10% 0% 55% Health Center Costs Per Patient 72% National Health Expenditures Per Capita Sources: Centers for Medicaid and Medicare Services, Office of the Actuary. National Health Expenditures Aggregate, Per Capita Amounts, Percent Distribution, and Average Annual Percent Change: Selected Calendar Years Based on Uniform Data System, Bureau of Primary Health Care, HRSA, HHS.

56 Health Center Funding Per Uninsured Patient Has Remained Constant as the Costs of Care Rises $700 $500 $425 $455 $479 Figure 7.2 Annual Federal Health Center Funding per Uninsured Patient Annual Health Center Cost per Patient $504 $515 $538 $562 $588 $600 $630 $300 $248 $260 $272 $270 $270 $267 $270 $281 $271 $273 $100 $(100) Note: Not adjusted for inflation. Federal appropriations are for consolidated health centers under PHSA Section 330. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

57 Percent of Charges Collected from Third Party Payers, 2010 Figure 7.3 Payments from Third Party Payers Are Less than Cost 90% 80% 81% 70% 60% 66% 61% 57% 50% 40% 30% 20% 10% 0% Medicaid Medicare Other Public Insurance Private Insurance Note: Health centers are non-profits, and thus charges are a proxy for costs. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

58 Figure 7.4 Health Center Operating Margins are Less than Hospital Operating Margins 6.0% Hospitals Health Centers w/ ARRA Funds Health Centers w/o ARRA Funds 5.5% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% -1.0% -2.0% -3.0% 4.0% 4.3% 4.4% 3.7% 3.6% 3.7% 3.3% 3.3% 3.4% 2.7% 2.0% 1.8% 1.3% 1.2% 0.9% 0.9% 1.0% 0.8% 0.5% 0.2% -0.1% % -2.4% Source: Avalere, Health analysis of American Hospital Association Annual Survey Data, 2010 for community hospitals, Trendwatch Chartbook 2012, Supplementary Data Tables, Trends in Hospital Financing. Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

59 Figure 7.5 Medicaid Revenue is Directly Proportional to Medicaid Patients, % 41.2% Grants/Contracts/Other 2.5% 13.9% 6.1% 6.8% 7.5% 5.8% 2.7% Uninsured/Self-Pay Private Other Public Insurance Medicare Medicaid 38.5% 37.7% Patients' Insurance Status Health Center Revenue Notes: Percents may not total 100% due to rounding. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

60 Figure 7.6 Health Centers Revenue Sources Do Not Resemble Those of Private Physicians 10.0% 11.6% 4.5% 9.9% 64.0% Self-Pay/Uninsured Private Insurance Other Public 64.0% 6.8% 25.3% Medicare Medicaid/SCHIP Health Center 15.5% Private Physicians Source: Private Physician data: 2009 National Ambulatory Medical Care Survey (visits). NACHC, Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System. Note: Private Physicians does not equal 100% due to reporting in NAMCS.

61 Figure 7.7 Medicaid Revenue as Part of Health Centers Total Revenue, % 35% 15% 22% 33% 29% 24% 15% 27% 45% 33% 43% 38% 21% 40% 17% 31% 25% 18% 18% 32% 36% 36% 33% 45% 33% 23% 17% 39% 36% 21% 22% 28% 29% 22% 19% 26% CT: 54% DC:22% DE:30% MA: 27% MD: 39% NH: 20% NJ:35% RI: 36% VT: 30% 25% 29% 13% 31% 42% 0% to 22% 22% to 30% 30% to 36% 36% to 55% Source: NACHC, Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System

62 Figure 7.8 Federal Health Center Appropriation History, In Billions $1.34 $1.50 $1.62 $1.73 $1.78 $1.99 $2.07 $2.19 $ FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 Note: Federal appropriations are for consolidated health centers under PHSA Section 330. Federally funded health centers only

63 Figure States Will Provide Funding to Health Centers in SFY2012 WA NH CA OR NV ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI OH IN KY TN VT NY PA DC WV VA NC SC ME NJ DE MD MA RI CT MS AL GA AK HI TX LA None $1.9 million or less $2 million - $15 million $29 million - $65 million Pending Source: NACHC, Calculating the Cost: State Budgets and Community Health Centers, State Funding for Community Health Centers Reaches Lowest Level in Seven Years as Demand for Services Rises, State Policy Report #39. FL PR GU VI

64 Figure 7.10 State Funding to Health Centers, FY12 35 states will receive a total of $335 million $60 million, or 15% less than reported in FY11. State funding for health centers has been steadily declining for the fourth year in a row and FY12 represents a seven year low at a time of significantly rising needs. FY12 Funding: Increased in 7 states (AR,GA,MA,NJ, NM,VT,WY) Decreased in 20 states (AK,CO,DE,FL,HI,IN,IA,KS,MI,MN,MO,NE,NH,NY,OK,PA,UT,WA,WV,WI) Remained level in 8 states (IL,MA,MS,NC,OH,RI,TN,VA,) No funding in 14 states and the District of Colombia (AL, AZ,CA,D.C.,ID,KY,LA,ME,MT,NV,ND,OR,PR,SC,SD) (Pending: CT and TX) Source: NACHC, Calculating the Cost: State Budgets and Community Health Centers Policy Report 39, November 2011,

65 Section VIII: Staffing / Workforce

66 Figure 8.1 Health Centers Utilize Multiple Health Professionals with Varied Skills to Increase Capacity, 2010 Physicians 29% Nurses 34% Health Centers Clinicians Pharmacy Personnel 8% Dentists 9% Physician Assistants 6% Certified Nurse Midwives 2% Nurse Practioners 12% Family Physicians 45% Health Centers Physician Specialties Other Specialists 4% Psychiatrists 4% OB/GYNs 9% General Practitioners/ Internists 20% Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. General Pediatricians 19%

67 Figure 8.2 The Number of Health Center Medical Providers Has More Than Doubled 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000-4,803 9,592 2, ,362 6,378 11,365 19,310 43,830 Physicans NP, PA, CNM Nurses Total Medical Care Providers Note: NP, PA, CNM stands for Nurse Practitioner, Physician Assistants, Certified Nurse Midwives. Total Medical Care Providers includes physicians, NP,s PA, CNM, nurses, and other medical personnel. Source: NACHC analysis of NACHC analysis of Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data Systems (UDS).

68 Figure 8.3 Health Centers Twice as Likely to Use Non- Physician Clinicians than Other Providers 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 88% Health Center 44% Other Primary Care Provider Note: Statistically Different (p <.01) Source: Hing, E., Hooker, R., & Ashman, J. (June, 2011). Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Comm Health, 36(3):

69 Number of Non-Physician Clinicians Figure 8.4 Health Centers Use More Non-Physician Clinicians than Other Providers Health Center 2.5 Other Primary Care Provider Note: Statistically Different (p <.01) Source: Hing, E., Hooker, R., & Ashman, J. (June, 2011). Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Comm Health, 36(3):

70 Full-Time Equivalent Staff Figure 8.5 Health Centers Need Between 47,801 and 54,488 Primary Care Providers to Reach 30 Million Patients * Nurse Practitioners, Physician Assistants, Certified Nurse Midwives. Source: NACHC, Robert Graham Center, and The George Washington University School of Public Health and Health Services, Access Transformed: Building A Primary Care Workforce For The 21 st Century, August 2008, Baseline is 2006.

71 Figure 8.6 Percent of Grantees Relying on Federal and State Workforce Programs, 2004 National Health Service Corps Scholarship National Health Service Corps Loan Repayment State Loan Repayment 40% 32.9% J-1 Visa Waiver 39.9% 37.6% 23.5% 23.3% 28.1% 25.2% 21.2% 20% 0% Urban Rural Note: Dentists not included. Source: Rosenblatt R, Andrilla H, Curtin T, and Hart G. Shortages of Medical Personnel at Community Health Centers JAMA, Vol. 295, No. 9:

72 Section IX: Remaining Challenges and Unmet Needs

73 Figure 9.1 Health Centers Are Not Present in at Least a Quarter of the Counties with Unfavorable Primary Care Needs Rural Primary Care Provider Preventable Hospitalizations Uninsured Mammography Screening ED Visits Health Status Diabetes Prevalence Not English Proficent Low-Income Low Birthweight HIV Prevalence 25% 54% 53% 50% 47% 42% 38% 36% 36% 34% 33% 63% 0% 10% 20% 30% 40% 50% 60% 70% Note: Counties with Unfavorable Primary Care Needs were identified by being in the either bottom or top quintile depending on the primary needs indicator. Low-Income map presents census tracts, but analysis for this figure was conducted at the county-level. Source: NACHC, Health Wanted NACHC analysis of data obtained from University of Wisconsin Population Health Institute County Health Rankings 2011; U.S. Census Bureau; and HRSA.

74 Figure Million People Are Medically Disenfranchised Percent of State Population Without Access to a Primary Care Provider, % to 11% 11% to 18% 18% to 35% 35% to 57% National Average = 19.4% Note: Does not subtract health center patients as state and U.S. medically disenfranchised figures do. Source: The Robert Graham Center and NACHC, Access Granted and Primary Care Access Health Services and Resource Administration (HPSA, MUA/MUP data, 2005 Uniform Data System), 2006 AMA Masterfile, Census Bureau 2005 population estimates, NACHC 2006 survey of non-federally funded health centers.

75 Percent Change Figure 9.3 Too Few Medical School Graduates Enter Primary Care, *Includes primary care Source: Woo B. Primary Care The Best Job in Medicine? 2006 New England Journal of Medicine 355;9: Data are from the National Resident Matching Program.

76 Figure 9.4 Health Centers Experience Primary Care Physician Vacancy Rates, % 20% 10% 13.3% Family Physicians/General Practitioner OBGYN Internist Pediatrician Psychiatrist 26.6% 25.1% 22.6% 20.8% 21.5% 19.0% 15.7% 14.1% 12.1% 9.1% 8.8% 9.2% 8.8% 7.4% 0% Total Rural Urban Source: Rosenblatt R, Andrilla H, Curtin T, and Hart G. Shortages of Medical Personnel at Community Health Centers JAMA, Vol. 295, No. 9:

77 Figure 9.5 Health Centers Experience Vacancies in Other Clinician Positions, 2004 Dentists Nurses Nurse Practitioner Physician Assistant Pharmacist 30% 26.7% 20% 18.5% 16.6% 15.4% 10% 10.6% 11.0% 9.0% 7.3% 11.1% 9.0% 9.2% 8.8% 9.0% 6.8% 7.4% 0% Total Rural Urban Source: Rosenblatt R, Andrilla H, Curtin T, and Hart G. Shortages of Medical Personnel at Community Health Centers. JAMA, 2006 Vol. 295, No. 9:

78 Federal Grant as % Uninsured Health Center Patient Costs # of Uninsured Health Center Patients Figure 9.6 Health Center Federal Grants Are Not Increasing at the Same Rate as the Costs of Caring for the Uninsured over the Last Five Years 55% 50% 45% % % % % % % 35% 30% Number of Uninsured Health Center Patients (in Millions) Federal Grant as Percent of Uninsured Health Center Costs Note: Uninsured patient costs were calculated assuming that the percentage of patients are proportional to patient costs. Federal Grant as a Percentage of Uninsured Health Center Patient Costs was calculated as federal grant revenue divided by uninsured patient costs. Source: NACHC Based on Uniform Data Systems, Bureau of Primary Care, HRSA, DHHS.

79 Figure 9.7 More than a Third of Health Centers Need to Build or Purchase Additional Facilities, Build/Purchase Replacement Facility 36% Other Major Capital Projects (incl HIT) 10% Build/Purchase Additional Facility 37% Equipment 8% Renovate Facility 4% Expand Facility 5% Total: $10.5 billion Source: NACHC, Community Health Ventures, and Capital Link, Access Capital: New Opportunities for Meeting America s Primary Care Infrastructure Needs, March 2008,