Casting Chicago s Health Care Safety Net:

Transcription

1 Casting Chicago s Health Care Safety Net: A 12 Year Review of Chicago s Community-Based Primary Care System Medicaid Assure Services Free Clinics KidCare Accessible Quality Care Community Health Centers County Health Services Healthy Equity Community- Based Federal Support Public Health Department City of Chicago Richard M. Daley Mayor Chicago Department of Public Health John L. Wilhelm, M.D., MPH Commissioner

2 Casting Chicago s Safety Net Acknowledgements Report Authors Erica Salem, M.P.H., Assistant Commissioner, Planning and Development Richard Ferguson, M.S., Consulting Analyst Report Design Rich Noty, Research Associate Other Chicago Department of Public Health contributors Jeni Beirne, Planning and Development Sheri Cohen, Planning and Development Epidemiology Program Joy Getzenberg, Policy and Legislative Affairs Kenzy Vandebroek, Office of Health Care Access For their contributions of data and/or guidance, we gratefully acknowledge Robert M. Goerge, Chapin Hall Center for Children, University of Chicago Lawrence Haspel, Metropolitan Chicago Healthcare Council Anne Marie Murphy, Illinois Department of Public Aid Kristin Rankin, University of Chicago, School of Public Health Deborah Rosenberg, University of Chicago, School of Public Health Scott Ziomek, Metropolitan Chicago Healthcare Council Chicago s network of community-based health centers Special thanks to Patrick Lenihan, Ph.D., former Chicago Department of Public Health Deputy Commissioner, for his vision of the Chicago Health and Health Systems Project and his continued support and guidance. This report and health system profiles for each of Chicago s 77 community areas and 5 hospitals are available on the Chicago Department of Public Health website, Suggested citation: Salem, E. and Ferguson, R. Casting Chicago s Safety Net: A 12-Year Review of Chicago s Community-Based Primary Care System. Chicago: Chicago Department of Public Health, Planning and Development Division, 25. This report was funded in part with support from the Otho S.A. Sprague Memorial Institute.

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10 Page 4 Casting Chicago s Safety Net by 38.1%. While the much smaller Asian population increased by 27% during this period, there were decreases in the number of African American (1.9%) and White (14.1%) residents. Number Figure 2: Population by Race/Ethnicity 199 and 2 1,2, 1,, 8, 6, 4, 2, African American White Hispanic Asian Other Figure 3 presents the 199 and 2 population distributions of each region by race and ethnicity. Among Hispanics, population increases were most notable in the Southwest (116.9%) and Northwest (71.2%) regions; decreases occurred in the South (12.9%) and West (2.4%) regions. The African American population increased in four regions, with the greatest increase, 5.4%, in the Northwest region. Decreases, all of less than 1%, were seen in three regions. The White population decreased in all but the West and Central regions, while the number of Asians increased in six of the seven regions. Percentage Northwest 199 Northwest 2 Figure 3: Population Distribution by Race/Ethnicity, 199 and 2 North 199 North 2 West 199 West 2 Central 199 Central 2 Southwest 199 Southwest 2 South 199 South 2 Far South 199 Far South and 2, there was an increase of 27% or nearly 25, Chicagoans who reported speaking a primary language at home that is not English. This population segment represented 29.1% of the city s entire population five years of age and older in 199 and 35.5% of the 2 population. By region, increases ranged from 4.6% (South) to 84.5% (Central). The West region was the only region that saw a decrease among this segment of the population (Figure 4). Figure 4: Chicagoans Whose Primary Spoken Language at Home is Not English 199 and 2 Asian White Hispanic African Amer Growing Number of Non-English Speaking Households An assessment of the adequacy of the health care system must consider the cultural and linguistic needs of the population. Given the changes in the city s racial and ethnic composition, it is not surprising that there were fairly dramatic changes in the primary language spoken by Chicagoans. Between Number 35, 3, 25, 2, 15, 1, 5, Northwest North West Central Southwest South Far South 199 2

11 !" # $! * * 5##& # 6! & & <<<! = * C & B;D?&#%! & <<<!? & & * C! 9 & ;<C *;&??&E(;F# Percentage Figure 5: Population Distribution by Age, 199 and #% & &' ( # * &&*@#>C*@@< &<<<E(BF#6@@<!;@!>; E#BCF & * & H<<< &&& ;;B!:@@#BC#!& & D#;C E F B#?C EF & # *& >C# Percentage ' & *!& & >#C! * << E( :F# 3 * & * * #6 & ;C C & & # ' #BC;#BC # Percentage Figure 6: Percent Population Living Below Poverty Level, 199 and 2 CHICAGO Northwest North West Central Southwest South Far South Figure 7: Percent Population Living Between 1-199% of Poverty Level 199 and CHICAGO Northwest North West Central Southwest South Far South

12 5 # 3 & & & & & &# /3! * &* & 3! & & & &*!B;#, 3 * & & & &! % &E& = F & * & = & * = &# ## % &! &&!& * #A & &! &*& &! & * <<< & * <<#!& 6<<!!@@D&! & <<!<<<# E(DF# " & & & & <#BC Rate (per 1, population) ( D#?C #" # & E& :;F * & E$//F# $//! &&! && & & &&:;#6! & <<&$//@< <!<<< # $//&& ' & Rate (per 1, Population) 1,4 1,2 1, Figure 8: Age-Adjusted Death Rates 199 and CHICAGO Northwest Figure 9: Years of Potential Life Lost Rates 199 and 22 2, 1,6 1,2 8 4 North West Central Southwest South Far South CHICAGO Northwest North West Central Southwest South Far South

13 A 12-Year Review Page 7 from 23.3% in the Northwest region to 44.1% in the Central region. One possible explanation for the decreases in YPLL could be the large reductions in infant mortality discussed in the following section. When controlling for these deaths, the YPLL rate decrease was 27.2%. Improvements Seen in Maternal and Child Health Status Maternal and child health status indicators are often considered a reflection of the overall health and well-being of a population and provide some insight into the responsiveness of the health care system. Between 199 and 22 Chicago saw improvements on several key indicators. Decreases were seen in the percent of births to teenagers, infant deaths and low birthweight births. In Chicago, the number of live births dropped by 2% from 6,242 in 199 to 47,958 in 22. The 6,96 births to teenage mothers in 22 represented a 4% reduction from the 11,528 such births in 199. The proportion of all births to teen mothers decreased by 25% from 19.1% to 14.4% during this period (Figure 1). Reductions occurred in each of the seven regions and ranged from a low of 5.5% in the Northwest region to decreases of 49% and 59% in the North and Central regions respectively. Percentage Figure 1: Percent Teen Births 199 and 22 CHICAGO Northwest North West Central Southwest South Far South The rate of deaths among infants during their first year of life decreased by 45% from 15.6 deaths per 1, live births in 199 to a rate of 8.6 in 22. Substantial decreases in the infant mortality rate occurred in every region and ranged from a 32% reduction in the Northwest region to 49% in the Far South region (Figure 11). Rate (per 1, live births) Figure 11: Infant Mortality Rates by Region 199 and CHICAGO Northwest North West Central Southwest South Far South Despite the large decreases in infant mortality, the proportion of low birthweight births citywide decreased by less than 5%, from 1.5% to 1%. Decreases in low birthweight rates were seen in four regions: Central (15.2%), Southwest (9.6%), South (9.7%), and West (.9%). Increases in low birthweight rates in the remaining three regions ranged from 2.6% (North) to nearly 12% (Northwest) (Figure 12). Figure 12: Low Birthweight Rates by Region 199 and 22 CHICAGO Percentage Northwest North West Central Southwest South Far South

14 Page 8 Casting Chicago s Safety Net Health Care Utilization Indicators A number of factors contribute to the health status of Chicagoans, including environmental influences, socioeconomic status, and personal behavior. For this reason the temptation to directly relate changes in health status to changes in the health care system should be resisted. However, two utilization indicators help to bridge the gap between the health of a population and how that population uses basic health care services: prenatal care and preventable hospitalizations. Significant Improvements in Prenatal Care In 199, 3.5% of pregnant women reported having received no prenatal care. In 22, that figure had decreased to 1.7%, a reduction of 51%. These decreases were seen in each of the seven regions. In six of the regions, the proportionate decreases were quite large, ranging from 31.4% in the South region to 78.3% in the Northwest. The decrease was smallest in the Far South region, 4.2% (Figure 13). Percentage Figure 13: Percent No Prenatal Care by Region, 199 and CHICAGO Northwest North West Central Southwest South Far South Uneven Changes in Preventable Hospitalizations Ambulatory care sensitive conditions (ACSC) are those for which appropriate outpatient care could prevent or reduce the need for hospital admission. Such hospitalizations are often a reflection of the accessibility of the local health care system as well as patient compliance. Between 1991 and 21 the rate of preventable hospitalizations across the city declined by less than one percent. Four regions showed improvements, generally of less than 1%. However, in three areas hospitalization rates for ACSC increased, with the greatest increase of 22.7% seen in the Far South region (Figure 14). Figure 14: Hospitalization Rates for Ambulatory Care Sensitive Conditions, 1991 and 21 Rate (per 1, population) CHICAG O Northwest North West Central Southwest South Far South At first look, the improvements in prenatal care but little overall change in the rate of preventable hospitalizations appears contradictory. This finding has at least two implications. First, it may be that the community-based health care system is working better for some populations, in this case pregnant women, than for others. But it s also important to remember that there are other factors that affect ACSC hospitalization rates. While the overall ACSC hospitalization rate decreased only marginally, it is notable that rates for several conditions decreased by over 7% while rates for other conditions had significant increases. Thus, closer study of these data are necessary before conclusions should be drawn.

15 A 12-Year Review Page 9 Access Indicators One of the greatest barriers to health care access is a lack of health insurance. Two data sources, the Illinois Department of Public Aid and the U.S. Census Bureau, provide some insight into the extent to which Chicago s population has either public or private health insurance. This section reports on slight increases in Medicaid coverage between 199 and 22 and essentially no changes in the proportion of uninsured Chicagoans. According to the U.S. Census Bureau s Current Population Survey, in 22 less than one percent of Illinoisans ages 65 years and older were uninsured. Since Medicare alone assures at least some level of access, the analysis in this section does not include persons over age 65. More Children Enrolled in Medicaid Low-income persons who meet certain criteria are eligible for health care coverage under the state s Medicaid Program. The majority of Medicaid enrollees are women and children. The smallest group of enrollees by age are persons 65 years and older. Between 199 and 22, the total number of Medicaid enrollees under age 65 increased by 4.4%. During this same period, however, the number of enrollees 18 years of age and younger increased by almost 3%. Children represented 54% of the 528,42 enrollees in 199 and 67% of the 551,472 covered in 22. This shift is not surprising given the institution of Illinois KidCare health insurance program in the late 199s. Figure 15 shows the number of Medicaid enrollees by age for selected years. It is notable that despite only a minor increase between 199 and 22, enrollment rose nearly 14% between 22 and 24. Number Across the city, changes in Medicaid enrollment varied greatly. As reflected in Figure 16, enrollment grew in four regions. These increases ranged from nearly 15% in the Far South region to 56% in the Northwest region. The decreases in enrollment that occurred in three regions ranged from 11.2% in the South region to 2.5% in the Central region. Number Figure 15: Chicago M edicaid Enrollees By Age 7, 6, 5, 4, 3, 2, 1, Figure 16: Medicaid Enrollees (under 65) by Region, 199 and 22 16, 14, 12, 1, 8, 6, 4, 2, Northwest North West Central Southwest South Far South Years -18 Years In 22, 21% of Chicagoans under 65 years of age were enrolled in Medicaid. By region, the Central region had the smallest proportion of the population enrolled (8.7%). In four regions (West, Southwest, South and Far South)

16 Page 1 Casting Chicago s Safety Net between 25.7% and 32% of the under-65 population were enrolled in Medicaid (Figure 17). Figure 17: Proportion of Population Under Age 65 Enrolled in Medicaid, 22 CHICAGOPercentage Northwest North West Central Southwest South Far South The Proportion of Uninsured Chicagoans Under Age 65 Has Not Changed The Current Population Survey provides estimates of insurance coverage based on an annual survey and projected population size. Between 199 and 22 the proportion of uninsured residents remained largely the same. Uninsured Chicagoans represented 22.5% of the city s estimated 199 population under 65 years old. Twelve years later, these persons represented 22.7% of the city s estimated population. IV. CHANGES IN COMMUNITY-BASED PRIMARY HEALTH CARE It is easy to point to the increasing number of sites to document the growth of Chicago s community-based health system. Yet because of variations in size and staffing, a better understanding of system changes comes from also considering the system s overall capacity to deliver primary care as well as the actual number of visits provided. The Number of Community-Based Health Centers Nearly Doubled In 199, Chicago s network of 41 communitybased health care safety net sites included 2 publicly-operated sites, 2 community health centers (CHCs), and one free clinic. By 22, the number of providers had increased 97% to 81 sites (Figure 18). Number Figure 18: Community-Based Health Centers by Type 199 and 22 Free County City CHCs By provider type, the greatest growth during this period occurred among community health centers, which operated 56 sites in 22. Much of this increase can be attributed to a single provider organization, Access Community Health Network. In 199, the organization did not exist; in 22 it accounted for 19 or 34% of all community health center sites in Chicago. Chicago s growth in community health centers largely reflects a significant federal investment. In 199, through the Health Resources and Services Administration s Bureau of Primary Health Care, the federal government earmarked $554 million for grants to community health centers across the country. By 22, this budget line had increased by 142% to $1.34 billion (Figure 19). The 24 federal appropriation was $1.6 billion.

17 A 12-Year Review Page 11 Dollars (in thousands) Figure 19: Federal Funding for Community Health Centers, 199 to 22 1,4, 1,2, 1,, 8, 6, 4, 2, Between 199 and 22, there was also a shift in the role of Chicago s public providers. During this period, the Cook County Bureau of Health Services community-based network of primary care sites increased from three to 11, while through a series of partnership arrangements, the Chicago Department of Public Health decreased from 18 to seven health centers. The analysis in this section does not include the County s Fantus Health Center as it more closely resembles a hospitalbased rather than a community-based provider. However, its important role as a safety net provider is addressed in Section V. The County s numerous suburban sites are also not included. Figure 2: Community-Based Health Centers by Region, 199 and 22 Number Northwest North West Central Southwest South Far South Service Availability Increased By Nearly Two-Thirds Health center capacity (potential available visits) is calculated through the application of a commonly accepted standard of annual visits per full-time physician and per full-time midlevel practitioner (see Appendix A). In 199, the 41 community-based health centers had the combined capacity to deliver 722,82 primary care visits. By 22, that available capacity had increased by 462,537 visits, or 64%, to 1,185,357 available visits. Capacity increases occurred in six of the seven regions and ranged from 18.5% in the South to 459% in the Northwest, which had the least capacity (6,3 available visits) in 199 (Figure 21). Consistent with its growth in health Figure 2 shows the growth in communitybased health centers by region. The largest increase occurred in the West region which expanded by 21 sites between 199 and 22. The next greatest increase was seen in the North region which grew by an additional six sites. The Southwest region was home to eight health centers in both 199 and 22. The geographic distribution of safety net sites in 199 and 22 are depicted in maps found on pages 12 and 13. Number 6, 5, 4, 3, 2, 1, Figure 21: Available Capacity (in visits) by Region, 199 and 22 Northwest North West Central Southwest South Far South

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20 Page 14 Casting Chicago s Safety Net centers, the greatest increase in terms of actual numbers was in the West region where capacity increased by more than 313, available visits between 199 and 22. The sole region with a decrease in capacity was the Southwest region, which experienced a reduction of 17.4% or 17,3 available primary care visits. Greater Utilization of Safety Net System The number of patient primary care visits delivered at community-based health sites increased by 52% from 78,923 visits in 199 to 1,77,845 visits in 22. Increases occurred in five of the seven regions (Figure 22). The greatest increase was seen in the West region, which with an additional 295,92 visits, provided 5% of all visits citywide in 22. The greatest proportion increase of delivered visits, 697%, occurred in the Northwest region, which had grown by 35,545 actual visits, yet still provided the fewest visits of any region in 22. In the South region, the loss of just over 8, visits represented a decrease of 4%, while the 37% decrease in the Southwest region represented a reduction of over 43, patient visits. Number 6, 5, 4, 3, 2, 1, Figure 22: Visits Provided by Region 199 and 22 Northwest North West Central Southwest South Far South Unused Capacity As noted earlier in this section, in 22 Chicago s community-based safety net providers had 1,185,357 potential primary care visits available and delivered 1,77,845 (91%) actual visits. The extent to which available capacity was used ranged from 69% in the Far South region to 94% in the West region. While the West region had the greatest proportion of available capacity used, because it had such a large proportion of available visits to begin with, its unused capacity, 36,711 visits, was the largest amount of unused available visits of any region. The Northwest and Central regions operated above capacity. In addition to documenting the remarkable growth in Chicago s health care safety net system, the data above when considered collectively underscore the need to consider from a variety of perspectives the capacity of the system to deliver care. Of the indicators considered above, the number of health centers may prove to be the least important. The relationship between the number of sites, available service capacity and actual visits is not always clear. This may be best reflected in the South region where the number of sites and overall capacity increased, but the actual number of visits declined. Similarly, in the Southwest region where there was no change in the number of health centers between 199 and 22, capacity decreased by over 17% and visits delivered declined by nearly 37%. V. THE ROLES OF OTHER PROVIDERS While an ideal standard of care for all populations would be that which is community-based, affordable, high quality and accessible, it is important to recognize that beyond the safety net providers that are the focus of this report, there are other sources of care for Chicago s uninsured.

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22 (5 Number Figure 23: Medically Needy by Region 199 and 22 16, 14, 12, 1, 8, 6, 4, 2, Northwest North West Central Southwest South Far South 6 &&!! && &* && #6<<! 9!:!?<::C! && A! & &!?!<<<>C! #! & & <C && E(?F# Figure 24: Distribution of Medically Needy by Region, 22 Southwest 17% Central 3% Far South 5% South 11% West 27% Northwest 19% North 18% ( ; << * & & B; # &! & & & D#BC &B;<<# & D#;C ( ;C A# Figure 25: Medically Needy as a Proportion of Total Population Under Age 65, 22!& % $ % 6 & &* = &# 6 <<! & * & E@CF! >C *! & E( BF# A & No rthwestp ercentage CHICAGO Percentage Figure 26: Distribution of Medically Needy Population and Existing Safety Net Capacity Northwest North 25.4 West Central No rth We st Ce ntral Southwe st South Far South Southwest South Far South 8.5 Medically Needy Capacity

23 A 12-Year Review Page 17 proportion of both medically needy residents (27%) and available capacity (5%). While no region, including the West, had adequate capacity to meet identified need, the fact that half of the city s total capacity was located in a single region suggests that the distribution of capacity may be getting out of balance. Another way to consider the distribution of capacity relative to need is to divide capacity by the number of medically needy. Recognizing that all available capacity is not earmarked for the medically needy, nevertheless, it is reasonable to propose that capacity be correlated with need. Figure 27 depicts this ratio for Chicago and by region. For the city overall, this ratio is 2.4, however, there is tremendous variation by region with the Northwest showing the lowest ratio at.4 and the Central region showing the highest ratio of 5.1, more than a tenfold difference. This would suggest that the system is severely unbalanced. data were reviewed from the 74 publiclyoperated and community health centers that existed in 22. Data were not available from the seven free clinics. Subtracting this number of uninsured patients seen for care in 22 from the number of medically needy residents results in an estimated number of Chicago s uninsured who were likely not receiving regular, community-based primary health care services. As reflected in Figure 28, in 22 there were 484,12 low-income Chicagoans who lacked either public or private health insurance. Of these persons, 171,725 or 35% received care from community-based safety net providers, leaving 312,395 Chicagoans in need of community-based primary health care. (It is important to remember that an estimated 48, of these persons are served at Fantus Health Center). Figure 28: Medically Needy Chicagoans With and Without Community-Based Care, 22 Figure 27: Ratio of Capacity to Medically Needy, 22 Ratio CHICAG O Northwest North West Central Southwest South Far South Most Medically Needy Lack A Community- Based Medical Home To estimate the number of uninsured Chicagoans who lack access to communitybased primary care, available payor source 312,395 With community-based care Without community-based care 171,725 As shown in Figure 29, across the city the number of uninsured without regular community-based care ranged from just under 4,7 in the Central region to 88,428 persons in the Northwest region (see Appendix D).

24 Page 18 Casting Chicago s Safety Net Figure 29: Medically Needy Without Community-Based Care, 22 Figure 31: Proportion of Medically Needy Lacking Care, 22 Number 1, 8, 6, 4, 2, 88,428 Northwest No rth 62,48 43,533 4,677 West Central 68,581 32,759 Southwest South Far South 12,369 Percentage CHICAG O 65 Northwest 94 North 7 West Central Southwest 84 6 South Far South 53 The extent to which the low-income uninsured population within a region had access to community-based primary care is reflected in Figures 3 and 31. The proportion of the medically needy who were not receiving care from safety net providers ranged from 33% in the Central region to 94% in the Northwest region. One way to determine if there is a relationship between the system s overall capacity to meet need and the need met among the low-income uninsured is to plot the ratio of capacity to medically needy against the percent of the medically needy in care. Figure 32 demonstrates a strong correlation between these two variables suggesting that increasing the capacity of the system to serve all populations will in fact result in more care to Chicago s low-income uninsured. Number Figure 3: Medically Needy With and Without Community-Based Care, 22 14, 12, 1, 8, 6, 4, 2, Northwest North West Central Southwest South Far South Uninsured without care Uninsured with care Percent in Care Figure 32: Correlation Between Capacity to Meet Need and Met Need, 22 North Southwest Northwest West Far South South Central Ratio of Capacity to Need

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28 Page 22 Appendix A Methodological Notes Casting Chicago s Safety Net Data Sources Chicago and Cook County Health Care Action Plan was used to obtain health care system capacity and utilization indicators for 199. These data were originally collected through a telephone survey of community-based safety net providers conducted by the Chicago Department of Public Health. The Chicago Department of Public Health (CDPH) Global Patient Information System provided encounter data for CDPH. Additionally, CDPH Division of Community Health staff provided annual staffing data by facility. The Chicago Health System Capacity Data Report is completed voluntarily by Chicago-based safety net providers annually. Based largely on the federal Health Resources and Services Administration s Uniform Data System, the Report collects annual information regarding staffing, patient characteristics and encounters. Analysis of these data are conducted as part of CDPH s Health and Health Systems Project. Data for this report were provided for year 22 activity. Cook County Bureau of Health Services (CCBHS) provided capacity and utilization figures on its Chicago-based ambulatory care facilities in operation in 22. The data were provided from the CCBHS patient information system. Illinois Department of Public Health Electronic Vital Records Data Sets. The IDPH computerizes all birth and death certificates and makes this data available electronically to local health departments and other interested parties. Preliminary preparation of these vital records data was conducted by the Chicago Department of Public Health s Epidemiology Program. Illinois Department of Public Aid provided Medicaid enrollment data for 199 and 22. Illinois Health Care Cost Containment Council s Uniform Data Set was used to compute ambulatory care sensitive condition hospitalization rates. The Uniform Data Set is an individual patient discharge data set that includes detailed diagnosis and procedure information used in processing insurance claims. Hospitals were mandated by the state to submit these data to the IH4C. The UDS was analyzed, compiled, and sold to researchers and other organizations by the IH4C. In 22, the IH4C was disbanded by the State of Illinois. Neither 199 nor 22 hospitalization data were available for this report and thus 1991 and 21 were used as the points of comparison. National Association of Community Health Centers provided data on federal funding for community health centers. United States Census Bureau enumerates the population of the United States every ten years. This information is made available electronically from their web site. 199 and 2 data were used to describe demographic and socioeconomic population characteristics. Determination of citywide levels of uninsurance were produced from the March Supplement of the Current Population Survey (CPS), which is conducted by the U.S. Bureau of the Census. The 1991 March Supplement, called the Annual Demographic Survey, provided estimates for 199, as the survey focuses on the "previous year". The 23 March Supplement, called the Annual Social and Economic Supplement (reflecting the supplement's name change in 23), provided data for the 22 estimates.

29 A 12 -Year Review Page 23 The estimates for 199 reflect 198 census-based population controls, while the estimates for 22 reflect 2 census-based population controls, which should have little impact on the percentages, but do have an impact on the total population of individuals in Chicago when making comparisons between 199 and 22. Important Notes about Analysis: Hospitalization and Medicaid Enrollment Data: Hospitalization and Medicaid Enrollee data are available by zip code. In order to report these data by regions, a conversion table was created showing for each zip code the proportion of its area that was in each community area. The data for each zip code were then divided up and allocated proportionally to the community areas found in the zip code. For example, if a given zip code had 2% of each area in community area 23, 3% in area 24, and 5% in area 25, then the hospitalizations occurring to residents of that zip code were divided up accordingly. Total hospitalizations by community area were then determined by adding up all of the allocations for each community. The same approach was taken to converting the Medicaid Enrollee data. Finally, community area data were then combined to allow for regional analysis. Primary Care Capacity: Primary care capacity was calculated based on previously suggested standards from the federal Health Resources and Services Administration s Bureau of Primary Care. These standards, based on a 4- hour work week, suggest that physicians should have the capacity to provide 42 encounters per year and midlevel providers (nurse practitioners, physician assistants, certified nurse midwives) should be able to deliver 21 encounters per FTE. It has been argued by some providers that these standards should be lowered; however, Project staff s exploration of practice standards supports the earlier HRSA guidance. Specifically, the Medical Group Management Association suggests the following annual standards for encounters by FTE practitioners: Family practice 44 encounters 48 encounters 3 encounters Nurse 25 encounters Thus, physician capacity was calculated based on 42 encounters per FTE and capacity for mid-level providers is based on 21 encounters. Note that capacity estimates for mid-level providers at Chicago Department of Public Health sites is based on 42 encounters per FTE as that is the standard applied by that agency.

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