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The History, Evolution, Current Status and Issues of Community Health Centers Michael E. Samuels, Dr.P.H. Distinguished Scholar and Endowed Chair in Rural.

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Presentation on theme: "The History, Evolution, Current Status and Issues of Community Health Centers Michael E. Samuels, Dr.P.H. Distinguished Scholar and Endowed Chair in Rural."— Presentation transcript:

1 The History, Evolution, Current Status and Issues of Community Health Centers Michael E. Samuels, Dr.P.H. Distinguished Scholar and Endowed Chair in Rural Health Policy Center of Excellence in Rural Health University of Kentucky College of Medicine Department of Health Services Policy and Management Arnold School of Public Health University of South Carolina McKissick Library September 20, 2005 Columbia, SC Rural Health Grand Rounds Rural Health S outh Research Center C arolina

2 History John Snow, MD ( ) 1854

3 Medicare/Medicaid Signed Into Law At the bill-signing ceremony President Johnson enrolled President Truman as the first Medicare beneficiary and presented him with the first Medicare card. This is President Truman's application for the optional Part B medical care coverage, which President Johnson signed as a witness. SSA History Archives.

4 “The only thing new is the history you haven’t read” President Harry S. Truman

5 Importance of History Live in A-historical country. Live in A-historical country. We think of it as not involved in our We think of it as not involved in our daily life. It has to do with our self perception. It has to do with our self perception. We think of history as myth. We think of history as myth. We are bound by unproven assumptions. We are bound by unproven assumptions.

6 Importance of History Our concepts (basic assumptions and Our concepts (basic assumptions and though patterns) come out of the past. History teaches inductive rather than deductive reasoning. History teaches inductive rather than deductive reasoning. History is necessary for long-range planning. History is necessary for long-range planning. History is about balance between change and continuity over time. History is about balance between change and continuity over time. Short term versus long term trends Short term versus long term trends

7 CHC Traditions Medical Care (Individual) Public Health (Group)

8 The Greek Tradition Hippocrates ( B.C. ) “To maintain the correct balance, eat good food, avoid red meat, drink pure water, get fresh air and exercise and above all avoid quarrelsome people for they cause stress and that is the most injurious to your health.” Oath of Hippocrates “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.”

9 Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind. This is the first and great commandment. And the second is like unto it: Thou shalt love thy neighbor as thyself. On these two commandments hang all the Law and the Prophets.Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind. This is the first and great commandment. And the second is like unto it: Thou shalt love thy neighbor as thyself. On these two commandments hang all the Law and the Prophets. Matthew 22:37-40 Before the Reformation, a religious duty for all Christians: feed the hungry give drink to the thirsty welcome the stranger clothe the naked visit the sick visit the prisoner bury the dead The Religious Tradition in Health

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11 US History of Health Care Puritans could look at poverty as revealing a flaw in the poor person's character; a sign that he or she was out of favor with the higher power. Puritans could look at poverty as revealing a flaw in the poor person's character; a sign that he or she was out of favor with the higher power. While acts of charity to help the needy were an important part of religious practice, there was not an expectation that such charitable acts would raise the underclass out of poverty. Charity was viewed as comfort to those unfortunates doomed to suffer in this world, and the charitable act a sign of the goodness of the giver. While acts of charity to help the needy were an important part of religious practice, there was not an expectation that such charitable acts would raise the underclass out of poverty. Charity was viewed as comfort to those unfortunates doomed to suffer in this world, and the charitable act a sign of the goodness of the giver. The University of Pennsylvania School of Medicine - first medical school Fall, 1765 The University of Pennsylvania School of Medicine - first medical school Fall, 1765 Benjamin Rush “Father of US Medicine” – Farming, misfortune of others Benjamin Rush “Father of US Medicine” – Farming, misfortune of others History of Physician Licensure History of Physician Licensure Education – B.A., M.D. Education – B.A., M.D First Stethoscope 1816 First Stethoscope 1869 –” Medicine, the most despised of the professions which liberally educated men are expected to enter” ( rd, st ) 1869 –” Medicine, the most despised of the professions which liberally educated men are expected to enter” ( rd, st ) Technology – 1877 First telephone exchange, 1890’s “Buick, the Doctors Car” Technology – 1877 First telephone exchange, 1890’s “Buick, the Doctors Car”

12 US History of Health Care AMA founded 1851 AMA founded 1851 Hospitals – Either 1846, Antiseptic surgery 1867, Mayo Brothers abdominal surgery (45), 1900 (612), 1915 (2,157). Hospitals – Either 1846, Antiseptic surgery 1867, Mayo Brothers abdominal surgery (45), 1900 (612), 1915 (2,157). Hospitals – ,000, 1920 >6,000. Hospitals – ,000, 1920 >6,000. Florence Nightingale Nursing, hospital architecture, health administration Florence Nightingale Nursing, hospital architecture, health administration First x-ray 1895 First x-ray 1895 Medical Education Flexner Report 1910, Johns Hopkins Model, Licensure 1877, Osteopathy 1891 Medical Education Flexner Report 1910, Johns Hopkins Model, Licensure 1877, Osteopathy 1891 Group Practice 1918 Mayo Brothers Group Practice 1918 Mayo Brothers Health Centers Dr. Herman Biggs, 1923, New York Health Centers Dr. Herman Biggs, 1923, New York Baylor Hospital / Dallas Teachers Union “Birth of the Blues” 1929 Baylor Hospital / Dallas Teachers Union “Birth of the Blues” 1929 California Blue Shield, 1939 California Blue Shield, 1939 Kaiser Permanente, 1942 Kaiser Permanente, 1942

13 Government 1798 “The Relief of Sick and Disabled Seaman” 1798 “The Relief of Sick and Disabled Seaman” 1906 The Pure Food and Drug Act, Meat Inspection Act 1906 The Pure Food and Drug Act, Meat Inspection Act 1912 First White House Conference 1912 First White House Conference urged creation of the Children's Bureau 1921 The Bureau of Indian Affairs Health Division 1921 The Bureau of Indian Affairs Health Division 1930 The National Institutes of Health 1930 The National Institutes of Health 1935 The Social Security Act 1935 The Social Security Act 1938 Federal Food, Drug and Cosmetic Act 1938 Federal Food, Drug and Cosmetic Act 1939 Federal Security Agency 1939 Federal Security Agency 1946 Centers for Disease Control and Prevention Centers for Disease Control and Prevention Department of Health, Education and Welfare 1955 Department of Health, Education and Welfare

14 Government 1961 Indian Health Service transferred to HHS from DI 1961 Indian Health Service transferred to HHS from DI 1964 The Migrant Health Act 1964 The Migrant Health Act 1965 First Surgeon General's Report on Smoking and Health 1965 First Surgeon General's Report on Smoking and Health 1965 Medicare and Medicaid, the Older Americans Act, Head Start 1965 Medicare and Medicaid, the Older Americans Act, Head Start 1966 The Community Health Centers Act (Section 330, PHS Act) 1966 The Community Health Centers Act (Section 330, PHS Act) 1970 National Health Service Corps 1970 National Health Service Corps 1980 Health Care Financing Administration 1980 Health Care Financing Administration 1989 Passage of the McKinney Act to provide health care to the homeless 1989 Passage of the McKinney Act to provide health care to the homeless 1989 Agency for Healthcare Research and Quality 1989 Agency for Healthcare Research and Quality 1993 Ryan White Comprehensive AIDS Resource Emergency (CARE) Act 1993 Ryan White Comprehensive AIDS Resource Emergency (CARE) Act

15 Government 1996 Personal Responsibility and Work Opportunity Reconciliation Act 1996 Personal Responsibility and Work Opportunity Reconciliation Act 1996 The Health Centers Consolidation Act 1996 The Health Centers Consolidation Act 1997 Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act (HIPAA) State Children's Health Insurance Program (SCHIP) 1999 State Children's Health Insurance Program (SCHIP) 2002 Centers for Medicare & Medicaid 2002 Centers for Medicare & Medicaid 2002 Office of Public Health Emergency Preparedness 2002 Office of Public Health Emergency Preparedness 2003 Medicare Prescription Drug Improvement, and Modernization Act 2003 Medicare Prescription Drug Improvement, and Modernization Act

16 Community Health Centers Present Lyndon Baines Johnson 1963–69 Ronald Wilson Reagan 1981–89 Richard Milhous Nixon 1969–74 Gerald Rudolph Ford 1974–77 Jimmy Carter 1977–81 George H. W. Bush 1989–93 Bill Clinton 1993–2001 George Walker Bush 2001–

17 Economic Opportunity Act of "War on Poverty" "War on Poverty" Executive Branch Initiatives Work toward elimination of poverty or its causes through developing: employment opportunities, improving human performance, motivation, and productivity. Usually through community activity. Health not an original OEO concern - Job Corps/Headstart physicals. Direct care - save money and effect basic way in which health care is delivered.

18 Dr. H. Jack Geiger and Dr. Count Gibson Concept of Neighborhood Health Center Developed by Tufts Medical School professors Count Gibson/Jack Geiger Original request from Tufts went to PHS June, 1965 Tufts Medical School receives funding for Columbia Point and Mound Bayou Neighborhood Health Centers Model comprehensive health center development, train and employ community residents, and involve them in community development.

19 Neighborhood Health Center Model Vehicle to community development and a challenge to mainstream medicine, dignified, accessible, comprehensive, and community based. Elements: Community health services - Public health model, deal with social and physical environment - Health care team - Decentralize health care outreach/communications family health care workers health education social advocacy (housing, welfare).

20 Neighborhood Health Center Model (Cont.) -Community economic development -Community participation. -Re-integrate public health and personal health care services, including prevention, environmental, and outreach. -Ignoring the previously negotiated boundaries between private medicine/public health. -Salaried physicians. -Health teams. -Consumer participation.

21 A New System "The hospital as we know it is an obsolete and ineffective institution for ambulatory care,... hospitals for the future should be vastly different - in effect, intensive care units for patients with critical and complex illness... The hub of the medical care universe would be a network of comprehensive community health centers" 1968 Dr. Jack Geiger. Alternative to hospital based care for the entire community. A system for the entire US. population.

22 More History Initially grants to hospitals/medical schools Initially grants to hospitals/medical schools 1966 Kennedy amendments (OEO Act) - planning and operation of comprehensive health service programs in urban/rural areas, low income requiring adequate health services. (100 centers by 1971) Kennedy amendments (OEO Act) - planning and operation of comprehensive health service programs in urban/rural areas, low income requiring adequate health services. (100 centers by 1971) “When they reach 25 centers, there will be no private practice” “Another step to socialism” “Dispensary abuse – 1890s” 1967 “When they reach 25 centers, there will be no private practice” “Another step to socialism” “Dispensary abuse – 1890s” "Limited to the poor:, limited to 20% self pay. "Limited to the poor:, limited to 20% self pay. -local opposition -involvement of organized medicine -means test -means test Most grants to medical schools Most grants to medical schools and hospitals – quick success/legitimacy PHS 314e (Phil Lee) Yellow berets PHS 314e (Phil Lee) Yellow berets

23 More History Most grants to medical schools Most grants to medical schools and hospitals – quick success/legitimacy Community participation vague at first Community participation vague at first PHS “Yellow Berets”, 314e (24 centers) PHS “Yellow Berets”, 314e (24 centers) e centers e centers Nixon transfer all OEO NHCs Nixon transfer all OEO NHCs to PHS

24 More History Family Health Center CHCs Family Health Center CHCs established established Rural Health Initiative CHCs established Rural Health Initiative CHCs established rd Party billing required rd Party billing required First Reagan budget cuts program in half First Reagan budget cuts program in half All funds restored All funds restored 2001 – 2006 President Bush Initiative doubling the number of patients served by Community Health Centers 2001 – 2006 President Bush Initiative doubling the number of patients served by Community Health Centers

25 Organizing New York Association of Neighborhood Health Centers New York Association of Neighborhood Health Centers 1971 – The Massachusetts League of Neighborhood Health Centers 1971 – The Massachusetts League of Neighborhood Health Centers National Association of Neighborhood Health Centers now National Association of Community Health Centers National Association of Neighborhood Health Centers now National Association of Community Health Centers 1975 – National Rural Primary Care Association now 1975 – National Rural Primary Care Association now National Rural Health Association

26 CHCs Grantees (51% Rural) 5,502 Service Delivery Sites 13,127,811 Patients

27 * Source: 2003 UDS data. HC

28 Health Center Patients By Income Level, 2004 Note: Federal Poverty Level (FPL) for a family of three in 2004 was $15,670. (See Based on percent known. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

29 Health Center Patients By Insurance Status, 2004 Note: Other Public may include non-Medicaid SCHIP. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

30 Health Center Patients By Race/Ethnicity, 2004 Note: Based on percent known. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

31 Health Center Patients By Age, 2004 Note: Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

32 United States, 2004 Health Center Staff and Related Patient Visits FTEPatient Visits Primary Care Physicians6, ,325,866 NPs/PAs/CNMs3, ,414,386 Nurses8,075.53,091,731 Dentists1,586.54,365,671 Dental Hygienists ,986 Mental Health & Substance Abuse Specialists 2,548.02,732,571 Pharmacy Total Enabling Services # Other Staff 1, , ,541.0 N/A 3,842,581 N/A Total † 83, ,323,834 * Includes psychiatrists and other specialist physicians. # Includes health educators, case managers, translators, transportation, eligibility workers, etc. Does not include workers for other social services, such as WIC, Head Start, housing assistance, food banks, and employment counselors. † Not all staff types are included in this table. Hence, total FTE and total patient visits are greater than the sum of all types listed above.

33 Percent of Health Centers Providing Select Services Onsite* Professional Services General Primary Medical Care 99% Prenatal Care 72% Preventive Dental Care 71% Mental Health Treatment/Counseling 72% Substance Abuse Treatment/Counseling 48% Hearing Screening 87% Vision Screening 93% Pharmacy 35% Preventive Services Pap Smear 97% Smoking Cessation Program 57% HIV testing and counseling 93% Glycosylated hemoglobin measurement, diabetes 83% Blood pressure monitoring 99% Blood cholesterol screening 89% Weight reduction program 76%

34 Enabling Services Outreach 91% Case Management 91% Eligibility Assistance 88% Health Education 98% Interpretation/Translation Services 88% Transportation 55% Outstationed Eligibility Workers 42% * “Onsite” includes services rendered by salaried employees, contracted providers, National Health Service Corps Staff, volunteers and others such as out-stationed eligibility workers who render services in the health center's name. Health centers may also provide services through formal referral arrangements. Percent of Health Centers Providing Select Services Onsite (cont.)*

35 Patient Visits and Patients by Selected Primary Diagnoses and Services Patient Patients Visits Medical Conditions Asthma773,763418,256 Diabetes mellitus 2,476, ,628 Hypertension 3,006,082 1,257,930 Heart disease (selected) 556,625230,596 Mental health & substance abuse 3,494,668 N/A Preventive Services Health supervision ages 0-11* 2,994,513 1,764,835 Selected immunizations# 2,364,496 1,610,822 Pap smear 1,509,973 1,333,253 Mammogram 256, ,083 HIV test 425, ,358 Oral Dental Exams 813, ,739 * Well child visits. * Well child visits. # Includes DPT, MMR, oral polio vaccine, influenza, hepatitis B, HIB. # Includes DPT, MMR, oral polio vaccine, influenza, hepatitis B, HIB.

36 The Future of CHCs

37 Health Center Patient Insurance Status and Revenue By Source, 2004

38 Percent of Health Center Charges Collected from Third Party Payers, Medicaid Medicare Other Public Private

39 Suggested Reading

40 Thank You Questions ?


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