Reform Update: Community health centers brace for influx of newly insured

The nation's 9,000 community health center locations, serving some 22 million patients, are bracing for an influx of patients in the 26 states that have expanded Medicaid under the Affordable Care Act.

Roughly 10,000 physicians make up about 60% of the community center clinical workforce; their work is supplemented by about 6,000 nurse practitioners and physician assistants, noted Dan Hawkins, policy director for the National Association of Community Health Centers. He is not sure if this will be enough for what he expects will be increased demand for services.

“That's what everyone is concerned about,” he said.

Of the 22 million patients who sought care at a community health center last year, Hawkins said, about 8 million, or 40%, were on Medicaid, while about 36% were uninsured. “The hope is that they will qualify for Medicaid,” Hawkins said.

“In Michigan, we're extremely excited,” said Stevi Riel, operations manager for the Muskegon (Mich.) Community Health Project, which oversees community health centers for Mercy Health, a division of the Catholic Health East/Trinity Health system.

“We're certainly going to have more people seeking access,” she said. That includes new patients and an increase in visits from established patients.

“A couple hundred” people enrolled in the Medicaid program at three Mercy sites this past weekend in Muskegon and Grand Rapids, Riel said. That included many in the 19- to 26-year-old range.

“Certainly, provider shortages are on everybody's mind,” Riel said, adding that Mercy has been actively recruiting for more primary-care doctors and has worked to increase efficiency with medical-home care teams.

Sip Mouden, CEO of Community Health Centers of Arkansas, said Medicaid expansion is expected to cut the state's uninsured population in half with 200,000 to 250,000 expected to enroll in either traditional Medicaid or the state's “public option” plan, which uses federal Medicaid funds to purchase private insurance for low-income residents.

She said assisters at community health centers, paid with either federal funds or state insurance department grants, had helped almost 25,000 people with the enrollment process from June through December.

It's unknown, however, how many of those actually enrolled. Figures for January through March are expected to be much higher.

There has been a general hesitancy in Arkansas to sign up for new health insurance options, Mouden said. Some are concerned that, even after enrolling, there will be expenses they can't afford, she explained. For those with higher incomes who would be seeking coverage through the health insurance exchange, “there's still some skepticism” that the individual insurance mandate will be enforced and they will be penalized for not buying insurance, she added.

After Massachusetts implemented health reforms that widened insurance coverage to state residents, Mouden said 20% to 25% of patients at the state health centers remained uninsured. She expects the same to happen in Arkansas, only the figure could be as high as 35%.

“I don't think we'll be far off,” Mouden said.

That said, she added that the state's 12 community health center organizations—which have 88 locations—have done their part to lower that number.

“We've done a tremendous amount of outreach,” Mouden said. This included advertising, telephone calls, going door to door and holding community forums.

Traditionally, the terms “productivity” and “volume” have been synonymous in describing a physician's workload, but a new study posted on the JAMA Internal Medicine website found that an increase in patient volume for hospitalist physicians can actually be counterproductive.

Researchers with Wilmington, Del.-based Christiana Care Health System found that increasing patient volumes for hospitalists led to measurable increases in length of stay and cost of hospitalization. The authors concluded that this could have consequences for payment reforms.

“Spurred in large part by programs such as the Centers for Medicare and Medicaid's Value-Based Purchasing Program, which seek to transform payment from fee-for-service models to payments based on quality and value, hospitals and hospitalists are under increasing pressure to manage both efficiency and quality,” the authors wrote. “Programs that employ or support hospitalist practices should be aware that policies and incentives that increase workload to minimize short-term costs may undermine larger system efforts targeting efficiency and costs of care.”

The authors analyzed patient records at Christiana hospitals between Feb. 2, 2008, and Jan. 31, 2011. The hospitalists averaged 15.5 patient encounters a day. With each additional patient a doctor saw, the authors calculated lengths of stay increased by two days (from 5.5 days to 7.5) and costs rose by $262. No effect was seen on other outcomes such as mortality, 30-day readmission or patient satisfaction.

Dr. Robert Wachter, associate chair of the department of medicine at the University of California at San Francisco, noted in an accompanying editorial that “tensions will inevitably arise” between organizations seeking the maximum return on their physician investment and hospitalists who seek a more manageable workload without a loss in compensation.

Hospitalists, however, may be used to these pressures.

“We have to be indispensible,” Wachter told Modern Healthcare in a March 2012 interview. “If we are not indispensible, we will be dispensed with.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks