Community Health Centers (CHCs) have assumed an important role in bridging coverage and access gaps for some of the most vulnerable Americans. Nevertheless, prominent gaps in coverage and access (discussed in more detail below) persist. Millions of lower-income Americans are still uninsured, and even for those with coverage, substantial barriers remain to accessing affordable, high-quality care.
We believe that major CHC expansion could go a long way toward addressing the remaining access to care barriers for lower-income Americans. However, CHC expansion is limited by the critical shortage of Primary Care Professionals (PCPs) necessary to accommodate a projected major increase in patients.
Teaching Health Centers (THCs) provide graduate education for primary care physicians and dentists who aspire to be based in CHCs and other community settings. However, in spite of successful achievement of their mission to date, THCs are currently underfunded and undergoing potential atrophy.
We describe the unique aspects of a proposed modified and greatly expanded THC model—Mega THCs—and suggest a program funded by the Center for Medicare and Medicaid Innovation (CMMI) to demonstrate this new paradigm. We conclude by describing in some detail the aforementioned coverage and access gaps which could be addressed by expanded CHCs. We believe that the Mega THC is essential in developing the workforce pipeline essential to enable CHC expansion to serve lower-income Americans.
Current Status of CHCs and THCs
Since the 1965 demonstration projects that launched them, CHCs have served to link clinical services and community health. After a half century of the program, 1,375 CHCs, located in every state, provide a wide range of services to over 24.3 million previously underserved Americans.
In 2010, federal CHC funding was expanded through an $11 billion, five-year Affordable Care Act (ACA) growth fund, which was extended for an additional two years under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These funds support services that many insurers do not cover. They also reduce patient cost sharing to affordable levels through the use of sliding fee schedules tied to family income. The recently updated Clinton health care proposal includes a doubling of current CHC funding, with support of $40 billion over 10 years.
THCs began development and evaluation in 2011, but are now jeopardized by inadequate federal funding. THCs are essential to train PCPs necessary for major expansion of CHCs. As of 2014, 60 THC programs in 24 states were training over 550 residents in primary care, dentistry, and psychiatry, with a projected expansion to 800 trainees in future years. The program was initially supported under the ACA by $230 million over five years, which expired at the end of FY 2015.
THC programs are located in community-based ambulatory care settings and serve a large number of Medicaid patients. Those who train in these underserved areas are likely to remain in practice in the same or similar settings, with location of residency training often predicting practice style regarding quality and cost.
Congress recently provided $60 million per year of continued support for THCs in FY 2016 and 2017. However, a greater level of funding is required to sustain THCs. While the demand for THC training is strong, existing programs have faced problems determining whether they would be able to continue their operations in view of limited funding.
Development Of The Mega THC
Mega THCs would greatly increase PCP production, enabling the further expansion of CHCs needed to accommodate an influx of patients due to addressing access barriers.
The Mega THC would be a multi-specialty primary care group practice augmented by increased utilization of non-physician PCPs and dentists in central and geographically extended CHCs. The model would feature the following characteristics:
Currently most THC programs support residents in just one of the primary care subspecialties, most often family medicine. These programs, of limited size and scope, have successfully pursued their goals but are currently impaired by inadequate funding. Mega THCs would include multiple types of primary care physicians who would train simultaneously, integrating their training and clinical roles and pursuing collaborative care with Nurse Practitioners (NPs), Physician Assistants (PAs), and pharmacists, as well as dental practitioners.
Neighborhood THC Clinics
Neighborhood THC clinics located in underserved urban areas or rural communities are a key component of the proposed Mega THC paradigm. NP faculty and their trainees would serve as the PCPs leading a local neighborhood team in collaborative practice, coordinating care with the central CHC through extensive use of electronic health records (EHRs). MDs in the appropriate primary care specialty within the central Mega THC would be available to support the neighborhood clinics electronically and with in-person consultation when needed, and Mega THC staff would arrange in-person and remote specialty and subspecialty consultations.
The evolving Patient Centered Medical Home (PCMH) model utilizes team-based care with clinicians and staff working at the top of their skill set. The Mega THC’s neighborhood-based approach could extend the patient-centered medical home (PCMH) into the communities where patients live. This approach to comprehensive primary care could be located in urban public housing developments or in small rural community clinics. Recognizing the large influence of social determinants on health, neighborhood clinic staff would work closely with varied personnel, including social workers and community and home health workers.
Increased Number Of Primary Care Professionals Trained
THCs are crucial for training urgently needed PCPs. However, current programs cannot train the number of PCPs necessary for CHC expansion.
Because Mega THCs would train different specialties of primary care physicians together, they would be an efficient way to train more primary care physicians as well as other primary care providers. Each Mega THC could produce up to 15 primary care physicians and dentists and 16 NPs per year. The three-year THC GME curriculum has been previously described. MEGA THCs could also increase the number of PAs, pharmacists, and other professionals who would receive training and clinical experience in a team-based environment.
As mentioned, this increased capacity would augment the primary care workforce. It would also provide increased opportunities for primary care physicians and non-physician primary care providers to train in the collaborative, team-based environment that will characterize 21st century medicine,
Interprofessional Education (IPE) occurs when members of two or more professions learn about each other, from and within each other’s area of expertise, to enable effective collaboration and improved health outcomes. The number of nurse practitioners educated in the United States has grown dramatically over the past decade. If these NPs (as well as other non-physician providers) are fully integrated into our delivery system and allowed to practice consistent with their education and training, this could help assure access to cost-effective care at CHCs and elsewhere. By providing IPE, the Mega THC model could enable such integration.
Just as previously described for their MD in-training colleagues, NP trainees seeking to serve in neighborhood clinic leadership roles would provide primary care for a panel of patients for an extended period of ambulatory training. Their NP faculty would provide supervision and also interact with their patients to provide continuity of care. Upon graduation from a Mega THC-based doctor of nursing program, these NP trainees would have gained expertise as nurse leaders of interdisciplinary health care teams, prepared to improve systems of care, patient outcomes, quality, and safety.
Pharmacy faculty and their trainees would contribute to care, as would other team faculty and trainees as required. PAs would be located in central CHCs, so that they could work alongside MDs.
Financial Support Of Faculty, Trainees, And Team Members
Neighborhood clinics would demonstrate a new venue for team care. This innovation would require a funding mechanism that is flexible and supports team members according to their participation; thus, global funding for patient care would be necessary. Just as with the current THC program, we propose that faculty and trainee salary be supported by federal funding, in this case via a demonstration grant from the Center for Medicare and Medicaid Innovation (CMMI), which is catalyzing profound changes in U.S. health care. Congress authorized CMMI at a level of $10 billion for fiscal years 2011-2019.
We propose that CMMI support faculty and trainee salaries for up to 10 MEGA THC demonstration projects in urban and rural CHCs, each at a level of $3 million per year for five years. Demonstration grants should be given preferentially to entities partnering with academic medical centers (AMCs) and integrating with their Graduate Medical Education (GME) programs and subspecialty networks. (The CHC and AMC partnerships (CHAMPs), which establish the relationship of THCs to the primary care track of AMCs, have been previously described.)
Also, applications should be enhanced by commitment of community resources to support THC facility development, accommodating increased staff and patients. In order to support their not-for-profit status, teaching hospitals have started to support CHC expansion as their contribution to community health.
Other funding would be derived from resources available to support the care of CHC patients. A recent study elucidated the distribution of expenses for THCs. The mechanism for federal THC funding, which flows to the site of residency training via educational consortia, has been described previously. MEGA THCs could depend on similar funding streams during the demonstration, with subsequent funding provided by Medicare GME support.
The Need For Mega THCs: Addressing Coverage And Access Gaps
Unavailable Medicaid Coverage
Medicaid enrollment now exceeds 66 million lower-income Americans at a cost of $449 billion, with 8 million additional Children’s Health Insurance Program (CHIP) enrollees. Cost has been driven largely by increased enrollment, not by per-enrollee costs, with one in six beneficiaries served by CHCs. This high CHC penetration likely results from the required location of CHCs to treat underserved areas and populations and the relatively limited participation in Medicaid among office-based physicians due to low reimbursement.
Moreover, needed Medicaid coverage may be unavailable because federal rules give states leeway. In many states, only extremely low-income residents qualify for Medicaid coverage and childless adults are excluded entirely. The ACA was intended to reduce this disparity by offering additional federal funding to states to expand Medicaid programs to cover all adults up to 138 percent of the federal poverty level. However, 19 states have exploited a Supreme Court ruling making the expansion optional, electing not to expand. Thus, up to 4 million lower-income Americans are uninsured, covered neither by premium subsidies or Medicaid.
High Deductibles and Co-Payments For Lower-Income Insureds
Many patients with incomes up to 200 percent of poverty who gained insurance under ACA exchanges have experienced financial distress because of high deductibles and co-payments. Increasing out-of-pocket expenses have resulted in millions of Americans becoming underinsured — they have insurance but must pay so much out of pocket that it creates a barrier to obtaining needed care. This barrier could be surmounted via CHCs with their sliding fee scale.
No Coverage For Non-Citizen Immigrants
About 15 to 20 percent of the remaining 29 million uninsured people consists of undocumented immigrants; they are excluded from ACA coverage. These individuals receive much of their care from emergency departments; thus, all citizens pay for their care through increased insurance premiums. Furthermore, because undocumented immigrants have prominent roles in the food and assisted-care industries, their lack of health coverage presents a public health hazard.
Unavailable Mental Health And Substance Abuse Therapy
Behavioral health services may be unavailable for lower-income Americans due to provider workforce shortages and a lack of insurance coverage. Addiction services are now of particular importance.
Unavailable Oral Health Coverage and Care
The prevalence of dental disease and tooth loss is disproportionally high among low-income people, reflecting lack of access to dental coverage and care. Dental benefits for Medicaid adults are not required by federal law but are offered as an option in some states, with most states providing only limited or no coverage. Medicare has no dental benefit.
Medicare currently covers 55 million Americans over the age of 65 and 9 million younger disabled people at a yearly cost of $585 billion; its achievements in improving life expectancy and reducing suffering have been enormous. However, as many rural communities age and lose population, their economic base and ability to support a primary care physician erodes. This compromises recruitment and retention, thus limiting access to primary care. Less than 6 percent of primary care residents’ training time is spent in rural settings, despite these locations being home to nearly 20 percent of the U.S. population.
Given evidence that rural training experiences influence physician career choices and that physicians tend to practice near their residency program after graduation, expanding training in rural areas is an opportunity to address these workforce shortages. Thus, THCs with neighborhood clinics could help buttress the rural primary care workforce and provide coordinated care to rural seniors, many of them with multiple conditions, in their communities.
Care of Veterans
Twenty-eight percent of veterans live in rural areas. They frequently do not have convenient access to Veteran Affairs (VA) facilities and would benefit greatly from local access to care. In 2014, in response to well publicized deficient access to care, Congress authorized a marked expansion of VA — paid care in the community with its “choice” program and a $10 billion appropriation. A 2015 law mandated consolidation of the Veterans Health Administration’s many established community care programs into the Veterans Choice Program.
In recent years, veterans of the Iraq and Afghanistan conflicts, female veterans, and aging veterans from earlier eras have substantially increased VA primary care needs. However, the increase in the number of VA physicians has been limited. In addition, mental health issues are becoming more prevalent. These changes have resulted in substantial health professional shortages in many VA ambulatory clinics. Because many veterans live in underserved areas—urban as well as rural—where access to care by private primary care physicians is limited, we propose encouraging veterans to obtain outsourced primary care at CHCs, a Tier 1 provider under the choice program. Their subspecialty care could be coordinated with a regional VA facility or affiliated Academic Medical Center (AMC).
Moving Forward: Potential Challenges
We have proposed a Mega THC model designed to cost effectively train the necessary primary care workforce for major expansion of CHCs. We currently possess the capacity to provide high-quality, universal health care for lower-income Americans if we continue to develop our CHC infrastructure to its maximum potential. The proposed Mega THC program could enable expansion, utilizing MDs but also NPs practicing to the fullest extent of their training as recommended by the Institute of Medicine.
Implementation of the MEGA THC might encounter three prominent obstacles:
- Inadequate availability of required THC faculty is a legitimate basis for skepticism. However, a recently described Kraft Center THC faculty training initiative could effectively address this deficiency.
- The Mega THC curriculum involves delivery of ambulatory primary care by trainees, under faculty supervision. This might raise concern regarding quality of care for THC patients. However, as a precedent, physician trainees (Residents) in our teaching hospitals provide the major component of care under faculty supervision. In both inpatient and existing THC ambulatory settings, quality of care is superb and patients thrive.
THC support involves GME funding. Any incursion on current GME Medicare funding has engendered intense controversy. However, the proposed CMMI support for THCs would not infringe on current GME funding during the five years of CMMI support.