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Carol Finn, the executive director of Heartland Community Health, hands Jenny, the health center’s referral coordinator and care coordinator, a tissue. Jenny’s shedding frustrated tears because this is the third time this week that she’s been unable to find a specialty care provider willing to treat one of the health center’s uninsured or underinsured patients.

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Heartland Community Health Center (CHC) is a federally-qualified health center (FQHC) operating in a medically underserved area (MUA) in a rural section of a midwestern state. FQHCs provide comprehensive primary care services to medically underserved communities regardless of their insurance status or ability to pay. The CHC receives an annual federal Section 330 grant to defray the cost of providing care to its uninsured and underinsured patients. The grant also funds enabling services that support and assist the delivery of primary care and facilitate patients’ access to care. Enabling services include case management, eligibility and enrollment services, transportation, interpretation, community health worker programs, and patient education. Uninsured and underinsured patients are charged a sliding fee, based on income, for the primary care services they receive.

Nearly two-thirds of Heartland CHC’s 2,700 patients live below the federal poverty line, and 96% have incomes below 200% of poverty (about $20,780 for a family of three). The racial demographics of Heartland CHC’s patient population mirrors that of the overall state. More than 85% of patients are White, 9% are Hispanic/Latino, 4% are African-American, and those that remain identify as American Indian or other Native people. As is common among low-income, vulnerable populations, Heartland CHC’s patients are more likely to experience a disproportionate share of chronic conditions such as obesity, diabetes, hypertension, high cholesterol, heart disease, cancer, asthma, HIV, mental illness, and substance abuse. Nearly a quarter of the center’s patients suffer from hypertension. Of those patients with blood pressure < 140/90, more than half (56%) are well controlled with medication, but the remaining 44% are not. More than 14% of the health center’s patients have been diagnosed with diabetes and the majority of those (69%) are well controlled. However, 34% of diabetics continue to receive HbA1c results > 9% or have not had a test in more than a year. Only 37% of the health center’s asthmatic patients report using appropriate medications.

To meet its patients’ needs, the health center provides comprehensive primary and preventive care including sick and well exams, including well gynecological services, immunizations, diagnostic services, screenings, testing for sexually transmitted infections, diagnostic lab and radiology, EKGs, outreach and education, and translation. A behavioral consultant is available to meet with patients and consult with Heartland’s providers regarding treatment plans. The health center refers patients who’ve selected Heartland as their medical home to a dental provider. Similarly, regular patients needing obstetrical/gynecological treatment are referred to an outside partner provider. The center is rapidly growing—its patient population has more than doubled in the last 2 years. As growth continues, it hopes to provide more services such as dental, obstetrics, pharmacy, and comprehensive outpatient mental health and substance abuse services in-house.

Sadly, many of Heartland CHC’s patients need more than primary care. Many require specialty care to treat their chronic conditions. For patients with insurance, especially commercial insurance obtained through an employer, or Medicare, it is relatively easy to see a specialist even in this small community. A nearby not-for-profit general hospital receives no tax support and is entirely self-sufficient. It has 175 beds and specialty clinics that include cardiology, oncology, radiology treatment, nephrology, orthopedics, rheumatology, urology, and pain management, among others. Heartland CHC does not have a formal affiliation with the hospital or its specialty clinics, but the providers typically accept appointments for the health center’s covered patients. Currently 37% of Heartland CHC’s patients have third-party insurance and 19% are enrolled in Medicare. However, obtaining specialty care is more challenging for those with Medicaid, and sometimes downright impossible for those who are either underinsured or uninsured. A fifth of CHC’s patient have Medicaid and one quarter remain uninsured.

Since the state has not taken advantage of the Affordable Care Act’s (ACA) option to expand Medicaid eligibility for those with incomes up to 138% of the federal poverty level, many low-income residents remain uninsured. In addition, these same individuals do not qualify for subsidies to purchase insurance through the ACA’s state marketplace. Other patients—those who purchased low-cost bronze level plans with deductibles of up to $5000 per year per enrollee, along with co-pays and co-insurance—remain underinsured because they cannot afford the out-of-pocket costs of care.

These are the patients for whom Jenny, the referral and care coordinator, struggles to find care. She spends the bulk of her time attempting to schedule appointments. Since Medicaid reimbursements are so low, specialists often limit the number of Medicaid patients they will see in a given year. This can lead to wait times of between 6 and 12 months for an appointment for the health center’s Medicaid patients. Finding a provider willing to treat an uninsured patient is even more difficult because specialists generally won’t offer sliding fees. Some local specialists are willing to take on one or two uninsured patients each year, but there are limited numbers of providers for each specialty in the community, and Jenny is wary of abusing their kindness lest they refuse to take uninsured patients all together. She often resorts to asking specialists around the state for their help. Even when she finds a willing specialist, they are often located quite a distance away, which poses a challenge for patients who lack reliable transportation and/or can’t afford to lose a day out of work to seek care. Faced with no other choice, some patients manage to attend that precious appointment, but some simply forego care, allowing their condition to deteriorate and their suffering to continue until their condition becomes an emergency. Since the CHC’s electronic medical record (EMR) system does not interface with the hospital’s system, Jenny expends significant effort tracking down reports for patients who do see a specialist or go to the ED. She fears she’s falling down on the care coordinator side of her job.

This week, Jenny kept it together as she sought in vain to find a cardiologist willing to treat an underinsured father with an irregular heartbeat, and an orthopedist to help a young uninsured construction worker whose broken arm has not healed properly. But today’s failed quest put her over the edge: a young Hispanic girl who is ineligible for either CHIP or Medicaid has severe asthma and needs a pulmonologist. Jenny wipes the tears from her eyes then levels her gaze on her boss Carol. “Isn’t there something we can do to help our patients get the specialty care they need?” 

Discussion Questions

Research the literature on community health centers, and especially strategies to increase patients’ access to specialty care.

  1. What are the facts in this case? Perform a SWOT Analysis.
  2. What are three factors contributing to the community health center’s problems?
  3. What are the consequences of failing to obtain specialty care for the community health center’s uninsured and underinsured patients?
  4. What are the ethical considerations of charity care? Are specialists in the hospital clinics wrong to limit access to appointments for Medicaid patients or to refuse care to those who are underinsured or uninsured?
  5. What strategies could either the executive director or Jenny employ to help increase the community health center’s patients’ access to specialty care? For example: Use evaluation metrics could be used to measure the success of the recommended solution. A baseline, target, and timeframe for each metric should be included such as:

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