Mexican American infant mortality rate: implications for public policy.

Infants of Mexican American descent have lower infant mortality rates (IMRs) than do non-Hispanic blacks and non-Hispanic whites. Because IMR is used in allocation methods for primary health care resources, the result could be discrimination against Mexican American populations in the distribution of resources. This study examined the National Center for Health Statistics' infant birth and death records, as well as unpublished data from the Bureau of Primary Health Care. This study found that the low Mexican American IMRs are real and not simply a data anomaly and that inclusion of birth outcomes has a small and mixed effect on the designation of high-Hispanic areas as being medically underserved or short of primary health care professionals. The authors suggest inclusion of an additional high-Hispanic health indicator in the designation criteria for health resources.

Managed care and community health centers.

This study has two objectives: (1) to examine the relationship between the involvement of community health centers (CHCs) in managed care and various center characteristics, including patient, provider, services, and financial characteristics, that are critically linked with the fulfillment of their mission and (2) to identify factors significantly associated with CHCs' involvement in managed care. Regarding the first objective, the study indicates that CHCs involved in managed care have more diversified sources of revenue and depend less on grant funding than other CHCs, and they serve a significantly smaller proportion of uninsured and homeless patients. Involvement in managed care is also associated with greater financial vulnerability, reflected in higher costs and net revenue deficits. Regarding the second objective, the study finds that CHCs have become involved in managed care largely in response to external market pressures, such as the prospect of reduced federal grant funding. Other significant factors include center size, location, and the percentage of users who are Medicaid patients.

Assessing primary care content: four conditions common in community health center practice.

Under managed care, community health center (CHC) care patterns will be increasingly subject to outside scrutiny. This article discusses results of medical records reviews assessing quality of care at CHCs for acute otitis media, diabetes, asthma, and hypertension. As a group, these safety net providers meet or exceed prevailing practice across other health care settings; however, there is substantial variation among sites. Regression analyses indicate that the individual CHC used by a patient is the most consistent determinant of whether a patient receives recommended care. Drawing on these results, the article explores approaches for improving care and discusses the implications for performance measurement among CHCs and other safety net providers.

An overview: health centers at the crossroads.

Health centers' flexibility in meeting changing political and economic demands throughout their history has allowed them to evolve and expand. In 1997, they served 8.3 million patients--40% uninsured and 35% Medicaid recipients. Thus far, most centers have been able to balance their mission of serving the underserved with economic survival. However, their future viability is threatened, by downward pressure on revenues, coinciding more frequently with growing numbers of uninsured patients. The centers' value as essential safety net providers, their adaptation to marketplace realities and their performance in terms of cost and quality outcomes appears to justify the increased subsidy that may be needed for continued operation.

Cancer screening among community health center women: eliminating the gaps.

OBJECTIVE: The elimination of health status gaps among minority and low income populations is part of the mission of community health centers (CHCs). Cervical and breast cancer incidence and mortality are related to both minority and socioeconomic status, and CHCs are in a unique position, by virtue of their target population, to effect positive outcomes through screening and early detection. METHODS: Completed in 1995, the survey described in this article included questions from the 1992 NHIS Cancer Supplement, which collected information on the utilization of cancer-screening services, including Pap smear testing, mammography, and clinical breast examination. RESULTS: CHCs are providing access to Pap smear testing, mammography, and clinical breast examination for women who are at an increased risk for morbidity and mortality associated with cancers of the cervix and breast. A higher proportion of CHC women of most racial and ethnic groups and women below poverty level are up to date on cancer screening than comparison groups. In most cases, CHC women meet or exceed the Healthy People 2000 objectives for the nation.

FQHC (Federally Qualified Health Center): harnessing the incentives of cost reimbursement.

Community health centers (CHCs) are federally supported primary care providers to the low-income and uninsured. The federally qualified health center (FQHC) legislation requires states to pay CHCs for Medicaid services on the basis of reasonable cost. The statute generated controversy, particularly in a time when, for most providers, cost-related reimbursement has given way to fixed payments and managed care. This article examines the impact of FQHC on revenue and utilization of CHCs, using data for 328 centers that were in continuous operation between 1989 (the year the legislation was enacted) and 1992, the first year of full implementation. During this period, the CHCs Medicaid revenue grew rapidly. FQHC is estimated to account for under one third of the total increase, while inflation and growth in utilization due to expanded Medicaid eligibility are estimated to account for the other two thirds. At the same time, the change to cost-related reimbursement had a significant increase in total service users and Medicaid recipients receiving care from CHCs. Although some expected that cost-reimbursement would lead to inflationary increase in utilization, this did not occur. There was no statistically significant relationship between the change in payment methodology and changes in encounters per user. The experience of FQHC indicates that, for safety net providers of primary care, cost-related reimbursement is not "inherently inflationary." Results of this study raise the question of whether payment within constraints, but bearing relationship to cost, is not an appropriate approach to developing primary care capitation rates for these providers--and assuring maintenance of the safety net for the uninsured.

Building a research agenda: responding to the needs of Community and Migrant Health Centers.

This article summarizes the results of an invitational conference designed to establish a research agenda for collaborative projects involving university-based health services researchers and staff (administrative and clinical) from Community and Migrant Health Centers (C/MHCs). More research related to C/MHCs needs to be developed, preferably by collaborative teams of researchers and C/MHC personnel. Specific research ideas are summarized, and five more detailed research proposals are presented. This is an especially important area that needs work, given the changes taking place in health care finance and the impacts of those changes on C/MHCs.

Health care consortia: a mechanism for increasing access for the medically indigent.

In response to poor coordination among health and social service providers, health care consortia have emerged in many areas of the United States. Consortia link multiple providers in a common structure to create comprehensive systems of care. They can be formally structured or informal combinations of providers that engage in coordination but otherwise do not comprise an independent organization. The functions most common among all types of consortia are shared services and service coordination; however, a number of consortia also operate outreach/education programs. Consortia represent an innovative response to the need both for vertical integration--case management of all levels of care--and horizontal integration to prevent duplication among primary care providers. We outline the history of consortia in which federally-funded community health centers have participated. We also suggest an analytical framework for the various types of consortia; discuss lessons learned about building and maintaining consortia; and provide preliminary outcome data.

Capital cost reimbursement to community hospitals under Federal health insurance programs.

Issues in current capital cost reimbursement to community hospitals by Medicare and Medicaid are described, and options for change analyzed. Major reforms in the way the federal government pays for capital costs--in particular substitution of other methods of payment for existing depreciation reimbursement--could have significant impact on the structure of the health care system and on government expenditures. While such reforms are likely to engender substantial political opposition, they may be facilitated by broader changes in the reimbursement system.