Recent circumstances have moved me to take a closer look at the importance of Federally Qualified Health Centers (FQHC) and their important role in the immediate future of the evolution of better care for the underserved populations of our nation. I have the bias that the majority of Americans, the twelve out of thirteen Americans who do not get their care at an FQHC, have little appreciation for the benefits they provide for the 8% of the population that are dependent on them. I have a feeling that most Americans who are concerned about the cost of their own care don’t know much about the system that has been trying to improve the health of the urban and rural poor for the last 50 years. Have you ever wondered where many of our fellow Americans without coverage go when they must go somewhere? Where does an undocumented immigrant go when care is needed? The answer is to a Federally Qualified Health Center. Did you know that the budget compromises last February that saved the CHIP program also saved the critical community health centers in a state of chronic underfunding until 2019? Does it concern you that uncertainty about funding is a chronic issue at community health centers across the country?
Until about four years ago I was ignorant of the real importance of FQHCs. I knew that they took care of a difficult population that had challenges that our system was ill prepared to serve. I was happy for the role they played, and took them for granted. I knew that back in the mid 60s, the Columbia Point Health Center in Dorchester became the first of more than 1,000 FQHCs across the country that now serve 27 million patients in over 10,000 communities, but my knowledge of their continuing vulnerabilities was not very deep. I was happy that they existed, but they were not my primary focus.
I was too busy to give them much thought while I was directing my managerial and strategic attention toward fostering systems improvements within our practice while trying to make connections with hospitals and academic medical centers that might create external efficiencies for us. In retrospect, I am embarrassed to say that although I had many conversations with the leaders of FQHCs in Massachusetts, I never seriously tried to solve the structural problems that prevented a more supportive relationship with any of them or with the Massachusetts League of Community Health Centers. In retrospect that was a huge missed opportunity for Atrius Health to make a difference in the care of the underserved while advancing the objectives of the Triple Aim.
Sometimes life gives you a second chance. I was extremely pleased when after I retired I got a call asking me if I would be interested in joining the Council of Advisors to The President and CEO of the Whittier Street Health Center, Frederica Williams. I immediately said yes. Over the last several years my contact with Whittier Street Health Center has been a rewarding learning experience. President Trump has commented that, “Nobody knew healthcare was so complex.” I doubt he was thinking about FQHCs when he said that, but he should have been. The world that they face is much more uncertain than any other form of organized practice with which I am familiar.
If you want to know more about FQHCs, I would recommend that you look at a “primer” on FQHCs offered by the National Association of Community Health Centers. What you will learn is that by law FQHCs must meet numerous requirements, including but not limited to:
- Serve a federally-designated medically underserved area or a medically underserved population;
- Serve all individuals regardless of ability to pay;
- Charge no more than a “nominal fee” to uninsured and underinsured individuals with incomes below 100% FPL, and charge uninsured and underinsured individuals between 101% – 200% FPL based on a sliding fee scale;
- Provide non-clinical enabling services to increase access to care, such as transportation, translation, and case management
Whittier Street Health Center easily meets all of these criteria. Its mission was launched long before the “War on Poverty” programs and federal legislation that created FQHCs as the most vulnerable part of our overall care system. WSHC was established in 1933 as a “well baby” neighborhood practice. In 1974 Whittier Street became a federally funded community health center. The link provides a beautiful time line visual of the evolution of care at WSHC over the last 85 years. On Thursday I will be speaking at the 85th anniversary celebration. Early in my relationship with the leadership of WSHC, when I learned that the life expectancy of Roxbury resident was 59 years and a few months, I knew that the time investment that I was making was important. Just across town, a couple of miles away in Back Bay, the life expectancy exceeds 90! In modern day America your ZIP code is a more important determinant of your health than your genetic code.
The header for this post is worth comment. It shows the beautiful, award winning for environmental design, six story, almost 80,000 square foot, home of WSHC. WSHC serves 30,000 patients here, but there is room for many more. The building sits on Tremont Street located across the way from the headquarters of the Boston Police Department, and not far from the Longwood Medical area or the Boston Medical Center. It is was completed in 2012 for 38 million dollars during an era when we were more actively investing in the care of the underserved. It was funded in part by a 12 million dollars from a Human Resources and Service Administration (HSRA) American Recovery and Reinvestment Act grant. What you see when you enter the building is evidence of what a coalition of concern can do when we care that everyone has the right to care in a convenient, comfortable environment that respects them as individuals. The building is a monument to the commitment of philanthropy and public investment brought together for the benefit of the community by managerial excellence and leadership in service to the underserved patients of Roxbury. The building gives testimony to the idea that we all deserve care in a respectful environment that signals our innate worth as members of the community. For me the building is emblematic of the work done, and evidence of the commitment to the work to be done.
An important continuing concern in the story of community health centers is the difficult experience of the dedicated healthcare professionals who provide the care. A study published in 2017 in HealthAffairs documents high rates of professional burnout in community health centers. It is hard work trying to overcome the handicaps associated with the social determinants of health. If you chose to work in a community health center, you are always swimming against the heavy current of the status quo, the impact of centuries of economic inequality, and the continuing biases of many who would prefer to think that the issues and illnesses of your patients suggest their personal moral failure rather than a heritage of oppressive disadvantage.That there are high turnover rates among providers at community health centers across the country does not surprise me. Robert Coles, in his 1994 book, The Call of Service, documented the personal stresses of all of those who feel a “call to serve” the underserved. In my mind those that even try at all are unsung social heroes and heroines. The many who labor for decades under the uncertainties of public support are social saints.
I appreciate the effort to try of those who come for a while and then go because they find that the work is too hard. I wish that I could say that I had responded to the call to try when I might have made a greater impact. Some of the professionals who come and go quickly on their way to an easier, more comfortable practice in the suburbs are choosing to work for a time in an FQHC environment as a way of gaining forgiveness for educational loans. I am happy that these forgiveness programs exist, but I am sure they create turnover that fragments the experience of patients and adds to the burden of the dedicated managers and providers who consider working in a community health center to be their calling for life.
Is it too much to propose that one way to lift many Americans out of their chronic illnesses related to the social determinants of health is to provide continuing support to the work of community health centers located in the disadvantaged neighborhoods of our cities and the thousands of small rural communities that together are the “other America” that so many of us can avoid seeing? The FQHCs that serve the urban and rural poor are working hard everyday to do a job that most of us do not think much about. The Commonwealth Fund has tried to document and catalog the healthcare issues that will be important in the 2020 election. It is a document that we all should read and act on if we want to preserve the benefit that FQHCs provide us all.
FQHCs like Whittier Street Health Center understand the challenges of Population Health. Whittier Street is leading the way in reducing healthcare disparities in its patient population with its Boston Health Equity Program, a system of care for people with chronic illnesses that fully integrates innovative community outreach, wellness support and care coordination and explicitly seeks to eliminate health disparities and their associated costs. The specific innovations within this system are:
- Innovative and culturally appropriate community outreach to increase access to care and early detection of illness with hard-to-reach populations;
- Primary care that includes visit redesign and a system of off-site Virtual Clinics and that integrates medical care, mental health care and social supports;
- Medication management to maximize safety for those with multiple complex health issues and to support optimal recovery;
- Wellness programming that is fully integrated with primary care, tailored to individual needs and buttressed by ongoing support to ensure patient compliance and self-management;
- Targeted care for cancer patients that fully integrates specialized medical care with wellness, psychosocial support and primary care;
- Education and assistance in properly utilizing primary care and the WSHC urgent care center to avoid hospital re-admissions and reduce emergency room use.
- Infrastructure improvements to technology systems to gain efficiency, effectiveness and provide data for continuous quality improvement, including a Personal Health Portal, an enhanced Cancer Registry and on-line transmission and review of Virtual Clinic data.
- Establishment of a fitness center to provide an integrative medicine model of care for the whole person.[Read More about BHEP].
The future of FQHCs is most threatened by our lack of interest in their work and the populations they serve. The work of FQHCs is threatened when we elect leaders who do not appreciate or value their contributions. It is hard to understand an electorate that could vote for such leaders even when they are critically dependent on the services FQHCs provide. In Kentucky, a state noted for its rural, mostly white, pockets of poverty, where in some counties more than 50% of income flows from public assistance, voters elect representatives who would undermine the funding of Medicare and Medicaid and the other social programs that support the work of Community Health Centers. We seem to live in a world where it is often true that “no good deed goes unpunished.” Visiting an organization like Whittier Street Health Center and observing the diversity of the clients who come and go and then examining the facts that describe what has been accomplished leaves no doubt of the value of FQHCs. What worries me is that so few Americans seem to understand what we are at risk of losing. Perhaps it is a function of the fact that the president was right; none of us really fully appreciates just how complex healthcare is. To that I would add that not enough of us understand the contributions of community health centers to the whole of our efforts to achieve the Triple Aim.
