The Health Care Safety Net in a Post-Reform World

Chapter 6 Examining the Structure and Sustainability of Health Care Safety-Net Services

126 In a period of increasing patient demand and waning financial resources, the sustainability of health care safety-net organizations (SNO) is not guaranteed. This chapter focuses on primary care SNOs such as federally qualified health centers (FQHC) (also known as community health centers, or CHC) and community-based organizations such as free clinics. Their ability to remain financially viable while maintaining their mission of providing health care to uninsured and underinsured populations (the target populations), depends on developing innovative and efficient health care delivery designs and strategies. Until now most SNOs have viewed themselves as mission-oriented; at best, attention to sound business practices has been a secondary consideration. But as financial pressures and growing unmet need threaten their survival, many SNOs have recognized the need to operate as small businesses with greater attention to efficiency (Jacobson et al. 2005). What they collectively lack, however, is the means to identify what those operational and organizational strategies should be and how they might be used. Despite their importance as providers of last resort for uninsured and underinsured populations, there is only limited empirical evidence about how SNOs are organized and how they deliver health care. Unlike the robust study of larger health care organizations, the thousands of clinics that comprise the health care safety net have not yet been studied thoroughly to determine which organizational structures would achieve the best outcomes and which practices would improve quality of care. One goal of this chapter is to stimulate rigorous health services research on SNOs. The chapter will broadly examine the current organizational models that SNOs are using and will assess whether the organizational and operational Examining the Structure and Sustainability of Health Care Safety-Net Services Chapter 6 Peter D. Jacobson, Valerie Myers, Judith G. Calhoun, and Jodyn E. Platt structures are adequate to meet the primary care needs of the target populations . These needs include acute care, triage, referrals to specialists, chronic care management, and access to pharmaceuticals. The questions to be addressed include the following: Are FQHCs, free clinics, or hybrids (clinics that take insurance but are also committed to serving those without insurance) capable of acting as medical homes? To what extent are connections to larger health care systems necessary to sustain SNOs? How will SNOs adapt to changes in target population groups (such as undocumented immigrants and newly unemployed individuals)? What types of administrative support systems are needed to sustain health care SNOs? What is the role of SNOs, especially free clinics, after health reform? How will the Patient Protection and Affordable Care Act (the Affordable Care Act, or ACA) affect the models clinics use to provide primary care services? After a summary of the background and context, we provide a synthesis of the current literature on models of care in SNOs. We then present results of a qualitative research project that examines organizational and operational efficiencies in Michigan’s SNOs. We conclude with policy recommendations, focusing on alternative organizational strategies that could best serve the target populations and ensure a sustainable health care safety net along with innovative policies that states can adopt. Background and Context At the outset, we note that the ACA promises profound changes for uninsured populations and, hence, equally important challenges and opportunities for SNOs. For FQHCs, the ACA promises enhanced fiscal resources along with an anticipated increase in demand for services. For free clinics, it promises only increased demand without providing any fiscal help. Ironically, the ACA could exacerbate the central problems free clinics already confront: depleted resources and ever-increasing demand for services. Thus, one of the premises of this chapter is that successful implementation of the ACA, and particularly the effective use of new funding, will depend on improving operational efficiencies and developing effective organizational structures. In 2000 the Institute of Medicine (IOM) provided an overview of the fraying health care safety net that was tellingly titled “America’s Health Care Safety Net: Intact but Endangered” (IOM 2000). Ten years later, the ability of SNOs to meet the needs of the nation’s uninsured and underinsured populations remains a major social problem in the United States. Administratively, safety-net clinics face budgetary constraints that impede their ability to operate efficiently and engage in strategic development and capacity building. Indeed, SNOs face a Structure and Sustainability of Safety-Net Services 127 range of management challenges including: leadership training and staff development ; recruiting...