So what is a federally qualified health center?
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So what is a federally qualified health center?

Date: April 4, 2007
By: Arlene L. Bishop
State Capitol Bureau
Links: HB 16, SB 577

JEFFERSON CITY - Marketta Hayes sat at her dining table in her Columbia home looking at an empty Lipton Iced Tea bottle.

"Oh," she said, sliding the bottle away from her. "I didn't know there was that many calories in here. That's a lot."

Hayes is a retired Kansas City school teacher who moved to Columbia 14 years ago when her daughters were attending college at MU. She raised three daughters and a son by herself after her husband was killed in a boating accident in Michigan in 1974.

Hayes said she has become far more health conscious since she started going to Columbia's Family Health Center in 1996.

"Could be because I'm getting older," she laughed. "But no, I'm just really more conscious about my health and stuff and wanting to live longer and be a productive member of society."

Family Health Center is Columbia's federally qualified health center. Under a supplemental appropriations measure passed by Missouri's House, federally qualified health centers statewide would receive $60 million for buildings and equipment. And under the legislature's plan to restructure Medicaid, federally qualified health centers would play a major role in providing health care coverage for lower-income Missourians.

Federally qualified health centers receive federal funding to provide medical care to the uninsured. The centers also get cost-based reimbursement from the state for Medicaid patients, and serve Medicare patients.

Gloria Crull, the center's executive director said that the center would see $1.3 million. Because the bill has yet to pass the state Senate and the money isn't yet in hand, she's counting her chickens carefully. But she has general ideas about the best way to spend it.

$500,000 would go toward new dental equipment and a new building or an expansion of their current dental satellite office in Salisbury, she said.

"Because there's not a dentist in Chariton County, what we're trying to do is solve the geographic barrier to access to care," she said. "So if we can build the building and the equipment we'll hire the staff on our own and we can then provide the services within that county."

Another $500,000 would go to the dental office in Columbia for expansion of their current building as well as additional dental equipment.

The remaining $300,000 would go to renovation of the primary site at the intersection of Worley and West Boulevard and additional equipment. She said the health center needs more space and more equipment to serve more patients.

"There's a capacity limitation to how many people we can see," Crull said. "I mean it's the reality and so there are people that are unserved. There is no doubt about that."

Statewide, 19 federally qualified health centers provide care to nearly 300,000 low-income, uninsured Missourians per year. Combined with satellite offices they provide 90 sites of service.

In 2006, Family Health Center and its three satellite offices saw 10,003 patients in 37,047 visits. Boone County and its nine neighboring counties share the health center.

Crull said that health center opened in 1992 as a result of citizen concern for the medically under-served.

"It was sort of shocking because, you know, there are so many health services in Columbia that you would not think there was a gap in service," she said. "The problem was that they couldn't pay full-charge, out-of-pocket."

She said low-income, uninsured people simply avoid medical services because they can't afford to pay for them. Then they do exactly what a federally qualified health center is designed to prevent: They go to the emergency room to receive much more expensive care.

"Your goal is to make it affordable so that they will manage their care at the primary-care level and not end up in the emergency room utilizing high-dollar services," Crull said.

In addition to being a patient, Marketta Hayes is secretary of the governing board of the center. She said she became a "consumer member" because she wanted to have an impact. She said she started going to the health center because her physician was too expensive.

"And back then, I was on my high horse. I could pay everything," she said. "And I told (my daughter), 'Oh, I don't want to go to that place (the health center). It's just like charity."

Later Hayes added, "I think I was talking to my daughter and I was saying to her, 'Karen, I just can't keep paying this money to this doctor,' and she said, 'Well, you knock them but give them a try," she said. "Give Family Health a try and if you don't like it, then you don't have to stay. And I stayed."

Rep. Robert Schaaf, R-St. Joseph, who is a family physician, was one of only four House members to vote against the funding bill, which passed 153-4.  He said that because of the cost-based reimbursement, federally qualified health centers get four times the reimbursement that physicians receive.

He said that if a Medicaid patient, "walks into my office, I get $23. They walk into a federally qualified health center -- depending on the reimbursement -- they get $85 to $100."

Schaaf said that the $60 million would create an unfair competitive advantage for federally qualified health centers and that the money would be better spent raising the Medicaid reimbursement rate for physicians than building new buildings.

"Putting $60 million into building more FQHCs that are highly paid when we won't pay our own physicians as much as it costs them to provide care -- it's immoral," he said. "It's an immoral use of our money."

Federally qualified health centers place a heavy emphasis on primary care. Each patient that walks through their doors is assigned a provider and placed on a treatment plan, whether they are a senior with diabetes or heart disease, or in their 20s with no known health problems.

"But a lot of people -- the urgent care system, if you will, is the way they think," said Kay Strom, chief operating officer of the health center. "If something's hurt, if something's broken they take that piece of them to the doc and get it treated, where the primary care concept is looking at the whole patient and a planned approach."

Hayes said she goes to the center about once every three months as long as she stays in good health. She said that she thinks the primary care aspect is "excellent."

Strom said that the treatment plan differs based on the needs of the patient. But essentially, it is a plan used to inform the patient of his or her primary care needs. A relationship is established with the assigned provider and the patient is able to actively participate in achieving the goals set out in the plan.

"But the thing that is different is that there is some responsibility and a plan for ongoing care in contrast to an emergency room that looks at the patient at this moment in time and says what they need to be treated for this day, this hour and then beyond that is not their job," Strom said. "It's somebody else's job."

Included in the treatment plan, Strom said, are goals for increasing exercise and quitting smoking.

"It may be something as simple as they need to increase their exercise and so to increase their exercise, they're going to walk around the couch three times during every commercial," she said. "That's a start. That's getting off the couch."

Strom said the goals are meant to be attainable so that as patients achieve them they can set new goals.

"If they start out with getting off the couch during commercials and then you have success on that so then maybe you take it to the next step and increase that," she said. "You pick a show that you don't like as much and you turn the TV off and you walk during that whole time spot."

Hayes, who is uninsured, said the sliding-fee scale that the center offers makes the same quality health care more affordable.

"I couldn't afford a real doctor," she said."It's just that simple. What they charge, I just couldn't afford and when you don't have any insurance it's hard."

To further make health care affordable, Strom said they have three programs to make prescriptions cheaper to ensure that people are getting the medication they need. 

They provide patients with samples. They participate in indigent drug programs with pharmaceutical companies, which offer discounted or free medications on a voluntary basis, and as a federally qualified health center they are able to purchase medications at the lowest federal pricing through a contract they have with Kilgore Medical Pharmacy.

Hayes said doctors are quick to, "write prescriptions and never take into consideration can the person really pay all this money for that."

Schaaf said that giving the money to the federally qualified health centers is a "systematic movement" to place Medicaid patients in a substandard tier of health care.

"When you want to encourage people to be seen by a certain provider, you jack up the reimbursement for that provider and that's what's happening here," he said.

Schaaf said that the level of care that patients receive at the federally qualified health center is not as good as what they receive at a physician's office because they get "shuffled off" to a nurse practitioner.

"You have to ask yourself the question: What is the quality of care delivered from a nurse practitioner as opposed to delivered by a doctor?" he said. "Well, the nurse practitioner will tell you that they're better, but they're obviously less-well trained."

Hayes said she has had a nurse practitioner since she started going to the center and that she likes it better because the nurse practitioner is female and she found it hard to find a female doctor when she moved to Columbia.

She said that it is not a requirement that health center patients see a nurse practitioner.

"If they assign you a nurse practitioner, you can ask, 'Can I be put on the doctor's list?'" Hayes said. "A lot of people have hang ups about -- quote -- doctors. But nurse practitioners, to me, are just -- they just didn't go to school to take up everything the doctor did, but they are good."

Strom said that many Medicaid patients have to come to the federally qualified health centers because many doctors won't see Medicaid patients.

"If the doc has got his practice full and he needs to cut somewhere because he can't take care of everything that's there, they may often cut the Medicaid because they're reimbursement rate is lower on that," she said. "And if you can only see 'x' number of patients a day, you want to maximize what you're going to get out of those patients"

Strom also said that some doctors don't think that Medicaid patients will mix well with their other patients in the waiting room.

"They don't want to lose their private-pay-insurance paying patients because of having the waiting room filled with people that may not have the same dress standards and behavior standards," she said. "That's a delicate one to walk around, but it's real."

All in all, Crull said her work as the health center is meaningful and that the patients are appreciative of having access to decent health care at a reasonable price.

She said that she thinks there is a general public opinion that people take advantage of the Medicaid system.

"I think it's very few people," she said. "By and large, people want to just take care of their families, make a living, be healthy, and pay their bills just like everybody else."