Reform could pave way for center expansions

COMMUNITY SPIRIT: Dr. John Moran with 1-year-old Giovani Andrade and his mother, Kim Andrade, at the Allen Berry Health Center. /
COMMUNITY SPIRIT: Dr. John Moran with 1-year-old Giovani Andrade and his mother, Kim Andrade, at the Allen Berry Health Center. /

The Chafee Health Center is bright, airy and modern, with large exam rooms, plenty of windows and a convenient location off Allens Avenue. It has a small lab on-site, plus ultrasound, family planning and other support services.
It’s the newest of Providence Community Health Centers’ six sites, opened in 2006, and it’s in high demand: Last year, it provided 19,000 medical visits, said CEO Merrill Thomas – double the previous year’s number.
The Providence centers are so busy, actually, that several aren’t taking new patients at all, Thomas said. Those that are, including Chafee, have seen a steady rise in uninsured visits: 42 percent of all patients now lack coverage, and 75 percent of new adult patients are uninsured.
“I can’t tell you how many calls we get,” said Chafee Director Lisa LaJoie. “You can only see so many new adults a day, because there’s only so much capacity, but it’s constant, daily – adults that have lost their insurance.”
The trend has been the same at Blackstone Valley Community Health Care, Thundermist Health Centers, East Bay Community Action Program, WellOne. Across the state, more and more patients are turning to health centers for affordable care.
Now, with $11 billion in new funding and several other benefits expected from health care reform, community health centers nationwide see a chance to expand, upgrade and position themselves to be the “medical home” for those patients, and millions more, for the long haul. In Rhode Island, where health centers served more than 112,000 people in 2008 (the most recent figure available), health care reform is inspiring big, ambitious plans.
“I’ve been meeting with our staff, saying, ‘We need to figure out how many new patients we can see, how many doctors it will take, what new space that will require,’ ” said Thomas, adding that “about 90 percent” of the Providence centers’ plans would be driven by the new law.
“This is unprecedented change,” he said. “This is like Medicare – this is how major this is. People don’t understand. We have like 140,000 uninsured in the state. All of these people are going to have access to care, and they’re going to want to go see someone.” Private medical practices, Thomas and several of his cohorts noted, don’t have the capacity to meet this new demand (that, indeed, has been Massachusetts’ experience). So the federal government is counting on health centers to grow, and it’s providing an extra $9.5 billion in the next five years – on top of nearly $11 billion in discretionary funding – to help them expand their capacity, plus $1.5 billion for related construction projects.
“Because we already have the infrastructure set up, it’s easier to invest in us and get us going quickly than to start from scratch,” Thomas said.
Recognizing that health centers struggle to attract doctors, the new law also provides $1.5 billion for the National Health Service Corps, which will put an estimated 15,000 primary care providers in communities with doctor shortages. In addition, it creates a new Teaching Health Centers program, with $230 billion to set up medical-residency programs at health centers.
Add to this the expansion of Medicaid to cover all adults up to 133 percent of the federal poverty level in fiscal 2014, and the huge projected growth in the insured pool, and health centers have every reason to expect a big boost in patients and in revenue.
“We don’t know how much is coming how soon, but $1 billion [is being added] next October,” Thomas said. “So we’re in the trenches right now trying to determine what that impact is going to be … 10 percent? 20 percent? 50 percent? That’s my challenge right now.”
“It’s clear to us that this bill is a game-changer,” said Jane A. Hayward, president and CEO of the Rhode Island Community Health Center Association. “It will require all of us to take a step back and look at what the structure ought to be to meet the goals. I don’t know what it’s going to look like, but I know it will be different.”
The health centers are also starting from very different points.
The Providence group is large, with more than 35,000 patients, and facilities that range from the sparkling Chafee clinic, to the very modest Allen Berry Health Center, which Thomas plans to replace with a 40,000-square-foot new clinic on the former Federated Lithographer site nearby. Thundermist is almost as big, serving about 28,000 patients at sites in Woonsocket, West Warwick and Wakefield – and with plans to build a new West Warwick clinic that Thundermist President and CEO Maria Montanaro said could boost that site’s volume fivefold, to 15,000 or 20,000 patients.
Blackstone Valley, meanwhile, has a more modest 11,000 patients, but it has a state-of-the-art dental clinic in Pawtucket, a plan for a new medical facility, a fast-growing Saturday walk-in clinic, and such a robust electronic medical record system that it actually serves as the IT hub for five other centers, and it’s creating its own health information exchange.
(Thundermist is also ahead of the pack in IT, but it uses a different EMR system and is a pilot site for currentcare, the Rhode Island Quality Institute-led exchange. Providence, on the other hand, is only now selecting an EMR, with more than $1 million in federal funds to help.)
In a whole other universe, there’s the tiny Block Island Health Services, which doesn’t qualify for federal community health-center grants, and the rural Wood River Health Services and WellOne (with sites in Pascoag, North Kingstown, Foster).
Those centers’ demographics are quite different from the urban clinics’ – mostly white, few if any immigrants, relatively few RIte Care beneficiaries (about 25 percent at WellOne, versus 42 percent for all centers combined), more commercially insured patients, senior citizens.
Yet even those centers are feeling the pressure from a 16 percent uninsured rate. WellOne President and CEO Peter Bancroft said the number of uninsured patients rose 88 percent from 2008 to 2009, and demand for services has grown so much that “we’re really tapped out on our space.”
Several centers, including WellOne, go well beyond basic primary care, offering dental care, behavioral health care, ob/gyn services, pharmacies, labs and more – even specialty clinics, such as Providence’s diabetes program.
With health care reform, several said they want to offer more specialized services, educational programs and care coordination. But reform will also ease the pressure on health centers to be all things to all patients; as Montanaro noted, getting coverage will make it much easier for patients to get specialty care and, when they need it, surgery and hospital care. “That whole array of services: tertiary care, specialty care, are largely unavailable to the uninsured in a way they can afford,” she said. “So that’s big. That’s huge. If there was nothing else in that bill, that alone would make it worthwhile.”
Looking ahead, health-center leaders are enthusiastic about improving and expanding their clinics, not just to meet the demand, but to be able to serve patients in attractive, modern, efficient facilities like the Chafee clinic. And they are eager to make the most of technology – even if they’re still mastering their EMRs.
Several have gotten a boost from federal stimulus funds already, though no Rhode Island applicants got capital-improvements grants last year, so everyone’s eager to jump on the $1.5 billion when it starts trickling down.
And being quite proud of the care they provide, which some say already meets the ambitious “patient-centered medical home” standards that most private physicians are only slowly working toward, health centers are eager to join pilot programs and demonstrations and lead the way in innovation and quality improvement.
They’re less optimistic about incentives for young doctors to go into primary care – it’s going to take a far more aggressive effort, several said – but they do hope to be able to attract more idealists who can afford to pursue their dreams if the government pays off their school loans.
“Primary care providers have already sort of weeded themselves out a little bit,” said Dr. Sarah Fessler, medical director at East Bay. “People who’ve decided to go into primary care have already decided to forfeit a lot of income … and health-center folks, we’re just kind of crazy and like to be on the forefront of things and [effect] change. I’m a sucker for liking to be challenged, and every day is a challenge.” •

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