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Rural Health Grand Rounds

C arolina. S outh. Rural Health. Research Center.

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Rural Health Grand Rounds

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  1. Carolina South Rural Health Research Center The History, Evolution, Current Status and Issues of Community Health CentersMichael E. Samuels, Dr.P.H.Distinguished Scholar and Endowed Chair in Rural Health PolicyCenter of Excellence in Rural HealthUniversity of Kentucky College of MedicineDepartment of Health Services Policy and ManagementArnold School of Public HealthUniversity of South CarolinaMcKissick LibrarySeptember 20, 2005Columbia, SC Rural Health Grand Rounds

  2. History 1854 John Snow, MD (1813-1858)

  3. Medicare/Medicaid Signed Into Law

  4. “The only thing new is the history you haven’t read” President Harry S. Truman

  5. Importance of History • Live in A-historical country. • We think of it as not involved in our daily life. • It has to do with our self perception. • We think of history as myth. • We are bound by unproven assumptions.

  6. Importance of History • Our concepts (basic assumptions and though patterns) come out of the past. • History teaches inductive rather than deductive reasoning. • History is necessary for long-range planning. • History is about balance between change and continuity over time. • Short term versus long term trends

  7. CHC Traditions Medical Care (Individual) Public Health (Group)

  8. The Greek Tradition Hippocrates (470 - 377 B.C. ) “To maintain the correct balance, eat good food, avoid red meat, drink pure water, get fresh air and exercise and above all avoid quarrelsome people for they cause stress and that is the most injurious to your health.” Oath of Hippocrates “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.”

  9. The Religious Tradition in Health • Before the Reformation, a religious duty for all Christians: • feed the hungry • give drink to the thirsty • welcome the stranger • clothe the naked • visit the sick • visit the prisoner • bury the dead • Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind. This is the first and great commandment. And the second is like unto it: Thou shalt love thy neighbor as thyself. On these two commandments hang all the Law and the Prophets. Matthew 22:37-40

  10. US History of Health Care • Puritans could look at poverty as revealing a flaw in the poor person's character; a sign that he or she was out of favor with the higher power. • While acts of charity to help the needy were an important part of religious practice, there was not an expectation that such charitable acts would raise the underclass out of poverty. Charity was viewed as comfort to those unfortunates doomed to suffer in this world, and the charitable act a sign of the goodness of the giver. • The University of Pennsylvania School of Medicine - first medical school Fall, 1765 • Benjamin Rush “Father of US Medicine” – Farming, misfortune of others • History of Physician Licensure • Education – B.A., M.D. • 1816 First Stethoscope • 1869 –” Medicine, the most despised of the professions which liberally educated men are expected to enter” (1925 3rd, 1933 1st) • Technology – 1877 First telephone exchange, 1890’s “Buick, the Doctors Car”

  11. US History of Health Care • AMA founded 1851 • Hospitals – Either 1846, Antiseptic surgery 1867, Mayo Brothers abdominal surgery 1889-1892 (45), 1900 (612), 1915 (2,157). • Hospitals – 1873 <200, 1900 > 4,000, 1920 >6,000. • Florence Nightingale Nursing, hospital architecture, health administration • First x-ray 1895 • Medical Education Flexner Report 1910, Johns Hopkins Model, Licensure 1877, Osteopathy 1891 • Group Practice 1918 Mayo Brothers • Health Centers Dr. Herman Biggs, 1923, New York • Baylor Hospital / Dallas Teachers Union “Birth of the Blues” 1929 • California Blue Shield, 1939 • Kaiser Permanente, 1942

  12. Government • 1798 “The Relief of Sick and Disabled Seaman” • 1906 The Pure Food and Drug Act, Meat Inspection Act • 1912 First White House Conference urged creation of the Children's Bureau • 1921 The Bureau of Indian Affairs Health Division • 1930 The National Institutes of Health • 1935 The Social Security Act • 1938 Federal Food, Drug and Cosmetic Act • 1939 Federal Security Agency • 1946 Centers for Disease Control and Prevention. • 1955 Department of Health, Education and Welfare

  13. Government • 1961 Indian Health Service transferred to HHS from DI • 1964 The Migrant Health Act • 1965 First Surgeon General's Report on Smoking and Health • 1965 Medicare and Medicaid, the Older Americans Act, Head Start • 1966 The Community Health Centers Act (Section 330, PHS Act) • 1970 National Health Service Corps • 1980 Health Care Financing Administration • 1989 Passage of the McKinney Act to provide health care to the homeless • 1989 Agency for Healthcare Research and Quality • 1993 Ryan White Comprehensive AIDS Resource Emergency (CARE) Act

  14. Government • 1996 Personal Responsibility and Work Opportunity Reconciliation Act • 1996 The Health Centers Consolidation Act • 1997 Health Insurance Portability and Accountability Act (HIPAA). • 1999 State Children's Health Insurance Program (SCHIP) • 2002 Centers for Medicare & Medicaid • 2002 Office of Public Health Emergency Preparedness • 2003 Medicare Prescription Drug Improvement, and Modernization Act

  15. Community Health Centers 1965 - Present Lyndon Baines Johnson 1963–69 Richard Milhous Nixon 1969–74 Gerald Rudolph Ford 1974–77 Jimmy Carter 1977–81 George Walker Bush 2001– Ronald Wilson Reagan 1981–89 George H. W. Bush 1989–93 Bill Clinton 1993–2001

  16. Economic Opportunity Act of 1964. "War on Poverty" Executive Branch Initiatives Work toward elimination of poverty or its causes through developing: employment opportunities, improving human performance, motivation, and productivity. Usually through community activity. Health not an original OEO concern - Job Corps/Headstart physicals. Direct care - save money and effect basic way in which health care is delivered.

  17. Dr. H. Jack Geiger and Dr. Count Gibson Concept of Neighborhood Health Center Developed by Tufts Medical School professors Count Gibson/Jack Geiger Original request from Tufts went to PHS June, 1965 Tufts Medical School receives funding for Columbia Point and Mound Bayou Neighborhood Health Centers Model comprehensive health center development, train and employ community residents, and involve them in community development.

  18. Neighborhood Health Center Model Vehicle to community development and a challenge to mainstream medicine, dignified, accessible, comprehensive, and community based. Elements: Community health services - Public health model, deal with social and physical environment - Health care team - Decentralize health care outreach/communications family health care workers health education social advocacy (housing, welfare).

  19. Neighborhood Health Center Model (Cont.) -Community economic development -Community participation. -Re-integrate public health and personal health care services, including prevention, environmental, and outreach. -Ignoring the previously negotiated boundaries between private medicine/public health. -Salaried physicians. -Health teams. -Consumer participation.

  20. A New System "The hospital as we know it is an obsolete and ineffective institution for ambulatory care, ... hospitals for the future should be vastly different - in effect, intensive care units for patients with critical and complex illness ... The hub of the medical care universe would be a network of comprehensive community health centers" 1968 Dr. Jack Geiger. Alternative to hospital based care for the entire community. A system for the entire US. population.

  21. More History • Initially grants to hospitals/medical schools • 1966 Kennedy amendments (OEO Act) - planning and operation of comprehensive health service programs in urban/rural areas, low income requiring adequate health services. (100 centers by 1971).  • 1967 “When they reach 25 centers, there will be no private practice” “Another step to socialism” “Dispensary abuse – 1890s” "Limited to the poor:, limited to 20% self pay. -local opposition -involvement of organized medicine -means test  • 1966-1970 Most grants to medical schools and hospitals – quick success/legitimacy • 1968 - PHS 314e (Phil Lee) Yellow berets

  22. More History • 1966-1970 Most grants to medical schools and hospitals – quick success/legitimacy • Community participation vague at first • 1968-69 PHS “Yellow Berets”, 314e (24 centers) • 1975 55 314e centers • 1970 - 1974 Nixon transfer all OEO NHCs to PHS

  23. More History • 1972-1974 Family Health Center CHCs • established • 1975-1977 Rural Health Initiative CHCs established • 1977 - 3rd Party billing required • 1981 - First Reagan budget cuts program in half • 1983 - All funds restored • 2001 – 2006 President Bush Initiative doubling the number of patients served by Community Health Centers

  24. Organizing • 1970 - New York Association of Neighborhood Health Centers • 1971 – The Massachusetts League of Neighborhood Health Centers • 1970 - National Association of Neighborhood Health Centers nowNational Association of Community Health Centers • 1975 – National Rural Primary Care Association now National Rural Health Association

  25. CHCs 2004 914Grantees (51% Rural) 5,502 Service Delivery Sites 13,127,811 Patients

  26. HC HC HC * Source: 2003 UDS data.

  27. Health Center Patients By Income Level, 2004 Note: Federal Poverty Level (FPL) for a family of three in 2004 was $15,670. (See http://aspe.hhs.gov/poverty/03poverty.htm.) Based on percent known. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

  28. Health Center Patients By Insurance Status, 2004 Note: Other Public may include non-Medicaid SCHIP. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

  29. Health Center Patients By Race/Ethnicity, 2004 Note: Based on percent known. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

  30. Health Center Patients By Age, 2004 Note: Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

  31. United States, 2004 Health Center Staff and Related Patient Visits

  32. Percent of Health Centers Providing Select Services Onsite*

  33. Percent of Health Centers Providing Select Services Onsite (cont.)*

  34. Patient Visits and Patients by Selected Primary Diagnoses and Services Patient Patients Visits Medical Conditions Asthma 773,763 418,256 Diabetes mellitus 2,476,613 778,628 Hypertension 3,006,082 1,257,930 Heart disease (selected) 556,625 230,596 Mental health & substance abuse 3,494,668 N/A Preventive Services Health supervision ages 0-11* 2,994,513 1,764,835 Selected immunizations# 2,364,496 1,610,822 Pap smear 1,509,973 1,333,253 Mammogram 256,811 234,083 HIV test 425,266 376,358 Oral Dental Exams 813,324 631,739 * Well child visits. # Includes DPT, MMR, oral polio vaccine, influenza, hepatitis B, HIB.

  35. The Future of CHCs

  36. Health Center Patient Insurance Status and Revenue By Source, 2004

  37. Percent of Health Center Charges Collected from Third Party Payers, 1999-2004 Medicaid Other Public Medicare Private

  38. Suggested Reading

  39. Thank YouQuestions ?

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