Testimony to the House Public Health Committee, Subcommittee on Indigent Health Care and Treatment

1. Testimony to the House Public Health Committee, Subcommittee on Indigent Health Care and Treatment Jos� E. Camacho Executive Director Texas Association of Community Health Centers October 13, 2008

2. The Community Health Center Program:Federally Qualified Health Centers (FQHCs) Includes all Community, Migrant, Public Housing Primary Care, and Homeless Health Centers Local, non-profit or public entity, community owned health care providers Four decades of Federal, State, and Local community investment in primary care infrastructure

3. The Community Health Center Program:Federally Qualified Health Centers (FQHCs) Providing communities the opportunity to respond to community-based health care needs National 1,200 funded organizations, 100 �Look Alikes� 7,000 service delivery sites 18 million patients served Texas 58 funded organizations, 6 �Look Alikes� 300 service delivery sites 770,000 patients served

5. Improving Service Delivery to the Medically Underserved Since 1996, Health Centers have strived for Stronger health outcomes for patients by moving to integrated health care Consistency in results by adopting measures and outcomes for clinical practice and access to care Increased ability to track and verify results Lower cost to the health care system

6. What is a Federally Qualified Health Center? Non-profit or public entity Community board structure Broad range of services Medical Dental Mental health and Substance Abuse treatment Pharmacy Community outreach, transportation, eligibility and enrollment services, patient and community education Culturally sensitive care Required to be located in a medically underserved area Required to see patients regardless of insurance status or ability to pay using a sliding fee scale for services

7. The Sliding Fee Scale � An FQHC Requirement Based on annual income and family size Nominal co-payments only for patients at or below 100% Federal Poverty Level (FPL) All patients are expected to participate in the cost of care at a level they can afford. FQHCs are not �free clinics.� Full charge for patients at or above 200% FPL Sliding scale discount for patients with incomes between 101% and 199% FPL Each community board determines sliding scale rates

8. Texas FQHC Clients by Insurance Status, 2007 Uninsured 436,141 Medicaid 182,376 CHIP 19,670 Medicare 46,640 Other Public 22,818 Private 62,933 Uninsured 436,141 Medicaid 182,376 CHIP 19,670 Medicare 46,640 Other Public 22,818 Private 62,933

9. Texas FQHC Clients by Income Level, 2007

10. Texas FQHC Clients by Ethnicity and Race, 2007

11. Texas Health Center Client Characteristics Compared to the State Population

12. FQHCs Provide Proven High Quality, Cost Effective, Accessible Care Health center uninsured patients are: less likely to have an unmet medical need,� less likely to have postponed or delayed seeking needed care, more likely to have had a�general medical visit, significantly less likely to have had an emergency room visit, and� less likely to have a hospital stay compared to other uninsured. (Hadley J and Cunningham P. �Availability of Safety Net Providers and Access to Care of Uninsured Persons.� October 2004 Health Services Research 39(5):1527-1546.) Despite the high prevalence of chronic conditions among health center patients, health centers meet or exceed practice standards for diabetes, acute ear infections, asthma, and hypertension. (Ulmer C. et al. �Assessing Primary Care Content: Four Conditions Common in Community Health Center Practice.� Journal of Ambulatory Care Management. 23(1):23-38, 2000, Jan.) FQHC Medicaid patients are less likely to use the emergency room or be hospitalized for primary care sensitive conditions than Medicaid beneficiaries using other providers for primary care. (Falik M, Needleman J, Herbert R et al. �Comparative Effectiveness of Health Centers as Regular Source of Care.� January-March 2006 Journal of Ambulatory Care Management 29(1):24-35.) For more studies on FQHC quality of care, improvement of access to care, cost effectiveness, and reduction of health disparities, see http://www.nachc.com/literature-summaries.cfm

13. Innovative Clinical Care and Improved Health Outcomes Integration of behavioral health and primary care Redesigning clinic processes to increase access Chronic disease management* Improved health outcomes in diabetes, cardiovascular disease, asthma, hypertension Reduction or elimination of health disparities

14. Growth in Patients Served at Texas FQHCs by Coverage Type, 2001-2007

15. Texas FQHC Provider Trends, 2000 - 2007

16. Significant Need for FQHC Services in Texas Texas FQHCs employ 0.5% of physicians licensed in Texas 0.8% of dentists licensed in Texas Texas FQHCs currently have 148 provider vacancies for providers to serve in rural and urban medically underserved areas. Today, Texas FQHCs serve only: 11% of uninsured Texans living at or below 200% FPL 7% of non-elderly Medicaid beneficiaries There is tremendous need for expansion.

17. FQHC Business Model Ideal business model 1/3 Federal grants to serve the uninsured 1/3 Patient-related revenue Including cost-based reimbursement in Medicaid 1/3 State and local contracts and grants, foundation grants, other funding sources Difficult for Texas health centers to achieve this balance: High numbers of uninsured in Texas

18. Texas FQHC Revenue, 2007

19. Health Center Revenue vs. Patient Insurance Status, 2007

20. Health Center Costs of Care - 2007 Average Cost per Patient per Year Cost Medical Costs per Medical Patient $372 Dental Costs per Dental Patient $307 Mental Health Costs per Mental Health Patient $377 Total Cost per Total Patient* $503 Average Cost per Patient Visit per Year Medical Cost per Medical Patient Visit $114 Dental Costs per Dental Patient Visit $135 Mental Health Costs per Mental Health Patient Visit $ 59 Pharmacy Costs per Medical Patient Visit $ 16 Lab & X-ray cost per Medical Patient Visit $ 12

21. What FQHCs Need for SuccessHow Texas Can Support FQHCs as One Solution for Addressing Health Care for Indigent Populations A Robust Primary Care Provider Base Support loan repayment for primary care providers who serve in rural and urban underserved areas Increased State Investment in Health Center Operations Reauthorize the FQHC Incubator program with changes to sustain existing health centers Increase funding for the Community Primary Care Services program at DSHS Support for Health Center Infrastructure including Facilities, Equipment, and Technology