Improving access to quality health care final

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Improving access to quality health care final

  1. 1. Improving Access to Quality Health Care ExpAndIng FEdErAlly QuAlIFIEd HEAltH CEntEr SErvICES In tHE grEAtEr dEtroIt ArEA
  2. 2. detroit Wayne County Health Authority Chris Allen, Executive Director & Chief Executive Officer In Cooperation with: prIMAry CArE nEtWorK CounCIl Sr. Mary Ellen Howard, Co-chair Richard Bohrer, Co-chair SAFEty nEt ExpAnSIon WorKgroup Wayne Bradley, Chair WorKForCE dEvElopMEnt WorKgroup Anthony King, Chair Improving Access to Quality Health Care ExpAndIng FEdErAlly QuAlIFIEd HEAltH CEntEr SErvICES In tHE grEAtEr dEtroIt ArEA Prepared by: MICHIgAn prIMAry CArE ASSoCIAtIon Kim Sibilsky, Executive Director Neal Colburn, Technical Assistance Consultant DeAnna Warren, Workforce Program Director March 11, 2009 Improving Access to Quality Health Care | 2
  3. 3. TA B L E O F C O N T E N T S IntroduCtIon.......................................................................................................................... 3 Chart: Comparative FQHC Funding ...............................................................................3 FQHCs: A SIgnIFICAnt CoMponEnt oF tHE SolutIon .........................................6 Chart: Population Served by FQHCs ...............................................................................7 Chart: FQHC Services ........................................................................................................7 Impediments to Growth ....................................................................................................7 CrItErIA For EvAluAtIon ...................................................................................................8 Chart: FQHC Sites by Zip Code (Wayne County) .........................................................9 proxIMIty to An FQHC dElIvEry SItE ..........................................................................9 Chart: FQHC Users Compared to Zip Code Population ..............................................10 Map: FQHC Users as a Percentage of the Population ...................................................13 Map: Primary Care Health Professional Shortage Areas (Ratios) .............................. 15 lACK oF HEAltH InSurAnCE CovErAgE.......................................................................15 Map: Wayne County MUA/P Census Tracts ..................................................................16 Map: Medicaid Beneficiaries as Percent of Population .................................................17 Chart: Designated Health Professional Shortage Areas ...............................................18 Chart: Zip Codes/VODI Estimated Uninsured Outliers ...............................................19 Chart: Poverty Rate & Probable Uninsured by Zip Code (Detroit) ........................... 20 Chart: Poverty Rate & Probable Uninsured by Zip Code (Suburbs) ......................... 22 povErty ........................................................................................................................................23 Map: Uninsured Population by Zip Code .....................................................................24 Chart: Patient Insurance Status (FQHCs 2007)...............................................................25 Map: Wayne County Poverty Levels ...............................................................................26 HEAltH StAtuS IndICAtorS ...............................................................................................27 Charts: Infant Mortality & Age Adjusted Death Rates .................................................28 Charts: Low Birth Weight & Infant Mortality Rates ......................................................29 ABIlIty oF FQHCs to ExpAnd SErvICES, InCrEASE SItES .................................... 29 Chart: FQHC Capacity .......................................................................................................31 Chart: Patient Income Status (By FQHC) ........................................................................32 nEW SItE rECoMMEndAtIonS ...........................................................................................33 Chart: Recommended Sites ...............................................................................................34 Charts: Recommended Sites..............................................................................................35-40 StAtIStICAl rAnKIng oF prIorIty ArEAS ................................................................. 41 InItIAl FIndIngS & AnAlySIS ........................................................................................... 41 Chart: High Need Zip Codes ........................................................................................... 42 Chart: Data Summary of High Need & Suggested New Site Areas........................... 44 Chart: Numeric Ranking of Priority Zip Codes ............................................................ 46 AddItIonAl WorKgroup SuggEStIonS ................................................................... 47 Chart: Priority Areas by Rank.......................................................................................... 47 prIorIty ArEAS: rECoMMEndAtIonS .......................................................................... 49 Chart: High Need Areas without FQHCs ...................................................................... 49 Chart: High Priority Areas with FQHCs ....................................................................... 50 Chart: Workgroup Suggestions, Not Among Selected Zip Codes ............................. 50 Improving Access to Quality Health Care | 1
  4. 4. poSSIBlE AltErnAtIvE SuggESttIonS .........................................................................51 ExpAnSIon StrAtEgIES..........................................................................................................51 New Access Points ...............................................................................................................51 Expanded Medical Capacity and Service Expansion .....................................................52 Change of Scope...................................................................................................................52 FQHC ‘Look-Alikes’ ............................................................................................................52 Chart: Zip Codes with over 10,000 Medicaid Beneficiaries....................................53 Chart: Detroit Zip Codes with Largest Estimated Uninsured ...............................53 Practice/Clinic Acquisition .................................................................................................53 Emergency Department Diversion....................................................................................54 School-Based and School-Linked Health Centers...........................................................56 Collaboration—Behavioral Health ....................................................................................56 Collaboration—Dental Services.........................................................................................57 Other Collaborations ...........................................................................................................57 Contracted Services .............................................................................................................57 Community Outreach and Marketing ..............................................................................58 IMprovIng ACCESS/rEduCIng FInAnCIAl IMpEdIMEntS...................................59 Extended Hours ...................................................................................................................59 Convenient Access ...............................................................................................................59 Hospitality—A Welcoming Environment ........................................................................59 Transportation ......................................................................................................................60 Sliding Fee Scale...................................................................................................................60 ExpAnSIon CHAllEngES .......................................................................................................60 Medicaid, Medicare Health Plans .....................................................................................60 Special Challenges to FQHC Development .....................................................................61 New Site, Services and Service Expansion Requirements .............................................61 Capital Development ..........................................................................................................61 Cooperative Effort (DWCHA) ...........................................................................................63 rECoMMEndAtIonS, plAnS & StrAtEgIES .................................................................63 High Need Areas without FQHCs ....................................................................................63 High Need Areas with FQHCs ..........................................................................................64 Other Workgroup Recommendations ..............................................................................65 WorKForCE dEvElopMEnt.................................................................................................66 Recommendation #1 ............................................................................................................68 Recommendation #2 ............................................................................................................70 Chart: Barriers/Advantages ........................................................................................71 Recommendation #3 ............................................................................................................72 SuMMAry: SAFEty nEt ExpAnSIon plAn ......................................................................73 Chart: High Need Areas without FQHCs ........................................................................73 Priority Areas for Development and Expansion .............................................................74 Map: Priority Areas ......................................................................................................75 Chart: High Priority Areas with FQHCs ...................................................................76 Chart: Workgroup Suggestion ....................................................................................76 prIMAry CArE nEtWorK CounCIl StAtEMEnt oF prInCIplES: SAFEty nEt ExpAnSIon ...............................................77 Improving Access to Quality Health Care | 2
  5. 5. INTRODUCTION The Detroit Wayne County Health Authority (DWCHA) engaged the Michigan Primary Care Association (MPCA) to work with the Primary Care Network Council (PCNC) to develop a 3-5 year safety net expansion plan for the DWCHA. MPCA includes in its membership all of the Federally Qualified Health Centers (FQHCs) in Michigan, including FQHCs located in the Detroit Wayne County area. The membership includes Community Health Centers, FQHC ‘look-alikes’ and one Urban Indian Health Care Clinic, all of which have a similar mission, organizational structure and services. The DWCHA has focused on expanding FQHCs, since they have distinct advantages to meet the challenge of providing comprehensive, quality primary care to a population with an inordinately high rate of uninsured, Medicaid, Medicare and public program coverage. FQHCs were selected as a key element in addressing the unmet health care needs in the Detroit Wayne County area due to their history of providing quality care to the uninsured and their unique funding and reimbursement methodology. This enables them to sustain the delivery of comprehensive quality primary care in underserved areas with low-income populations and high concentrations of Medicaid beneficiaries and uninsured. Beyond this, FQHCs are also cost-effective. In Michigan, the Michigan State University Institute for Health Care Studies obtained permission to utilize de-identified 2003-2004 Medicaid data to study the cost-effectiveness of FQHCs. Its 2006 report found that, “Comparing per-member-per-month costs for FQHC users and non-FQHC users, FQHCs produced a per-member-per-month cost savings of $44.87.” This is also echoed in a number of reports on FQHCs completed over the last decade. In addition, FQHCs’ comprehensive set of primary care services provide a complete medical home, including preventive care, chronic disease management, outreach, translation, case management and other enabling services to help improve access and the quality of care provided. Presently, 32 FQHCs provide care to nearly half a million patients in Michigan, over two-thirds of which have incomes below the Federal Poverty Level (FPL), and 40% of which are covered by Medicaid. The Detroit Wayne County area is served by eight Health Center organizations with 22 clinics serving in excess of 70,000 patients. In addition, services are provided to the homeless in various locations. These include: n Five Community Health Centers with full Section 330 funding: Advantage Health Centers, Community Health and Social Services, Covenant Community Care, Detroit Community Health Connection, and Western Wayne Family Health Center. n Two FQHC ‘look-alikes’ that provide similar services: Health Centers Detroit Medical Group, The Wellness Plan Health Centers n One Urban Indian Health Care Clinic: American Indian Health and Family Services All FQHCs receive Medicaid and Medicare payment improvements in return for complying with specific quality, access and operational requirements of the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Community and Migrant Health Centers also receive federal grant funding to cover the costs of providing a sliding fee scale to adjust fees to patients’ ability to pay, as well as Federal Tort coverage to minimize or eliminate the need for malpractice costs. Indian Health Clinics receive Indian Health Service (IHS) grants and Improving Access to Quality Health Care | 3
  6. 6. improved Medicaid and Medicare payment rates. As a result, these safety net providers of primary care services have distinct advantages in responding to the health care needs of the underserved populations of the Detroit Wayne County area. For brevity, the term “FQHC” will be used in this report to reference Health Centers. The specific terms of Community Health Center (CHC), FQHC ‘look-alike’ (LA), and Indian Health Service (IHS) clinic will be used when distinction is required. All have similar missions and operate under many of the same federal requirements. Despite their advantages, these providers face substantial challenges. One of the most significant challenges is financial in nature. Caring for a very high rate of uninsured patients challenges the limited resources available for their care. Private medical practices are able to control their patient mix. By agreement with HHS, FQHCs must open their doors to all patients, regardless of insurance coverage, making the challenge of financially sustaining their Health Centers a primary concern. In addition, competition from private practice and emergency departments for a limited number of patients with some type of insurance or public program coverage intensifies the financial challenge. As a result, FQHC safety net provider expansion in the Detroit Wayne County area has been limited. The number of organizations, clinics and services has been identified as smaller than expected for the size of the area’s population and its need for quality services. Recognizing this unmet need, the DWCHA is now working in cooperation with MPCA, the PCNC and other health care and community organizations to make quality health care more accessible to the area’s uninsured, Medicaid beneficiaries and underserved populations. The Greater Detroit area is in critical need of improved access to quality health care. Once one of the financially healthiest cities in the nation, Detroit was the center of the automobile industry and home to the Big Three’s headquarters and primary manufacturing base. Workers enjoyed relatively high wages and generous benefits, including health benefits. The City of Detroit’s population approached 2 million at its peak. With GM, Ford and Chrysler’s loss of market share and downsizing, Detroit’s unemployment is often reported as triple the national rate. Detroit remains the 11th largest U.S. city with an estimated 950,271 residents (U.S. Census, 2005), or about one-half of its peak population. A Centrum Healthiest Cities study of the largest 50 cities based on 2003 data rated Detroit 44th for overall quality of health (www.bestplaces.net/docs/studies/healthy.aspx). The study utilized data from the Centers for Disease Control and Prevention (CDC), U.S. Census and American Medical Association and considered several factors, including mental wellness, lifestyle pursuits, physical activity, health status and nutrition. The Detroit metropolitan area also has limited resources with which to respond to the primary health care needs of the underinsured. On page 5 is a chart comparing Detroit’s FQHC funding to the funding of FQHCs in other Midwest cities (Michigan Department of Community Health, 2007). Wayne County (Detroit) receives a paltry $11.10 per low-income resident compared to Ramsey County’s (St. Paul, MN) receipt of $46.41 and Marion County’s (Indianapolis, IN) receipt of $37.32 per low-income resident. It will be very important for FQHCs and other organizations in the Detroit area to successfully compete for Health Center funding to better meet the needs of the area’s low-income residents. Improving Access to Quality Health Care | 4
  7. 7. FQHC Funding Fy 2006 Midwest Counties with Large Cities County (City) FQHC Grants Population Funds per Population Funding % Funding Awarded Resident <200% FPL Per Low- Population Income <200% FPL Resident Wayne $7,399,592 4 2,061,162 $3.59 666,726 $11.10 32.9% (Detroit, MI) Cook $42,110,988 20 5,376,741 $7.83 1,558,780 $27.02 29.5% (Chicago, IL) Marion $8,818,535 5 860,454 $10.25 236,321 $37.32 28.1% (Indianapolis, IN) Cuyahoga $11,591,092 3 1,393,978 $8.32 397,268 $29.18 29.1% (Cleveland, OH) Hamilton $5,312,123 4 845,303 $6.28 214,755 $24.74 26.0% (Cincinnati, OH) Hennepin $5,969,180 7 1,116,200 $5.35 216,570 $27.56 19.8% (Minneapolis, MN) Ramsey $5,707,577 2 511,035 $11.17 122,994 $46.41 24.8% (St. Paul, MN) Milwaukee County $6,855,224 4 940,164 $7.29 297,565 $23.04 32.5% (Milwaukee, WI) Source: Michigan Department of Community Health, 2007 The 2000 Census reported that over one in four of Detroit’s population was at or below the Federal Poverty Level (FPL), and nearly half (48.5%) was at or below 200% FPL. A 2006 American Community Survey named Detroit as the poorest city in the U.S. with an estimated 32.5% of residents living in poverty. In the last quarter, it was reported that the State of Michigan experienced the second highest unemployment rate in the nation with the City of Detroit having the highest unemployment rate in the state. More recently, the major employers—the Big Three auto manufacturers—reported their critical financial status and the possibility of bankruptcy. Layoffs from the auto industry, centered in Detroit, have already negatively impacted the city. Further deterioration could be economically catastrophic for the area. Since most health insurance is employer-based, this leaves an ever increasing number of Detroit residents without health insurance coverage and without the income to purchase needed health care services. The purpose of the DWCHA’s plan is to be a significant catalyst in improving universal access to quality health care services for all, including primary, specialty, ancillary and tertiary care in cooperation with the area’s many health care planning, coordinating and provider organizations. This element of the overall plan is focused on expanding access to comprehensive, quality primary care services. Improving Access to Quality Health Care | 5
  8. 8. FQHCs: A SIGNIFICANT COMPONENT OF THE SOLUTION There are compelling reasons to look to Federally Qualified Health Centers as a significant part of the solution to the HEALTH CENTER FACTS primary health care needs of the Detroit Wayne County area. FQHCs have a history of generating cost savings in the care of patients as evidenced in national and state studies. Much of Number of organizations this is the result of FQHCs focusing on comprehensive quality 1,200 primary care, similar to what is now being called a medical home. In addition, more recent studies have shown that FQHCs Number of delivery sites eliminate health disparities, producing similar health outcomes regardless of cultural or racial differences. Finally, FQHCs 7,000 contribute to the local economy by providing employment and purchasing goods and services in low-income areas. Total Patients 18 million FQHCs are non-profit, community-directed organizations governed by boards whose majority of members are users of Percent of all vulnerable U.S. the FQHC’s services. The benefits of FQHCs have been well residents served by FQHCs documented: Low income uninsured n Are located in high-need areas with elevated poverty, infant 21% mortality and physician shortages Medicaid beneficiaries Are open to all residents regardless of insurance status or 6% n ability to pay Population below 100% poverty 16% n Tailor services which are culturally and linguistically appropriate to meet specific community needs Economic benefits of FQHCs n Provide comprehensive primary care and other needed Value of avoided emergency services such as transportation, translation and case department visits in 2006 management $18.4 billion n Provide high quality care and improve patient outcomes Economic benefits for local communities in 2006 n rovide cost-effective care that reduces emergency room P $12.6 billion visits, hospital stays and referrals to specialty care, saving the health care system $9.9 to $17.6 billion a year (Access Granted 2007, released by NACHC, Robert Graham Center, and Capital Link) Improving Access to Quality Health Care | 6
  9. 9. Health Center population Served (united States, 2007) FQHC Services A History of Services to the Medically Underserved professional Services Income, insurance status, race/ethnicity Health U.S. Center Population General Primary Medical Care Population Prenatal Care At or below 100% FPL 70% 17% Preventive Dental Care Mental Health Treatment, Counseling Under 200% FPL 91% 36% Substance Abuse Treatment, Counseling Pharmacy Uninsured 39% 12% Hearing Screening Vision Screening Medicaid 35% 13% preventive Services Medicare 8% 15% Smoking Cessation Program Hispanic/Latino 34% 15% HIV Testing & Counseling Blood Pressure Screening African American 28% 13% Blood Cholesterol Screening Weight Reduction Program Asian/Pacific Islander 4% 5% Glycosylated Hemoglobin Measurement Diabetes Management American Indian/Alaska Native 1% 1% Enabling Services White (including Hispanic, Latino) 62% 80% Case Management Eligibility Assistance Health Education Transportation IMPEDIMENTS TO GROWTH Translation FQHCs face a number of obstacles to fulfilling their role, including lack of available capital and workforce, particularly professional workforce. They are experiencing growth in their uninsured populations (55.5%) at double the general U.S. rate (22.3%) (NACHC Chart Book 2008). Their percent of low-income patients is growing dramatically faster than the U.S. low-income population in general: (48.7% versus 6.2%) (U.S. Census, Bureau of Primary Health Care Uniform Data System). These national rates are even more pronounced in Detroit. The growth rate in the uninsured increases the amount of uncompensated care provided, outstripping the fixed grant allocations for this purpose. As a result, FQHCs are facing increasing financial challenges that are diminishing their ability to plan for and carry out further development and expansion. Another element exacerbating this trend is the inappropriate use of emergency departments (ED). While patients receive acute care, greater emphasis on prevention and aggressive management of chronic disease is needed. This will require substantial change from the traditional episodic acute care that often results from the overuse of hospital EDs in lieu of establishing a primary care medical home. EDs often have a number of incentives for caring for a non-emergent patient population, including qualifying for disproportionate care hospital funds, providing patients to physician training programs, Improving Access to Quality Health Care | 7
  10. 10. maintaining sufficient volume to support established ED physician group contracts or maintaining a referral stream of new patients to affiliated physician groups. Hospitals often position themselves as acute care providers, advertising short wait time, professional staff and facility expertise to attract patients. Although it is generally accepted that establishing an on-going relationship with a primary care physician or medical home is of great benefit to the patient, as well as a more cost effective use of limited health care resources, establishing EDs as convenient 24-hour acute care services is a significant factor in their use for non-emergent services. As a result, FQHCs find themselves in direct competition with well-funded hospital EDs. This tends to diminish FQHCs’ access to Medicaid beneficiaries, which is their primary source of patient revenue. This revenue is not only necessary for FQHCs to provide medical services and comprehensive chronic care management, but also to provide enabling services such as case management, translation, health education and community outreach. Diminished Medicaid revenues also hinder the ability of FQHCs to care for the increasing number of uninsured that are in need of a medical home in today’s economic environment, as well as planning for new clinic sites or expanded services. The DWCHA is committed to addressing these challenges. It also intends to seek opportunities that may help the area’s FQHCs expand services and even establish new sites of health care delivery. It plans to facilitate the development of Patient Centered Medical Homes for all, particularly the uninsured and otherwise underserved populations of the Detroit Wayne County Area. C R I T E R I A F O R E VA L U AT I O N Developing criteria for growth targets for FQHC services and sites is a process that utilizes a number of sources of information. U.S. Census updates and studies have been reviewed, as has Uniform Data System (UDS) data that FQHCs submit to both HRSA and MPCA on an annual basis. Data from the State of Michigan and local health department, as well as published reports from local planning agencies, the DWCHA, and the East Side Planning Team of the PCNC, have also been reviewed. Finally, inquiries have been made and discussions initiated with the executive staff of area FQHCs regarding their present capabilities, views regarding the area’s needs, perceived opportunities for expansion and the many challenges they face. There is no one criterion that can be used alone to prioritize areas of underservice. For example, health status may be one indicator, but personal income, insurance coverage, educational level and available access to health care are also important considerations. In addition, such factors as health status data are not generally available on a sub-municipal basis. As a result, other criteria, utilizing various statistical proxies, have been selected to identify sub-municipal areas of highest need. The criteria for evaluating growth targets for FQHC services in this plan will include: proximity to an FQHC delivery site; existing federal designation as a Medically Underserved Area/Medically Underserved Population; existing designation as a Health Professional Shortage Area; lack of health insurance; poverty; health status; and ability/plans of existing FQHCs to expand to meet identified needs within 3–5 years. Improving Access to Quality Health Care | 8
  11. 11. FQHC Sites by Zip Code FQHC Site/Clinic Address Zip Code Advantage Health Centers Thea Bowman Community Health Center 20548 Fenkell, Detroit 48223 Advantage Family Health Center 4777 E. Outer Drive, Detroit 48234 Waller Health Care for the Homeless 2395 W. Grand Blvd, Detroit 48208 American Indian Health American Indian Health & Family Services 4880 Lawndale, Detroit 48210 & Family Services Community Health CHASS Southwest Center 5635 W. Fort St., Detroit 48209 & Social Services CHASS MidTown Center 7436 Woodward, Detroit 48202 Covenant Community Care Covenant Community Care 559 W. Grand Blvd., Detroit 48216 Southwest Solutions 1700 Waterman, Detroit 48209 detroit Community East Riverside Health Center 13901 E. Jefferson, Detroit 48215 Health Connection Eastside Health Center 7901 Kercheval, Detroit 48214 Bruce Douglas Health Center 6550 W. Warren, Detroit 48210 Woodward Corridor Family Medical Center 611 MLK Blvd., Detroit 48201 Nolan Family Health Center 111 W. Seven Mile, Detroit 48203 Health Centers detroit Health Centers Detroit Medical Group 7633 E. Jefferson, Suite 340, Detroit 48214 Medical group University Health Center 4201 St. Antoine 7-A, Detroit 48201 Advance Building 23077 Greenfield, Suite 489, Southfield 48075 the Wellness plan Gateway Medical Center 2888 W. Grand Blvd., Detroit 48202 Health Centers East Area Medical Center 4909 E. Outer Drive, Detroit 48234 Northwest Medical Center 21040 Greenfield, Oak Park 48237 Western Wayne Family Western Wayne Family Health Center 2500 Hamlin Court, Inkster 48141 Health Centers Source: Michigan Primary Care Association Guide to Michigan Community Health Centers PROXIMITY TO AN FQHC DELIVERY SITE Convenient availability of a FQHC is the first criteria in determining the optimal growth and location of new services. Convenient access is critically important to the poor, since those with limited income and resources tend to have fewer transportation options. With the rise in gas prices and inadequate public transportation, the more immediate and convenient access to quality care the better. In addition, those working at the bottom end of the wage scale tend to have less paid leave time and very structured work schedules. Many are raising children in two-wage-earner families, making time and convenience a critical factor in obtaining appropriate primary and preventive care for both parents and children. Therefore, proximity is a key factor. Since FQHCs are created to provide access to primary care services regardless of ability to pay by adjusting fees according to family size and income as well as accepting Medicaid, Medicare and insurance, it is a reasonable assumption that convenient availability to an FQHC improves access to primary care. The existence of a FQHC in the zip code has been chosen as an indicator of proximity and convenience. The existence of a FQHC in a contiguous zip code can also be taken into consideration on Improving Access to Quality Health Care | 9
  12. 12. FQHC users Compared to Zip Code population (Impact) Detroit, Hamtramck, Highland Park City Zip Code Population # FQHC % Population Population % Uninsured Users in FQHCs <200% FPL detroit *48201 15,080 1,019 6.8% 10,721 30.1% detroit *48202 21,870 1,267 5.8% 11,636 15.0% Highland park/detroit *48203 45,260 2,178 4.8% 25,855 18.6% detroit 48204 42,316 2,103 5.0% 21,444 14.0% detroit 48205 67,012 2,640 3.9% 36,176 17.8% detroit 48206 32,378 2,042 6.3% 17,562 15.9% detroit 48207 25,614 964 3.8% 13,093 12.3% detroit *48208 12,867 1,170 9.1% 8,360 17.9% detroit *48209 38,895 6,919 17.8% 22,505 17.4% detroit *48210 39,671 5,781 14.6% 23,663 16.3% Hamtramck (part) 48211 10,886 380 3.5% 6,897 24.3% Hamtramck 48212 46,136 1,139 2.5% 23,414 9.7% detroit 48213 43,996 2,194 5.0% 26,193 20.3% detroit *48214 32,845 1,760 5.4% 18,455 18.8% detroit *48215 19,224 1,233 6.4% 10,894 16.0% detroit *48216 6,668 819 12.3% 4,029 23.1% detroit 48217 10,515 474 4.5% 4,666 10.8% detroit 48219 59,447 1,629 2.7% 19,964 2.4% detroit 48221 45,381 1,134 2.5% 12,291 2.4% detroit *48223 36,037 1,182 3.3% 15,575 13.7% detroit 48224 55,437 1,957 3.5% 19,076 1.6% detroit 48226 6,138 163 2.7% 1,517 7.6% detroit 48227 61,118 2,356 3.9% 28,035 11.1% detroit 48228 65,051 2,108 3.2% 29,404 7.8% detroit *48234 45,797 2,302 5.0% 20,257 7.6% continued on page 11 Improving Access to Quality Health Care | 10
  13. 13. FQHC users Compared to Zip Code population (Impact) continued Detroit, Hamtramck, Highland Park City Zip Code Population # FQHC % Population Population % Uninsured Users in FQHCs <200% FPL detroit 48235 53,353 1,719 3.2% 16,835 1.4% detroit 48238 44,909 2,087 4.6% 23,618 14.7% other/unknown 994 total/Average % 983,901 51,713 5.3% 472,135 11.9% Source: Chart & FQHC User Data-Michigan Primary Care Association; Demographic Data-U.S. Census, 2000 *FQHC located in zip code a case basis, depending if it is located close to the border of two zip codes or on a direct bus line serving a substantial number of those in the contiguous zip code. However, it would be preferred to have a FQHC in each zip code as long as each organization can function in a reasonably defined service area for effective delivery of care. FQHCs currently have facilities delivering health care in nine of Detroit’s 25 zip codes. There are 16 zip codes to be potentially considered for FQHC development. In addition, the suburbs of Hamtramck and Highland Park do not have FQHC sites within their boundaries. These are land-locked suburbs located within the outer boundaries of the City of Detroit, with similar demographics and health care needs. Beyond this, there is one FQHC health care delivery site, Western Wayne Family Health Centers, in a nearby suburb (Inkster) located in Wayne County). It is a Section 330 funded Community Health Center. Proximity is not the only important factor. The degree to which a FQHC impacts the area’s population is also important, as is the percentage of the population served by the FQHC. If it is not significant, FQHC capacity, extended hours, cultural competence and language services, and types of services provided are important factors in making services accessible. There may also be a need for increased and more effective community outreach for services to be appropriately accessible. The actual utilization of any FQHC by the community will be a mitigating factor. Low utilization may indicate lack of capacity or some other form of barrier to accessing care. Expanding services or a New Access Point may be a strategy to respond to lack of capacity. Other factors, such as hours of operation, scheduling policies, and appropriate providers may also need to be reviewed. FQHCs may also need to engage more comprehensively in community outreach in order to make their services known to the community and to encourage the proper utilization of the comprehensive preventive primary care services they provide. Outreach activities may range from providing health education experiences and informational material and presentations in community venues to developing collaborative health care projects and programs with other health care providers, schools, businesses, social groups, churches and other organizations. Improving Access to Quality Health Care | 11
  14. 14. FQHC users Compared to Zip Code population (Impact) Suburbs in Near Proximity or with Over 4% FQHC Users City Zip Code Population # FQHC % Population Population FQHC Users in FQHCs <200% FPL Population vs. <200% FPL Southfield 48034 31,699 170 0.5% 6,285 2.7% Southfield 48075 22,598 123 0.5% 3,797 3.2% dearborn 48120 7,480 17 0.2% 3,912 0.4% Melvindale 48122 10,755 58 0.5% 2,844 2.0% dearborn 48214 33,257 31 0.1% 3,611 0.9% dearborn Heights 48125 22,648 59 0.3% 4,276 1.4% dearborn 48126 46,535 196 0.4% 22,714 0.9% dearborn Heights 48127 35,600 84 0.2% 5,566 1.5% dearborn 48128 10,519 5 0.0% 820 0.6% Inkster *48141 30,115 674 2.2% 11,498 5.9% lincoln park 48146 39,775 187 0.5% 8,901 2.1% romulus 48174 29,937 157 0.5% 7,528 2.1% taylor 48180 65,868 314 0.5% 16,901 1.9% Westland & Wayne 48184 19,121 88 0.5% 4,261 2.1% Westland 48185 49,003 214 0.4% 8,528 2.5% Westland 48186 37,995 178 0.5% 7,491 2.4% river rouge 48218 10,060 210 2.1% 4,666 4.5% Harper Woods 48225 14,413 129 0.9% 1,997 6.5% Ecorse 48229 11,088 219 2.0% 5,120 4.3% grosse pointe & park 48230 18,183 72 0.4% 1,454 5.0% oak park *48237 32,493 418 1.3% 8,643 4.8% redford township 48239 37,608 156 0.4% 5,810 2.7% redford township 48240 19,151 71 0.4% 3,326 2.1% total/Average % 622,495 3,580 0.6% 145,073 2.5% Sources: Chart & FQHC User Data-Michigan Primary Care Association; Demographic Data-U.S. Census, 2000 *FQHC located in zip code Improving Access to Quality Health Care | 12
  15. 15. FQHC users as a percent of the population Improving Access to Quality Health Care | 13
  16. 16. EXISTINg FEDERAL DESIgNATION AS A MEDICALLY UNDERSERVED AREA OR MEDICALLY UNDERSERVED POPULATION Nearly all of the City of Detroit is designated as Medically Underserved Area (MUA) or Medically Underserved Population (MUP), except for an area roughly corresponding to zip codes 48219, 48235 and part of 48238, and a small section of 48204. All other areas of the City of Detroit have the existing designations that qualify them for possible FQHC establishment and federal funding (see map on page 16). In addition, other Wayne County areas are also federally designated including part of the City of Dearborn corresponding to zip codes 48126 and 48120; all of Inkster (48141); Van Buren and Sumpter Townships (48111); Brownstown Township (48173); Huron Township (48164; parts of 48174 and 48134); Romulus (48242, 48174); and part of Taylor (48180). Two zip codes in Dearborn contiguous to Detroit have underserved designations and also have heightened rates of poverty. This is a key element in qualifying for grant awards. Although there are non-FQHC community-based health services in the area, it is an area to be considered for review for an FQHC. Two other areas, River Rouge and Ecorse, are not designated MUAs or MUPs at this time, nor do they have an FQHC, but they are worth considering for designation since they have heightened rates of poverty. They are also contiguous to a southern projection of Detroit with a MUA designation. This zip code (48217) could be a potential site to serve this cluster of zip codes. These areas have been thoroughly reviewed by the Shortage Designation Branch of HRSA and have been designated as having high need under federal criteria. In addition, they have the necessary designation for establishment of FQHCs. The existing designation of an area of high need provides the possibility of initiating applications for federal assistance for additional medical services as well as establishing additional service delivery sites in these areas. MUA designation takes into consideration the percentage of the population with income below the FPL, the percentage of population 65 years and older, infant mortality (5-year average), and the ratio of the current number of physicians providing primary care to the target population (primary care physicians per thousand). Both MUA and MUP designations involve application of the Index of Medical Underservice (IMU) to data on an underserved population group. These groups have economic or cultural and/or linguistic access barriers to primary medical care services. For an MUP criteria similar to the MUA, the data is made specific to the target population and those who presently provide it with health care services. These criteria are used to qualify areas for application for FQHCs including Community Health Centers, FQHC ‘look-alikes’ and other FQHCs defined in Section 330 of the Public Health Service Act. SHORTAgE OF HEALTH CARE PROVIDERS The Shortage Designation Branch of HRSA designates Health Provider Shortage Areas (HPSAs). HPSAs may be designated as having a shortage of primary medical, dental or mental health providers. Although population-to-medical provider ratios exceeding 2000 to 1 are often seen as maximum acceptable ratios (1,500 to 1 are preferred), with few exceptions, HPSAs require population-to-medical provider ratios of 3,500 to 1 for designation. There are exceptions in areas with populations with documented low income. Lacking a sufficient number of medical providers available to provide health care services to the underserved is by definition an impediment to appropriate access to care. HPSA designation is not required for areas to be eligible for FQHC funding consideration; however, this designation does make facilities located in them eligible to apply for National Health Service Corps personnel. Large areas of Improving Access to Quality Health Care | 14
  17. 17. primary Care Health professional Shortage Area ratios, Wayne County Detroit are designated as HPSAs; they are listed in the chart on page 18 and shown in the map above. As can be readily seen, population-to-medical provider ratios exceed reasonable maximum ratios for good access to primary medical care. MPCA, in cooperation with the State of Michigan, systematically reviews available data to identify areas that may be eligible for HPSA, MUA, and/or MUP designations. It then proceeds to seek designations. Once designated a MUA or MUP, the area may apply for FQHC funding or for clinical staff if designated as a HPSA. LACk OF HEALTH INSURANCE COVERAgE The lack of health insurance is somewhat problematic as a criterion, since data at the county and sub-county level has presented a challenge. Therefore, a statistical proxy is utilized to identify areas with high numbers of uninsured individuals. The formula identifies the remainder of the population below 200% FPL, less those covered by Medicaid, including Medicaid-Medicare dual-eligible beneficiaries. This is not intended to represent a definitive result, but rather to be a relative indicator of need. Since most of the potentially uninsured have incomes below Improving Access to Quality Health Care | 15
  18. 18. Wayne County MuA/p Census tracts Improving Access to Quality Health Care | 16
  19. 19. Medicaid Beneficiaries as Percent of Population Improving Access to Quality Health Care | 17
  20. 20. 200% FPL, this number is taken as a factor indicating the potentially uninsured. There are others uninsured, particularly those under 300% FPL, and there are some individuals with incomes below 200% FPL who are covered by insurance. However, this number is an indicator of probable uninsured. Therefore, the population with incomes below 200% FPL less the population covered by Medicaid is recommended as a reasonable proxy to identify the degree to which the population in an identified area (zip code) is in need of insurance or public program coverage. The U.S. Census Bureau reported that the nation’s medical uninsured rate was 15.3% in 2007. Due to Detroit’s history with the auto industry setting the employer standard, Michigan, including Detroit, has enjoyed higher than average insured rates. This is due to a higher than average number of area employers that continue to provide health insurance benefits. In addition, comparison between the 2000 uninsured rate and the 2007 census national uninsured rate in designated Health professional Shortage Areas a deteriorating economy tends to make Detroit look healthier than Service Area Type Population to Provider Ratio it is. However, specific areas of high rates of unemployment do Inkster Geographic 11,952 to 1 emerge, and these can be useful. Chene Low-income population 3,085 to 1 Using the methodology noted Eastside detroit Geographic 4,401 to 1 above, 12 of Detroit’s 27 zip codes exceed the national uninsured tireman/Chadsey Geographic 8,973 to 1 rate of 15.3% (U.S. Census McKenzie Brooks Geographic 9,031 to 1 2007). In addition, three Detroit zip codes exceed 150% of the Southwest detroit Geographic 4,071 to 1 reported national uninsured rate. Brightmoor Geographic 5,689 to 1 One of these zip codes includes part of Highland Park. Since the numbers are based on a statistical proxy, this statistic is best used as one factor with which to prioritize heightened need, rather than to determine baseline need. Other estimates, including those by Kaiser Foundation and Gallop, indicate substantially higher uninsured rates. In comparing this calculation against the Voices of Detroit Initiative (VODI), there are some instances in which VODI collected registrations of uninsured in excess of the numbers of estimated uninsured (see chart on page 16). VODI pioneered a system that tracks registered patients lacking insurance with participating providers willing to provide medical services to the uninsured. In most cases, the differences were minor and confirm the methodology. Although minor variation in estimated uninsured versus identified uninsured is expected, a few cases where there are large differences are somewhat problematic and may be worth additional investigation in order to assure that areas of high uninsured are not overlooked. However, in most instances, the relatively small differences are understandable, since the estimates made use of data from different years, and the number of those with incomes below 200% FPL may have increased substantially between the 2000 census used in the estimates and the most recent VODI data collection. Improving Access to Quality Health Care | 18
  21. 21. The Kaiser Commission on the Uninsured has reported that 17% of the non-elderly population is uninsured. *Kaiser also recently reported that 66% of the non-elderly under 200% FPL in Michigan are uninsured. In Detroit, this would be approximately 279,202 uninsured (472,135 [<200% FPL] x 89.6% [age 65+] x 66% uninsured). This estimate greatly exceeds the 117,353 uninsured estimate of the methodology using the remainder of the <200% FPL less the Medicaid population. (*Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s Zip Codes Where vodI registered March 2007 and 2008 Current Population Survey uninsured Exceed Estimated uninsured (CPS: Annual Social and Economic Supplements). City Zip Code Probable VODI Uninsured Registered A May 23, 2008, Gallop Poll reports Detroit as (<200% FPL- Uninsured having 15% uninsured or 147,585 uninsured Medicaid) (15% x 983,901). Both of these alternate methods detroit 48205 11,915 13,491 exceed the 117,353 uninsured estimate of the methodology using the remainder of the 2000 U.S. detroit 48224 874 11,984 Census <200% FPL population less the average 2007-08 Medicaid population. So, it would appear detroit 48234 3,461 7,936 that the methodology has underestimated the detroit 48235 748 4,830 actual number of uninsured. However, it remains useful in conservatively identifying areas having romulus 48174 0 284 the highest percentages of uninsured populations Westland/Wayne 48184 0 131 and establishing priority rankings for response to highest need. Westland 48185 531 643 Westland 48186 172 375 It is the mission of FQHCs to provide quality, comprehensive care to all and to eliminate barriers Harper Woods 48225 0 2,733 to accessing health care. Those who are not covered by insurance or do not have adequate insurance grosse pointe/ 48230 598 2,965 grosse pointe park coverage may qualify for step discounts based on family size and income for coverage by the oak park 48237 1,508 3,017 FQHCs’ sliding fee scale program. Federal funds are provided for this purpose; however, these funds redford twp. 48239 778 1,152 are limited and are not increased with the growth redford twp. 48240 414 677 in the number of uninsured. The funding formula does not take into consideration the challenge of caring for high concentrations of uninsured that substantially exceed the average, nor does it provide for increased base funding to meet annual increase in cost. Some of the FQHCs in the Detroit area serve high percentages of uninsured, and this has presented significant financial challenges that not only burden them in the delivery of present services, but also diminishes their ability to plan for expansion to new areas of need where additional uninsured populations are located. Therefore, collaboration with other organizations and new sources of funding will be needed for expanding FQHCs. As can be ascertained by the percentage of patients without insurance, the percentage of patients without insurance far exceeds the national average of 39.8% (NACHC Chart Book) in all but two Health Centers—Health Centers Detroit Medical Group and The Wellness Plan Health Centers (chart page 25). Improving Access to Quality Health Care | 19
  22. 22. poverty rate & probable uninsured by Zip Code, detroit Includes Land-locked Suburbs Zip Code Population 200% % Medicaid % Population Probable % Uninsured Poverty Poverty Beneficiaries Uninsured at 200% FPL 48201 15,080 10,721 71.8% 6,178 41.0% 4,543 30.1% 48202 21,870 11,636 56.6% 8,354 38.2% 3,282 15.0% 48203 Highland park 45,260 25,855 57.8% 17,445 38.5% 8,410 18.6% 48204 42,316 21,444 52.1% 15,535 36.7% 5,909 14.0% 48205 67,012 36,176 54.4% 24,261 36.2% 11,915 17.8% 48206 32,378 17,562 54.8% 12,406 38.3% 5,156 15.9% 48207 25,614 13,093 52.9% 9,953 38.9% 3,140 12.3% 48208 12,867 8,360 65.2% 6,056 47.1% 2,304 17.9% 48209 38,895 22,505 58.7% 15,754 40.5% 6,751 17.4% 48210 39,671 23,663 60.0% 17,198 43.4% 6,465 16.3% 48211 Hamtramck (part) 10,886 6,897 67.7% 4,250 39.0% 2,647 24.3% 48212 Hamtramck 46,136 23,414 54.1% 18,923 41.0% 4,491 9.7% 48213 43,996 26,193 60.2% 17,281 39.3% 8,912 20.3% 48214 32,845 18,455 58.1% 12,267 37.3% 6,188 18.8% 48215 19,224 10,894 57.8% 7,827 40.7% 3,067 16.0% 48216 6,668 4,029 60.5% 2,489 37.3% 1,540 23.1% 48217 10,515 4,666 44.8% 3,528 33.6% 1,138 10.8% 48219 59,447 19,964 45.6% 18,519 31.2% 1,445 2.4% 48221 45,381 12,291 34.2% 11,185 24.6% 1,106 2.4% 48223 36,037 15,575 27.8% 10,624 29.5% 4,951 13.7% 48224 55,437 19,076 43.8% 18,202 32.8% 874 1.6% 48226 6,138 1,517 24.7% 1,052 17.1% 465 7.6% 48227 61,118 28,035 46.3% 21,254 34.8% 6,781 11.1% continued on page 21 Improving Access to Quality Health Care | 20
  23. 23. poverty rate & probable uninsured by Zip Code, detroit continued Includes Land-locked Suburbs Zip Code Population 200% % Medicaid % Population Probable % Uninsured Poverty Poverty Beneficiaries Uninsured at 200% FPL 48228 65,051 29,404 45.8% 24,362 37.5% 5,042 7.8% 48234 45,797 20,257 44.9% 16,796 36.7% 3,461 7.6% 48235 53,353 16,835 31.9% 16,087 30.2% 748 1.4% 48238 44,909 23,618 53.1% 16,996 37.8% 6,622 14.7% total/% 983,901 472,135 53.1% 354,782 36.1% 117,353 11.9% National average: 29.6% Sources: Population data-U.S. Census, 2000; Medicaid Beneficiaries-Michigan Department of Community Health (Monthly average 7/2007–6/2008; Chart-Michigan Primary Care Association poverty <200% uninsured <35% 0-9.9% 35 – 49.9% 10 - 14.9% In fact, Detroit Community Health Connection 50 – 59.9% 15 - 19.9% has reported that its percentage of uninsured is now approaching 50% and this is a potential 60%+ 20%+ severe financial challenge. Health Centers Detroit Medical Group and The Wellness Plan Health Centers are FQHC ‘look-alikes’. FQHC ‘look-alikes’ don’t receive federal grant funding, but they do receive improved Medicare and Medicaid payments for the provision of a bundle of FQHC services, including enabling services provided to Medicaid and Medicare patients served. Therefore, the bulk of funding for uninsured patients must come from other sources, such as charitable donations, pay- for-performance, gain-sharing or use of the group’s unobligated revenue, potentially resulting in diminution of its operating capital or investment capital for expansion. Health Centers Detroit Medical Group and The Wellness Plan Health Centers have not indicated receiving significant sustaining donations or other non-patient revenue sources of funding at this time. Fortunately, both presently enjoy higher than normal Medicaid beneficiary patient populations. The Wellness Plan Health Centers has an unusually high Medicaid percentage since its clinics were previously part of The Wellness (Medicaid) Health Plan clinic system. It has recently become an FQHC ‘look-alike’, and is now responsible for providing the full range of FQHC services to all its patients. It is reasonable to expect this atypical Medicaid percentage will be reduced as the FQHC ‘look-alike’ begins to serve more uninsured patients. The enhanced Medicaid reimbursement of FQHC ‘look- alikes’ contributes to maintaining their financial health, and it provides opportunity for them to care for additional uninsured and to establish additional services and service delivery sites in the future. The Improving Access to Quality Health Care | 21
  24. 24. probable uninsured by Zip Code, Selected detroit Wayne County Suburbs Suburbs Near Detroit Zip Code Population <200% % Poverty Medicaid Medicaid Probable % Uninsured FPL <200% Beneficiaries % Population Uninsured East pointe 48021 33,405 6,414 19.9% 5,765 17.3% 649 1.9% Southfield 48075 22,598 3,797 17.3% 3,644 16.1% 153 0.7% Warren 48089 34,268 10,223 30.4% 9,766 28.5% 457 1.3% Warren 48091 31,985 8,747 27.4% 8,423 26.3% 324 1.0% Warren 48092 25,345 4,421 17.5% 3,797 15.0% 624 2.5% Allen park 48101 28,762 3,106 10.7% 2,281 7.9% 825 2.9% dearborn 48120 7,480 3,912 52.6% 3,156 42.2% 756 10.1% Melvindale 48122 10,755 2,844 26.5% 2,697 25.1% 147 1.4% dearborn 48124 33,257 3,611 10.9% 2,676 8.0% 935 2.8% dearborn Heights 48125 22,648 4,276 19.1% 4,015 17.7% 261 1.2% dearborn 48126 46,535 22,714 49.1% 21,028 45.2% 1,686 3.6% dearborn Heights 48127 35,600 5,566 15.8% 6,681 18.8% -1,115 -3.1% dearborn 48128 10,519 820 7.8% 864 8.2% -44 -0.4% garden City 48135 29,416 4,263 14.5% 3,265 11.1% 998 3.4% Inkster 48141 30,115 11,498 38.6% 10,669 35.4% 829 2.8% lincoln park 48146 39,775 8,901 22.5% 7,615 19.1% 1,286 3.2% livonia 48150 28,069 2,684 9.7% 2,021 7.2% 663 2.4% livonia 48152 32,142 3,459 10.8% 2,336 7.3% 1,123 3.5% livonia 48154 40,556 3,782 9.5% 2,115 5.2% 1,667 4.1% romulus 48174 29,937 7,528 25.5% 7,612 25.4% -84 -0.3% taylor 48180 65,868 16,901 26.0% 14,490 22.0% 2,411 3.7% Westland/Wayne 48184 19,121 4,261 22.7% 4,430 23.2% -169 -0.9% Westland 48185 49,003 8,528 17.6% 7,997 16.3% 531 1.1% Westland 48186 37,995 7,491 19.9% 7,319 19.3% 172 0.5% continued on page 23 Improving Access to Quality Health Care | 22
  25. 25. probable uninsured by Zip Code, Selected detroit Wayne County Suburbs continued Suburbs Near Detroit Zip Code Population <200% % Poverty Medicaid Medicaid Probable % Uninsured FPL <200% Beneficiaries % Population Uninsured Wyandotte 48192 44,894 8,617 19.5% 3,489 7.8% 5,128 11.4% Southgate 48195 30,136 4,562 15.3% 3,700 12.3% 862 2.9% river rouge 48218 10,060 4,666 44.8% 3,582 35.6% 1,084 10.8% Ferndale 48220 25,170 6,152 24.7% 3,853 15.3% 2,299 9.1% Harper Woods 48225 14,413 1,997 14.0% 2,382 16.5% -385 -2.7% Ecorse 48229 11,088 5,120 46.3% 4,304 38.8% 816 7.4% grosse pointe/ 48230 18,183 1,454 8.0% 856 4.7% 598 3.3% grosse pointe park grosse pointe/ 48236 31,366 2,048 6.6% 1,070 3.4% 978 3.1% grosse pointe park oak park 48237 32,493 8,643 26.7% 7,135 22.0% 1,508 4.6% redford township 48239 37,608 5,810 15.5% 5,032 13.4% 778 2.1% redford township 48240 19,151 3,326 17.8% 2,912 15.2% 414 2.2% total 1,019,716 212,142 182,977 17.9% 29,165 2.9% National average 29.6% Sources: Population-U.S. Census 2000; Chart-Michigan Primary Care Association; Medicaid Beneficiaries: Michigan Department of Community Health (Monthly average 7/2007 – 6/2008) combination of additional FQHC federal funding, FQHC ‘look-alike’ enhanced Medicaid and Medicare revenues, significant philanthropy and other revenue sources will be required to significantly expand area FQHC services. Also, the provision of such funding will need to be stable and reoccurring if it is to create the environment needed to address the risks inherent in service and facility expansion. POVERTY Since numerous studies have consistently found that poverty is correlated with lowered health status, and since this data is available by both census tract and zip code, it is an excellent factor by which to identify high need areas. A review of Detroit area data indicates clearly defined areas of high poverty and near poverty, as opposed to significantly more affluent areas of quality health care. Rates of infant mortality, low birth weight and common diseases have been reviewed for indicators of lower than average community health status. Lack of income is a crucial factor in identifying areas with barriers to accessing health care services. Based on the CDC’s Health, United States, 2007, the National Center for Health Statistics reported in a press release (December 3, 2007) that nearly one in five Americans say they can’t afford needed health Improving Access to Quality Health Care | 23
  26. 26. uninsured population percentages by Zip Code Improving Access to Quality Health Care | 24
  27. 27. care. “The report…shows that nearly 20 percent of adults reported that they needed and did not receive one or more of these services in the past year—medical care, prescription medicines, mental health care, dental care, or eyeglasses—because they could not afford them.” In the same report, it was also noted, “In 2005, one out of five people under the age of 65 reported being uninsured for at least part of the 12 months prior to being interviewed. The majority of this group reported being uninsured for more than 12 months.” Beyond this, the report noted that about one-third of all children living below the poverty level did not have a dental visit in 2005. The CDC Chartbook on Trends in the Health of Americans sums up the influence of health on poverty. “Children and adults in families with income below or near the federal poverty level have worse health than those with higher income. Although in some cases illness can lead to poverty, more often poverty causes poor health by its connection with inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy lifestyles, and decreased access to and use of health care services.” Using 2000 U.S. Census data, poverty rates were identified by zip code. The stark differences in income within relatively short distances made identification of potentially high need areas relatively simple. This criterion quickly and clearly identified nearly all of the City of Detroit; two land-locked suburbs within the city, three nearby suburbs, and two zip codes of another near-city suburb as having high poverty rates compared to their neighbors’ relative affluence. Areas of potential high need indicated by poverty rates include the City of patient Insurance Status, 2007 Detroit, Hamtramck*, Highland Park*, Ecorse, FQHC No Medicare Medicaid Other Public Private Insurance Insurance Insurance River Rouge, and Inkster. (*Land-locked suburbs Advantage Health Center 82% 2% 10% 3% 3% of Detroit, within its American Indian Health 76% 2% 11% 8% 3% exterior borders.) & Family Services If, for the purpose of Community Health 82% 2% 13% 0% 2% this plan, we define & Social Services heightened poverty Covenant Community NR NR NR NR NR rates as those exceeding Care 150% of national average poverty rate, then 21 of detroit Community 44% 7% 39% 0% 11% Health Connection the 25 Detroit zip codes exceed this rate. Two Health Centers detroit 24% 10% 50% 6% 10% exceed triple the national Medical group average (48201, 48216). the Wellness plan 1% 1% 97% 0% 1% Furthermore, if a similar Health Centers parameter is applied to rates of near poverty Western Wayne Family 54% 7% 25% 0% 14% including those with Health Centers incomes below 200% Sources: Michigan Primary Care Association 2008 Guide to Michigan Community Health Centers FPL, 20 of 25 Detroit zip NR: Covenant is new and has not yet reported Improving Access to Quality Health Care | 25
  28. 28. Wayne County poverty levels codes meet this criteria, with another zip code within 0.6% of this parameter. If this marginal zip code is accepted and both poverty parameter criteria are accepted to qualify a zip code for inclusion, then only two Detroit zip codes would not be considered in heightened poverty. Consideration of those with incomes between 100% and 200% FPL is important. This group is often identified as the working poor. Many in this group have low-wage jobs with no health insurance. As a result they are often lack the ability to purchase health insurance coverage due to their low income, but what income they do receive makes them ineligible for Medicaid or public assistance. As a result, they often have less ability to pay for regular access to quality health care than those who are very poor, many of whom have access to publicly funded health care coverage. The Cities of Hamtramck and Highland Park are geographically encircled within the outer perimeter of the City of Detroit. They have separate municipal governments but share similar poverty statistics. Both meet the heightened poverty parameters. Hamtramck has a rate double the national poverty rate and Highland Park has a rate nearly triple the national poverty rate. Improving Access to Quality Health Care | 26
  29. 29. Two zip codes in the suburb of Dearborn, contiguous to Detroit, have substantially heightened poverty rates. These (48120, 48126) have rates exceeding double the national Federal Poverty Level (>200% FPL). About half of their residents of this area have incomes below 200% of poverty. These residents are also reported (U.S. Census, 2000) to have very high second language rates, indicating need for translation services and organizations with culturally competent medical staff. The Cities of Ecorse (48218) and River Rouge (48209) also have heightened poverty rates. These are small communities downriver of Detroit nestled between the southern most projection of the City of Detroit and the Detroit River. These cities easily meet the heightened poverty parameters. Finally, the City of Inkster (48141) also has a heightened rate of poverty. Poverty is a key indicator of need. It is recommended that these areas be reviewed for possible designation and potential FQHC development. HEALTH STATUS INDICATORS Poor health status is generally accepted as an indicator of need. Lack of access to health care on a regular basis is a significant factor in contributing to poor health status as shown in the charts from MDCH on pages 28 and 29. The scope of this review is limited to the areas identified with heightened poverty rates. Data was not published or available for River Rouge. Infant mortality and the incidence of low birth weight is a commonly utilized indicator of health status and the degree of need for health care. Age-adjusted mortality rates for heart disease, cancer and diabetes are other useful indicators. Heart disease and cancer rates are included here. Diabetes rates are only available for the state, Wayne County, Detroit and Dearborn. Statistically valid mortality rates for other leading causes of death are not readily available for small areas. With regards to infant mortality, it should be noted that the statistical confidence interval for small populations is less in smaller communities. However, these infant mortality rates were made available by MDCH with varying parameters of confidence. Please refer to MDCH’s Community Health Statistics for more information. It is apparent that Detroit, Ecorse and Highland Park have substantially higher (>150% of Michigan) infant mortality rates. The chart on page 29 reports a 5-year average of births by low birth weight, 2002-2006. The overall Wayne County low birth weight statistics are only slightly heightened over the Michigan rate. The cities of Detroit, Ecorse, Highland Park and Inkster clearly indicate heightened rates of low birth weight with rates exceeding 150% of the state norm. Detroit, Ecorse, Highland Park, Taylor and the City of Wayne have substantially higher than average (>150% of Michigan) health disease death rates and generally higher than state average cancer and Diabetes Mellitus rates. This may indicate need for greater access to comprehensive quality primary care services, including such other health and enabling services as health education, community outreach, case management and other assistance. The East Dearborn zip codes also have high poverty rates, which may be an indicator of lower health status. There are substantial poverty rate differences between the eastern and western zip codes of Dearborn. The eastern zip codes of 48120 and 48126 have large populations with incomes under 200% FPL of 52.6% and 49.1% respectively. Western Dearborn zip codes of 48124 and 48128 have minimal low-income populations below 200% FPL of 10.9% and 7.8% respectively (U.S. Census, 2000). The blending of the overall Dearborn health statistics may tend to mask possible lower health status in these eastern zip codes contiguous to Detroit. Another consideration is health disparities. Minority populations tend to have diminished access to quality health care, increased rates of poverty, and lower rates of health insurance coverage. Living and Improving Access to Quality Health Care | 27
  30. 30. working in areas with greater environmental stressors and having less healthy lifestyles also tend to contribute to lowered health status. A recent Kaiser publication (Key Facts, Race, Ethnicity & Medical Care, January 2007) reported that, as of 2005, nearly one-third of the U.S. population identified themselves as a member of a racial or ethnic minority group. It also noted that, “People of color are more likely than non-Hispanic Whites to have low incomes, which may have implications for both their health and insurance status.” This has significant implications for Detroit and some of its nearby suburbs, since they have a high percentage of minority populations and the incidence of poverty is well documented. The U.S. Census reports about 90% of Detroit’s population to be non-white with the largest ethnic group being Black or African American (81.6%). The U.S. Census also reports over three-quarters of Inkster’s population as non-white, two-thirds (67.5%) of which are identified as Black or African American. Inkster is a near-Detroit suburb. Similarly, River Rouge and Ecorse located immediately to the south of Detroit have significant Black or African American populations (42.01% and 40.56% respectively). These and other near-Detroit suburbs have growing rates of non-white populations with correspondingly above average rates of poverty. Both of these are indicators of lower than average health status and a heightened need for access to high quality primary health care services. Infant Mortality, 2002-2006 Age-Adjusted death rates, 2006 5-Year Average Community Heart Disease Cancer Death Diabetes Community Neonatal Post Neonatal Infant Death Rate* Rate Mellitus Rate Morality Rate Mortality Rate Morality Rate Michigan 226.7 190.8 26.7 Michigan 5.5 2.4 7.9 Wayne County 286.5 212.0 29.8 Wayne County 7.9 3.2 11.1 dearborn 201.5 158.1 25.3 dearborn 3.4 1.5 4.9 detroit 331.3 229.4 33.0 detroit 11.0 4.7 15.6 Ecorse 397.9 198.3 * Ecorse 11.9 * 15.5 Hamtramck 318.6 155.5 * Hamtramck 5.4 * 6.8 Highland park 404.3 255.1 * Highland park 13.3 * 16.2 Inskter 279.1 211.1 * Inskter 7.2 2.7 9.9 river rouge n/a n/a n/a river rouge n/a n/a n/a taylor 309.2 221.3 46.8 taylor 7.8 2.3 10.1 City of Wayne 315.8 273.5 * City of Wayne * * 6.8 Source: Michigan Department of Community Health Source: Michigan Department of Community Health *Number too small for comparative purposes *A rate is not calculated when there are fewer than six events. Age-adjusted death rates per 100,000 population in specific group. Improving Access to Quality Health Care | 28
  31. 31. This ethnic-related income correlation has implications regarding access to health care. low Birth Weight, 2002-2006 The Urban Institute and Kaiser Commission 5-Year Moving Average on Medicaid and the Uninsured (March 2006) Community Total Births Low Birth Very Low Birth estimates the percent of ethnic populations with Weight % Weight % incomes below 200% FPL as Hispanic 58%; African American 54%; American Indian/Alaska Native Michigan 129,026.6 8.3 1.7 57%; two or more races 41%; Asian and Pacific Wayne County 28,221.2 10.6 2.4 Islander 33%. The same study states, “American Indian/Alaskan Natives, African Americans, dearborn 1,876.2 6.5 1.2 Hispanics, and those who identify themselves as detroit 13,646.2 13.6 3.4 of two or more races are more likely to rate their health as fair or poor compared to Whites and Ecorse 168.0 12.7 2.6 Asians.” It also states, “Infant mortality rates, considered one of the most sensitive indicators Hamtramck 410.2 9.9 1.9 of the health and well-being of a population, are Highland park 209.8 16.0 4.9 higher among African Americans and American Indians/Alaska Natives than among other racial/ Inskter 444.0 12.8 2.5 ethnic groups, even when comparing women of river rouge n/a n/a n/a similar socioeconomic conditions, as measured by years of education completed.” As reported in taylor 868.2 7.8 1.8 the chart on page 24, Detroit, Highland Park and City of Wayne 263.0 6.9 1.1 Ecorse have more than double Michigan’s infant mortality rate. These communities and Ecorse also Source: Michigan Department of Community Health have heightened incidence of low birth weight. *A rate is not calculated when there are fewer than six events. AbILITY OF FQHCs TO EXPAND SERVICES, INCREASE DELIVERY SITES TO MEET Infant Morality rates for Mothers Age 20+ IDENTIFIED NEEDS wITHIN 3-5 YEARS By Race/Ethnicity and Education, 2001-2003 Site visits were conducted, discussions were initiated and questionnaires were sent to identify Race/Ethnicity < High High School College+ School issues and develop indicators of the area FQHCs’ ability to expand to meet identified needs. In African American/ 15.1% 13.4% 11.5% non-Hispanic addition, FQHC Uniform Data System (UDS) reports were reviewed as was information American Indian/ 10.7% 9.2% 7% provided in the 2008 Guide to Michigan Community Alaska native Health Centers, an annual report of MPCA. During White, non-Hispanic 9.2% 6.5% 4.2% discussions and reviews it became apparent that the high rate of uninsured in the city was a Asian/native 5.0% 5.6% 3.9% serious matter for the FQHCs to consider in terms Hawaiian/Pacific of expanding. Serving large numbers of poor, Islander uninsured patients who can pay little or nothing for Hispanic 5.2% 5.3% 4.6% care seriously strains FQHC resources. Historically, FQHCs have served patient populations that Source: National Center for Health Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data. include about one-third uninsured. However, this Improving Access to Quality Health Care | 29
  32. 32. is changing. The most recent National Association of Community Health Centers (NACHC) Chart Book reports that nationally this rate is now approaching 40% (39.8%). Locally, a number of the FQHCs have patient populations exceeding these national uninsured rates. For example, three Detroit area FQHCs report serving patient populations exceeding 70% uninsured. Federal grant funding has been relatively stable and less than 15.8% of FQHC income is generated by private insurance (NACHC) . Most of the remaining sources of income are publicly funded programs including Medicaid, Medicare and SCHIP. Medicaid and Medicare provide special payment formulae for FQHCs, which have been helpful in providing a degree of financial stability to FQHCs. However, with the growing number of uninsured in the Detroit area, the patient mix has placed some of the area’s FQHCs under financial stress. This not only presents an immediate challenge to the delivery of existing services, but it also weighs heavily upon decisions to expand, since expansion of services of the addition of new sites may well present an FQHC with a new population of uninsured for which it has inadequate resources to serve. The primary challenge identified by the present providers is lack of capital. Since it is generally more efficient to expand an existing FQHC’s services to new sites, as well as introduce new services in present locations, this would be the first option to consider. However, if no existing organization is prepared to establish services in an identified high-need area, providing assistance to a new organization to meet identified need may be considered in the planning process. Should an area be in an FQHC’s plans for a New Access Point, this would be a solution to their primary health care needs. If need is identified and no FQHC plans to respond to the need, it will be important to encourage an FQHC to add the area to its plans or to encourage and assist a new organization to respond to the need. Other considerations would include language, ethnicity and culture, and availability of appropriate transportation. As mentioned above, on-going input received from the safety net primary care provider organizations, the many organizational representatives of the DWCHA, the PCNC, and community organizations is very important. These organizations have been responding to the many challenges of providing quality health care for the area’s underserved population for many years and their experience and observations are of great value. These criteria will be valuable in identifying need, the ability of organizations to respond to need, and the resources, opportunities and challenges of the community in establishing achievable growth targets. Once these needs are identified by area and the ability and plans of organizations to respond are known, a reasonable set of benchmarks can be established to measure progress. FQHCs are of various sizes and capabilities. As can be ascertained, the Detroit area FQHCs are primarily providing medical services. However, they do provide preventive dental services and routinely arrange for referrals for dental and behavioral health services. Three (Advantage Health Center, Community Health and Social Services, and Detroit Community Health Connection) directly provide dental services. In addition, a few of the FQHCs have reported developing dental and behavioral health services. FQHCs are also required to provide enabling services, such as case management, eligibility assistance, community outreach, translation and health education in order to assist patients in their access to, and utilization of, quality services. FQHC ‘look-alikes’ are required to provide similar services. Improving Access to Quality Health Care | 30

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