Fac­ing ACA re­peal, com­mu­nity clin­ics are look­ing down a dou­ble-bar­reled gun

Modern Healthcare - - NEWS - By Steven Ross John­son

It’s a long drive from Dr. Van Breed­ing’s home­town of Whites­burg, Ky., to Lex­ing­ton. As a child, his fam­ily fre­quently made the trip to take his oc­to­ge­nar­ian grand­mother to the near­est car­di­ol­ogy clinic.

“I re­mem­ber you had to get up at 3 o’clock in the morn­ing in or­der to drive down for her to make her 9 o’clock ap­point­ment,” Breed­ing said.

To­day, Breed­ing serves as di­rec­tor of clin­i­cal af­fairs for Moun­tain Com­pre­hen­sive Health Corp., a com­mu­nity health cen­ter net­work based in Whites­burg that serves 30,000 pa­tients a year across six coun­ties in eastern Ken­tucky. One-third of res­i­dents in the Whites­burg re­gion are poor and many are ad­dicted to heroin. Nearly a quar­ter of the res­i­dents of Whites­burg’s Letcher County have di­a­betes, and adults have higher rates of col­orec­tal can­cer, hy­per­ten­sion, asthma, stroke and heart dis­ease than oth­ers in the state.

“My heart is in these hills and with these peo­ple,” Breed­ing said.

And he’s been able to help them in ways he never imag­ined. In the past seven years, Breed­ing has seen his prac­tice grow from five clin­i­cians at two sites to 300 em­ploy­ees at seven clin­ics. Moun­tain also has a den­tal clinic and an op­tom­e­try clinic. And in 2015, it opened its Far­macy pro­gram, which gives low-in­come peo­ple

On av­er­age, health cen­ters in ex­pan­sion states served 40% more pa­tients than those in non-ex­pan­sion states, re­ported higher staffing ra­tios for oral and be­hav­ioral care, and were more likely to re­port in­creased ca­pac­ity to pro­vide ser­vices. Source: Health Re­sources and Ser­vices Ad­min­is­tra­tion’s Uni­form Data Sys­tem

vouch­ers to buy fresh pro­duce from lo­cal farm­ers.

Much of Moun­tain’s growth oc­curred through the Af­ford­able Care Act, which fun­neled grants aimed solely at help­ing com­mu­nity health cen­ters pro­vide ser­vices not tra­di­tion­ally cov­ered by third-party pay­ers. Between 2011 and 2015, lo­cal clin­ics across the coun­try re­ceived $11 bil­lion in Sec­tion 330 grants through an ACA pro­vi­sion called the Com­mu­nity Health Cen­ter Fund. Con­gress ex­tended the pro­gram in 2015, pro­vid­ing $7.2 bil­lion over the next two years.

But the fund is set to ex­pire in Septem­ber, and its fu­ture is in doubt. Com­mu­nity health cen­ter op­er­a­tors are fairly con­fi­dent law­mak­ers will reau­tho­rize the fund be­cause their work has con­sis­tently re­ceived bi­par­ti­san sup­port. Plus, Con­gress has al­ready ex­tended the fund twice.

The dif­fer­ence this time around is how it can con­tinue with­out the ACA, which has been its fund­ing mech­a­nism over the past sev­eral years. It’s un­clear where the money will come from if the health law is re­pealed. Also un­cer­tain is whether fund­ing would con­tinue to be a part of manda­tory fed­eral spend­ing or be­come dis­cre­tionary and sub­ject to the an­nual con­gres­sional bud­get ap­pro­pri­a­tion process.

Thanks to the fund, 950 com­mu­nity health cen­ter sites have opened since 2010. In all, the U.S. has 9,800 such sites serv­ing more than 24 mil­lion pa­tients an­nu­ally.

The Com­mu­nity Health Cen­ter Fund ac­counts for more than 70% of com­mu­nity clin­ics’ fed­eral fund­ing. It made up nearly a fifth of to­tal health cen­ter rev­enue in both 2013 and 2015, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. Med­i­caid makes up 44% of health cen­ters’ $21 bil­lion in to­tal rev­enue in 2015.

At the same time, the number of unin­sured pa­tients fell in states that chose to ex­pand Med­i­caid. Ken­tucky’s ex­pan­sion caused the state’s unin­sured rate to fall by nearly 13 per­cent­age points from 2013 to 2016. It’s one of the coun­try’s suc­cess sto­ries, which is why for­mer Gov. Steve Bes­hear was asked to re­spond to Pres­i­dent Don­ald Trump’s speech to Con­gress last week. Trump asked mem­bers of both par­ties to sup­port re­plac­ing the ACA and chang­ing Med­i­caid.

“This isn’t a game,” Bes­hear said in de­fense of pre­serv­ing the health law. “It’s life and death to peo­ple.”

Re­cent pro­pos­als to change Med­i­caid would sig­nif­i­cantly re­duce the pro­gram’s fed­eral fund­ing. One pro­posal would turn Med­i­caid into a block­grant pro­gram or im­pose a per capita limit. The left-lean­ing Cen­ter on Bud­get and Pol­icy Pri­or­i­ties last year es­ti­mated ei­ther of those plans would re­duce the number of Med­i­caid ben­e­fi­cia­ries by 14 mil­lion to 20 mil­lion over a decade.

“It’s kind of like the Jenga game,” said Louise Reed, CEO for the West Vir­ginia Pri­mary Care As­so­ci­a­tion. In her state, com­mu­nity health cen­ters pro­vide care for a quar­ter of the state’s pa­tients and 38% of its Med­i­caid benefi- cia­ries. “You pull one of these pins out, and the whole thing could come tum­bling down.”

Moun­tain in Ken­tucky en­rolled more than 6,000 pa­tients in Med­i­caid, which helped cut the self-pay pop­u­la­tion from 20% to 3%. The added rev­enue from in­sured pa­tients has freed up money for Moun­tain to open its clin­ics on Satur­days.

Moun­tain’s physi­cians, Breed­ing said, have gone from try­ing to find drug sam­ples for pa­tients to hav­ing enough time to coun­sel them on ways to stay healthy.

Ver­nita Todd, ex­ec­u­tive vice pres­i­dent of ex­ter­nal af­fairs for Health Cen­ter Part­ners of South­ern Cal­i­for­nia, a con­sor­tium of 17 com­mu­nity health­care or­ga­ni­za­tions with 126 sites, wor­ries about what lower fund­ing will mean for net­works like hers. She said cut­ting al­ready low Med­i­caid re­im­burse­ment rates has made it hard to re­cruit providers and other clin­i­cal staff.

She ex­pects the need for physi­cians will re­main high, but wor­ries that more cuts to Med­i­caid re­im­burse­ment will ne­ces­si­tate trim­ming other clin­i­cal staff.

“I think cen­ters are be­ing very cau­tious,” said Ted Boe­sen, CEO of the Iowa Pri­mary Care As­so­ci­a­tion. “The pos­si­bil­i­ties from the cam­paign rhetoric are just very con­cern­ing to ev­ery­one.”

For Breed­ing, re­duc­ing ser­vices would take on a more per­sonal tone. Over the past sev­eral years, Moun­tain has brought on two full-time car­di­ol­o­gists for its clin­ics, which are equipped to pro­vide all of the ser­vices that his grand­mother had to travel sev­eral hours to re­ceive.

“It’s just been so ex­cit­ing and it’s made the prac­tice of medicine so much more mean­ing­ful,” Breed­ing said. “Be­cause I’m from the area, it’s keep­ing my fam­ily, it’s keep­ing my friends and it’s keep­ing my kin­folk all health­ier.”

In 2015, 76% of health cen­ter pa­tients were in­sured, – 49% through Med­i­caid– up from 65% in 2013, the year be­fore the ACA cov­er­age ex­pan­sions took ef­fect. Source: Health Re­sources and Ser­vices Ad­min­is­tra­tion’s Uni­form Data Sys­tem The Com­mu­nity Health Cen­ter Fund ac­counts for more than 70% of com­mu­nity clin­ics’ fed­eral fund­ing.

Dr. Van Breed­ing ex­am­ines a pa­tient—renowned moun­tain banjo player Lee Sex­ton, of Whites­burg, Ky.

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