My name is David Brewton, and I am Director of Development for the East Liberty Family Health Care Center, a faith-based community health center that has successfully provided quality, whole-person health care for residents of the City of Pittsburgh for nearly twenty years, without regard to ability to pay.  While I have been employed by the Center for five years, I and my family have been patients there since literally the first day the Center opened in 1982, so I am well acquainted with the quality, compassionate, and accessible care the Center provides every day to all who come. 

I want to thank you all for the unwavering support this Subcommittee has given our health center and our colleagues around the country in our work to care for the uninsured and underserved.  I come in support of the National Association of Community Health Center's position in regard to the extension, reauthorization, and expansion of the Section 330 community health centers program and the National Health Service Corps (NHSC).  The unique perspective that I wish to emphasize in my comments is that we are a demonstration of how a faith-based health center can produce effective health outcomes for the underserved by combining the power of faith-based (or what we call "whole-person") care with the institutional strength that comes from full participation in the section 330 health centers program.   

Our Center was incorporated as a 501(c)(3) non-profit corporation in 1982.  Our founding physician, Dr. David Hall, had a deep sense of calling to provide health care wholistically for the poor in his hometown of Pittsburgh, and to do so as an expression of his conviction that true healing incorporates the physical, mental, emotional, and spiritual dimensions of the human person.  The Rev. Douglas A. Dunderdale, Senior Pastor of Eastminster Presbyterian Church, had been praying for a health ministry out of his church, located in the heart of a severely medically-underserved community in Pittsburgh's East End.   When the two came together, they knew that it was a confirmation of their visions, and in 1982, the Center opened up a small office in the basement of Eastminster Presbyterian Church.  It is important to note that while a Presbyterian Church provided us our start, the Center is non-denominational, and an expression of ministry supported by persons of many different faiths who share a common sense of mission. 

Today, the East Liberty Family Health Care Center operates two offices in the East End, and last year provided more than 27,000 patient encounters without regard to ability to pay for more than 5,000 individuals.  The Center employs a staff of 60 with a budget in excess of $3 million, and provides more than ten distinct forms of outreach to the low-income community it serves to meet needs beyond the walls of its two welcoming, culturally-sensitive offices.  

Faith-based and federally funded, we at the Center believe that these two forces are a powerful combination to effectively serve everyone in our community:  the insured and the uninsured, those on Medical Assistance and Medicare, the homeless, and yes, even those who are privately insured but want quality care with a difference. 

Here's the difference our faith-based perspective makes: 

•  It provides a value system with deep historical roots that helps us to care not only for the physical, but all dimensions of human existence.  It reminds us of the dignity of every human being, who is created in God's image--even, and perhaps, especially, those who do not share our particular religious values.  That is why we are in an underserved community, and why we never turn anyone away.

•  It provides a motivation that makes our practitioners by and large stay with us for longer than in most such demanding settings.  In our 19+ years, we have had four NHSC participants, all of whom are still serving at the Center today out of a sense of God's calling.  (How's that for retention!)  This enables them to develop lasting relationships with their patients, most of whom NEVER had a primary care physician before, and were used to relying solely on strangers at emergency rooms for care.  Because of this spiritually motivated commitment, our "poor" patients develop the kind of lasting relationships with their own family doctors at the Center that most of us take for granted.  

•  It means we spend time--lots of it--with each patient to get to know the whole person, even when insurance and federal subsidy won't pay for that time.  This is why one patient spoke for many when she said recently:  "When I'm with Dr. Hall, I feel like I'm his only patient." 

• It means we offer prayer with every visit--and please note--we do not force or require prayer, we simply offer it at the conclusion of each visit, gently, and respectfully.  Some patients decline, and we fully respect their decision.  There is no pressure.  Others specifically request it and will testify that it is the primary reason they come to us for care (never mind that we employ 11 outstanding board certified physicians with years of experience and from some of the best medical schools in the country).  Sometimes, our patients from different religious backgrounds, including Jewish and Muslim, will also ask for prayer, and we are careful to do so in a way that respects our similarities and differences. 

Finally, it means that we have not just a compassion for people, but a passion for quality care.  Our faith motivates us to provide the best care we can and to strive to measure the results.  So, it should not surprise you that we have been innovators and results-producers since our inception:  All of our physicians are Board certified.  Our founder has received numerous awards in the community for community outreach.  Our Homebound Elderly Outreach Program has been named a "Best Practice in Faith-based Health Care" in a national competition, underwritten by the Bureau of Primary Health Care (BPHC).  A few years back, we documented 92% compliance with State immunization requirements for all our patients through age 2, when the region's largest Medicaid HMO had a rate of 62%.  We participate in research studies at Pittsburgh's fine universities to help improve our patients' care.  And, we are on the cutting edge in some administrative areas, implementing a computerized medical records system to measure outcomes among our populations, and being the founding member agency of a nationally-recognized integrated healthcare delivery system (the "Coordinated Care Network," or CCN) that is transforming the way managed care works for those on Medical Assistance and the uninsured.  Simultaneously, the CCN is re-capturing the savings generated to provide even better wrap-around, preventive care for these high cost users of the medical system in Pittsburgh.  (To demonstrate our achievements, I have included as Attachments A and B of my statement our 2000 Annual Report and our Health Care and Business Plans.) 

Please be clear:  our faith NEVER leads us to exclude anyone, in fact, just the opposite:  It compels us to be open to all.  Period.  If we did exclude folks, you would have a right to judge us harshly, for we would not be supporting the goals of the community health center program which we all share:  100% access to care and zero health disparities. 

Which brings me to my second and final point.  Here's the difference federal support makes:  

For our first 17 years, we relied solely on private charitable support to make up the difference between the cost of the care we provide and what our patients can pay.  Most of it comes from church-going people, by the way, who continue today to provide well over $1 million per year to pay for those parts of the care we provide that no one else can or will.  

But in 1999, we were one of the top ten applicants for health center funding in a very competitive cycle, and so became a full-fledged CHC.  Without this reliable, accountable, and renewable support, we never could have grown to meet the real needs in our community.  Private support--while significant--is simply not enough!  

Without CHC funding, we couldn't have opened our second office in the even more underserved community of Lincoln-Lemington, two miles from our home office.  We couldn't have started a dental program, our addiction outreach program, or our important programs in ob/gynecology and parent education.  We couldn't have seen our annual visits more than double from 12,000 in 1996 to more than 27,000 in the year 2000.  And about now, we would have been overrun and had to close our doors to the more than 1,000 new patients who were added to our rolls just this year, because of welfare reform and PA's managed care initiative for those on Medical Assistance.  

Beyond that, we would like to say that the guidelines and regulations of the community health center program, while sometimes seeming(!) to be onerous, are actually strong encouragements for us to be more accountable and more outcome-oriented in all we do.  It is often tempting to grumble about regulations and standards, but our view is this: if we are going to be faithful to our God, we should see government standards as MINIMUM standards, and do our best to achieve or even exceed them. 

Through our participation in the CHC program, we have had the opportunity to pursue JCAHO accreditation (we hope to complete this process in the next year or two), to participate in collaboratives with other groups around specific issues to improve our handling of high-incidence diseases such as diabetes and hypertension, and just the accountability that comes through knowing that we are responsible for meeting the goals we set for ourselves in our annual federal review process.  

Are there areas of tension in this alliance of faith and government funding?  Undoubtedly.  But as long as we focus on our common objective (100% access, 0 disparities); and recognize that both church and state have a role in the promotion of the public good, and are clear about the distinctions of those roles, we believe that we are a forthright demonstration of how the two can work together in integrity and accountability.  

I urge you to extend, reauthorize, and expand the vital Section 330 Health Centers and the National Health Service Corps programs, and to strengthen these programs in accordance with the proposed improvements of the National Association of Community Health Centers.  I have included these proposals as Attachment C of my statement. 

Thank you again for the opportunity to present my views here today.  I would be pleased to answer any questions you may have.

Caring for the Whole person

Annual Report 2000

and Final Report on

"The Campaign for Whole-person Health Care for the Twenty-first Century."

"For Thou didst form my inward parts, Thou didst knot me together in my mother's womb.  I praise Thee for I am fearfully and wonderfully made.  Wonderful are they works!"

Psalm 139: 13-14 

Reflect with us for a moment on the amazing wonder of the human body: 

• A baby is born, and mother and father marvel at the unspeakable miracle.

• Daily that baby develops intangible qualities which transform a physical body into a person:  a personality, a will, a heart, a spirit, and along with them, a smile or whole-face-frown that instantly translate the intangibles into the tangible.

• By high school, the developing person studies biology and learns in ever-greater detail the amazing complexity of the human body, and how all the internal systems work together to effortlessly perform the daily functions that we take for granted.

• wo people make a lifetime commitment of marriage and celebrate their union bodily in an act of spiritual and physical one-ness. 

• Over time, the body ages, creaks and groans, expands and sags, until at some point, life is no longer contained in that failing body.  We see a shell, and we look and long for a restored, transformed, renewed, imperishable body.

When we in the Center speak of "whole-person care," we begin with this understanding:  that our visible bodies and invisible spirits are bound together in God's creation and are fearfully and wonderfully made.   We join good science and deep faith to attempt to bring healing and hope to the wondrous persons who come to our two offices for care.  And when we start with the fact of our wondrous creation by our wondrous God, it makes all the difference.  It affects everything we do.   

•  It's why we are open to all:  for all of us are made by the same God in His very image. 

• It's why we strive to link counseling, social services, and spiritual support with our care:  for health is about much more than the physical.  

• It's why we take the time-lots of time-to listen to our patients' stories:  for care is about much more than making the right diagnosis, it's about love and trust. 

• And it's why we offer prayer with every visit:  because the One who made us is the only one who can restore us to whole-person health:  physical, emotional, and spiritual health. 

Now the reality of our human existence is this:  None of us is fully whole; none of us is fully broken.  God's image is in each one.  But the broken-ness of sin and sickness is also in each one.   

So we celebrate the great steps we've made as a ministry toward healing and wholeness, but we remember that much remains to be done.  Health and wholeness will never be complete.  But oh, the joy of being a part of the process of restoration!  God has allowed us to achieve much; much remains to be done.  Won't you join us in our mission? 

Mission Statement:  The East Liberty Family Health Care Center is dedicated to witnessing to God's love, known in Jesus Christ by providing quality, whole-person health care to all, especially the poor.  

Accomplishments of the "Campaign for Whole-person Health Care for the Twenty-first Century" (1997-2001) 

• Opening of the Center's first satellite office:  the Lincoln-Lemington Family Health Care Center, March, 1998. 

• Creation of the Coordinated Care Network (CCN) to join with twelve other agencies to bring whole-person care to virtually all of Allegheny County's uninsured and Medical Assistance recipients. 

• Renovation of the East Liberty Office (in memory of Mr. and Mrs. William H. Ochiltree) for greater patient volume and efficiency. 

• Implementation of a single computerized record system that includes scheduling, billing, and medical records. 

• Purchase of the Dorothy Day Apartments, construction of the Center's first Dental Office, and renaming of the entire Lincoln-Lemington facility in memory of The Rev. Dr. Bruce W. Thielemann. 

• Addition of seven new services to our "whole-person care" model:  Obstetrics/gynecoloy, addiction outreach and case management, mental health counseling, parent education, podiatry, dental care, and transitional housing. 

• Doubling of our patient volume from 12,000 visits in 1996 to more than 27,000 visits in 2000! 

Accomplishments of the Year 2000 

• Provided a record 27,000+ patient services without regard to ability to pay: for the insured, uninsured, the homeless, and those on Medical Assistance and Medicare. 

• Delivered a record 63 babies, with only four below normal birthweight 

• Provided for the first time ever 399 dental visits 

• Provided for the first time ever 86 podiatry visits 

• Provided 2,500+ home visits to the homebound elderly, providing medical and daily living assistance, preventing more than 30 unnecessary hospitalizations.  As a result, this program was named a "Best Practice in Faith-Based Health-Care in a National Competition. 

• Provided in-home pediatric services for more than 50 families 

• Supported 94 persons in recovery from addiction to drugs and/or alcohol, helping 64% of them maintain continuous sobriety throughout the year 

• Conducted a patient satisfaction survey showing a >90% satisfaction rate among our patients 

• Began strategic planning with Board, staff, and community experts to begin discerning God's direction for the next five years.  

Whole-Person Care in the Words of our Patients 

Primary Care

Long-time patient, Verneeta Griggs:  I trust in the Lord, and I trust Dr. [David] Hall.  Whenever I have any problem in my life, I can ask him anything.  The quietness with which he speaks reassures me.  We just talk about it and he prays for my peace, and that helps me.  And I pray for him and the Center, too, that they would stay in Him, that their strength and peace would be rooted in Him."   

Pediatric Home Outreach

Ms. Daniell Arms, mother of pre-mature twins Dai-mon and Dai-jah:  "When I moved way out of town to escape the bad influences of my old crowd, Susan Triggs (RN) didn't leave me.  She came to my home to give my twins the medicine they needed because of their pre-mature birth.  When I couldn't get ACCESS to provide transportation, Susan could!  When one of my twins was sick in the evening, she came all the way out, took us to the hospital, and brought us back home around midnight.  So this past New Year's Eve, when I decided to give my life to Jesus Christ, Susan was the first person I called.  Then the Center got me a Bible to read.  Susan is always there for me."   

Homebound Elderly Outreach

Patient Paul Sandfield:  "Last year, I had two heart surgeries, and other operations.  My left leg was removed.  The Center had cared for my father in his home until he died, so when I lost my leg I asked them to care for me.  Debbie [Keck] comes every week, checks my blood and orders my medicine.  I take many medicines, three times a day.  George [Rivers] comes and picks up my medicine at the drug store once a week.  He also gets my groceries for me and brings them in, because I never get out of my place.  If they didn't come, I absolutely would NOT go to a nursing home, so I suppose I'd just stay here until I was deceased.  But I sure couldn't manage without Deb and George."   

Obstetrics

New mother, Sharine Edwards:  "[Dr.] Irene [Frederick] was wonderful the whole time.  I had a lot of complaints during my pregnancy, and she answered every one, never making me feel judged.  She was so attentive.  She never left my side during the whole delivery.  She did everything possible, including massage to avoid a C-Section, but when it became necessary, she supported me through that.  We prayed before, during, and after.  When Charonn was born, Irene gathered all my family and friends into the room and the seven of us all prayed.  She still checks up on me:  When I was going through some post-partum depression, she even called me when she was on vacation." 

Homeless Outreach

Homeless Patient, Harold Hughes:  "Doctor Pete [Peter Murray, Physician's Assistant] helped me when I buried my mom and was homeless for awhile.  I broke up with my wife and he got me medication for my depression.  I am a diabetic, and he got me the right medicine for that.  He always has love and kindness.  We always pray.  He goes to my church [Samaritan Worship at East Liberty Presbyterian, where Pete is a member].  When my mom died and my wife was gone, Peter was an inspiration of love and care to not give up on God or this world." 

Community Recovery Services

Recovering Addict, Sheila F.:  "Where would I be without Bobby [Booker, Addiction Outreach Worker]?  I relapsed last year in the worst way.  My face got cut.  I checked into detox and had to be released in 5 days, but I wasn't ready.  There were no beds available in rehab.  A girlfriend took me to a meeting where I talked about my fear of "picking up" again.  After the meeting, this man (Bobby) spoke to me, and he got me into rehab the next day.  When I had to go to court, Bobby went with me.  I had to spend a week in jail, and when I got out, Bobby was the first person I called.  He got me into the Zoar Program, which I completed last year.  I went to more than 90 meetings in 90 days.  Now, I have a job, I'm going to Community College for Drug and Alcohol Counseling, Before, I "belonged" to a bar; now I'm the Vice President of the Sorority at my church.  Now, I chase recovery like I used to chase the drugs.  I just love Bobby.  He's my mentor, he checks up on me and sometimes, even calls my mom to check on me.  There's no doubt in my mind that this is a lifelong friendship." 

Parent Education (with Arsenal Family & Children's Services)

Gloria Morris, raising her grandson Markeith:  "[Parent educator] Janet [Edwards Anti] is patient with him, and shows me how to be more patient.  I've gotten control of myself, now.  I know how to deal with him.  I don't get as upset as much.  I speak like Janet does instead of hollering at him.  Before I was timid and would boil over.  Now, I know to be specific and stren to help him know what I expect and that I mean it.  Now, my grandchild says to me, "I'm not going to be like that anymore!" 

Counseling Services (with Pittsburgh Pastoral Institute)

"I knew I was emotionally falling apart, but I couldn't get it together to ask for help.  I came into the Center for a physical problem, and Pete Murray told me that their counselors would be there the next day to screen for depression.  He helped me sign up--I knew I could do that much.  That we the first step that gave me hope to begin making some positive changes in my life.  I'm feeling much better already."  

East Liberty Family Health Care Center

BPHC Section 330 Community Health Center "New Start" Program

Health Care Plan

I.       Problem/Need:  The need to inc. access by the underserved/vulnerable to comprehensive primary and preventive health care.  The need to replace reliance on Emergency Room and Hospital-based care for primary care needs with preventive, primary care.

Problem/Need:  Health Disparities:  Infant Mortality remains above 17/1,000 in the East End, and is approximately double that among African-Americans.

III.  Problem/Need:  Children need prompt immunizations and comprehensive, preventive well-child care in the first two years of life.  Research shows that prompt immunizations correlate to better overall health and child development.

IV.  Problem/Need:  Hypertension is a major health concern for adults in the service population, especially minorities.  Hypertension leads to Cardiopulmonary Disease, and must be regularly monitored.  Dietary and exercise behaviors must be consistently adhered to by patients.

V.  Problem/Need:  Drug and alcohol addiction is a major health concern for adults in the target population, contributing to mental health and physical disorders, addicted (NICU) infants, and crime, imprisonment and other deleterious social problems.

VII. The Homebound Elderly are a grossly underserved population.  By providing regular nursing visits to high-risk Homebound Elderly, unnecessary hospitalizations and ER visits can be significantly reduced.

East Liberty Family Health Care Center

BPHC Section 330 Community Health Center "New Start" Program

Business Plan

Note:  Needs I-IV are addressed by the Center's 1996 Strategic Plan.  Needs I-II, V-VI are addressed by the Center's 1999 "SMART" Plan.  

I.       Problem/Need:  The need for additional clinical and administrative space, as well as administrative and clinical staff to relieve overcrowding at East Liberty Office and to reach out to more of the underserved and vulnerable in Pittsburgh' East End.

II.    Problem/Need:  The need for a strong Administrative Infrastructure to undergird the clinical program of the Center in the rapidly changing managed care environment.

Problem/Need:  The need to respond in collaboration with other providers to achieve enough scale to effectively serve our population in the State-mandated Conversion of Medical Assistance to managed care.

IV. Problem/Need:  In order to support its planned expansion to serve more underserved persons, the Center's financial base must be expanded and diversified, moving away from reliance on non-renewable (primarily local foundation) forms of support.

V.    Problem/Need:  The need to effectively reach out and communicate our mission to the underserved and unserved in our target area in order to attract new patients to use the Center for their primary care needs.

VI. Need/Problem:  The need for the Center's staff to systematically evaluate internal processes for continuous improvement, to better serve patient needs.

EXPLANATION OF PROPOSED CHANGES IN THE CURRENT SECTION 330

HEALTH CENTERS AUTHORITY 

Background 

            In the 35 years since their creation, America's Community Health Centers have proven their durability as a model health care program and their resilience in adapting to a dramatically changed American healthcare system while maintaining their original mission and purpose.

             Health centers were established to provide access to quality preventive and primary health care for the medically underserved - including the millions of Americans without health insurance, low income working families, members of minority groups, rural residents, homeless persons, agricultural farmworkers, and those living with HIV or with mental health needs.  Since their inception, health centers have served as a prototype for effective public-private partnerships, demonstrating their ability to meet pressing local health needs while being held accountable for meeting national performance standards.  The success of the Health Centers program can be directly traced to the core elements found in Section 330 of the Public Health Service Act, its authorizing statute.  These elements stipulate that each federally-supported health center must: 

• Be located in, and serve, a community that is designated as "medically underserved," thus ensuring the proper targeting of federal resources on areas of greatest need;

• Make its services available to all residents of the community, without regard to ability to pay, and to make those services affordable by discounting charges for otherwise uncovered care to low income families in accordance with family income;

• Provide comprehensive primary health care services, including preventive care (such as regular check-ups and pap smears), care for illness or injury, services which improve the accessibility of care (such as transportation), and the effectiveness of care (such as health/nutrition education);

• Be governed by a board of directors a majority of whose members are active, registered patients of the health center, thus ensuring that the center is responsive to the health care needs of the community it serves.

      In 1996, the Congress consolidated four separate targeted primary care programs (Migrant Health, Health Care for the Homeless, Public Housing health centers, and Community Health Centers) under a single authority, extending the consolidated program for five years.  The new authority also included a limited new provision to fund health center-led networks and a new federal loan guarantee program.  The consolidated Health Centers authority, at Section 330 of the Public Health Service Act, expires on September 30, 2001, and therefore requires reauthorization this year. 

PROPOSED CHANGES TO SECTION 330 HEALTH CENTERS AUTHORITY

1. Extension/reauthorization of Section 330 Health Centers authority for at least 5 years, at not less than $1.344 billion for FY 2002 and "such sums" for all future years

Explanation 

President Bush has publicly unveiled a multi-year plan to double the number of people served by health centers.  More than 60 percent of Members of Congress have endorsed a similar plan.  The Congress began that effort by providing $1.169 billion for FY 2001 for Section 330, a $150 million (15 percent) increase from the previous year.  This year, a funding increase of at least $175 million will be needed to sustain and continue that effort.  Under this plan, more than 10 million Americans will gain access to health center services in thousands of communities across the country. 

2.   Restoration of facility construction, modernization, and expansion as allowable uses of funds (both Planning/Development and Operational grants) 

Explanation 

Many health centers operate in facilities that desperately need renovation or modernization.  In some cases, rapidly growing patient populations have strained the capacity of existing facilities-these facilities must be expanded.  Other facilities are old, or inadequate for the efficient delivery of primary health care-these facilities must be modernized or replaced.  A recent survey of health centers in 12 states found that almost two-thirds of them currently need to upgrade, expand or replace their current facilities.   Moreover, many needy communities are not yet served by health centers-new facilities will have to be built (or existing facilities modernized, expanded or replaced) in order to extend health center services there.

 However, most health centers have limited financial capacity to undertake needed facility improvements, expansions or new site development.  Because health centers serve a large and growing uninsured patient base, operating margins are slim to non-existent for most health centers.  That means that most health centers have only a very limited ability to support loans for their facility needs, and thus must rely on grants and charitable contributions.  Yet, because they serve low-income individuals who generally cannot contribute significantly to capital campaigns, health centers have great difficulty raising charitable contributions.   

At the same time, construction costs have soared in the strong economy.  As a result, the gap between what health centers can afford and the cost of capital projects is growing.  Restoring the government's ability to make grants for capital projects is critical to enabling health centers to maintain, modernize and expand their current facilities - or to replace old facilities or build new ones - to meet the growing demand for their safety net services.

 3.   Enhancement of current Loan Guarantee authority in Section 330 to cover facility loans 

Explanation

 Health centers' capital needs could also be more successfully met by enhancing the current federal Loan Guarantee authority in Section 330 -- which only permits the issuance of loan guarantees for managed care-related purposes -- to include loan guarantees for facility construction, modernization, and expansion, and for acquisition of facilities and equipment.  In 1997 and 1998, Congress earmarked, out of appropriations made for Section 330, a total of $14 million for loan guarantees to 330-funded health centers, both for managed care purposes authorized under Section 330 and for capital purposes as authorized under Title XVI of the PHS Act (although Title XVI continues to exist in the PHS Act, Congress has not directly appropriated funding for Title XVI programs in years).  Enhancing the current Loan Guarantee authority to cover facility loans would be consistent with Congressional intent to provide capital loan guarantees for health centers without having to appropriate funds against an otherwise dormant legislative authority, and would also permit other improvements to address shortcomings in current loan guarantee policy, including:

Ø      Allowing the guarantee to cover more than 80% (and up to 100%) of the outstanding principal amount would allow lenders to price the loans at significantly lower interest rates by reducing the risk to them.  Currently, OMB has determined that the federal loan guarantee for facilities can cover only 80% of the outstanding loan amount provided by a lender.  Financial experts have stated clearly that partial guarantees are not sufficient to leverage capital at below-market interest rates, because lenders still perceive significant risk in these loans and fear that, in the event of default, they may not be able to collect even a small amount of the unsecured debt they financed. 

Ø      Refinancing of existing loans is currently not an eligible use for loan guarantee funds.  If the refinancing results in significantly lower interest rates, the savings would benefit both the health center and the government.  In addition, some health centers that have experienced financial difficulties are not able to obtain loan renewals from lenders without guarantees, severely limiting their use where they are most needed. 

Ø      Permitting federal loan guarantees to be used with tax-exempt debt financing mechanisms would allow health centers to access the lowest cost capital available to nonprofit institutions, benefiting both health centers and the government.  Because the interest income from tax-exempt bonds is exempt from federal (and sometimes state) taxation, investors require lower returns on their investments than would otherwise be the case for taxable investments.  That tax-savings would translate into lower interest rates, allowing health centers to invest more of their operating resources into programs and services for vulnerable populations. 

In combination with the restored capital grant authority discussed above, a revised loan guarantee program would be more effective in meeting the pressing capital needs of health centers. 

4.   Clarification of funding authority for networks at least majority controlled and, as applicable, at least majority owned by health centers funded under Section 330 

Explanation 

Health centers currently collaborate with each other, and with other community providers, in many different forms of networks and partnerships designed to improve access to and quality of care for their patients, especially uninsured patients. These include practice management networks, designed to improve quality through shared expertise (such as centralized pharmaceutical or laboratory services, clinical outcomes management, or joint management/ administrative services), to lower costs through shared services (such as unified financial or Management Information systems, or joint purchasing of services or supplies), or to improve access and availability of health care services provided by the health centers participating in the network.  Most of these networks, once developed, need ongoing operational support to continue and further enhance their benefits.  However, current law only authorizes support for the planning and development of managed care networks and plans.  Expanding the types of health center-directed networks that can receive planning and development support, and allowing limited operational support for networks that are owned and/or controlled by Section 330-funded health centers, would substantially aid in achieving the health centers' mission and objectives. 

5.   Restoration of proportional funding allocation requirement for Community, Migrant, Homeless, and Public Housing Health Centers 

Explanation 

When four separate health center programs (Community, Migrant, Homeless, and Public Housing) were consolidated under a single Section 330 authority in 1996, the law included a requirement for allocating funds appropriated under Section 330 for each of the consolidated programs in accordance with the proportion of total funding they each had received in FY 1996.  Despite the fact that this statutory funding allocation requirement expired in 1998, BPHC has continued to adhere to the methodology in distributing overall Health Centers funding among the Community, Migrant, Homeless, and Public Housing health centers.  Vulnerable populations have benefited from BPHC's actions, and would be best served by restoring the original funding allocation methodology to the overall statute, thus ensuring the continued distribution of Section 330 funds to key underserved populations such as farmworkers, homeless persons, and public housing residents. 

6.   Clarification of eligible populations under Migrant and Homeless Health Center sub-authorities 

Explanation 

During consolidation of the health center authorities in 1996, coverage for formerly homeless individuals during the first 12 months following their transition to permanent housing was inadvertently dropped. Also, current authority fails to specify homeless youth as eligible for services, even though they remain a key homeless population. In addition, current law fails to recognize as eligible for services many farmworkers who, due to changes in agricultural employment, migrate for employment purposes but remain in farm work all year.  Clarifying the eligibility of farmworkers employed on a year-round basis, as well as homeless youth and formerly homeless persons following their transition to permanent housing would ensure that the program remains appropriately targeted to the most vulnerable populations. 

7.   Clarification on provision of required services 

Explanation 

Under Section 330, all federally-supported health centers are required to provide or arrange for certain key health and related services, including medical, diagnostic lab and radiology, pharmaceutical, preventive dental, and patient case management services.  Centers may also furnish additional services if needed by their patient populations, if resources are available. 

Despite the statutory requirement, many health centers (especially newer centers and those serving rural communities) have not been adequately funded to support the provision of all required services.  While this disparity has been reduced somewhat in recent years and may eventually be eliminated, and while the statutory requirement to provide comprehensive services remains a vital part of the health center model, clarification is needed to ensure that federally-supported health centers are expected "to the maximum extent practicable" to provide all required services, subject to available resources (both federal grant and other resources).

EXPLANATION OF PROPOSED CHANGES IN THE NATIONAL HEALTH SERVICE CORPS STATUTE

Background 

The National Health Service Corps (NHSC) plays a critical role in providing care for underserved populations by placing clinicians in urban and rural communities with severe shortages of health care providers.  Currently 2500 NHSC clinicians, including physicians, dentists, nurse practitioners, physician assistants, nurse midwives, and behavioral health professionals, provide health care services to 4.6 million Americans, including 2.2 million Health Center patients. 

While the NHSC program has proven successful in addressing health professional shortages in many areas, funding limitations have restricted the program's ability to meet its primary goal.  According to HHS, more than 12,000 physicians would be needed to place sufficient providers in all health professions shortage areas (4 times the current number of NHSC providers), and more than 20,000 would be needed to bring all areas of the country to the same staffing ratios for providers that are used by both managed care organizations and Health Centers (8 times the current number of NHSC providers).  The NHSC also needs to be streamlined to work more effectively with safety net providers, including Health Centers, which share the goal of improving health care access in underserved areas. 

PROPOSED CHANGES TO NATIONAL HEALTH SERVICE CORPS AUTHORITY 

1.         Reauthorize the National Health Service Corps for five-years at not less than $150 million for the first year and for such sums as are necessary for each subsequent fiscal year. 

Explanation 

Although the NHSC's most recent reauthorization was for a ten-year period, most parties agree that five years is preferable this time.  A five-year reauthorization demonstrates continued support for the purpose and role of the NHSC as a federal safety net program; provides for continuity in the administration of the program; and also allows for a more timely opportunity for Congress to review and make modifications in response to changes in the health care environment.  The NHSC also warrants a substantial funding increase to address the significant need in designated underserved areas for NHSC Scholarship and Loan Repayment program recipients, and to support other critical activities such as site development, evaluation, faculty and student placement, retention incentives and research. 

2.         Automatically designate all Federally Qualified Health Centers and Federally Certified Rural Health Clinics that meet the accessibility and affordability requirements (above) as Health Professional Shortage Area (HPSA) facilities.

 Explanation 

The NHSC and the Health Centers Programs are intended to address the same goal (to meet the health care needs of underserved populations) and are administered by the same federal agency, the Bureau of Primary Health Care.  Requiring a health center to obtain a Health Professional Shortage Area (HPSA) designation, even though each health center already serves a  "medically underserved area or population" creates a bureaucratic hurdle to placement of NHSC personnel at health centers.  Providing automatic HPSA facility status to health centers and rural health clinics, thus making them eligible for placement of NHSC personnel, will reduce bureaucratic barriers and allow coordinated use of federal resource in meeting the health care needs of areas that lack sufficient health care services. 

3.         Eliminate duplication of effort in the placement of NHSC personnel. 

Explanation 

After completing their taxpayer-funded medical education, many NHSC Scholars request -- and HHS often approves -- a waiver of their NHSC service obligation if they agree to establish a "private practice option (PPO)" in a designated HPSA.  In most such cases, the Scholar is free to practice in virtually any HPSA (whereas those who fulfill their service obligation through assignment are targeted to high-need HPSAs).  Currently, these "private practice option" clinicians are not subject to the requirement that they open their practice to all in the community regardless of ability to pay; and, in some cases, these NHSC-subsidized for-profit practices have been found to resist caring for uninsured - and even Medicaid-covered - patients, instead referring them to nearby health centers and other local safety net providers.  Congress should remedy this by restricting PPO placements to HPSAs that are not currently being served by a health center or rural health clinic, except where the PPO clinician is placed at the center or clinic. 

4.         Ensure fairness in priority consideration for NHSC placements. 

Explanation 

While intended to ensure that all Corps placements were made in areas of highest need, the current criteria used to determine whether a site is included on the high priority placement list has actually had the effect of discriminating against health centers and other similar entities, because it severely restricts the Secretary's flexibility to consider certain factors as indicators of need, including documented access barriers such as linguistic or cultural isolation, transportation barriers, and other factors highly correlated with underservice - such as large uninsured, elderly, disabled, or minority populations.  Thus, an area or population distinguished by the above-noted characteristics, but with a relatively low infant mortality rate or what appears to be an adequate supply of health professionals, for example, would be penalized by being deemed a low priority for the placement of a new NHSC assignee. 

5.         Establish due process rights in cases of HPSA de-designations and priority list development. 

Explanation 

Under current law, the Secretary is required to notify interested organizations and individuals in an area of that area's de-designation as a HPSA, but is not required to follow the same procedure in the case of a population group's or facility's de-designation.  Furthermore, while current law requires the Secretary to publish annually list of priority placement sites for new NHSC assignments, it does not require notice to entities that are not included on the list, nor does it provide any due process rights to such entities to provide supplemental information or to file an appeal of their exclusion.  Such due process rights are a central part of many other statutes, and should be included in the NHSC law, particularly in view of the consequences of the loss of HPSA designation or priority status to areas that had previously been considered high-priority shortage areas. 

6.         Allow NHSC scholarship and loan repayment program recipients to fulfill their commitment on a part-time basis.  This option would only be available if such service is agreed to by 1) the placement site or sites as well as the scholarship and loan repayment recipients and 2) so long as the total obligation is fulfilled.   

Explanation

 Flexibility should be provided to enable Scholarship or Loan Repayment program recipients to complete their service obligation on a full-time or part-time basis, with the approval of the placement site.  Many small rural communities may not have sufficient volume to support a full-time health care practitioner.  In addition, some sites may not need particular types of providers on a full-time basis.  Flexibility should be given to the Department to permit part-time service in meeting community needs.  In addition, some practitioners may find part-time service more attractive, which in turn could improve both recruitment and retention at these sites. 

7.         Include a specific allocation for site development and community needs assessment.   

Explanation 

The NHSC was created to meet the needs of communities that lack access to health care services.  In many cases, those shortage communities require physical, oral, and mental/behavioral health care services.  Over the years, the NHSC has recognized that each community has unique health needs and has placed a wide variety of health professionals in sites to meet those needs.  However, many believe that the NHSC needs to dedicate additional resources to inform and educate communities about the variety of placement opportunities provided by the NHSC, and to assess the real health care needs of communities that are applying for placement of personnel.  In order to ensure that communities receive the maximum benefit from the program, the NHSC should allot adequate resources to inform communities of the variety of health care resources available through the NHSC and how those resources can best be used to meet the unique health needs of communities, in collaboration with those communities and other health partners. 

8.         Assist communities and sites in developing incentives to support the retention of NHSC providers beyond their obligation. 

 Explanation 

Many current and former NHSC recipients have expressed concerns about professional isolation and burnout during their term of obligated service.  While most initially declare their intent to remain after completing their obligation, many change their minds by the time their assignments are completed.  In many communities, the NHSC recipient may be the only health care professional.  As such, they are "on" 24 hours per day, 7 days per week.  Providing scheduled breaks for professional development or personal time will increase the likelihood that recipients will remain in these communities beyond the period of their assignment.  Examples of incentives might include support for locum tenens, mini-sabbaticals, continuing professional education, and increased practice management technical assistance for current scholarship and loan repayment recipients. 

9.         Eliminate the community cost-sharing provision (Section 334 of the Public Health Service Act). 

Explanation 

Section 334 of the Public Health Service Act ("Cost Sharing") requires that an entity to which a member of the NHSC is assigned must reimburse the Federal government for the cost of that NHSC member.  In practice, this requirement is waived in almost all cases.  In 1998, the cost-sharing requirement was waived in at least 95% of cases and the cost of collecting the remaining 5% of payments exceeded the funds received.  This provision should be eliminated because it creates an undue burden on communities (which are economically unstable by definition) in seeking an NHSC clinician, and it poses an unnecessary administrative burden on the NHSC.  Clearly, these dollars could be better used in providing access to care.  This action is consistent with the spirit of the Paperwork Reduction Act and will facilitate increased usage of NHSC' clinicians by underserved communities.

10.       Require all NHSC Scholarship and Loan Repayment recipients, as well as all NHSC placement sites, to (1) serve all residents regardless of ability to pay (2) bill and collect from third party payers for care furnished to covered individuals and (3) discount normal charges for out-of pocket costs based on ability to pay. 

Explanation 

Section 334 (repealed above) included language requiring that Corps personnel ".to the maximum extent feasible, provide.services.to all individuals in, or served by, such HPSA regardless of their ability to pay for services.."  These provisions need to be retained elsewhere in the NHSC statute and to be clarified to reinforce the principle that a vital purpose of the NHSC is to reduce access barriers for everyone living in communities lacking health professionals, regardless of their income or ability to pay for services.  In addition, language is needed to require DHHS to monitor this requirement to determine whether Corps personnel and their sites are actually meeting these requirements and to enforce compliance. 

Related Recommendations:  

1.         Exclude from Federal income, FICA, and self-employment taxation tuition, fees and related educational expenses to individuals participating in the NHSC Scholarship, Loan Repayment, Community Scholarship and State Loan Repayment program (group with other retention provisions).   

Although this falls under the jurisdiction of other Congressional Committees, and must therefore be moved through separate legislation, all parties agree with the NHSC and the NHSC Advisory Council that taxing students adversely affects the financial incentive to participate in the NHSC and provide health care services in underserved communities, many of which are frontier communities.

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