I need the following question answered?
Question
- Federally Qualified Health Centers (FQHC's) were originally established to provide healthcare to those who did not have insurance. Since the Affordable Care Act requires all Americans to have health insurance or pay a fine, do you believe that those who do
notsign up for health insurance should be able to access free healthcare services at an FQHC?
*** References are attached****
ORIGINAL CONTRIBUTION Shortages of Medical Personnel at Community Health Centers Implications for Planned Expansion Roger A. Rosenblatt, MD, MPH C. Holly A. Andrilla, MS Thomas Curtin, MD L. Gary Hart, PhD RESIDENTS OF THE UNITEDStates lack universal access tohealth care, and millions ofpeople have difficulty obtain- ing medical care.1,2 The year 2005 marked the 40th anniversary of one of the nation’s most enduring attempts to remedy this problem: the creation of community health centers (CHCs) as part of the “war on poverty.”3-8 The na- tional importance of these centers has grown during the ensuing 4 decades, and the federal government provides funding through a variety of categori- cal mechanisms under the collective term federally qualified health centers. CHCs provide medical, dental, and mental health care for migrant work- ers, the uninsured, the homeless, and others in need, and the number of people they have served has expanded rapidly in the 21st century.9 The role and responsibility of CHCs have increased as more people in the United States have difficulty gaining ac- cess to medical care.10 CHCs now pro- vide care to more than 14 million US residents in more than 3500 commu- nities.9 Governed by nonprofit boards with majority representation from the patient population served, CHCs are different from the private practices and for-profit entities that deliver most am- bulatory care in the United States.11 A national decision to invest fur- ther in CHCs has occurred during a pe- riod when access to health care in the United States is limited for more peopleFor editorial comment see p 1062. Author Affiliations: WWAMI (Washington, Wyo- ming, Alaska, Montana, Idaho) Rural Health Re- search Center, Department of Family Medicine, Uni- versity of Washington, Seattle (Drs Rosenblatt and Hart and Ms Andrilla); and National Association of Com- munity Health Centers, Bethesda, Md (Dr Curtin). Corresponding Author: Roger A. Rosenblatt, MD, MPH, University of Washington, Department of Fam- ily Medicine, Box 354696, Seattle, WA 98195-4696 (rosenb@u.washington.edu). Context The US government is expanding the capacity of community health cen- ters (CHCs) to provide care to underserved populations. Objective To examine the status of workforce shortages that may limit CHC ex- pansion. Design and Setting Survey questionnaire of all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Co- lumbia, conducted between May and September 2004. Questionnaires were com- pleted by the chief executive officer of each grantee. Information was supplemented by data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted to be nationally representative. Main Outcome Measures Staffing patterns and vacancies for major clinical dis- ciplines by rural and urban location, use of federal and state recruitment programs, and perceived barriers to recruitment. Results Overall response rate was 79.3%. Primary care physicians made up 89.4% of physicians working in the CHCs, the majority of whom are family physicians. In rural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians compared with 38.9% in urban CHCs. There were 428 vacant funded full-time equiva- lents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were vacancies for 13.3% of family physician positions, 20.8% of obstetrician/ gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a higher proportion of vacancies and longer-term vacancies and reported greater difficulty fill- ing positions compared with urban CHCs. Physician recruitment in CHCs was heavily dependent on National Health Service Corps scholarships, loan repayment programs, and international medical graduates with J-1 visa waivers. Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities. Conclusions CHCs face substantial challenges in recruitment of clinical staff, par- ticularly in rural areas. The largest numbers of unfilled positions were for family phy- sicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be chal- lenged by these workforce issues. JAMA. 2006;295:1042-1049 wwww.jama.com 1042 JAMA, March 1, 2006—Vol 295, No. 9 (Reprinted) ©2006 American Medical Association. All rights reserved. Downloaded From: http://jama.jamanetwork.com/ by a Oklahoma State University User on 07/16/2014 than ever before in the country’s his- tory.10,12,13 Ongoing plans include a 5-year initiative that will increase fed- eral spending on CHCs by at least $2.2 billion through fiscal year 2006 and substantially increase the number of treated patients.14-17 We examined the status of the health care workforce in CHCs in the United States, with particular attention to the types of personnel who are most diffi- cult to recruit and retain. Rural health care delivery systems are smaller and less well staffed than their urban coun- terparts; 20% of the US population lives in rural areas but only 9% of physi- cians practice there.18,19 We therefore also examined whether workforce shortages are more acute in rural CHCs and whether rural and urban CHCs dif- fer in their staffing patterns, the source of their clinicians, and their ability to retain clinicians. METHODS The study was undertaken by the Ru- ral Health Research Centers of the Uni- versity of Washington and the Univer- sity of South Carolina and the National Association of Community Health Cen- ters (NACHC). A questionnaire was created and pretested with the assis- tance of an advisory committee com- posed of representatives from the Of- fice of Rural Health Policy, Bureau of Primary Health Care (BPHC), and Bu- reau of Health Professions, all compo- nents of the Health Resources and Ser- vices Administration of the US Public Health Service. For questions about per- ceived barriers to recruitment, respon- dents answered on a 4-point scale (1=not important, 4=important), and the answers were dichotomized into im- portant or not important. The survey instrument and research methods were reviewed and approved by the Office of Management and Budget and by the in- stitutional review boards of the partici- pating universities. The study population included the 890 nonprofit organizations that re- ceived funding from the federal govern- ment’s Section 330 Consolidated Health Center Program15 and reported data to BPHC’s Uniform Data System (UDS) as of 2004. We excluded grantees that did not directly provide general clinical ser- vices or were outside of the 50 states and the District of Columbia, leaving a sam- pling frame of 846 grantees. The survey instrument was mailed to the chief executive officer of each grantee, with a cover letter from NACHC, on May 7, 2004. A reminder postcard was sent on May 21, and a sec- ond mailing and questionnaire with a new cover letter was sent to nonrespon- dents on June 11. After 2 mailings, all nonrespondents from rural CHCs were surveyed by telephone between Sep- tember 2 and 17 and asked a subset of the original questions restricted to cli- nician supply issues. The final re- sponse rate was 79.3%, ranging from 85.3% for the largest grantee category (CHCs without other federal funding sources) to 50.9% for the CHCs that re- ceived funding solely as homeless cen- ters. Rural grantees’ response rate (in- cluding the minimal data set obtained by telephone) was 97.5%; urban cen- ters’ response rate was 68.5%. Exclud- ing the 2 categories of centers with re- sponse rates below 60% did not change the results. Urban and rural designations are based on the ZIP code version of the Ru- ral-Urban Commuting Area (RUCA) classification system.20,21 Because of dif- ferential response rates between orga- nizations in urban and rural locations, as well as regional differences, survey re- sults were weighted to make them na- tionally representative. Weights were tested by being applied to survey re- sponses and comparing the results with UDS variables, including CHC type, size, and patient population. Many CHCs have multiple clinical sites, but each re- ports data to the federal government only in aggregate. Therefore, the results re- ported apply to the grantee as a total en- tity and not individual clinical sites. The information from the returned questionnaires was coded and data were entered for analysis. The data were checked for systematic errors during routine data cleaning. When response categories for data collected in the UDS matched survey questions exactly, missing data were imputed from the 2003 UDS. The validity of this imputation was supported by comparison of 2004 survey data and 2003 UDS data for those items in which the response categories were identical, with survey results similar for each category and around 10% higher than UDS, consistent with the 1-year program growth. The source of data on number of patient visits was the 2003 UDS. Means were compared using t tests, and proportions were compared using �2 tests. All tests were 2 sided, and significance was set at P�.05. Data analysis was performed with SPSS statistical software version 11.5 (SPSS Inc, Chicago, Ill). RESULTS Location, Structure, and Staffing The majority of CHCs (62.8%) in the United States are funded as CHCs only (TABLE 1). An additional 114 grantees are funded as homeless centers (13.4%), either as stand-alone entities or in con- junction with CHCs. An additional 93 grantees (11.0%) are either migrant health centers (MHCs) or a combina- tion of CHCs and MHCs. The other 108 health centers represent institutions with other funding combinations. As a group, US CHCs are in the pro- cess of expanding their capability of providing services, with 66.3% of the grantees planning to expand their op- erations and 54.6% in the process of adding new clinical sites (Table 1). Only 18.1% of the grantees replied that they were planning to do neither. One of the most important determi- nants of the structure and function of the CHCs is whether they are located in ru- ral or urban areas. Urban grantees are much more likely to receive their fund- ing from categorical grant programs that grew out of the initial CHC program; 46.5% of urban grantees receive some or all of their funding from the newer fund- ing streams compared with 21.6% of the rural grantees (P�.001). Rural CHCs have a mean of 30.9 clinical full-time equivalents (FTEs) compared with the urban CHCs, with a mean of 51.8 FTEs; SHORTAGES OF MEDICAL PERSONNEL AT COMMUNITY HEALTH CENTERS ©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, March 1, 2006—Vol 295, No. 9 1043 Downloaded From: http://jama.jamanetwork.com/ by a Oklahoma State University User on 07/16/2014 rural centers serve a mean of 9921 pa- tients and have a mean annual budget of $4 615 639, compared with urban grant- ees who serve 16 536 patients and spend $8 488 775 per year. The main objective of CHCs is the provision of primary care services, and their clinician mix reflects this mis- sion (TABLE 2). Primary care physi- cians comprise 89.4% of CHC physi- cians. Family physicians are the single largest category of specialists in both ru- ral and urban centers, accounting for 48.1% of the total physician staff. Ur- ban grantees employ more internists and pediatricians, but even in these set- tings the total number of family phy- sicians equals the combined number of internists and pediatricians. Obstetrician/gynecologists and psy- chiatrists represent less than 10% of the CHC physician workforce and are more likely to be found among urban grant- ees. There are few other specialty phy- sicians; “other specialist physicians” ac- count for only 2.6% of the total number of physicians employed by the CHCs, from the 2003 UDS. Of the grantees, 62.5% of those from rural areas and 28.8% of those from urban areas em- ploy only physicians from the 3 pri- mary care fields. The physician staff is comple- mented by a substantial number of primary care nonphysician clinicians, represented by nurse practitioners, phy- sician assistants, and certified nurse midwives. In rural CHCs, 46% of the direct clinical providers of care are non- physician clinicians compared with 38.9% in urban CHCs. Urban grantees are more likely to employ nurse prac- titioners. The distribution of nurse mid- wives is similar to that of obstetricians. The CHCs have a large comple- ment of registered nurses, with a mean of 3.8 FTEs for rural grantees and a mean of 5.7 FTEs for the urban grant- ees. Mental health clinicians and den- tists are present in most of the CHCs; the number of dentist FTEs in urban areas is almost twice that of their rural counterparts. Pharmacists are com- monly found in both settings. Clinician Vacancies Funded staff vacancies are common in CHCs (TABLE 3). The greatest aggre- Table 1. Structural Characteristics and Expansion Plans of Federally Funded Health Centers, by Grantee Type* Grantee Type No. of Clinical Sites per Grantee, Median (Range) No. (%) Mean No. in 2003† Encounters per FTE Physician in 2003† No. (%) Grantees Survey Response Rate Rural Patients Visits Clinical FTEs Planning to Expand Operations Planning to Expand Sites CHC only 3 (1-21) 531 (62.8) 453 (85.3) 247 (46.5) 11 315 43 792 35.0 3855 379 (73.2) 293 (57.8) CHC/MHC 5 (1-26) 80 (9.5) 67 (83.8) 44 (55.0) 21 571 86 059 71.4 4158 51 (73.7) 51 (68.4) Homeless only 7 (1-88) 57 (6.7) 29 (50.9) 1 (1.8) 5512 26 437 13.9 2630 21 (58.2) 16 (45.6) CHC/homeless 6 (1-27) 57 (6.7) 44 (77.2) 4 (7.0) 18 387 69 553 58.0 3995 46 (79.0) 40 (74.8) CHC/school health 8 (1-36) 35 (4.1) 21 (60.0) 6 (17.1) 26 546 119 546 95.6 3706 19 (81.4) 19 (79.4) MHC only 6