Community health clinics serve as a crucial safety net in South Los Angeles, where health insurance and access to primary care is anything but a given.
Starting in 2010, the Affordable Care Act (ACA) gave these clinics what will eventually total an $11-billion boost, aimed at expanding primary and preventive care services.
But it's a different story when it comes to "subspecialty care," a term one new study used to refer to cardiology, gastrology, neurology, urology and "the whole spectrum of specialities and subspecialties under those." ACA funding won't necessarily increase access to care like this, and this study was an attempt to pin down the best system for providing subspecialty care within the constraints of a community health clinic system.
Dr. Katherine Neuhausen was the study's lead author, and said clinics already struggle to provide their patients with access to subspecialty care – for example, she said, a considerable 25 percent of visits to community health clinics result in specialty care referral.
"And the demand is only going to increase," she said, pointing to the ACA's impending Medicaid expansion. In her conversations with clinic directors nationwide, Neuhausen said "it became very clear that their Achilles heel is specialty care access."
Why providing subspecialty care is a challenge
The doctor says the reason providing subspecialty care an Achilles heel is twofold: There's a lack of financial incentives and often a barely-there clinic infrastructure.
Financially speaking, Neuhausen said most specialists who contribute their services within the safety net don't get paid for what they do. "They're really seeing [patients] out of the goodness of their hearts," she said.
As far as infrastructure, there really isn't one – with a few exceptions, Neuhausen allows. She explained that clinics began as a grassroots, hyperlocal way of responding to the underserved within a certain community. While that "historic legacy" of responsiveness and local focus was one of the things that allowed community clinics to be so effective, says Neuhausen, it's also part of the reason they never – on a broad scale, at least – formed comprehensive networks with providers who did more than primary and preventive care.
So, while community health clinics aim to become patients' medical home, said Neuhausen, what they ought to be striving for is to "move them from a medical home to a medical neighborhood."
As such, she and her fellow researchers identified six models of how clinics provide subspecialty care:
1. Tin cup: In this model, which researchers said is the most prevalent one, the clinic relies on its providers' personal relationships with informal networks of subspecialists, with the hope that those subspecialists will provide the uninsured with charity care. (In other words, this is the model where specialists see uninsured patients "out of the goodness of their hearts.")
2. Hospital partnership Clinics negotiate a contract with a community hospital that will provide clinic patients with subspecialty care.
3. Buy your own: Clinics hire their own subspecialists.
4. Telehealth/telemedicine: Clinics use telecommunications equipment to remotely connect patients with subspecialists.
5. Teaching community: Clinics bring subspecialists on board to train their primary care specialists on how to provide subspecialty care.
6. Integrated systems: Clinics integrate with local government health systems or with safety net hospitals that already have their own networks of subspecialists. (This is the "medical neighborhood model.")
Researchers found that community clinics' use of integrated systems was the most effective route to providing subspecialty care.
"[That] makes perfect sense, clinically, with what I would expect," said Neuhausen, explaining that integrated systems are highly effective outside the medical safety net – so it'd only make sense they work well within the safety net, too.
How integrated systems work and their place in L.A.
Neuhausen explained how integrated systems work in Denver, which was one of the focal points of her study and is, in her view, a sterling example of how community health clinics can thrive within an integrated system.
The Denver Health Network includes eight community health clinics and 12 school-based centers. She said all those clinics share an electronic health record with the area's general hospital, and that all clinic patients have access to the hospital's in-patient care services and its full spectrum of specialists.
Sharing an electronic health record is crucial. That means if, for example, a patient with diabetes, heart problems and hypertension goes to a clinic, the clinic provider can refer the patient to a cardiologist at the hospital. That cardiologist, in turn, will be able to see all the clinic provider's notes and charts on the patient via a web-based portal. It works the other way, too – the cardiologist can make notes on the patient that the clinic provider will be able to access next time he or she sees the patient.
"It really promotes these seamless care transitions where patients aren't falling through the cracks," said Neuhausen.
She said Los Angeles is on its way toward an integrated system. The L.A. County Department of Health Services has more than 100 public/private partnerships, she said, where the county will pay private entities to provide primary care for the uninsured. It's also in the midst of creating a "transformative" electronic referral system, said Neuhausen, which will allow primary care providers to know what's happening with their patients at the specialist's office and vice versa.
That doesn't necessarily happen right now, and it's resulting in a lot of still-sick people and a lot of lost dollars.
"It will be a much more active, two-way exchange of information between primary care provider and specialist," said Neuhausen.
Nina Vaccaro is the head of the Southside Coalition of Community Health Clinics, which has eight member sites in South L.A., and says Neuhausen's findings are right on.
"These band-aid approaches to providing access to subspecialty care only work as long as the relationships and the individuals that have built those workarounds are there," said Vaccaro. "They're not really sustainable and the systemic integration of those relationships and services are really the most ideal way to go."
Vaccaro says what's happening in Los Angeles has a lot of the characteristics of an integrated system, but it's not quite there – yet.
"We're getting there," she said. "We're working on it."
Neuhausen agrees, provided that community health clinics "really buy in" and decide integrated systems are the next step, and that certain policy initiatives pick up sufficient momentum. She said the Center for Medicare & Medicaid Services (CMS), for example, sent a letter last month to Medicaid directors describing pathways for how states can implement integrated systems models for Medicaid populations. Neuhausen also said CMS has set aside $275 million for states to design and test new payment models, which could include integrated system-like plans.
"I do think this could be the future," she said. "But I do think there's more to be done."
This post has been corrected and clarified.