Department  of  Health and Human  Setices 
OFFICE  OF 
INSPECTOR  GENERAL 
AN  OVER~W 
DECE~ER  1992 
  OFFICE  OF INSPECrOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Semites (HHS) 
programs as well as the health and welfare of beneficiaries sexved by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Semites, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE  OF AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors  in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE  OF INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment  by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF EVALUATION  AND  INSPECITONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs.  This report was prepared in the Boston regional 
office under the direction of Mark R. Yessian, Ph.D., Regional Inspector General,  and Martha 
B. Kvaal, Deputy Regional Inspector General.  Project staffi 
Dana L. Miller, Projecr Leader  Maruta Zitans 
Timothy J. Corbett  Barbara Tedesco 
Madelaine T. Tully 
Deborah Skahan 
For additional copies of this repo~  please contact the Boston regional office at 617/565-1050.  Depatiment  of  Health  and Human  Sefices 
OFFICE  OF 
INSPECTOR  GENERAL 
AN  OVER~W  EXECUTIVE  SUMMARY 
PURPOSE 
This  report  describes  recent  trends  in the  perinatal  service  capacity  of the  community 
health  centers  funded  under  Section  330 of the  Public  Health  Service  Act. 
BACKGROUND 
Community  health  centers  (CHCS)  play an important  role  in reducing  infant  mortality 
by delivering  comprehensive  perinatal  care  to high-risk  women  in medically  undersexed 
areas  across  the  nation.  Many  of these  women  are  difficult  to reach  and  do not 
appreciate  the  importance  of prenatal  care.  In  1991, the  Federal  government  supported 
services  at 514 CHCS through  Public  Health  Service  (PHS)  Section-330  grants,  PHS 
Section-329  and  -340 grants  for migrant  workers  and  the  homeless,  Medicare  and 
Medicaid  reimbursements,  Maternal  and  Child  Health  grants,  and  the  National  Health 
Service  Corps. 
In recent  years  the  Federal  government  has made  an  increasing  investment  in the 
centers.  Little  information  is available,  however,  on the  extent  to which  the  centers  are 
able  to meet  the  perinatal  care  needs  of the women  they serve.  To  examine  the  capacity 
of the  centers  to provide  perinatal  care,  we conducted  a mail  sumey  of all CHCS; 
inte~iewed  center  staff and  management;  held  discussions  with PHS  administrators,  State 
officials,  and  infant  health  care  experts;  and  reviewed  relevant  literature  and  data.  Our 
sumey  was completed  in June  1991.  our  findings  are  based  primarily  on  information 
reported  by the  centers  to us and  to PHS. 
FINDINGS 
Increased  Capacity  The  capacity  of the  community  health  centers  to provide  perinatal 
care  increased  in several  respects  between  1988 and  1990: 
  Prenatal  caseloads  increased  an average  of 22 percent. 
  The  range  of medical  and  health  promotional  services  increased  at 68 percent  of 
the  centers.  The  services  added  at the  largest  number  of centers  were  HIV 
testing  and  counseling,  smoking-cessation  programs,  and  classes  in parenting  and 
childbirth. 
F  The  range  of ancillary  services--such  as home  visiting  and  transportation--increased 
at  32 percent  of the  centers. 
F  Total  center  revenues  increased  27 percent. 
i  Increased  Demand:  Despite  these  increases  in capacity,  demand  for perinatal  services 
has continued  to grow, and  many  center  clients  still do not  receive  the  optimal 
coordinated  package  of care  in a timely  fashion. 
Fourteen  percent  of the  centers  reported  that  they  provided  no perinatal  services 
on site between  1988 and  1991.  Our  study did not  examine  the  extent  to which 
these  centers  made  alternative  perinatal  care  arrangements  for their  clients. 
Demand  for services  increased  at 82 percent  of the  centers;  39 percent  of these 
centers  reported  their  capacity  to meet  this growing  demand  either  decreased  or 
remained  the  same. 
Many  centers  reported  that  they  do not  coordinate,  as part  of their  perinatal 
case-management  efforts,  all of the  health  and  social  services  recommended  by the 
Public  Health  Semite.  This may,  in part,  reflect  variations  in the  definition  of 
case management  among  centers. 
On  average,  55 percent  of each  centers  prenatal  clients  entered  care  during  the 
first trimester  in  1990.  Nationally,  76 percent  of all women,  62 percent  of minority 
women,  and  58 percent  of women  in Healthy  Start  project  areas  entered  care 
during  the  first  trimester. 
On  average,  21 percent  of each  centers  first-trimester  enrollees  received  fewer 
than  9 prenatal  visits.  Our  study did not  examine  the  extent  to which  these 
patients  may have  received  care  elsewhere. 
Limitations  to Care:  Centers  identified  several  major  constraints  that  seriously  limit their 
capacity  to provide  perinatal  care.  Among  these  are: 
_  Medical  staff shortages,  in part  as a result  of cuts  in the  National  Health 
Setice  Corps  in the  1980s, present  serious  problems  at 63 percent  of centers. 
Although  the  number  of prenatal  clients  increased  an average  of 22 percent  at the 
centers,  the  number  of obstetricians,  family physicians,  and  certified  nurse 
midwives  increased  an  average  of 5 percent. 
Medical  Mahxwtice  Lnsurance.  The  high cost of medical  malpractice  insurance 
has been  a serious  problem  at  56 percent  of centers.  In late  1992, Congress  took 
initial  steps  to address  this problem  by passing  legislation  (P.L.  102-501) that 
extends  medical  malpractice  liability protection  under  the  Federal  Tort  Claims  Act 
(ITCA)  to health  care  providers  at the  centers. 
Communiw-Provider  Relations.  Seventy-six  percent  of the  centers  report  serious 
problems  stemming  from  inadequate  coordination  of perinatal  services  in the 
community,  a lack of other  local  providers  willing to treat  uninsured  and 
ii  publicly  insured  women,  difficulty arranging  obstetric  backup  for center  staff and 
for consultation  for high-risk  clients,  or difficulty  obtaining  hospital  privileges  for 
center  staff. 
Health  Insurance.  On  average,  19 percent  of each  centers  perinatal  clients  were 
uninsured  in 1990.  At 9 percent  of centers,  more  than  half  of the  perinatal  clients 
were  uninsured. 
Medicaid  Funding:  Medicaid  is an important  source  of revenue  for the  centers  perinatal 
semices. 
On  average,  67 percent  of each  centers  perinatal  clients  were  enrolled  in 
Medicaid  in  1990. 
Medicaid  reimbursements  to centers  increased,  as a percentage  of total  revenues, 
from  approximately  17 percent  in 1988 to 21 percent  in 1990. 
Nonetheless,  73 percent  of the  centers  reported  serious  problems  with Medicaid-
burdensome  application  procedures,  inadequate  and/or  slow reimbursement, 
restrictive  eligibility  criteria,  or a limited  range  of covered  services. 
Only  56 percent  of centers  reported  that  they offered  on-site  assistance  with 
enrollment  in Medicaid,  even  though  recent  Federal  law required  that  the  States 
outstation  workers  to do so. 
Only  27 States  and  the  District  of Columbia  had  begun  to implement  cost-based 
reimbursement  to the  CHCS by May  1991, as called  for in the  Federally  Qualified 
Health  Centers  mandate. 
Comprehensive  Perinatal  Care  Program  (CPCP):  The  CPCP  provided  supplemental 
funds  for enhanced  perinatal  services  to approximately  two-thirds  of the  centers  for at 
least  one  year  between  1988 and  1991. 
  Eighty  percent  of centers  that  received  CPCP  funds  expanded  their  range  of 
perinatal  services  between  1988 and  1990, compared  with 50 percent  of other 
centers. 
  A larger  percentage  of CPCP  grant  recipients  than  of other  centers  coordinate  all 
of the  PHS-recommended  health  and  social  services  through  their  perinatal  case-
management  efforts. 
  Responses  to our  survey  indicated  no significant  differences  between  CPCP  grant 
recipients  and  other  centers  in the  percentage  of clients  who entered  care  in the 
first trimester  in 1990.  We did not gather  information  on changes  over  time  in 
first-trimester  enrollment. 
... 
111    Responses  to our  survey  indicated  no significant  differences  between  CPCP  grant 
recipients  and  other  centers  in the  percentage  of first-trimester  enrollees  who 
received  at  least  nine  prenatal  visits in 1988 or  1990. 
Urban-Rural  Comparisons:  Between  1988 and  1990, the  capacity  of urban  and  rural 
centers  to provide  perinatal  care  increased  in terms  of prenatal  caseload  size, the  range 
of services  offered,  and  overall  revenues.  The  increases  were  greater  for  urban  centers 
than  for  rural  centers. 
*  A greater  percentage  of rural  centers  (20 percent)  than  urban  centers  (6 percent) 
offered  no perinatal  services  on site between  1988 and  1991.  Our  study did not 
examine  the  extent  to which  these  centers  made  alternative  perinatal  care 
arrangements  for their  clients.  Rural  centers  with  perinatal  programs  offered 
more  timely  care  than  urban  centers. 
>  Urban  and  rural  centers  identified  the  same  factors  as serious  limitations  to their 
ability  to provide  perinatal  care.  Limited  space  was a problem  for  a greater 
percentage  of urban  centers,  and  staff shortages  were  a problem  for  a greater 
percentage  of rural  centers. 
KEY  AREAS  FOR  ACIION 
In recent  years,  government  at all levels has looked  to the  CHCS to play  a more 
prominent  role  in providing  perinatal  care  to poor,  high-risk  women.  As the  data  in this 
report  suggest,  the  capacity  of centers  to provide  perinatal  services  has  increased  in 
several  important  respects  since  1988.  More  women  are  being  served  and  a wider  range 
of services  is being  offered.  Many centers,  however,  are  burdened  by major  problems 
that  limit their  ability  to meet  the  heightened  expectations  they face.  The  problems  are 
pervasive  and  suggest  vulnerabilities  that  cannot  be  effectively  addressed  by the  centers 
alone. 
In part,  the  difficulties  facing  centers  reflect  problems  of access  and  cost  in the  nations 
health  care  system  and  are  dependent  for resolution  on broad  reforms  in that  system. 
Nonetheless,  there  are  important  actions  policy makers  can  take  now to strengthen  the 
capacity  of centers  to provide  care.  The  data  in this report  suggest  four  critical  areas 
that  warrant  immediate  attention.  Policy makers  at all levels of government--Federal, 
State,  and  local--need  to: 
E  Address  the  staffing  needs  of the  centers.  If community  health  centers  are  to 
meet  the  increasing  demand  for services,  they  need  to be better  able  to attract,  retain, 
and  utilize  clinicians.  Thus,  it is vital  to identify  cost-effective  steps  to  (1) ensure  an 
adequate  supply  of clinicians,  (2) develop  more  effective  incentives  for  clinicians  trained 
with  public  funds  to locate  in undersexed  areas,  and  (3) ease  undue  restrictions  on the 
credentialing  of certified  nurse  midwives,  nurse  practitioners,  and  physician  assistants. 
iv    Assure  that  recent  legislation  effectively  relieves  the  centers  of the  high cost of 
medical  malpractice  insurance.  The  high cost of malpractice  insurance,  particularly  for 
clinicians  providing  perinata]  care,  has limited  the  centers  ability  to offer  services.  In 
late  1992, Congress  took  initial  steps  to address  this  problem  by extending  medical 
malpractice  liability  protection  under  the  Federal  Tort  Claims  Act  (ITCA)  to health  care 
providers  at  the  centers.  It is necessary  to monitor  this new arrangement  to ensure  that 
it effectively  addresses  the  centers  concerns. 
  Continue  to imprwe  ties between  the  centers  and  the  Medicaid  program.  An 
effective  link between  centers  and  the  Medicaid  program  is vital  given the  high 
proportion  of Medicaid-insured  women  served  by the  centers  and  the  expanded 
Medicaid  coverage  now available  for their  prenatal  care.  It is particularly  crucial  to 
ensure  that  the  law requiring  outstationing  of Medicaid  eligibility workers  at CHCS 
and  the  law  ensuring  cost-based  reimbursement  to centers  as Federally  Qualified 
Health  Centers  (FQHC)  are  both  fully implemented  and  working  optimally. 
Continue  to strengthen  relationships  with other  health  and  social  seMce 
p~oviders.  To  be  more  comprehensive  and  efficient,  the  perinatal  services  offered  by 
centers  must  be  more  effectively  linked  with those  of other  providers  in the 
community.  It is particularly  important  to increase  the  number  of providers  willing to 
serve  Medicaid  patients,  to simpli~  enrollment,  to facilitate  referrals  among  programs, 
and  to ensure  that  center  clinicians  have  staff  privileges  at hospitals  in their 
communities. 
RECOMMENDATION 
The  Assistant  Secretary  for  Health  the  Administrator  of the  Health  Care  Financing 
Administratio~  and  the  Assistant  Secretary  for  Planning  and  Evaluation  should 
develop  a plan  of action  to address  the  key areas  outlined  above. 
The  PHS  and  HCFA  should,  individually  and  collaboratively,  develop  plans  of action 
that  incorporate  specific  targets  and  concrete  steps  to ensure  that  the  key areas  for 
action  are  addressed.  The  ASPE  should  review  these  plans  and  assure  that  they are 
compatible  and  adequate  to meet  the  nations  health  goals for the  year  2000 to reduce 
infant  mortality  rates  and  increase  access  to perinatal  care.  The  ASPE  should 
coordinate  activities  and  monitor  implementation  of the  plans. 
The  PHS  cannot  effectively  address  these  problems  alone.  Other  Departmental 
components,  State  and  local government  agencies,  and  nongovernmental  organizations 
must  be  involved  in planning  and  implementation.  of  particular  importance  is 
cooperation  between  public  health  and  health  care  financing  agencies  at both  the 
Federal  and  State  levels. 
Only through  concerted  action  to address  the  key problem  areas  identified  above  can 
the  potential  for the  community  health  centers  be  more  fully realized.  Strategies  for 
improving  perinatal  care,  such  as expanded  insurance  coverage  and  aggressive 
v  outreach  programs,  will be successful  only to the  extent  that  centers  can  provide 
sufficient  clinical  services  linked  effectively  with other  health  and  social  semtices. 
Unless  the  serious  problems  affecting  the  community  health  center  system  are 
addressed,  the  centers  capacity  to meet  increased  demand  and  heightened 
government  expectations  will continue  to be strained  and  the  system will remain 
vulnerable. 
COMMENTS  ON THE  DRAFT REPORT 
We  received  formal  comments  on our  draft  report  from  the  Public  Health  Sewice 
(PHS),  the  Office  of the  Assistant  Secretary  for Planning  and  Evaluation  (ASPE),  and 
the  Health  Care  Financing  Administration  (HCFA).  These  comments  are  reproduced 
in appendix  C. 
The  PHS  and  ASPE  concurred  with our  recommendation  and  proposed  steps  to 
implement  it.  The  HCFA  did not  concur  with our  recommendation.  The  HCFA 
suggested  that  the  key areas  for action  we identified  are  being  addressed  by current 
efforts  in the  Department  and  that  the  implementation  of our  recommendation  could 
result  in a duplication  or delay  of these  ongoing  efforts. 
We continue  to believe  that  the  development  and  implementation  of an  interagency 
action  plan  by PHS,  ASPE,  and  HCFA  is critical  to the  strengthening  of the 
community  health  centers  perinatal  care  capacity.  The  participation  of HCF&  which 
plays a vital  role  in support  of the  community  health  centers  provision  of perinatal 
care,  is important  to this effort. 
We  recognize  that  PHS,  ASPE,  and  HCFA  are  involved  in ongoing  initiatives  that 
address  concerns  about  infant  mortality  and  perinatal  care.  We urge  PHS,  ASPE,  and 
HCFA  to consider  these  current  activities  as resources  upon  which  to draw  in 
developing  a comprehensive  plan  that  incorporates  both  specific  targets  and  concrete 
steps  to ensure  that  the  key areas  for action  are  addressed.  We  hope  the  interagency 
effort  will provide  an opportunity  to further  involve State  and  local  policy  makers  in a 
concerted  plan  to support  the  centers  provision  of perinatal  care. 
We  have  revised  our  draft  reports  to reflect  additional  comments  we received  from 
PHS,  ASPE,  and  HCFA. 
vi  TABLE  OF  CONTENTS

EXE~  SU19WY 
1

INTRODUmION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FINDINGS

4

Increased  Capaci~  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.5

Increased  Demand  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

Limitations  to Care  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

Medicaid  Funding  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

Comprehensive  Perinatal  Care  Program  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

..11

Urban-Rural  Comparisons  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

K_FYAR~FOR  A~ON  ...,,...  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.  17

RE~MME~A~ON  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

~MME~ONTHED~~PORT  . . . . . . . . . . . . . . . . . . . . . . . . . . ...18

APPENDI= 
A-1

A:  Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.  B-1

B:  Survey  Responses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c-1

c:  Detailed  Cc>mments on the  Draft  Report  . . . . . . . . . . . . . . . . . . . . . . . 
. .  D-1

D:  Notes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

vii  INTRODUCTION 
PURPOSE 
This  report  describes  recent  trends  in the  perinatal  service  capacity  of the  community 
health  centers  funded  under  Section  330 of the  Public  Health  Service  Act. 
BACKGROUND 
Birth  Outcomes  in the  United  States:  The  high rate  of infant  mortality  in the  United 
States  continues  to be a cause  for concern.  Each  year,  approximately  40,000 infants 
die before  their  first birthday--about  1 percent  of all live births  in the  nation.  In the 
1950s, the  U.S. ranked  5th among  the  worlds nations  in lowest  infant  mortality;  in 
1991, it ranked  23rd.  The  rate  for black  infants  continues  to be double  that  for white 
infants. ] 
Perinatal  Care:  A pregnant  woman  with  no prenatal  cm-e is three  times  more  likely to 
have  a baby  born  at  low birthweight--a  key indicator  of the  risk of infant  death--than  a 
woman  with  adequate  care.  The  Public  Health  Service  (PHS)  recommends  timely, 
high-quality  care  before,  during,  and  after  birth  as an effective  way to lower  the  infant 
mortality  rate  and  ensure  healthier  infants.  Such  perinatal  care should  include  early 
and  continuing  risk assessment;  health  promotion;  and  medical,  nutritional,  and 
psychosocial  intementions  and  follow-up.2 
Several  factors,  however--including  financial,  geographic,  and  cultural  barriers--prevent 
many  women  from  obtaining  timely  perinatal  care.3  Rising  medical  malpractice 
insurance  costs,  inadequate  health  insurance  coverage,  a decreasing  supply  of obstetric 
providers,  and  a lack of physicians  willing to treat  low-income  women  are  among  the 
factors  that  have  further  limited  the  accessibility  of perinatal  care.4  In  1989, almost 
170,000 American  women  received  no prenatal  care  until  the  third  trimester,  and 
another  86,000 received  no care  at all during  pregnancy.  Thirteen  percent  of whites 
received  inadequate  care;  the  proportion  of blacks  and  Hispanics  is twice  that.5 
Community  Health  Centers:  Community  health  centers  (CHCS)  play an  important 
role  in reducing  infi~nt mortality  by delivering  comprehensive  perinatal  care  to high-
risk women  in medically  undersexed  areas  across  the  nation.  Many of these  women 
are  difficult  to  reach  and  do  not appreciate  the  importance  of prenatal  care. 
The  CHC  program  was established  in 1965 to meet  the  health  care  needs  of the 
nations  medically  undeserved.  Federal  administration  of the  program  was 
consolidated  in  1975 under  Section  330 of the  Public  Health  Semite  Act.  The  total 
number  of centers,  however,  has not been  maintained  at the  level originally 
envisioned.6  The  number  of grantees  was cut substantially  in the  early  1980s--from 
867 in  1981 to 530 in 1983, a 39 percent  decrease.  At the  time  of our  survey,  in 
1  1991, PHSfunded  514centers;  60 percent  of these  sened  predominantly  rural 
populations,  and  40 percent  served  predominantly  urban  populations.8  As of 
December  1992, PHS  funded  549 centers. 
The  Federal  government  supports  the  services  provided  by community  health  centers 
through  PHS  Section-330  grants  as well as through  Medicare  and  Medicaid 
reimbursements,  Maternal  and  Child  Health  grants,  PHS  Section  329 and  340 grants 
for  migrant  workers  and  the  homeless,  the  National  Health  Service  COrpS,9 the 
Supplemental  Food  Program  for Women,  Infants,  and  Children  (WIC),10 and  the
11  r 
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for migrant  workers  and  the  homeless,  the  NZIWMZH~~iii~fi;=;t }=%=21~-~1~w= 
Supplemental  Food  Program  for Women,  Infants,  and  Children  (WIC),1 and  the 
Rural  Health  Clinic  Programll.  In recent  years,  funding  for the  centers  has 
increased,12  and  several  initiatives  have  been  implemented  to expand  center  services 
and  imrmwe  access  to care.  These  include: 
Medicaid  Expansions:  Since  1982, Congress  has enacted  several  changes  in the 
Medicaid  program,  including  mandated  and  optional  changes  in eligibility  requirements 
and  other  measures,  intended  to improve  the  availability  of perinatal  care.13 
Federally Qualified  Health  Centen  Legklation:  The  Omnibus  Budget  Reconciliation 
Acts  of  1989 and  1990 require  State  Medicaid  programs  to cover  a core  set  of services 
provided  by community  health  centers  and  to reimburse  centers  for the  reasonable 
cost  of covered  services. 
The Comprehensive  Perinatal  Care Program (CPCP):  The  CPCP  provides 
supplemental  funding  to some  CHCS for enhanced  perinatal  setices,  including 
improved  outreach  and  case  management.  Funds  were  first awarded  in 1989.14 
Healthy  Start:  In September  1991, HHS  awarded  competitive  grants  to  15 
communities  in support  of coordinated  programs  to reduce  infant  mortality  rates. 
Although  there  has been  increasing  Federal  interest  in perinatal  care  and  the 
community  health  centers,  little  information  is available  on the  extent  to which  the 
centers  are  able  to address  the  perinatal  care  needs  of the  women  they  seine.  A clear 
understanding  of the  centers  current  capacity  to provide  perinatal  care  is vital  to 
further  planning  and  program  design. 
This  report  presents  an ove~iew  of recent  trends  in the  perinatal  service  capacity  of 
the  Section-330-funded  centers,  and  summarizes  and  compares  data  on urban  and 
rural  centers.  It also presents  information  on two areas  of special  policy interest: 
Medicaid  reimbursements  to the  centers,  and  CPCP  funding  of the  centers.  COMPANION  REPORTS 
This  is one  of three  reports  on the  capacity  of the  community  health  centers  to 
provide  perinatal  care.  Two  companion  reports  address  the  provision  of perinatal 
services  at  urban  and  rural  centers:  7%e Perinatal Service Capacity of the Federally 
Funded  Community  Health  Centem:  Urban Centers, 0EI-01-90-02330,  and  Z4e 
Perinatal  Service  Capacity of h  Federally Funded  Community  Heahh  Centem:  Rural 
Cen[en,  OEI-01-90-0233  1.15 
METHODO~Y 
To  examine  the  capacity  of the  community  health  centers  to provide  perinatal  care,  we 
conducted  a mail  sumey  of Section-330-funded  centers,  interviewed  staff and 
management  at  10 centers;  held  discussions  with PHS  administrators,  State  officials, 
and  infant  health  care  experts;  and  reviewed  relevant  literature  and  data. 
We  sent  the  mail  suwey  to all 514 community  health  centers  receiving  Section-330 
funds  in June  1991; of these,  431 (84 percent)  responded.  Our  findings  are  based 
primarily  on the  responses  of those  369 centers  (72 percent  of all centers)  that 
reported  that  they  offered  perinatal  services  on site during  the  1988-91 period.  (See 
appendix  A for  a detailed  methodology.) 
Our  review was conducted  in accordance  with the  Interim  Slandards for  Inspections 
issued  by the  Presidents  Council  on  Integrity  and  Efficiency. 
3  FINDINGS

INCREASED  CAPACITY:  7he capacity  of the  commundy  health  centem  to pmide 
peri.natal  care  increasd  between  1988 and  19X)  in terms  of prenatal  casehad  ~  the 
range  of services  offm~  and jhiing. 
Caseloads:  The  number  of prenatal  clients  served  by the  centers  rose  22 percent 
 
between  1988 and  1990, from  an average  of 359 per  center  to 436.  The  number  of 
births  to center  clients  rose  19 percent  during  the  same  period,  from  an average  of 
253 per  center  to 300.  Centers  reported  a total  of  140,157 prenatal  clients  and  88,142 
births  in 1990. 
E  Setices:  The  range  of perinatal  services  increased  at  68 percent  of the  centers. 
The  services  added  at the  largest  number  of centers  were  HIV  counseling  and  testing, 
smoking-cessation  programs,  and  classes  in parenting  and  childbirth. 16 The  range  of 
ancillary  services  increased  at 32 percent  of the  centers.  Home-visiting  services  were 
added  at the  largest  percentage  of the  centers  and  child care  during  appointments  was 
added  at the  smallest  percentage  (see  figure  1). 
Figure  1 
Percentage  of Centers that Provided 
Each Perinatal  Service, Including Ancillary  Services 
Either On Site or Off Site, 1988 and 1990 
F~9 
.8	  
E 
: 
i! 
2 
T~ 
1988 
ti  -~ 
1 
3 
u  addedby 1990 
m 
2 - - Chi!l dCare  1 I  1  1 
o%  20%  40%  60%  80%  100% 
Percentageof CentersProvidingEach Senrice 
SourceO: IGSurvey of Comnmnity Health Centers, June 1991. 
N-369 
4
 Sixty-five percent  of the  centers  offered  on-site  assistance  with enrollment  in the 
Supplemental  Food  Program  for Women,  Infants,  and  Children  (WIC)  in 1990, an 
increase  from  57 percent  in  1988.17 
Revenues:  Total  revenues  for all center  services  increased  27 percent  between 
 
1988 and  1990; this includes  an  18 percent  increase  in Section-330-grant  funding.18 
Fifty percent  of the  centers  reported  that  the  amount  of funding  available  for perinatal 
senices  had  increased  since  1988. 
INCREASED  DEMAND:  Despite  these  increases  in capacity,  demand  for perinatal 
services  has  continued  to grew,  and  many  center  clients  still do  not  receive  the  optimal 
coordinate  package  of care  in a timely filshion 
Availability  of setices:  Sixty-two (14 percent)  of the  centers  that  responded  to 
 
our  survey  provided  no perinatal  setices  on site from  1988 to  1991.19 While  these 
centers  are  required  to ensure  that  clients  receive  services  elsewhere,  our  study  did not 
examine  the  extent  to which  centers  did so.  Twenty-nine  (47 percent)  of the  centers 
that  did  not  provide  on-site  perinatal  semices  indicated  that  they would  have  liked  to, 
but  noted  that  budgetary  constraints,  a lack of obstetric  providers,  and  an  inability  to 
obtain  hospital  privileges  prevented  them  from  doing  so. 
Demand  for services:  Eighty-two  percent  of the  centers  that  offered  perinatal 
 
care  reported  an  increase  in the  demand  for sewices  since  1988.  Of these,  39 percent 
reported  that  their  capacity  to address  this demand  had  either  decreased  or remained 
the  same.  An additional  12 percent  of the  centers  reported  that  demand  for perinatal 
semices  had  not  changed  since  1988.  Of these,  17 percent  reported  that  capacity  to 
meet  demand  had  decreased. 
Several  centers  reported  that  they were  overwhelmed  by demand  and  have  been 
periodically  forced  to turn  away new perinatal  clients  because  they  lack the  capacity  to 
seine  them.  Centers  attributed  increased  demand  for services  to several  factors, 
including:  Medicaid  eligibility  expansions,  and  presumptive  and  continuous  eligibility 
provisions;  a diminishing  number  of community  providers  willing to treat  low-income 
and  Medicaid  patients;  and  increasing  unemployment  rates  among  center  clients. 
Many  unemployed  women  have  neither  the  income  nor the  health  insurance  to afford 
private  medical  care,  and  therefore  seek  subsidized  care  at the  centers. 
Case  management:  According  to PHS,  perinatal  care  should  include  risk 
 
assessment;  health  promotion;  and  medical,  nutritional,  and  psychosocial  services  and 
follow-up.20  To  maximize  the  accessibility,  quality,  and  comprehensiveness  of services, 
PHS  requires  centers  to provide  case-management  services.21 
Although  centers  may provide  some  of the  senices  recommended  by PHS,  63 percent 
of the  centers  reported  that  they do not  provide  case  management  for all of these 
sewices  (see  figure  2). 
5  Figure 2 
Percentage of Centers that DO NOT Case Manage Each Perinatal SeMce 
m~titi  13% 
14% 
Health E&carion -~ 
Nutritional Services -~  15% 
ASSiStmcwcithWC 
Medical Semites On-Sit.c 
Medical Services Off-Site -1  2s% 
31% 
Social Saivcesi On-Site i 
social Services Off-Site -I  34% 
Delivery Se$v&g -I  34% 
Discharge Planning  so% 
,
o%  10%  30%  40%  so%  60% 
Percentage of Centers th  DO NOT Case Manage Each Service 
!kunx. 010SUIVoCfyc ommuniHtyealthcenm he  1991. 
N-369 
There  is no commonly  accepted  definition  of case  management,  and  the  process  has 
been  implemented  differently  at different  centers.  Centers  might  coordinate  the 
delivery  of semices  and  not  refer  to such coordination  as case  management. 
Centers  reported  several  problems,  however,  that  indicate  inadequate  coordination  of 
care: 
o	 Missed  appointments  are  not  rescheduled  for an average  of 35 percent  of each 
centers  perinatal  clients. 
o	 The  timely  transfer  of medical  records  to and  from  facilities  for delivery  and 
other  semices  is a problem  at 27 percent  of the  centers. 
o	 Follow-up  care  within  the  first 8 weeks  after  birth  was not  provided  for an 
average  of 27 percent  of each  centers  prenatal  clients  in 1990. 
Timing  of care:  On  average,  55 percent  of each  centers  prenatal  clients  entered 
 
care  during  the  first trimester  of pregnancy  in 1990.  Nationally,  76 percent  of all 
women,  62 percent  of minority  women,  and  58 percent  of women  in federally 
designated  Healthy  Start  project  areas  entered  care  during  the  first trimester.zz 
These  rates  compare  with a PHS goal of 90 percent  of all women  by the  year  2000.X 
Number  of visits:  The  American  College  of Obstetricians  and  Gynecologists 
 
recommends  that  women  entering  care  in the  first trimester  receive  a minimum  of 9 
prenatal  visits.24  On average,  however,  21 percent  of each  centers  first-trimester 
enrollees  received  fewer  than  9 prenatal  visits at the  center.  Our  study  did not 
examine  the  extent  to which  these  patients  may have  received  care  elsewhere. 
6
 Availability  of appointments:  Thirty-seven  percent  of thecenters  did not  offer 
 
prenatal  appointmentsat  times  convenient  forworking  women  in 1990.  Restricted 
appointment  hours  may force  working  women  to choose  between  work  and  prenatal 
care. 
Waiting  times:  At 27 percent  of the  centers,  waits for initial  prenatal  visits are 
 
2 to 4 weeks;  at 4 percent,  waits  are  more  than  1 month.  Long waits  for initial 
appointments  can  have  adverse  effec~s.  If a woman  tests  positive  for pregnancy  in her 
second  month  and  then  must wait  4 weeks  for her  first prenatal  appointment,  she may 
enter  care  in her  second  trimester.  The  implications  of such waits  are  even  more 
problematic  when  pregnancy  is detected  later  and  when  the  mother  is at high risk, as 
many  center  clients  are. 
sixteen  percent  of the  centers  reported  that  office waiting  times  grew longer  between 
1988 and  1990.  Centers  reported  that  long office waits  may discourage  women  from 
making  and  keeping  appointments. 
LIMITATIONS  TO  CARE:  7%  centem &&m@Zedseveral  major  constnints  that 
seriously  limit their capacity  to pmvkii?  painatal  care.  7kse  inchuie  medical  staff 
shortage+  medical  malpractice  insumnce  cmtis, unsatii$actq  community  suppo~  kited 
spacq  and  inadequate  health  insumnce  of center  clientk 
Medical  staff  shortages:  Medical  staff shortages  are  so severe  that  they 
 
seriousl~  hinder  the  provision  of perinatal  sexvices at 63 percent  of the  centers. 
While  the  number  of perinatal  clients  served  by the  centers  increased  an average  of 
22 percent  between  1988 and  1990, the  number  of full-time  equivalent  (FTE) 
obstetricians,  family  physicians,  and  certified  nurse  midwives  increased  an average  of 5 
percent.  Twenty-six  percent  of the  centers  reported  that  at least  1 obstetrician,  family-
physician,  or  nurse-midwife  position  had  been  vacant  for longer  than  1 year  (see  table 
1). 
Table 1 
Percentageof Centers Reporting at Least One C1.inieaPlroviderPmition Vacan# 
Currently  Vacant more  Vacant more 
Stafl Position  Vacant  than SixMonths  than one year 
Obstetrician-Gynecologist  26~o  22%  13% 
II FamilyPhysician  II  31%  I  26fZo  I  15%  II 
II Nurse  Midwife  11  13%  I  1170  I  6%  II 
Source:  OIG  Swvey  of Community  HealthCenters,  June  1991 
N=369 
Centers  face  serious  problems  recruiting  and  retaining  medical  staff.  The  work  is 
demanding,  and  wages  and  benefits  are  generally  not  comparable  to those  in the 
private  sector.  Although  the  National  Health  Service  Corps  used  to supply  a large 
7  percentage  ofcenter  providers,  funding  forthecorps  was seriously  cut  in the  1980s. 
In recent  years  the  corps  has  produced  a decreasing  number  of providers.27 
Obstetricians  are  in short  SUpply, and  many  are  unwilling  to work  in community  health 
centers.  They  are  also the  most  expensive  providers  to support:  Their  salaries  and 
medical  malpractice  insurance  premiums  are  substantially  higher  than  those  of other 
providers.  Family-physician  and  certified-nurse-midwife  models  of care  also  pose 
problems:  The  supply  of family physicians  and  nurse  midwives  is limited;  many 
obstetricians  are  reluctant  to provide  supervision  and  backup  services  for  them;  and 
many  hospitals  will not extend  delivery  privileges  to them.  Thus,  these  more 
affordable  staffing  models  are  impractical  for many  centers. 
Malpractice  insurance  costs:  The  cost of medical  malpractice  insurance  has been 
 
a serious  drain  on resources  at 56 percent  of the  centers.  The  cost of medical 
malpractice  insurance  has become  a more  serious  limitation  since  1988 at  27 percent 
of the  centers.n 
These  costs  have  made  it difficult  for centers  to expand  their  staffs, since  scarce  funds 
must  be spent  on  insurance  instead  of salaries.  Centers  that  contract  for  care  have 
had  difficulty  paying  the  rising wages  necessary  to meet  the  insurance  costs of private 
physicians.  One  center  reported  that  it has been  unable  to obtain  coverage  at  any 
cost . 
In late  1992, Congress  took  initial  steps  to address  this problem  by passing  legislation 
that  extends  medical  malpractice  liability protection  under  the  Federal  Tort  Claims 
Act  (ITCA)  to health  care  providers  at the  centers.29 
Unsatisfactory  community  support:  The  PHS  expects  that  centers  be  active 
 
participants  in their  communitys  health  care  system.  . . .  This  typically  means 
fostering  partnerships  and  participating  in consortia  and  task  forces  addressing  the 
areas  health  care  issues.~  These  consortia  should  include  local health  departments, 
social  services  departments,  hospitals,  and  other  public  and  private  health  care 
providers.  Thirty-five  percent  of the  centers,  however,  do not  participate  in perinatal 
care  consortia. 
Inadequate  coordination  of perinatal  services  in the  community,  insufficient  support 
from  the  local  medical  establishment,  or limited  hospital  privileges31 seriously  restrict 
the  provision  of services  at 76 percent  of the  centers.  Unsatisfactory  community 
support  is indicated  by several  problems  cited  as serious  impediments  to the  delivery 
of care: 
o  a lack  of other  local  providers  willing to treat  uninsured  and 
publicly-insured  women  (59 percent); 
0  difficulty  arranging  obstetric  backup  for family physicians,  certified  nurse 
midwives,  or nurse  practitioners  (35 percent); 
0  difficulty  arranging  medical  consultation  for high-risk  clients  (29 percent); 
8  o  difficulties  obtaining  admitting  or delivery  privileges  for staff  obstetricians, 
family  physicians,  or nurse  midwives  (35 percent);  and 
o  a decrease  between  1988 and  1990 in the  percentage  of staff providers  with 
hospital  admitting  privileges  (19 percent). 
Mted  space:  Limited  space  seriously  hinders  the  provision  of sewices  at 
 
55 percent  of the  centers.  This  problem  has become  more  serious  since  1988 at 
31 percent  of the  centers.  In addition,  limited  collocation  of setices  on site  seriously 
restricts  the  comprehensiveness  of care  at 26 percent  of the  centers.  Centers  that 
cited  limited  space  as a serious  problem  more  frequently  cited  limited  collocation  of 
semices  as a serious  limitation. 
Inadequate  health  insurance:  An average  of 19 percent  of each  centers  perinatal 
 
clients  were  uninsured  in  1990.  At 29 percent  of the  centers,  25 percent  or more  of 
the  perinatal  clients  were  uninsured.  At 9 percent  of the  centers,  more  than 
50 percent  were  uninsured.  These  clients  received  semices  free  of charge  or  at 
reduced  rates,  according  to a sliding scale. 
MEDICAID  FUNDING:  iUedica&i fiuuiing  for petital  care at the  centm  has  increased 
in recent yea~  but  centzm  repti  that  Medicad  policia  and pmcedures-inchding  a 
burdensome  application  process,  inadequate  reimhuxement  rota,  a reistited  mnge  of 
covered  servicq  and  limited  eliility--are  among  the facton  that  serixdy  inhibit  the 
pmvkion  of care  at mmt  centem 
Medicaid  reimbursements:  Medicaid  reimbursements  to the  centers  increased 
 
approximately  56 percent  between  1988 and  1990.32 As a percentage  of total  center 
revenues,  they  increased  from  approximately  17 to 21 percent. 
Medicaid+mrolled  clients  as a portion  of perinatal  caseload:  An average  of 
 
67 percent  of each  centers  perinatal  clients  were  Medicaid-enrolled  in 1990.  At 
50 percent  of the  centers,  at  least  71 percent  of these  clients  were  Medicaid-insured. 
Medicaid  limitations:  Medicaid  eligibility expansions  or presumptive  and  continuous 
 
eligibility  provisions  resulted  in an increase  in demand  for perinatal  services  at 57 percent 
of the  centers,  but  difficulties  with Medicaid  policies  and  procedures--including 
burdensome  application  procedures,  inadequate  and/or  slow reimbursement,  restrictive 
eligibility  criteria,  or a limited  range  of covered  services--seriously  limit the  provision  of 
perinatal  care  at  73 percent  of the  centers  (see  table  2). 
9  Table 2 
Percentage of Gnters  Citing Each of the Following 
Medicaid Factors as a Serious Limitation 
I 
Burdensome  application  procedures  1  5470 
II  Inadequate  reimbursement  rates  I  4970  II 
I  Restrictive  eligibility  criteria  I  42$Z0  II 
11 Slow reimbursement  process  i  41%  II 
II  Limited  range of covered  services  !  40%  II 
Source  OIG  Survey  of Community  Health  Centers,  June  1991 
N=369 
Several  recent  Medicaid  reforms  have  been  designed  to increase  access  to perinatal 
care.  These  had  not yet been  fully implemented  at the  time  of our  survey: 
o  Only  56 percent  of centers  offered  assistance  with Medicaid  enrollment  on 
site,  even  though  Federal  law required  that  the  States  outstation  workers  to 
do S0.33 
o  Only  27 States  and  the  District  of Columbia  had  begun  to implement  cost-
based  reimbursement  to CHCS as of May  1991, even  though  the  Federally 
Qualified  Health  Center  provisions  of the  Omnibus  Budget  Reconciliation 
Acts  of  1989 and  1990 called  on the  States  to do so by April  1, 1990.~ 
COMPREHENWVE  PERINATAL  CARE  PROGRAM  (CKT):  7%e CPCP  p~vidt?d 
supplemental  jiuuis  for  enhanced  petitid  servhx  to approximately  two-thinh  of the 
centem for  at least  one year  between  198/3 and  1991.  A  bger  pemntage  of centm  that 
received  CPCP  fiuds  than  of those  that  did  not  expanded  their range  of semices  between 
1988 and  1990.  CPCP  gmnt  recipients  conduct  more  extensive  case  management  than 
other  centem  There  were no significant  ~krences,  howeve~  between  gnmt  recipik~  and 
other  centen  in either  the penzntage  of ciknts  who  entered  care  in the jht  Oimester  in 
1990 or the pacentage  of these  who  received  at ikast  nine prenatal  visits. 
Caseload  size:  In 1988, before  CPCP  funds were  awarded,  those  centers  that 
 
eventually  received  CPCP  funds  served  an average  of 454 prenatal  clients,  compared 
with an average  of  156 sewed  by other  centers.  In  1990, CPCP-funded  centers  served 
an average  of 547 prenatal  clients;  other  centers  served  an average  of 201.35 Thus, 
CPCP-funded  centers  seined  considerably  more  clients  than  other  centers,  but  there  is 
no significant  difference  between  CPCP-funded  centers  and  other  centers  in the  rate 
at which  caseload  size grew between  1988 and  1990.M 
~  Semites:  CPCP  funds  were  intended,  in part,  to support  increased  perinatal 
services  at the  centers,37 and  80 percent  of the  CPCP-funded  centers  reported  that 
10  the  range  of perinatal  semices  increased  between  1988 and  1990.  Half  of the  other 
centers  reported  that  the  range  of services  increased. 
E  Case  management:  CPCP  funds  were  also intended  to support  better 
coordination  of care  for perinatal  clients,w  and  46 percent  of the  CPCP-funded 
centers  provide  case  management  for all of the  sefices  recommended  by PHS. 
Twenty-two  percent  of the  other  centers  provide  case  management  for all of these 
services. 
In addition,  70 percent  of the  funded  centers  participated  in perinatal  care  consortia; 
58 percent  of the  other  centers  did S0.39 
Timing  of care:  The  CPCP  was further  intended  to support  early  entry  into  care 
 
and  more  prenatal  visits.w  Responses  to our  survey,  however,  indicate  that  CPCP-
funded  centers  and  other  centers  did not  differ  significantly  in terms  of either  the 
percentage  of center  clients  that  entered  care  in the  first trimester  in  1990, or the 
percentage  of first-trimester  enrollees  that  received  nine  or more  prenatal  visits in 
1988 or  1990.  Our  study does  not  allow a comparison  of CPCP  grant  recipients  and 
other  centers  with  regard  to trends  over  time  in first-trimester  entry  into  care. 
URBAN-RURAL  COMPARISONS:  Urban  centers  exhibited  greater  painatd  care 
capacity  in terms  of prenatal  casekuui  S@  the  mnge  of semiax  Offi?r@ and  revenuex 
Rural  centen  provided  more  timely  perinatal  care.  Urban  and  mml  centm  identified  the 
same  factom  as setiu  limitations  to the pmvkion  of painatal  care. 
*  Caseloads:  Urban  centers  served  more  prenatal  clients  and  experienced  greater 
caseload  growth  than  rural  centers.  Prenatal  caseloads  at  urban  centers  increased  an 
average  of 23 percent  between  1988 and  1990, from  477 to 586.  Prenatal  caseloads  at 
rural  centers  grew  an average  of 20 percent,  from  261 to 312. 
*  SeMWs:  Only 6 percent  of the  urban  centers  that  responded  to our  survey  did 
not  offer  any perinatal  services  on site between  1988 and  1990; 20 percent  of the  rural 
centers  did not  do so.  Of those  that  did offer  sewices,  a greater  percentage  of urban 
(78 percent)  than  rural  (63 percent)  centers  reported  that  the  range  of perinatal 
semices  they  provided,  either  on or off site, increased  between  1988 and  1990. 
A higher  proportion  of urban  centers  offered  on-site  assistance  with  enrollment  in 
both  Medicaid  and  WIC  in 1990.  Sixty-six percent  of urban  centers  offered  on-site 
assistance  with enrollment  in Medicaid  and  81 percent  offered  on-site  assistance  with 
enrollment  in WIC;  49 percent  of rural  centers  offered  on-site  assistance  with 
enrollment  in Medicaid  and  54 percent  offered  on-site  assistance  with enrollment  in 
WIC. 
E  Case  management:  A greater  percentage  of urban  (44 percent)  than  rural  (32 
percent)  centers  provide  case  management  for all the  services  recommended  by PHS. 
11  A greater  percentage  of urban  (34 percent)  than  rural  (18 percent)  centers,  however, 
also often  encounter  problems  with the  timely  transfer  of medical  records  to and  from 
referral  facilities  for setices  other  than  delivery. 
Revenues:  Total  revenues  for all services  at urban  centers  increased  31 percent 
 
between  1988 and  1990; total  revenues  for all setices  at rural  centers  increased  20 
percent.  Section-330  funding  increased  approximately  18 percent  at urban  and  rural 
centers  alike.  This  funding  represented  3S percent  of total  1990 revenues  for urban 
centers  and  44 percent  for rural  centers.  Medicaid  reimbursements  increased  59 
percent  at  urban  centers  and  42 percent  at rural  centers.  These  reimbursements 
represented  25 percent  of total  1990 revenues  for urban  centers,  and  13 percent  for 
rural  centers.4* 
Timing  of care:  Rural  centers,  on average,  provided  more  timely  prenatal  care 
 
than  urban  centers.  Seventy-six  percent  of the  rural  centers  conducted  initial  prenatal 
visits for their  clients  within  2 weeks  of a positive  pregnancy  test,  compared  with 60 
percent  of the  urban  centers.  On  average,  59 percent  of each  rural  centers  clients, 
and  51 percent  of each  urban  centers  clients,  entered  care  in the  first trimester  in 
1990.  In addition,  an average  of 82 percent  of the  first-trimester  enrollees  at  rural 
centers  and  74 percent  at  urban  centers  received  at  least  9 prenatal  visits in 1990. 
Limitations:  Urban  and  rural  centers  alike  reported  that  their  provision  of 
 
perinatal  care  is seriously  inhibited  by several  factors,  including  medical  staff  shortages, 
medical  malpractice  insurance  costs, unsatisfactory  community  support,  limited  space, 
and  inadequate  health  insurance.  There  were  significant  differences  between  urban 
and  rural  centers  involving space  and  staffing. 
Limited  space  seriously  restricts  the  provision  of perinatal  care  at a greater  percentage 
of urban  (64 percent)  than  rural  (48 percent)  centers,  and  has become  a more  serious 
problem  since  1988 at a greater  percentage  of urban  (38 percent)  than  rural  (24 
percent)  centers. 
Staff shortages  present  serious  limitations  to care  at a larger  percentage  of rural  than 
of urban  centers.42  At rural  centers  there  was a  1 percent  decrease  in the  number  of 
FTE  obstetricians,  family physicians,  and  certified  nurse  midwives between  1988 and 
1990; at  the  same  time  there  was a 20 percent  increase  in the  size of the  prenatal 
client  caseload.  At urban  centers  there  was a  12 percent  increase  in the  number  of 
FTE  providers  and  a 23 percent  increase  in the  size of the  prenatal  caseload. 
Difficulty  arranging  backup  for obstetric  supervision  of family physicians  is a serious 
limitation  to the  provision  of care  at  a greater  percentage  of rural  (34 percent)  than 
urban  (22 percent)  centers.  Consultation  for high-risk  patients  is also  a serious 
problem  at a greater  percentage  of rural  (36 percent)  than  urban  (21 percent)  centers. 
In addition,  high medical-staff  turnover  has become  a more  serious  limitation  to the 
provision  of perinatal  care  since  1988 at a greater  percentage  of rural  (18 percent) 
than  urban  centers  (11 percent)  (see  table  3.). 
12  Table  3 
Section-330-Funded  Urban  and  Rural  Community  Health  Centem  Compared 
~~+ 
~ 
Average  increase  in the number  of prenatal  client.sat  each center,  1988to  1990:  23%  / 2070 
SERVICES 
Percentage  of survey rm~  ndents  that did not offer any perinatal  semkes  on site 
between  1988 and  1991:  69Z0  20% 
-E 
Percentage  of centers  that  reported  an increase  in demand  for perinatal  services:  899Z0  75% 
Percentage  of the above centers  that  reported  that  capacity  to meet  this demand 
had decreased  or remained  the same:  3470  42?Z0 
Percents  e of centers  that  re  orted  that  the range of perinatal  services had 
increas J  between  1988 and  1990:  R 78%  63% 
Percentage  of centers  that  offered  on-site  assistance  with  Medicaid  enrollment  in  66?Z0  4970 
1990: 
Percentage  of centers  that  offered  on-site  assistance  with  WIC enrollment  in 1990: I  81%  I 54% 
CASE MANAGEMENT 
Percentage  of centers  that  re  orted  that  they provide  case management  for all 
services  recommended  by P r-?S:  m 
REVEhJUE@ 
Percentage  increase  in total  center  revenues  between  1988 and  1990:  3170  2070 
PHS  Section-330  grants  as a percentage  of total  center  revenues  in 1990:  35%  4470 
Medicaid  reimbursements  as a percentage  of total  center  revenues  in 1990:  E 259Z0  13% 
TIMING  OF CARE  ~~ 
Percentage  of centers  that offered  an initial  prenatal  visit within  two weeks 
of a positive  pregnancy  test:  6070  76% 
Percentage  of each centers  clients  enrolled  during  the first trimester:  51%  59?Z0 
Percentage  of each centers  first-trimester  enrollees  who received  at least 
nine  prenatal  visits:  ~ 74%  82?Z0 
LIMITATIONS 
Percentage  of centers  that  reported  serious  medical  staff shortages:  59$Z0  67?ZOC 
Percentage  change  in the  number  of full-time-equivalent  obstetricians,  family 
physicians,  and certified  nurse  midwives at centers  between  1988 and  1990:  12%  -l%c 
Percentage  of centers  that  reported  serious  difficulties  stemming  from high 
~ract]ce  insurancecosts:  56?40  559Zod 
Percentage  of centers  that  experienced  serious  problems  as a result  of Medicaid 
Dolicies and  Procedures:  FE 76%  7090d 
Percentage  of centers  that  reported  serious  roblems  with communit 
coordination,  community  supp ort,  or limit J  hospital  admitting  privi eges-
Percentage  of centers  that  reported  serious  space limitations:  - ~k 
Source:  OIG  Sumwy of Community  Health  Centers,  June  1991 
N= 167 for Urban  Centers;  N=202  for Rural  Centers 
a  These  were  not  included  in the  calculation  of other  statistics  presented  in the  this report  (see  appendix  A for methodology). 
b  These  data  were  prowded  by the  Public  Health  Semke  (see  note  20).  Statistical  significance  was not determined. 
c  The  differences  noted  are statistically  significant  at the 0.1 kwel. 
d  The  differences  noted  are  not s[atisticalty  significant. 
13  KEY  AREAS  FOR  ACTION 
In recent  years,  government  at all levels has looked  to the  community  health  centers 
to play a more  prominent  role  in providing  perinatal  care  to poor,  high-risk  women. 
The  growing  financial  investment  in centers  reflects  heightened  expectations  for their 
performance.  These  expectations  rest  on the  assumptions  of many  policy makers  that 
centers  are  able  to meet  the  growing  demand  for comprehensive,  timely  perinatal 
semices. 
As the  data  in this report  suggest,  the  capacity  of centers  to provide  perinatal  services 
has increased  substantially  since  1988.  More  women  are  being  served,  a wider  range 
of services  is being  offered,  and  total  revenues  for all center  services  have  increased. 
At the  same  time,  there  is reason  for concern  about  the  capacity  of the  community 
health  centers  to deliver  all that  is expected  of them.  The  findings  of this report, 
based  on the  most  current  and  comprehensive  data  available,  confirm  that  many 
centers  are  burdened  by major  problems  that  limit their  capacity  to provide  care. 
These  difficulties  reflect  problems  of access  and  cost in the  nations  health  care 
system,  and,  as such, are,  in part,  dependent  for resolution  on broader  national 
reforms. 
Independent  of such  reforms,  however,  we believe  there  are  important  actions  that 
policy  makers  can  take  now to strengthen  the  capacity  of centers  to provide  care.  The 
data  in this report  suggest  four  areas  in particular  that  warrant  immediate  attention. 
Below we identi$  these  four  critical  areas  and  offer  suggestions  for action. 
Federal,  State,  and  local  policy makers  should  take  steps  to: 
  Address  the  staffing  needs  of the  centers. 
If community  health  centers  are  to serve  more  women,  reach  them  earlier  in their 
pregnancies,  and  provide  adequate  care,  they  need  a sufficient  supply  of obstetricians, 
family physicians,  certified  nurse  midwives, and  nurse  practitioners. 
Centers  need  to be better  able  to attract,  retain,  and  utilize  various  types  of clinical 
staff who are  skilled  in providing  perinatal  care;  who are  motivated  to seine  poor, 
high-risk  women;  and  who are  allowed  to practice,  without  undue  restriction, 
consistent  with  their  training  and  experience.  Thus,  it is vital  for policy makers  to 
identify  cost-effective  steps  they can  take  to: 
(1)  ensure  an adequate  supply  of those  types  of clinicians  needed  to provide 
perinatal  services  in ambulatory  primary  care  settings  such  as centers;43 
(2)  develop  more  effective  incentives  for  clinicians  trained  with  public  funds 
to locate  in underserved  areas.  In this regard,  it is particularly  important 
14  that  the  revitalized  National  Health  Service  Corps  maximize  its potential 
for addressing  staffing  needs  through  its loan  repayment  program, 
support  training  for an appropriate  mix of clinical  disciplines,  and  ensure 
that  its recruitment  and  placement  policies  enhance  the  attractiveness  of 
the  program  to young  clinicians;  and 
(3)  ease  undue  restrictions  on the  credentialing  of certified  nurse  midwives, 
nurse  practitioners,  and  physician  assistants  to allow their  fuller 
participation  in perinatal  sexvice delivery. 
  Assure  that  recent  legislation  effectively  relieves  the  centers  of the  high cost of 
medical malpractice  insurance.  The  high cost of malpractice  insurance,  particularly  for 
clinicians  providing  perinatal  care,  has limited  the  centers  ability  to offer  services. 
In late  1992, Congress  took  initial  steps  to address  this problem  by passing  legislation 
that  extends  medical  malpractice  liability protection  under  the  Federal  Tort  Claims 
Act  (FTCA) to health  care  providers  at  certain  Federally  supported  health  care  clinics, 
including  Section-330-funded  community  health  centers.~  Under  the  FIC~  center 
providers  will be  defended  by the  Justice  Department  in any malpractice  litigation,  and 
any judgments  will be  paid  out  of a Justice  Department  fund,  into which  the  centers 
will pay annual  contributions.  This  extension  will be  in effect  for a trial  period  of 
three  years,  after  which the  financial  benefits  of the  arrangement  will be assessed. 
This  coverage  is intended  to help  alleviate  the  burden  on the  centers  of malpractice 
insurance  costs.  It is necessary  to monitor  this new arrangement  to ensure  that  it 
effectively  addresses  the  centers  concerns. 
  Continue  to improve  ties between  the centers  and the Medicaid  program.  An 
effective  link between  centers  and  the  Medicaid  program  is vital given the  high 
proportion  of Medicaid-insured  women  sewed  by the  centers  and  the  expanded 
Medicaid  coverage  now available  for their  prenatal  care.  It is crucial  for public  health 
and  Medicaid  officials  to take  steps  to: 
(1)  continue  to expedite  the  application  and  eligibility determination 
processes  for Medicaid  to improve  the  access  of high-risk  women  to 
more  timely  perinatal  care.  In this regard,  it is particularly  important  to 
simpiify the  application  forms,  to streamline  enrollment  procedures,  and 
to ensure  that  eligibility workers  are  outstationed  at the  centers;  and 
(2)  ensure  that  the  Federally  Qualified  Health  Centers  mandate,  which 
allows centers  to be reimbursed  for reasonable  costs,  has been  fully 
implemented  and  is working  optimally. 
Steps  such  as these  are  consistent  with the  current  directions  of the  Departments 
Interagency  Committee  on  Infant  Mortality  and  with the  recommendations  and 
15  suggestions  of other  studies  including  two recent  OIG  reports  on Medicaid  coverage 
for prenatal  care.45 
  Continue  to strengthen  relationships between  the centers  and other  health and 
social seMce  providers in the community. 
The  perinatal  semices  offered  by the  centers  must  be  linked  more  effectively  with 
those  of other  health  and  social  service  agencies.  This  coordination  must  go beyond 
the  mere  sharing  of information  to include  effective  working  relationships  for referral 
of clients  and  delivery  of services.%  It is particularly  important  to search  for ways to 
increase  the  number  of obstetric  providers  who are  willing to seine  Medicaid 
patients.47 
Moreover,  strategies  to locate  multiple  programs  at a single site and  to provide 
eligibility  determination,  complete  program  enrollment,  and  the  delivery  of services  at 
a single  site  deseme  further  emphasis.  Other  strategies  warranting  continued  attention 
are  those  that  encourage  more  extensive  use of common  application  forms  and  generic 
eligibility  workers. 
It is particularly  important  to link centers  and  hospitals  more  effectively.  Centers  must 
rely on hospitals  to provide  inpatient  care,  including  delivery  services,  for their 
patients;  yet  many  centers  have  difficulty  securing  hospital  privileges  for their 
physicians  and  certified  nurse  midwives.  Such privileges  are  critical  for delivering  the 
comprehensive,  continuous  care  that  the  centers  high-risk  perinatal  clients  need. 
Thus,  it is important  for policy makers  to identify  ways to ensure  that  center  physicians 
and  midwives  who  meet  appropriate  requirements  for  licensure  and  training  have  staff 
membership  at  hospitals  in their  communities.  This  membership  should  encompass 
both  admitting  and  delivery  privileges.  At present,  the  National  Health  Semite  Corps 
statute  requires  hospitals,  as a condition  of their  participation  in Medicare,  to grant 
privileges  to corps  physicians.  This  approach  might  be  used  to obtain  privileges  for 
other  clinical  staff.w  Alternative  approaches  to explore  include  linking  the  licensure 
or tax-exempt  status  of hospitals  to their  guarantees  of broader  privileges  for center  staff. 
16  RECOMMENDATION 
The  Assistant Secretary  for Healt4  the Administrator  of the Health  Care  Financing 
Administration  and  the  Assistant  Secretq  for Planning and Evaluation  should 
develop  a plan of action  to address the key areas  outlined abave. 
The  PHS  and  HCFA  should,  individually  and  collaboratively,  develop  plans  of action 
that  incorporate  specific  targets  and  concrete  steps  to ensure  that  the  key areas  for 
action  are  addressed.  The  ASPE  should  review these  plans  and  assure  that  they  are 
compatible  and  adequate  to meet  the  nations  goals  for the  year  2000 to reduce  infant 
mortality  rates  and  increase  access  to perinatal  care.  The  ASPE  should  coordinate 
activities  and  monitor  implementation  of the  plans. 
The  PHS  cannot  effectively  address  these  problems  alone.  Other  Departmental 
components,  State  and  local government  agencies,  and  nongovernmental  organizations 
must  be  involved  in planning  and  implementation.  Of particular  importance  is 
cooperation  between  public  health  and  health  care  financing  agencies  at both  the 
Federal  and  State  levels. 
Only through  concerted  action  to address  the  key problem  areas  identified  above  can 
the  potential  for the  community  health  centers  be  more  fully realized.  Strategies  for 
improving  perinatal  care,  such  as expanded  insurance  coverage  and  aggressive 
outreach  programs,  will be successful  only to the  extent  that  centers  can  provide 
sufficient  clinical  services  linked  effectively  with other  health  and  social  semices. 
Unless  the  serious  problems  affecting  the  community  health  center  system  are 
addressed,  the  centers  capacity  to meet  increased  demand  and  heightened 
government  expectations  will continue  to be strained  and  the  system will remain 
vulnerable.  COMMENTS  ON  THE  DRAFT  REPORT

We  solicited  and  received  formal  comments  on our  draft  report  from  the  Public

Health  Semite  (PHS),  the  Office  of the  Assistant  Secretary  for Planning  and

Evaluation  (ASPE),  and  the  Health  Care  Financing  Administration  (HCFA).  We

respond  here  to the  major  themes  contained  in the  comments.  We  first summarize

the  comments,  and  then  provide  our  response  in italics.  We  include  the  complete  text

of the  agencies  comments  in appendix  C.

The  PHS  and  ASPE  concurred  with our  recommendation  that  PHS,  ASPE,  and

HCFA  work  together  in developing  and  implementing  a plan  of action  addressing  the

key areas  for concern  identified  in the  report.  These  include  the  staffing  needs  of the

centers,  the  high cost of medical  malpractice  insurance,  the  ties between  the  centers

and  the  Medicaid  program,  and  the  relationship  between  the  centers  and  other  health

and  social  service  providers  in the  community.  The  HCFA  did not  concur  with our

recommendation.

To  implement  our  recommendation,  PHS will develop  an action  plan  and  will then

host  a meeting  of representatives  of other  agencies  to review  the  plan  and  help

formulate  steps  involving offices  outside  PHS.  Among  the  Department  of Health  and

Human  Service  agencies  that  will be asked  to participate  are  ASPE,  HCF~  the  Office

of the  Assistant  Secretary  for  Management  and  Budget,  and  the  Administration  for

Children  and  Families.  Also asked  to participate  will be  the  Department  of

Agricultures  Food  and  Nutrition  Sewice,  which  administers  the  WIC  program.

The  ASPE  proposed  that  it review  a jointly  developed  PHS-HCFA  plan,  assure  that

this plan  meets  national  objectives  for the year  2000 to reduce  infant  mortality  rates

and  increase  access  to perinatal  care,  and  incorporate  the  plan  into  those  actions

already  in progress  to meet  the  Secretarys  Program  Directions.

The  HCFA  did  not  concur  with our  recommendation.  It suggested  that  the  key areas

for action  we identified  are  being  addressed  by current  efforts  in the  Department.

The  HCFA  expressed  concern  that  implementation  of our  recommendation  could

result  in a duplication  or delay  of these  ongoing  efforts.

l%e development  and implementation  of an interagency action plan  by PHS, ASPE,  and 
HCFA  is critical to the strengthening  of the community  health  centem perinatal  care 
capaci~.  We are pleased  that ASPE  and PHS have  agreed with our recommendation  for 
an interagency effort to address the key areas for action  that  we identified. 
We continue  to believe that the participation  of HCFA,  which plays a vital role in suppoti 
of the community  health  centen provkion  of pennatal care, is important  to thti  effort, 
and  we urge that HCFA  reconsider its position. 
18
 We recognize that PHS, ASPE,  and HCFA  are involved  in ongoing inihahves  that address 
concerns  about  infant  mortality  and pen-natal care.  We uige PHS, ASPE,  and HCFA  to 
consider these current activities as resources upon  which  to draw in developing  a 
comprehensive  plan  that incorporates bo~h specific targets and concrete steps to ensure 
that the key areas for action  are atiressed.  We suggest that the drafting and 
implementation  of such a plan  be used as an opportunity  to bnngsharper focus  to efforts 
addressing pemistent  problems,  and that the agencies not duplicate  or delay current work 
We hope  the interagency effort will also provide  an oppo~nity  to further  involve  State 
and  locatpolicy  maken  in a concerted plan  to suppon  the centem provision  of perinatal 
care. 
Technical  Comments 
Medical  Malpmctice  Liability 
After  our  draft  report  was released,  Congress  passed  legislation  (P.L.  102-501) that 
extends  medical  malpractice  liability  protection  under  the  Federal  Tort  Claims  Act 
(FTCA)  to health  care  providers  at certain  Federally  supported  health  care  clinics, 
including  Section-330-funded  community  health  centers.  Under  the  FTC~  center 
providers  will be  defended  by the  Justice  Department  in any malpractice  litigation,  and 
judgments  will be paid  out  of a Justice  Department  fund,  into  which the  centers  will 
pay annual  contributions.  This  liability protection  will be  provided  for three  years,  at 
which  time  the  financial  benefits  of the  arrangement  will be  assessed. 
We have  revked  our report to reflect the new legislation.  We believe that the centem 
medical  malpractice  insurance  concerns  warrant continued  attention,  and  we u~e  PHS, 
ASPE,  and HCFA  to incorporate  into their action plan  an effort to monitor  the 
implementation  of the law and assess the cente~  expenencewith the new arrangement. 
Methodology 
The  HCFA  expressed  concern  that  our  report  might  be based  on incomplete 
information  because  we did not  intetiew  representatives  of HCFA  or State  Medicaid 
agencies. 
Our report focuses  on trends in the community  health  centen  capaci~  to provide 
perinatal  care.  As  a bask for our findings,  we relied primarily on information  reported by 
the centens.  A  comprehensive  assessment  of the Department k efforts relevant  to infant 
mortality  and perinatalcare would be beyond  the scope of this report.  We have revised 
our report to indicate  more explicitly the focus  and methodology  of our study. 
19
 The Implemenuwn  of Rec&  Me&a&i  Refonru 
The  HCFA  cites  information  on the  outstationing  of Medicaid  eligibility workers  and 
the  implementation  of FQHC  cost-based  reimbursement  that  is more  recent  than  that 
in our  report. 
Our information  on the outsta~ioning of Medicaid  eligibility workers came from  centen 
responses to our suIvq  in June  1991.  our  information  on the implementation  of FQHC 
cost-based  reimbursement  to the centen  was provided  by PHS  and  was accurate  as of 
May  1991. 
We expect that progress s}lould have been made  in both  areas since the time  of our study. 
771ecenters cited several additional  Medicaid factors  as serious limitations  to their 
prowkion  of perinatal  care, however, and we continue  to believe that  the ties between  the 
centers and the Medicaid program need to be improved. 
20  APPENDIX  A 
METHoDoImGY 
We  obtained  information  for this report  through  a mail sumey  of all community  health 
centers  receiving  Section-330  funds  as of June  1991, site visits to several  centers,  a 
series  of intewiews,  and  a review  of relevant  literature  and  data.  our  findings  are 
based  primarily  on the  centers  responses  to our  survey. 
Mail Survey  We  sent  a mail  survey of perinatal  services  to all Section-330  grant 
recipients  in June  1991.  Of 514 centers,  431 (84 percent  of rural  and  84 percent  of 
urban  centers)  responded,  including  centers  in every  HHS  region  and  every  State  and 
territory  in which  centers  are  located,  with the  exception  of Washington,  D. C., and  the 
U.S. Virgin  Islands.  A review  of geographic  and  demographic  information  suggests  no 
significant  differences  between  respondents  and  nonrespondents. 
of  the  431 respondents,  62 (14 percent)  provided  no perinatal  services  on site during 
the  1988-91 period.  The  numbers  and  percentages  in the  body of this report,  unless 
otherwise  noted,  reflect  the  responses  of those  369 centers  (72 percent  of all centers) 
that  offered  semices  on site  in at  least  1 year  during  the  1988-91 period. 
Of the  369 respondents  that  provided  semices  on site during  the  study  period,  235 (64 
percent)  received  CPCP  funds.  For  the  purposes  of this report,  a CPCP-funded 
center  is any center  that  received  CPCP  grant  funding  at any time  during  the  past  3 
years,  regardless  of the  year  in which its initial  grant  was awarded. 
Not  all respondents  provided  complete  information.  We calculated  the  trends 
presented  in the  body of this report  from  the  responses  of those  centers  that  provided 
the  relevant  information  for all years. 
Unless  otherwise  noted,  the  statements  in the  body of this report  that  compare  groups 
of centers  (for  example,  rural  and  urban  centers)  reflect  statistical  significance  at  the 
.05 level.  In reporting  responses  to survey questions  that  solicited  information  on a 
scale,  we combined  responses  of moderately  and  substantially  and  reported  them  as 
seriously or serious. 
Site Visits:  The  study team  conducted  site visits to nine  centers:  three  in 
Massachusetts,  two in Connecticut,  and  one  each  in Texas,  Wisconsin,  Ohio,  and 
Oregon.  The  team  toured  these  facilities  and  interviewed  management  and  clinical 
staff.  The  study  team  also conducted  a telephone  interview  with administrative  and 
clinical  staff  at  a center  in Mississippi.  We choose  the  centers  based  on discussions 
with  regional  PHS  staff and  with consideration  of geographic  representation  and 
community  size.  Of the  ten  centers,  seven  had  received  CPCP  funding. 
A -1  Intetiews:  The  study  team  held  discussions  with (1) officials  in PHSS Bureau  of 
Primary  Health  Care  (BPHC)  (at  that  time  called  the  Bureau  of Health  Care  Delivery 
and  Assistance),  both  in headquarters  and  in those  regional  offices  responsible  for the 
oversight  of site-visit  centers;  (2) State  primary  care  association  and  cooperative 
agreement  staff  in those  States  and  regions  in which site-visit  centers  are  located;  and 
(3) infant  and  community  health  experts,  including  staff at the  Childrens  Defense 
Fund,  the  National  Commission  to Prevent  Infant  Mortality,  and  the  National 
Association  of Community  Health  Centers. 
Literature  and Data  Review:  The  team  reviewed  extensive  literature  in the  areas  of 
infant  and  community  health.  The  Public  Health  Service  provided  us with  financial 
data  that  were  collected  from  the  centers  through  the  Bureaus  Common  Reporting 
Requirements  reports,  and  with financial  and  user  data  that  were  collected  from  CPCP 
applicants  through  the  Perinatal  User  Profile  reports.  APPENDIX  B 
URBAN AND RURAL SURVEY RESPONSES 
The Office of Inspector General suwey was mailed to 514 community health centers in May 
1991. Of the  431 (84 percent)  that  responded,  62 provided  no perinatal  sexvices on site during 
the  1988-91 period.  Below we present  the frequencies  and mean  responses  for those 369 
centers  that  did Drovide sefices  at some p. oint  during   this period.  Not  all centers answered
every question.  me  number  of respondents  to each  field (N) is indicated in parentheses as 
appropriate. 
Any discrepancies  between  the  responses  below and the data presented in the body of this 
report  are a result  of the  methods  used in aggregating  data  and calculating  trends.  Please  see 
appendix  C for a discussion  of statistical  methodology. 
Number  of centers  that  offered  pcrinatal  sexvices on site in each year: 
1988:  Yes=331  No=33 
1989:  Yes=341  No=26 
1990:  Yes=352  No=16 
1991:  YeS=349  NO=18 
A  CASELOAD  1988  1989  1990 
1. Please  indicate: 
MEAN(N) 
a. the  number  of women  who received prenalal 
care at your center:  359  (283)  391  (323)  406  (345) 
b. the  percentage  of these  clients who were 
high-risk as defined  by your center:  31%  (222)  33%  (259)  33%  (288) 
c. the percentage  of these  clients who were 
low~ris~ as ~efined  by your center:  55%  (217)  55%  (255)  56%  (279) 
d. the number  of births  to your centers 
clients:  253  (259)  273  (296)  310  (284) 
2. Of the women  who gave birth  in your setice 
area, what  percentage  received  prenatal  care 
at your center?  37%  (199)  40%  (218)  43%  (214) 
B-1  B. COMMUNITY COORDINATION 
1. Does  your center  currently  participate  in a consortium  of perinatal  care providem? 
Yes  =240  No  =128  If YES,  please  continue. 
2. ~ich  of the following participate in the consortium? (Please check all that apply): 
a. state  health  department:  107  f. nonteaching  hospitals:  84 
b. local health  department:  173  g. private-practi~  physicians:  113 
c. health  clinics:  116  h. gov. social setvice  agencies:  104 
d. schools:  67  i. non-profit  organizations:  116 
e. teaching  hospitals:  122  j. other:  24 
3. On  the  last page of this survey, briefly describe  the  coordination  of consortium  activities  and 
your centers  involvement. 
C. CLINIC  SITES  AND  HOURS  1988  1989  1990 
1. Please  indicate  the  number  OE  MEAN  (N-) 
a. clinic sites operated  by your center:  2.2  (351)  2.3  (353)  2.4  (357) 
b. clinic sites at which prenatal  care 
was provided:  1.7  (357)  1.7  (359)  1.8  (361) 
2. On  how many days a week did your center 
provide  scheduled  prenatal  appointments 
either  before 8AM or after 6PM?  1.0  (344)  1.1  (347)  1.2  (351) 
3. On  how many Saturdays a month  did 
your center  provide  scheduled 
prenatal  appointments?  0.5  (340)  0.5  (342)  0.6  (347) 
D. Funding 
1. Compared  with  1988,the amount of funding available for perinatal  care at your center  in 1990 
was: 
Larger= 185  Smaller=47  Unchanged= 114 
2. Please  indicate  the percentage  of your centers  1990 perinatal  clients  covered  by:  MEAN  ~ 
a. Private  insurance:  10.3%  (318)  c. Medicaid:  66.9%0 (319) 
b. No insurance:  18.9%  (321)  d. Other:  3.1% (330) 
B-2  3. To what extent have the following factors resulted in increased demand for perinatal services 
at your center over the past three years? 
Not at all/  Moderately/ 
Somewhat  substantially 
a. Medicaid  eligibility  expansions:  134  194 
b. Medicaid  presumptive  and 
continuous  eligibility  provisions:  150  174 
IZ PERINATAL  OUTREACH 
1. To which of the  following groups  does your center  currently  target  specific  perinatal  outreach 
efforts?  (Please  check  all that  apply) 
a. Teenagers:  310  c. Non-English  speakers:  157 
b. Substance  abusers:  133  d. Other:  106 
2. At which of the  following locations  does your center  currently  conduct  perinatal  outreach? 
(Please  check  all that  apply) 
a. Community  d. Schools:  238 
centers:  179  e. Welfare  offices:  120 
b. Shops:  47  f. Churches:  107 
c. Door-to-door  in the  g. Other:  128 
neighborhood:  76 
3. Through  which of the  following media does your center  currently  conduct  perinatal  outreach? 
(Please  check  all that  apply) 
a. Television:  61  d. Radio:  104 
b. Newspapers:  180  e. Other:  97 
c. Pamphlets:  283 
4. Compared  with  1988, your centers  outreach  efforts  in 1990 were: 
Greater= 232  SmaUcr=27  Thesame=87 
5. Compared  with  1988, your centers  outreach  efforts  in 1990 yielded: 
More clients=245  Fewer clients=23  The same number of clients=57 
B-3  F. PEIUNATfi  SERVIL~ 
1. Please indicate which of the following services were provided by your center.  If these were 
--either through contract, affiliation, 
offered on site, please circle On. If these were offered off site
or paid referrall-pleme  circle OK 
1988  1989  1990 
~.~  On=lol  orl=l13 
a. Ultrasound: 
0ff=230  off=224  0ff=226 
On=ls  on=14  on=20 
b. Amniocentesis: 
01x=286  off=295  0ff=297 
Orl=so  orl=53  on=59 
c. Genetic  counseling: 
~=237  0ff=244  0ff=247 
on.~  on=95 
on=71 
d. Non-stress  testing: 
0ff=220  off=210  off=211 
on=201  on=199  on=206 
e. Dental  care: 
Off=llo  OEi= 122  0il=131 
0n=285  orl=2%  0n=312 
t.  Nutritional  setices:  0E=43  0fi=42  Off=27 
011=307  on=319  on=339 
h. Health  education: 
0ff=27  0ff=21  0fl=16 
0n=161  on=179  On=l% 
i. Birthing  classes: 
off=  133  Off= 127  Off= 126 
0n=163  0Q=181  0n=223 
j. Parenting/infant  care classes: 
off=  120  0H=116  Off=% 
011=326  on=330  on=343 
k. Family planning: 
0ff=12  0ff=13  0ff=13 
on=137  0n=142  0n=165 
1.Smoking  cessation  programs: 
Off= 122  Off= 126  Off= 128 
0n=63  0n=62  on=79 
m. Substance  abuse  treatment: 
off=220  0H=227  0ff=233 
on=179  0u=230  0n=278 
n. HIV  counseling/testing: 
off=  105  0ff=81  0ff=56 
2. Compared  with  1988, the  range of perinatal 
semices  offered  by your center  in 1990 was: 
Greater= 250  Smaller=30  Unchangd=79 
3. Were  perinatal  clients  enrolled  on-site  at the center 
in the  following  programs] 
yes=89  yes=135  Yes=205 
a. Medicaid: 
No=256  No=213  No=156 
yes=212  Yes=230  Yes=241 
b. WIC: 
No=136  No=124  No=121 
B-4
 1988  1989  1990 
4. Did  other  government  orprivate  social  setice 
organizations	 provide  sewica  on-site  at your  Yes=98  Y~=108  Yes= 138 
center?  No=247  No=242  No=224 
5. Did your center  facilitate  access to perinatal 
care by providing  the  following services? 
Yes=161  yes=186  yes=211 
a. Transportation  to and from appointments:  NO=183  No=164  No=150 
Yes=205  Yes=215  Yes=230 
b. Translation  for non-English  speaking  clients: 
No=113  No=11O  No=99 
yes=30  yes=34  yes=47 
c. Child care  during  center  appointments: 
No=316  No=319  No=311 
Yes=161  yes=204  Yes=230 
d. Home  visits:  ;0=184  No=150  No=131 
G. STAFFING 
1988  1989  1990 
1. How many full-timeequivalenfi  of each 
of the  following  provided  perinatal  services 
MEAN  (N=369) 
on-site  at the  center? 
0.64  0.70  0.66 
a. obstetricians: 
1.08  1.09  1.11 
b. Family physicians: 
0.23  0.25  0.28 
c. Certified  nurse  midwives: 
0.56  0.62  0.66 
d. Nurse  practitioners: 
0.29  0.31  0.34 
e. Physician  assistants: 
7 
Please  indicate  below:  (i) the number  of your perinatal  provider  positions  which are currently 
L. 
vacant;  (ii) the  number  which  have been  vacant  for more  that  six months;  and  (iii) the  number 
MEAN  (N=369)
which have been  vacant  for more  than  one year 
(i)  (ii)  (iii) 
Number of  More than  More than 
vacancies  six  months  one year 
0.33  0.27  0.16 
a. Obstetrician: 
0.41  0.35  0.20 
b. Family physician: 
0.14  0.11  0.06 
c. Certified  nurse  midwife: 
3.	 Compared  with  1988, the  percentage  of your perinatal  providers  with  admitting  privileges  at 
local hospitals  in 1990 was: 
Larger=93  Smaller=67  Unchangd=  188 
B-5  H. TIMING OF CARE 
1. Please  indicate  the percentage  of your centers  1990 prenatal  clients who entered  care in the: 
w 
a. First  trimester:  55.0%  (N=337) 
b. Second  trimester:  34.6%  (N=334) 
c. Third  trimester:  10.1%  (N=302)  MEAN  (n) 
1988  1989  1990 
2. Of those  clients who entered  care during  the 
first trimester,  and carried  to term, what 
percentage  received  at least nine  prenatal
. 
medical visits?  75%  (183)  76%  (218)  79%  (255) 
3. What  percentage  of your centers  prenatal 
clients  returned  for postpartum  visits 
during  the  first eigh~ weeks after  delivery?  68%  (205)  70%  (263)  73%  (303) 
4. What  percentage  of all infants  born  to center 
r)renatal  clients  returned  for newborn  visits 
~uring  the  first four weeks after  birth?  68%  (200)  70%  (248)  73%  (286) 
1. APPOINTMENTS FOR CARE 
1. If  a woman  called  today  to  schedule  a  pregnancy  test,  how  long  would  she  wait  for  an 
appointment? 
Pregnancy  tests are offered  Less than  one week:  113 
on a waik-in basis:  228  One-two  weeks:  20 
More  than 
two weeks:  5 
2. If the  pregnancy  test were  negative,  would she be referred  to family planning  services? 
Yes=328  No=35 
3. If the  pregnancy  test were  positive,  how long would  she wait for her first prenatal  visit? 
The  first perinatal  visit is  Less than two weeks:  193 
provided  in conjunction  Two-four  weeks:  100 
with the  pregnancy  test:  59  One-two  months:  9 
More  than 
two months:  4 
4.  Compared  with  1988, waiting  room  waiting  times  at  perinatal  appointments  in  1990 were 
generally: 
Shorter= 121  Longer=59  The same= 162 
B-6  J. CASE MANAGEMENT 
promote the coordination of services 
1. Does your center  currently  provide  case management  to 
for perinatal  clients? 
Yes=337  No=32  If YES,  please continue. 
by (please check only one): 
2. Case  management  at your center  is primarily conducted 
The  clients primary care doctor:  32 
The  clients primary care nurse:  37 
The  appointmen~  secretary:  2 
A multidisciplina~  team:  123 
A center  employee  whose  main 
responsibility  is case management 
for perinatal  clients:  126 
Other:  18 
3. Case  management  at your center  is provided  for (please  check only one): 
All perinatal  clients:  272 
All high-risk  perinatal  clients:  43 
Only certain  groups  of 
perinatal  clients:  23 
4. Case management  of perinatal  clients  at your center  comprises  (please  check  all that  apply): 
a. Risk  assessment:  320 
b. Planning  of care:  314 
c. Assessment  of adequacy  and 
appropriateness  of setices:  278 
d. Client  advocacy:  277 
e. Contact  with other  organizations 
to arrange  for services / 
schedule  appointments:  322 
f. Assistance  with paperwork  related  to 
WIC,  Medicaid,  and other  programs:  299 
g. Discharge  planning:  186 
Coordination  of 
h.  Medical  services  provided 
on-site  at the center:  311 
i.  Medical  sexwices provided 
off-site:  276 
B-7  Continued: 
j.  Delivery  services:  245 
k.  Social sewices  provided 
on-site  at the center:  253 
1. Social semices  provided 
off-site:  243 
m.  Nutritional  services:  313 
n.  Health  education:  315 
0.  Other: 
5. Compared  with  1988, the  percentage  of all center  perinatal  clients  case managed  by your staff 
in 1990 was: 
L.arger=266  SmalIer=17  Unchanged=44 
6. Does  your center  often  encounter  problems  assuring  the timely transfer  of medical  records  to 
and from facilities  to which perinatal  clients  are referred? 
For delivery:  Yes=76  No=262 
For other  care:  Yes=84  No=244 
7.  Please  estimate  the  percentage  of  cases  in which  your  center  contacts  perinatal  clients  to 
reschedule  missed appointments: 
~m 
65%  (N=309) 
8. Please  indicate  the  manner  in which you contact  clients  to reschedule  missed  appointments 
(please  check  all that  apply): 
Mail= 305  Phone=  329  Home  visit=  207  Other=  25 
9. Are  perinatal  clients  at your  center  routinely  attended  by either  the  same  primary  medical 
provider  or the same provider  team  at each  perinatal  visit? 
Yes=321  No=13 
B-8  K LIMITATIONS ~  CARE  Please indicate  the  degree  to which  each  of the  following  factors 
limits  your  centers  ability  to  provide  perinatal  setvices: 
Not at W  Moderately/ 
Somewhat  substantially 
1. Shortage  of medical  staff  132  227 
2. Shortage  of nonmedical  staff  250  95 
3. High medical  staff turnover:  240  105 
4. High  nonmedical  staff turnover:  303  38 
Difficulty  obtaining  admitting  privileges 
at local hospitals  for: 
5. obstetricians:  276  31 
6. family physicians:  275  46 
7. certified  nurse  midwives:  178  83 
8. High cost of malpractice  insurance:  150  190 
Difficulty  obtaining  malpractice  insurance  for: 
9. obstetric  providers:  255  62 
10. all providers:  280  51 
Difficulty  arranging  medical  backup  for: 
11. OB supervision  of certified  nurse  midwives/ 
nurse  practitioners:  185  102 
12. OB supewision  of family physicians:  209  85 
13. coverage  during  center  staff vacations, 
holidays,  and weekends:  1%  143 
14. consultation  for high-risk  patients:  240  99 
15. Limited  relationships  with  local 
community  and government  organizations:  318  31 
16. Lack of other  providers  in the community 
willing to treat  uninsured  or publicly 
insured  women:  142  206 
Non-acceptance  of cer~ified nurse  midwives/ 
nurse  practitioners: 
17. by the  medical  community:  204  108 
18. by patients:  277  21 
19. Inadequate  center  funding:  139  210 
20. Difficulties  related  to funding  obtained 
from  many different  sources:  187  147 
Medicaid-related  problems: 
21. slow reimbursement  process:  207  141 
22. inadequate  reimbursement  rates:  175  170 
23. limited  range  of covered  services:  206  135 
24. restrictive  eligibility  criteria:  199  146 
25. burdensome  application  procedures:  163  188 
26. Limited  case management:  246  94 
27. Limited  collocation  of services:  242  83 
28. Limited  space:  156  193 
29. Other  37  28 
B-9  mich  of these  factors  have  become  LESS  SERIOUS  or  MORE  SERIOUS  limitations  since 
1988? 
More 
serious  serious 
139  49 
1. Shortage  of medical  staff 
43  44 
2. Shortage  of nonmedi~l  staff 
51  45 
3. High  medical  staff turnover: 
15  45 
4. High  nonmedid  staff turnover: 
Difficulty  obtaining  admitting  privileges 
at local hospitals  for: 
17  40 
5. obstetricians: 
23  33 
6. family physicians: 
26  29 
7. certified  nurse  midwives: 
91 25
8. High  cost of malpractiu  insuranu: 
Difficulty  obtaining  malpractim  insuran~  for: 
32  27 
9. obstetric  providers: 
21  27 
10. all providers: 
Difficulty  arranging  medical  backup  for: 
11. OB supervision  of certified  nurse  midwivti/ 
55  29 
nurse  practitioners: 
45  28 
12. OB supetision  of family physicians: 
13. coverage  during  center  staff vacations, 
76  31 
holidays,  and weekends: 
54  33 
14. consultation  for high-risk  patients: 
15. Limited  relationships  with  local 
12  69
community  and  government  organizations: 
16. Lack of other  providers  in the community 
willing  to treat  uninsured  or publicly 
111  28
insured  women: 
Non-acceptanm  of certified  nurse  midwivti/ 
nurse  practitioners: 
27  50 
17. by the medical  community: 
8  48 
18. by patients: 
89 44
19. Inadequate  center  funding: 
20. Difficulties  related  to funding  obtained 
69  22
from  many different  sources: 
Medicaid-related  problems: 
54  66 
21. slow reimbursement  process: 
57  90 
22. inadequate  reimbursement  rates: 
44  69 
23. limited  range  of covered  servim 
49  110 
24. restrictive  eligibility  criteria: 
63  80 
25. burdensome  application  procedures: 
32  86 
26. Limited  case management: 
22  52 
27. Limited  collocation  of services: 
107  43 
28. Limited  space: 
8  2 
29. Other 
B-10  L  CONCLUSION 
1. Over  the  past  three  years,  demand  for  perinatal  care  at your  center  has: 
Imxeasd=201  Decreased  =22  Not  changed=40 
2. Over  the  past  three  years, your centers  capacity  to address  the  demand  for perinatal  care  in 
your setvice  area  has: 
Inereawxl=210  Dtxxead=88  Not changed=64 
OPEN-ENDED  QUESTIONS:  [Center  responses  are  not included  here]: 
3. What  are  the  three  most  significant  barriers  to delivering  perinatal  care  that  your  center  has 
faced in the  past  three  years? 
4. What  special  projects,  initiatives,  or  programs  has your center  undertaken  over  the  past three 
yms  to improve its ability to respond to perinatal care needs in your setvice area? 
B-n  APPENDIX  C 
DETAILED  COMME~  ON  THE  DRAFI  REPORT 
h  th~s appendti,  we present  the  complete  comments  on the  draft  repofi  received  from 
the  Public  I-lea\th  Setice  (PHS),  the Office  of the  Assistant  Secretaq  for Planning 
and  Evaluation  (ASPE),  and  the  Health  Care  Financing  Administration  (HCFA). 
Page  C-2 
Public  Health  Sewice 
Page  C-5 
Assistant  Secretary  for Planning  and  Evaluation 
Page  C-6 
Health  Care  Financ~ng Admlnlstratlon 
c-1  ,. ,11*1 <,, >,.
...+ 
*  (
-i-  DEPART,tlENTOF HWLTII & HUALNJSERVICES  f%bfiHceakh SeMce 
~-;   *3
56>
~,ilc~ 
Memorandum 
w 
C3:e    NOV  ~ 
~fom  -
~~ssi~tant  secret s.-y for  Health 
Office of Inspec:cr General Reports on the Perinatal Service 
UbmCqapacity  of the Federally Funded Community Health Centers, 
OEI-01-90-02330,  OEI-01-90-(12331,  and  OEI-01-90-02332 
To 
Acting  Inspector General, OS 
Attached  are  the  Public Health  Servi-ce  (PHS)  conmen~s  on  the 
subject  Inspector  General reports- We concur with the 
recommendation  for PHS, in coordination with the Health Care 
Financing ~%dmini~tration and the Assistant  Secretaq  for 
?lanning  and  Evaluation, to develop and hnplement a plan  of 
action  to address  the  key  areas for action  identified  in these 
reports.  Our coxmenta discuss some of the actions planned  or 
underway  to  Lnprove perinatal services in the community health 
center~  . 
k 
()+WW- 
ames  O. Mason,  M.D., DroP~ 
v 
~Attacbunent 
C-2  PUBLIC !~ZALT1iSERVTCE  {PHS\ COMMENTS ON THE OFFICE OF INSPECTOR 
GENERAL  (OIG\ 2EPORTS ON THE PERINATAL SERVICE  CAPACITY 
OF THE FEDE?ALLY  FUNDED  COMKUNITY  HEALTH  CENTERS, 
OE1-01-90-02330,  OEI-01-90-02331,  AND OEI-01-90-02332 
The OIG reports sm~arize  the results of an inspection  which 
revealed  that  the  per~natal  capacity  of  the  co~~lty  health 
centers  (CHC)  inc~cased  in several  respects  between 1988 and 
1990.  However,  OIG reports that the inspection also  revealed 
that  the  demand  for  ~e~~ices  also  i~cre~sed  apd  ~ny  clients  do 
not  receive  the optimal  coordinated  package  of  care  in  a  t~ely 
fashion.  The  reports note t-hat  several  key  constraints  limit  the 
perinatal  capacity of the CHCS.  OIG  suggests  that  a  cooperative 
effort  involving  government  at  the Federal, State,  and  local 
levels  ,  as  well as non-governmental  organizations  is needed  tO 
acidxessi  these  find~ng8. 
The OIG report  desc~lbes  many  programs  ud  lniti.atf-ves  Of  the

Bureau of Healti Care Delivery and Assistance  (BHCDA).  BHCDA,

which  is  part  Of  the PHS Health  Resources and  Services

Unistration  (lIRSA),ha6  reorganized  and  is  now  called  the

Bureau  of  Primary !-lealthCare  (BPHC).  In  the  PHS  comments  Which

follow,  we  will  refer  to  the  organizatiorl  responsible  for

managing  the  CIIC  program  by  this  new  title.

OIG Recommendation

We recoxmnend that  PHS,  the  Health Care Pinancing Administration 
(HCFA),  and  the  Assistant Secretary  for  planning  and  Evaluation 
(ASPE) develop  and iii,plementa  plan  of  action  to:  (1)  address 
the  staffing  needs of the CHCS,  (2) relieve the CHCS of the high 
co~ts  of medical  malpractice  insurance,  (3) improve  ties  between 
the  CHCS  and  the-xedi.caici  pragram,  and  (4)  strengthen 
relationships  between  the CHCS and  other  health  and  social 
service  providers  in the co~~ityc 
PHS Comments

We concur with this recommendation.  We are particularly 
appreciative  of the OIG recommendation to bring together agencies 
throughout  the Department of Health  and  Human  Semites  that  can 
work  with  BPHC  on i.nprovingperinatal  services  in  CHCS. 
Furthermore,  13PHCis prepared to take the lead on development  on 
the plan recommended k~ OIG.  we consider it critical that the

plan be the result of a process that includes  the participation 
of  Departmental  agencies and other  affected parties  (e.g., State 
and local govenm,ent  agencies,  grantees) . 
The  lEISA and the 21{SInteragency Committee on Infant Mortality 
(ICIM) are prep~r~d tO  ~orkwith other agencies throughout  the 
Department  of ~IeaL:hand Human Semites  to address the key issues 
c-3  2

identified  in  the  OIG  report  and  improve  perinatal  se~~ces  in 
the  CHCS.  HRSA  plans to take the following actions  to  Implement 
this recommendation: 
internal  work  group  to 
1.	 In the Autuii  of  i992, convene an 
outline  the  steps  and  develop  an implementation  plan  that 
describe  the  direction  BPHC and  its  p~09~~s  f~~l  ake  n 
addressing  the  OIG  reports  recomendation~ 
implementation  plan will be developed to co+.ncidewith 
discussion  affecting  Fiscal  Year  1993  fmdlng= 
2.	 In  collaboration  with the ICIM, convene a meeting of 
who  can  review  BPHCS  plan  and 
Departmental  representatives 
help  formulate  step8  involving offices external to  BPHC* 
Agencies  asked  to  participate  will  include  other  l?HS 
components?  XPE~  ~~c~h~the Office of the Msi.s tmt  . 
for

Secretaq  for Management  and Budget, the AtinistrntlOn 
Childzen  and  Families, and the Depa~ent  of  Agricultures 
WIC Program.

this  meeting  before  the  end  of
The KRSA plans to  convene 
a plan with admhistrative
calendar  year  1992  and
 produce 
hnrovments  and  action  steps to  coincide  with  the  budget

an; legislative  cycle.

We  concur  that  X5PZ  approve  and  nonitor  this  plan once it 
has  been  apprcved  by  the  Assistmt  Secretaq  for  Health
. 
CongreSs
In  a directly  related matter, before adjoum>ng  the 
passed  ~egi~lation  {i?.~.  6183)  which  extends  Federal  Tort  Clahs 
to health  care providers 
fict  (FTCA) protection  for three years 
employed  by certain Federally-funded  health care entlties~ 
including  CHCS.  The FTCA coverage is paid for by a Judqent  Fund 
in the U.S. Treasury,  and the Depar~ent  of Justice handlee theThe 
cases with help  frcn the General Counsel of each Deparment 
bill requires  annual  contributions  from  the  relevant progr~f 
Fund, baaed on the prior  years 
e.g., CHCS, to  the  Juaqent 
experience.  There  are  riaxi.mm  limits  to  the  annual 
contributions .  At the time these comments were prepared,  the 
President  had  not  signed  this  bill. 
C-4
 ~+     f,
 
:. ,   DEPARTMENT  OF HEALTH  & HUMAN  SERVICES offkaofthas~ 
:. 
,
-0 ~ 
*,
b>I,.,,a  Washington,  D.C.20201 
JLJL161W 
TO:  Richard  P. Kusserow 
Inspector General 
FROM :  Assistant  Secretary  for Planning  and  Evaluation 
SUBJECT :  OIG Draft Reports on the Perinatal SeNice  capacity of 
the Federally Funded Community Health Centers, OEI-Ol-
9002330;  OEI-01-90-02331;  and  QEI-G1-90-02332 
Thank you for  submitting  for my  review  and  comment  the  draft 
copies of the  subject  reports.  The  reports  provide  useful 
information on issues pertaining to peiinatal  senice  capacity in 
Community Health Centers  [CHCS). 
I support the recommendation  that the Assistant  Secreta~  fOr 
Health  and  the  Administrator  of  the  Health  Care  Financing 
Administration  develop a plan of action to address the key areas 
outlined  in these reports, and that the Assistant Secretary  for 
Planning  and  Evaluation  review  such  a plan  to assure that our 
national objectives  to reduce infant mortality  rates and increase 
access  to perinatal  care are met  by the  year 2000.  The role of 
CHCS is increasingly  important  in our  efforts  to  achieve health 
care refom  and provide better access to undersexed  communities. 
We look fonard  to workin~ with PHS and HCFA to assure hat Ur 
limited health  care  resou~ces  are  used  as  effectively  as 
possible. 
We  intend  to  incorporate  this  action  plan  into the actions 
already in progress  in the Secretarys Program Directions plan to 
improve  pre- and  perinatal  care. 
lf you  have any questions,  please  phone  Elise  Smith on 690-1870. 
. 
c-5  Health  Care 
DEPARTAIENTOF HEALTH & HUhlAN  SERVICES 
financing  Administration 
n*ln?Ann 
Z74L  Memorandum 
Date 
h  \Villim  Toby,  Jr. 
rem  ()  .Aicting Adminktrator 
Office  of Lnspector  General  (OIG)  Draft  Reports  on the  PerinaEl  Setice  Capacity  of 
5Ublecl 
the  FederaLIy  Funded  Communltv  Health  Centers,
/ 
OEI-01-90-02330,  OEI-01-90-02331,  and  OEI-01-90-02332 
TO 
Bryan  B. Ltitchell 
Principal  Deputy  Inspector  General 
. 
We  have  rcvicwcci  the  three  above-referenceci  reports  on  perinatal  scnnce 
capacitoyf fedcr~y-findeci  Urban community  health  Ce-nters, mral  cornmuni~  health 
centers,  and  all co~unity  health  centers. 
We  agree  bat  tic  icdcraily-funded  community  and  migrant  healthcenters 
(C~4HCs)  plav  an  important  role  in national  strategies  to  reduce  infant  mortality,  and 
that  Nledicaid  rcunburscmcnt  and  strong  relationships  between  C/MHCS  and  s~~c 
Medicaid  programs  are  essential.  In fac~  beause  of our  stiong  belief  in  this  objective, 
we aiready  have  a varlc~  of actions  underway  in concefi  witi  the  Health  Resources 
and  Setices  A~inis~aLOn  and  with  the  A&tant  Secretav  for planning  and 
Evaluation  (ASPE)  to address  better  program  coordination.  L)vlanyof these  activities 
~0 beyond  the  Icgal  authoritimeesntioned  in the  OIG  report-
Not  all  of the  issues  mentioned  in the  report  relate  toprogramcoordinationA. 
number  of  tic  issues  need  to  bc  addressed  directly  by the  Public  ~ealti  Senice  (PHS) 
and  the  QMI-Ics,  such  as Staffinagndspaceneeds. 
Partlybecause  of  the  delay  in collecting  information  and  incorporating  those 
data  JDIOt.hc OIG  rCPo~  ~nd, partly  as a  result  of  the  methodology  used  as the  basis 
[or  the  recommendations  in  the  repoz  we  bebe~e the  OIG  overlooked  a broad  Variety 
of  steps  the  Dcpar~cnt  IS taking  to address  the  chief  concerns  identified  in  the 
reports.  [n  addition,  the  reports  fail  to  recognize  the  elements  of  the  Presidents 
Hcaiti  Care  Reform  plan  that  are  responsive,  albeit  on  a broader  bask,  to some  of the 
issues  raked  in the  audits.  Limits  on malpractice  insurance  are  one  exampie  of Such 
an  eIemen  L 
C-6  Conscquentl},  ~vc  do notsupport  the  recommendation  for a new  initiative  on 
the  part  of the  Dcp2~cnt  lnvol~ting ASpE,  pHS  and  HCFA  to address  these 
concerns  since  wc  hcllcve  hat  such  a recommendation  duphcates  efforts  that  are 
aircadv  under  \vav.  ~ese  ~~ent  cffo~  are  a comb~ation  of HCFAS  Medicaid 
innovations  dea~g  w~~ OuVcach,  s~etied  e~gibfi~  dete~tiations.  new 
reimbursement  approaches,  special  HCFA-PHS  cooper~~e  efforts,  and  special 
responses  to tie  Secrews  progr~  ~xtiatives  w~ic~ are  ~e~g  conducted  under  the 
overnight  of ASPE.  -
~ttacbed  foryourconsideratiaorneour  detaded  comments.  Thank  you  for the 
opportunl~  to review  and  comment  on these  draft  reports.  please  advise  us ~ you 
agree  ~~~  our  position  on  he  repom  reco~endations  at  your  earfimt  convenience. 
Attachment  ~omrncnts  of  [hc  Heaith  Care  Financ]ng  Administration  (HCF4] 
on  ~(flcc  of  Inspector  C~cnerai  (OIG)  Draft Repo~ 
on  the  Pcrlnntal  Semcc  Capacity  of  the 
Federnil\  F-tlncicd Communltv  Health  Centers 
0EI-fil-(jO-~12330.  0[31- 01-90-02331, and  OEI-01-90-02332 
OIG  Rccommcndation 
The  Assistant  Secrctaw  for Health,  the  Admkkrator  of tie  Heal~  Care 
Financing  Administrationa,nd  the  Assistant  Secretary  for  Planning  and 
Evaluation  should  develop  a plan  of action  to address  the  key areas  outlined 
above. 
HCFA  Response 
~~e be~icve  that  OIG  has  ldcnt]ficd  pertinent  problems  that  community  and 
migrant  heaith  centers  iCNHC)  face  when  delivering  perinatil  care  to  low 
Income.  high  risk women.  However,  since  I-ICFA and  the  Public  Health 
ScWIcc  (PfiS)  arc  already  l~orking  together  to  resolve  many  of these  issues, 
we cannot  commit  to dc~cioping a new initiative  which  may  duplicate  or  delay 
ongoing  efforts.  The  following  arc  activities  already  undemay: 
o  Under  the  Deparments  Interagenm  Committee  on 
Infant  Nlortaliw  (on  which  the  Assistant  Secretary  for 
Planning  and  Evaiuatlon  (ASPE)  is also  represented), 
the  Directors  of  HCFAS  ,Medicaid  Bureau  and  PHSS 
Bureau  of  Health  Care  Delivery  and  Assistance  co-chair 
an  ACCCSS\Jork  Group.  Its agenda  includes  streamlined 
eligibility  and  outstatloning  eligibility  workers  at 
C/MHCs. 
o	 HCF:\  has  an  ]ntcragcnc~  agreement  with  the  Health  Resources 
and  Scmlccs  ,\dmlnl;tratlon-concerning  federally  qualified  health 
centers  (FQHCs)  (I.e.,  [cderallv-finded  C/MHCs).  Reguiar 
meetings  nrc  held  to  plan  and  assess  progress  in  achieving  mutuai 
perlnatai  care  stratcglcs  and  Medicaid  coordinated  care  initiatives. 
0	 The  Secrcums.  Program  Directions,  monitored  by ASPE.  inciude 
several  primary  and  pcrlnatai  care  Initiatives  involving  C/MHCS  and 
Jfedicald  c!cmcnts. 
Insummam,  Jvc bclic~e  [hc  reports  do  not  adequately  address  current  issues 
and  or  dcpnrtrncn~l  plann]ng  and  implementation  initiatives. 
c-s  Page  2 
General  Comments 
The  following  comments  arc  directed  to  the  summary  repofl:  The  PerinataI 
Service  Capaci~  of  the  Federally  Funded  Community  Health  centers 
(OEI-01-90-02332). 
1.	 Discussions  on pages v, 10, and  16 imply that  little  is being  done  about 
outstationed  eligibility  workers.  In contras~  the  National  Governors 
Asoaation  1992 repor~  Outstationin  p Medicaid  Eli~ibiliN  Workers  at 
~  sQted* ~ost  of the  s~dY  c~Hcs  repofl  that  oufi~tioning 
also  has  improved  the  centers  fiscal condition,  at  least  as it pertains  to 
the  delivery  of perinat.al  sewices  . . . .  In general,  the  s~dy  C~HCS  are 
very  satisfied  with  their  outstationing  arrangements  . . . . 
Discussions  on pages v,  10, and  16 imply that  only  half the  States  have 
implemented  the  FQHC  reimbursement  provisions.  All States  are 
implementing  the  provisions,  and  ail but  one  State  plan  amendment  has 
been  approved. 
2.	 The  following  commen~  relate  to  the  Key  Areas  for  Action  on  pages  iv 
and  v: 
o  Addressthes(affinn~e edsofcenter
sOIG  did  not  consider  the 
five-point  plan  in  the  Presidents  budget  which  calls  for  e~anding 
C/MHCs  and  increasing  funding  for  the  Nationai  Health  Senice 
corps. 
In addition,  States  set  credentiaiing  criteria.  The  Federai

government  does  not play a large  role  in this  area.

o  Relieve  the  centers  of  the  hi~h  cost  of  medicai  malpractice

insurance  - The  h]gh  cost  of malpractice  insurance  affects  the  entire

health  care  system:  ongoing  studies  have  shown  that  C/MHCs  are

particularly  affected  by this  problem.  while  immediate  fixes may

bring  temporary  relief,  we believe  that  C/MHCs  would  be  better

sewed  by a long-tcnn  solution  to  our  medical  liability  crisis.  The

President  has addressed  the  issue  of heaith  care  liability  in his

proposai  for CamprchensiVe  heaith  reform  and  in subsequent  draft

legislation  submitted  to Congress  on Juiy  2.

c-9  Page  3 
0	 Improve the  tics  between  the  centers  and  the  Medicaid  pro~ram  -
A modci  auuiica~on  form  for Maternal  and  Child  Assistance 
Programs  &s  dcveioped  by the  Administration  for  Children  and 
the 
Famdies.  HCFA,  PHS,  and  the  Food  and  Nutrition  Sefice  of 
Department  of Agriculture,  and  was published  in the  Federal 
Register  on December  9, 1991. 
use  a 
Also,  tic  Medicaid  program  already  gives States  the  option  to 
shortened  application  form,  implement  an  expedited  eligibility 
program  for women  and  children,  and  outstation  eligibility  workers. 
In addition,  HCFA  is working  closely with  PHS  to implement  the 
FQHC  mandate.  HCFA  has distributed  lists of FQHCS  tO the 
States,  and  issued  policyand  retiew  guidelines. 
o	 Stren~then  relationships  be~een  the  centers  and  other  heakh  and 
soclai  sewce  prowders  In the  communi~  - HCFA  beiieves  that 
coordinated  care  is the  best  route  to increasing  access  to  providers. 
HCFA  is aiready  working  with  PHS  on  how  to  best  integrate 
FQHCS  into  coordinated  care  ne~orks. 
In addition,  the  Omnibus  Budget  and  Reconciliation  Act  of  1989 
requires  States  to raise  Medicaid  obstetric/pediatric  paymenfi  to 
ensure  that  access  to services  by Medicaid  recipients  is comparable 
to the  general  population  in the  same  area.  This  mandate  should 
have  the  effect  of strengthening  the  relationships  between  the 
centersan
 d  individual  providers  in their  community. 
3.	 ~- Although  the  reports  address  financing  and  Medicaid 
issues,  no intewiewswere  held  with  officials  in  State  Medicaid  agencies 
or  central  and  regional  offices  of HCFA.  Based  on  these  incomplete 
data.  we suggest  that  OIG  include  a Medicaid-related  discussion  in  the 
report  and  arrange  an  Information  gathering  conference  with  HCFA. 
c-lo  APPENDIX  D 
NOTES 
1.  National  Center  for Health  Statistics  (NCHS),  1992.  The  1989 U.S.  infant 
mortality  rate  was 9.8 deaths  per  1,000 live births.  The  provisional  rate  for 
1990 is 9.1 deaths  per  1,000; and  the  provisional  rate  for  1991 is 8.9 per  1,000. 
These  rates  represent  considerable  improvement  over  the  1950 rate  of 29.2, but 
the  pace  of improvement  has slowed  in recent  years  and  has  not  been 
experienced  equally  by all segments  of the  population.  According  to the  most 
recently  published  international  data,  the  1988 U.S. infant  mortality  rate  for 
whites  alone  places  the  nation  17th lowest  in the  world,  while  the  rate  for 
blacks  alone  places  it 36th.  Native  Americans  and  Puerto  Ricans  also have 
infant  mortality  rates  considerably  higher  than  the  national  average. 
2.  U.S. Public  Health  Service  (PHS),  Healthy  People 2(900: National  Health 
Promotion  and Dhease  Prevention  Objectives,  Washington,  D.C.,  1990, p. 366. 
PHS,  Caring for  Our Future:  7%e Content  of Prenatal  Care:  A  Repo~  of the 
PHS  Expert Panel on the Content  of Prenatal  Care, Washington,  D. C.,  1989, p. 2. 
3.  Sarah  S. Brown,  editor:  Institute  of Medicine,  Prenatal  Care: Reaching  Mothen 
Reaching  Infants,  National  Academy  Press,  Washington,  D. C.,  1988, p. 4. 
4.  Deborah  Lewis-Idema,  Increasing Provider Participation,  National  Governors 
Association,  Washington,  D. C., 1988, pp 20-23.  An  increasing  number  of 
physicians  who practice  obstetrics  are  unwilling  to accept  low-income  or 
Medicaid-insured  patients  because  of high malpractice  premiums  and  low 
Medicaid  reimbursement  rates. 
In September  1990, the  American  College  of Obstetricians  and  Gynecologists 
(ACOG)  reported  that,  as a result  of the  risk of malpractice,  12 percent  of its 
members  had  discontinued  their  obstetric  practices,  24 percent  had  reduced  or 
eliminated  services  to high-risk  women,  and  10 percent  had  decreased  the 
number  of deliveries  they  performed.  Average  obstetric  premiums  rose  248 
percent  between  1982 and  1989.  (ACOG,  prepared  by Opinion  Research 
Corporation,  Professional  Liability  and  Its Effects:  Report  of a  1990 Survey of 
ACOGs  Membership,  Washington,  D.C.,  September  1990.)  The  ACOG 
repeated  this sumey  in September  1992, and  found  no statistically  significant 
differences  from  the  prior  survey. 
In addition,  as of  1987, 64 percent  of family  physicians  who once  provided 
obstetric  semices  had  discontinued  such care.  (American  Academy  of Family 
Physicians,  Family Physicians  and  Obstetrics:  A Professional  Liability  Study, 
1987.) 
D-1  5.  NCHS,  Advance  Report  on Final  Natality  Statistics,  1989, Monthly  Htal 
Statistics  Repoti,  vol.  40, no. 8, Supplement,  December  12, 1991, p. 43.  These 
1989 data  are  the  most  current  available. 
Alan  Guttmacher  Institute,  Prenatal  Care in the  United States,  New  York,  N.Y., 
1987, vol. I, p. vi.  Adequacy  of care  is a function  of time  of entrance  into  care 
and  number  of visits.  During  the  period  1984-86, 24 percent  of women  entered 
care  after  the  first trimester,  24 percent  had  fewer  than  9 visits, and  34 percent 
received  less than  adequate  care. 
6.  Alice  Sardell,  771eU.S. Experiment  in Social Medicine:  l%e Community  Health 
Center Program, 1965-1986,  University  of Pittsburgh  Press,  Pittsburgh,  P&  1988, 
p. 66. 
7.  Bonnie  Lefkowit~  Bureau  of Primary  Health  Care  (BPHC),  PHS,  The 
Institutionalization  of Community  Health  Centers,  speech  to the  American 
Public  Health  Association,  November  13, 1983, p. 4.  This  number  represents 
consolidation  as well as elimination  of grantees. 
8.  All of these  centers  received  Section-330  community  health  center  grants. 
Some  also  received  Section-329  funds  for care  provided  to migrant  workers;  an 
additional  71 centers  received  only Section-329  funding. 
9.  Through  the  National  Health  Service  Corps  (NHSC),  PHS  offers  scholarships 
and  loan  repayment  to health  providers  who  commit  to work  in designated 
Health  Professional  Shortage  Areas  for a given period.  A large  percentage  of 
corps  providers  have  traditionally  worked  in community  health  centers.  After 
substantial  cuts  in program  size in the  early  1980s, the  NHSC  received 
increased  funding  in 1990; the  number  of loan  repayment  candidates  is limited, 
however,  and  most  scholarship  recipients  will not  be available  for service  until 
the  mid-1990s. 
10.  The  Department  of Agriculture  provides  vouchers  through  this program  to 
address  the  nutritional  needs  of pregnant  and  lactating  women  and  their 
infants. 
11.  The  Rural  Health  Clinic Services  Act of  1977 provides  cost-related  Medicaid 
reimbursement  for semices  at rural  centers  in Health  Professional  Shortage 
Areas  or Medically  Underserved  Areas.  Qualifying  centers  must  be staffed  by 
at  least  one  certified  nurse  midwife,  nurse  practitioner,  or physician  assistant, 
whose  practice  must  be within  the  scope  of State  law and  regulation.  Prior  to 
passage  of this act,  these  providers  were  not  eligible  for Medicaid 
reimbursement  in some  States.  Because  of problems  with regulation, 
certification,  and  reimbursement,  however,  far fewer  centers  than  expected  had 
availed  themselves  of reimbursement  under  the  act. 
D-2  12.  Section  330 funding  was $435 million  in FY  1989, $457 million  in FY  1990, and 
$478 million  in FY  1991 (Health  Resources  and  Sexvices Administration 
(HRSA)  FY  1993 Justification  of Appropriations,  vol.  1, p. 63.) 
Section  330 funding  for FY  1992 was $532 million.  The  FY  1993 appropriation 
is $559 million.  (BPHC  and  the  Assistant  Secretary  for Management  and 
Budget  [ASMB].) 
13.  Congress  has provided  for:  (1) expanded  eligibility:  States  are  now mandated 
to extend  coverage  to all pregnant  women  below  133 percent  of the  Federal 
poverty  level, and  have  the  option  of extending  coverage  to women  between 
133 and  185 percent  of the  poverty  level; (2) continuous  eligiii.lity  eligibility 
for coverage  is now guaranteed  throughout  pregnancy  and  the  postpartum 
period,  regardless  of income  changes;  (3) presumptive  eligibility  States  have 
the  option  of granting  temporary  coverage  based  solely on self-reported 
income;  (4) expanded  coverage:  case  management  services  are  now 
reimbursable;  and  (5) outstationing  States  must  place  eligibility workers  at 
locations  other  than  AFDC  enrollment  sites,  including  CHCS. 
14.  CPCP  funding  was $30 million  in FY  1990 and  $33 million  in FY  1991.  (HRSA 
FY  1993 Justification  of Appropriations,  vol.  1.) 
In fiscal years  1992 and  1993, $44.7 million was appropriated  for the  CPCP. 
(BPHC  and  ASMB  data.) 
Eighty  percent  of urban  and  51 percent  of rural  centers  that  responded  to our 
survey  and  offered  perinatal  services  had  received  CPCP  funding  at  some  point 
during  the  1988-1991 period. 
15.  The  HHS  Office  of Inspector  General  (OIG)  has addressed  the  issue  of 
perinatal  care  for underserved  women  in several  prior  studies:  Medicaid 
Expansions  for Prenatal  Care:  State and Local  Implementation 
(OEI-06-90-O0160),  January  1992; Comprehensive  Perinatal  Care Program 
(OEI-01-90-00460),  November  1990; Access to Medicaid-Covered  Prenatal  Care 
(OE1-06-90-00162),  October  1990; Evaluation  of the Boston  Healthy  Baby 
Program (OAI-01-88-01420),  July  1989; and Local  Management  and 
Implementation  Strategies to Reduce  Infant  Mortality  (OA1-01-88-01420),  July 
1989. 
16.  Our  sumey  inquired  about  the  provision  of a representative  range  of perinatal 
medical  and  health-promotion  services:  ultrasound,  amniocentesis,  genetic 
counseling,  non-stress  testing,  dental  care,  nutritional  services,  health  education, 
childbirth  classes.  parenting/infant-care  classes,  family planning, 
smoking-cessation  programs,  substance-abuse  treatment,  and  HIV 
counseling/testing.  Our  survey also inquired  about  the  provision  of four  ancillary 
D-3  services  that  facilitate  access  to care:  translation,  transportation,  home  visiting, 
and  child  care  during  appointments. 
17.	 Some  centers  completed  enrollment  on site.  Other  centers  only began  the 
enrollment  process  at  the  center  and  applicants  had  to  complete  it at  the 
appropriate  State  offices.  In some  instances,  centers  completed  all nutritional 
assessment  and  WIC  paperwork  on  site,  but  clients  had  to  obtain  vouchers  at  a 
different  location. 
18.  Bureaus  Common  Reporting  Requirements  (BCRR)  Database,  BPHC,  PHS. 
This  database  contains  self-reported  financial  and  caseload  data  from  Section 
330 grantees.  We derived  the  percentage  change  in center  revenues  from  data 
for those  146 urban  centers  that  both  responded  to our  sumey  and  provided 
financial  data  to  BPHC  through  the  BCRR  form  for  1988 and  1990;  and  for 
214 rural  centers  that  provided  financial  data  to  BPHC  through  the  BCRR 
form  for  1988 and  1990.  Some  of these  rural  centers  did not  respond  to  our 
survey. 
Total  reported  revenues  for these  360 centers  increased  from  $630 million  in 
1988 to  $803 million  in 1990.  Urban  center  revenues  increased  from  $415 
million  to  $544 million;  rural  center  revenues  increased  from  $215 million  to 
$259 million. 
PHS  Section  330 grants  increased  from  $258 million  in 1988 to  $305 million  in 
1990.  Urban  centers  received  $163 million  in 1988 and  $193 million  in  1990, 
while  rural  centers  received  $95 million  and  $113 million. 
Medicaid  reimbursements  to  these  centers  increased  from  $107 million  in  1988 
to  $167  million  in 1990.  At urban  centers,  Medicaid  reimbursements  increased 
from  $84 million  to  $134  million.  At rural  centers,  reimbursements  increased 
from  $23 million  to $33 million. 
These  centers  received  additional  revenues  from:  Maternal  and  Child  Health 
block  grants,  PHS  Section  329 and  340 grants  for migrant  workers  and  the 
homeless,  WIC  grants,  Title  X grants,  Title  XVIII  Medicare  payments,  Title 
XX payments,  other  third  party  payments,  patient  collections,  State  and  local 
revenues,  and  donations. 
19.	 We excluded  these  62 centers  from  the  calculations  of the  statistics  presented  in 
the  body  of this report  (see  appendix  A for detailed  methodology). 
20.  PHS,  Caring for  Our Future,  p. 2. 
H-IS, Healthy  People 2000, p. 366. 
D-4
 In our  survey,  we  used  the  terms  health  education  for health  promotion  and 
social services  for psychosocial  services. 
21.  BPHC,  PHS,  Program  Expectations,  (hereafter  P.E.),  May  1, 1991, p. 21. 
This  document  outlines  both  requirements  of law  and  regulation  and 
Departmental  priorities  for the  centers. 
BPHC,  PHS,  Regional  Program  Guidance  Memorandum  84-52, May  15, 1984. 
22.  NCHS,  1992.  These  1989 data  are  the  most  current  available.  The  average  of 
62.2  percent  for  minority  women  was  calculated  from  rates  for  Mexican 
American,  Puerto  Rican,  Cuban,  Central  and  South  American,  other  Hispanic, 
Chinese,  Japanese,  Filipino,  Hawaiian,  other  Asian,  American  Indian/Alaskan 
Native,  and  Black  women. 
The  BPHC  provided  the  rate  for  women  in federally  designated  Healthy  Start 
project  areas.  The  BPHC  calculated  this  rate  from  information  reported  by  the 
15 projects  for  a time  period  between  1984  and  1989.  The  project  areas  are: 
Aberdeen,  South  Dakota  (rates  are  for  the  Northern  Plains  Native  American 
populations  in North  Dakota,  South  Dakota,  and  Nebraska);  Baltimore, 
Maryland;  Birmingham,  Alabama;  Boston,  Massachusetts;  Chicago,  Illinois; 
Cleveland,  Ohio;  Detroit,  Michigan;  Lake  County,  Indiana;  New  orleans, 
Louisiana;  New  York,  New  York;  Oakland,  California;  the  Pee  Dee  region, 
South  Carolina;  Philadelphia,  Pennsylvania;  Pittsburgh,  Pennsylvania;  and 
Washington,  D.C. 
23.  PHS, Healthy  People 2000, p. 381. 
24.  ACOG,  Standards for  Obstetric-Gynecological Services, 7th cd., Washington, 
D. C.,  1989,  p.  16. 
The  PHS  has  required  that  all centers,  regardless  of size,  must  assure  that  the 
services  that  they  deliver  conform  to  the  Sfandards for  Obsle&ic-Gynecologzc 
Services (Perinatal  Care:  How  to  Establish  Perinatal  Services  in Community 
Health  Centers,  PHS,  1985, p. 96). 
A  1989 PI-IS report,  Caringfor Our Future:  Tile Content of Prenatal Care, 
suggests  slightly different  guidelines.  This report  recommends  that  healthy 
women  receive  a minimum  of nine  prenatal  visits during  a first pregnancy  and 
seven  prenatal  visits during  subsequent  pregnancies  (p. 50).  The  report 
suggests  that  women  at risk, because  of either  psychosocial  or physical  factors, 
might  require  more  prenatal  visits (p. 71).  Psychosocial  and  physical  risk 
factors  include:  inadequate  personal  support  systems,  single marital  status, 
adolescence,  advanced  age,  high stress  and  anxiety,  less than  high school 
education,  low income,  inadequate  housing,  inadequate  nutritional  resources, 
communication  barriers,  smoking,  alcohol  abuse,  and  illicit drug  use  (p. 79). 
D-5  25.  In reporting  responses  to survey questions  that  solicited  information  on  a scale, 
we  have  combined  responses  of moderately  and  substantially  and  have 
reported  them  as seriously  or  serious. 
26.  Nonresponses  may  have  resulted  in an  underestimate  of the  percentage  of 
centers  with  such  vacancies. 
27.  See  note  9. 
28.  A substantial  increase  in commercial  medical  liability insurance  rates  and 
cutbacks  in the  National  Health  Service  Corps  program  have  resulted  in 
dramatically  increased  expenditures  on medical  liability coverage  for the 
centers. 
According  to the  U.S. General  Accounting  Office,  insurance  premiums  in 1990 
amounted  to an estimated  10 percent  of the  centers  total  Federal  grant 
funding--or  4.4 percent  of center  revenues  (Medical  Malpractice:  Data  on 
Claims  Needed  to Evaluate  Health  Centers) Insurance Alternatives,  I-IRD-91-98, 
Washington,  D.C., May  1991, p.  l.). 
29.  P.L.  102-501.  Under  the  ITC&  center  providers  will  be  defended  by the 
Justice  Department  in any  medical  malpractice  litigation,  and  judgments  will be 
paid  out  of a Justice  Department  fund,  into  which  the  centers  will  pay  annual 
contributions.  This  liability  protection  will be  provided  for  three  years,  after 
which  time  the  financial  benefits  of the  arrangement  will be  assessed. 
30.  P. E.,  pp.  4-5. 
31.  our  survey questions  addressed  only admitting  privileges.  During  interviews, 
center  staff reported  hospital  restrictions  on the  delivery  privileges  of certified 
nurse  midwives  and  family physicians. 
32.  See  note  18. 
33.  The  Omnibus  Budget  Reconciliation  Act of  1990 mandated  that  States  locate 
eligibility  workers  at  sites other  than  AFDC  enrollment  sites,  including  CHCS, 
by July  1991. 
34.  Bonnie  Lefkowitz,  BPHC,  PHS, written  communication  to OIG,  December  24, 
1991. 
In addition,  only 26 States  had  adopted  presumptive  eligibility  as of June  1991 
(Medicaid  Expansions for Rrenatal  Care:  State  and Local  Implementation, 
appendix  E). 
According  to the  OIG  report,  Medicaid  Expansions for  Prenatal  Care: An 
D-6  Updale (OEI-06-90-O0161),  three  States  still used  an asset  test  to determine 
Medicaid  eligibility  as of January  1992. 
35.  According  to an internal  BPHC  draft  report,  CPCP  1990 Data  Report: 
Moving  Ahead,  CPCP-funded  centers  served  33,938  pregnant  teens  in  1990, 
which  they  report  is more  than  triple  the  number  sexved  in  1988.  AlSO 
according  to  this  report,  in  1989,  CPCP-funded  centers  provided  setices  to 
13.4 percent  of all  pregnant  teens  age  15 or  younger  in the  United  States. 
BPHCS  CPCP  data,  however,  does  not  permit  a comparison  of CPCP-funded 
centers  and  other  centers. 
36.  Unless  otherwise  noted,  the  differences  between  groups  (for  example,  CPCP-
funded  centers  and  other  centers)  cited  in this  report  are  statistically  significant 
at  the  .05  level. 
37.  BPHC,  PHS,  Supplemental  Grants  for  the  Development  of a Comprehensive 
Perinatal  Care  Program  in Community  and  Migrant  Health  Centers, 
Application  Guidance,  undated  document,  p.  9. 
38.  BPHC,  PHS,  Supplemental  Grants,  p.  1. 
39.  Of  those  centers  that  did  participate  in consortia,  a larger  percentage  of CPCP 
grant  recipients  than  of other  centers  reported  collaboration  with  schools, 
hospitals,  private-practice  physicians,  government  social-semice  agencies,  and 
nonprofit  organizations. 
40.  BPHC,  PHS,  Supplemental  Grants,  p. 9. 
41.  We  did  not  calculate  the  statistical  significance  of the  difference  between 
urban  and  rural  center  revenues.  For  more  information  on  center 
revenues,  see  note  18. 
42.  The  difference  between  the  percentage  of urban  centers  and  the  percentage  of 
rural  centers  that  reported  medical  staff  shortages  as a serious  limitation  to  the 
provision  of  perinatal  setices  was  statistically  significant  at  the  .1 level. 
Additionally,  the  difference  between  the  1 percent  decrease  in FTE  provider 
staff  at  rural  centers  and  the  12 percent  increase  in FTE  provider  staff  at  urban 
centers  is statistically  significant  at  the  .1 level. 
43.  PHS,  Seventh  Report  to the President and  Congress on the Status  of Health 
Penonnel  in the  United States,  March  1990. 
Robert  M. Politzer,  Donna  L. Harris,  Marilyn  H. Gaston,  and  Fitzhugh  Mullan, 
Primary  Care  Physician  Supply  and  the  Medically  Undersexed,  Journal of the 
American  Medical  Association,  July 3, 1991, vol. 266, no.  1, pp.  104-109. 
D-7  John  E. Verby,  J. Paul  Newell,  Susan  A. Andersen,  and  Walter  M. Swentko, 
Changing  the  Medical  School  Curriculum  to  Improve  Patient  Access  to 
Primary  Care, Journal  of the American  Medical Association,  July 3, 1991, 
vol. 266, nO. 1, p.  110-113. 
44.  P.L.  102-501. 
45.  See  the  OIG  reports,  Access  to Medicaid-Covered  Prenatal  Care (OEI-06-90-
00162),  October  1990,  and  Medicaid  Expansions for Prenatal  Care:  State  and 
Local  Implementation  (OE1-06-90-00160),  January  1992. 
46.  For  an  analysis  of one  citys experience,  see  OIG  reports  Evaluation  of the 
Boston  Healthy  Baby Program (OE1-01-88-01420),  July  1989, and  Local 
Management  and Implementation  Stratepesto Reduce  Infant  Mortality 
(OEI-01-88-01420),  July  1989. 
47.  For  a description  of various  State  approaches  to reducing  Medicaids 
administrative  burden  on physicians,  see the  OIG  report,  Medicaid  Hassle: 
S/a/e  Responses  to Physician  Complaints  (OEI-O1-92-OO1OO),March  1992. 
48.  Sara  Rosenbaum  and  Marilynn  Sager,  Unlocking  the  Hospital  Doors:  Medical 
Staff  Membership  and  Physicians  Who  Serve  the  Poor,  Yale Law  & Policy 
Review,  vol. 9, no.  1 (1991). 
D-8