I 
Department  of  Health and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
THE  PERINATW  SERVICE  CAPACIH 
OF  THE  FEDEWLY  FUNDED 
COMMU~H  HEALTH  CENTERS: 
URBAN  CENTERS 
DECEMBER  1992
 OFFICE  OF INSPE~OR  GENERAL 
Themission  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  Services  (HHS) 
programs  as well  as the  health  and  welfare  of beneficiaries  sewed  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  Senkes,  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 
TheOIGS  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 
TheOIGS 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  INSPECTIONS 
TheOIGS  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  staff 
REGION  HEADQUARTERS 
Dana  L. Miller,  Projecf  Leader  Maruta  Zitans 
Timothy  J.  Corbett  - Barbara  Tedesco 
Madelaine  T.  Tully 
Deborah  Skahan 
For  additional  copies  of this repor$  please  contact  the  Boston  regional  office  at 617/565-1050.  Department  of  Health and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
THE  PERINATAL  SERVICE  CAPACITY 
OF  THE  FEDERALLY  FUNDED 
COMMtJNrIy  HEALTH  CENTERS: 
URBAN  CENTERS

DECEMBER  1992  OEI-01-9W2330
 EXECUTIVE  SUMMARY 
PURPOSE 
This  report  describes  recent  trends  in  the  perinatal  service  capacity  of  urban 
community  health  centers  funded  under  Section  330  of the  Public  Health  Service  Act. 
BACKGROUND 
The  high  rate  of  infant  mortality  in the  United  States  continues  to  be  a cause  for

concern.  The  problem  is particularly  acute  in the  nations  urban  areas:  the  22 largest

U.S.  cities  account  for  14 percent  of all  live  births,  yet  19 percent  of  all  infant  deaths.

The  Public  Health  Service  (PHS)  recommends  timely,  high-quality  care  before,  during,

and  after  birth  as  an  effective  means  of lowering  the  infant  mortality  rate  and  ensuring

healthier  newborns.  A  number  of obstacles,  however--including  rising  medical

malpractice  insurance  costs,  inadequate  health  insurance,  and  a decreasing  supply  of

obstetric  providers--prevent  many  women  from  obtaining  perinatal  care  in a timely

fashion.

Community  health  centers  play  an  important  role  in reducing  infant  mortality  by

delivering  comprehensive  perinatal  care  to  high-risk  women  in medically  underserved

areas  across  the  nation.  In  1991,  PHS  funded  services  at  212  urban  centers;  these

represented  40  percent  of all Section-330  centers.  The  Federal  government  provides

additional  support  for  the  centers  through  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  seine.  To  examine  the

capacity  of  urban  centers  to  provide  perinatal  care,  we  conducted  a mail  sumey  of all

urban  community  health  centers  receiving  Section-330  funds  as  of June  1991  (to  which

84  percent  responded);  made  site  visits  to  8 centers;  held  discussions  with  PHS

administrators,  State  officials,  and  infant  health  experts;  and  reviewed  relevant

literature  and  PHS  data.  Our  findings  are  based  primarily  on  information  reported  by

the  centers  to  us and  to  PHS.

FINDINGS 
7he  capacily  of urban  cornrnun iy  heahh  centem  to provkie  pai.n.atdcare  has  increa.wd  h 
several  rt.xpects since  1988. 
The  number  of  prenatal  clients  served  by the  centers  rose  23 percent  between 
	
1988  and  1990,  from  an  average  of 477  per  center  to  586.  The  number  of births 
to  center  clients  rose  17 percent  during  the  same  period,  from  an  average  of  320 
i  percenterto  374.  Sumeyrespondents  reported  atotalof  87,560  prenatal  clients 
and  51,826  births  in  1990. 
The  range  of  perinatal  services  increased  at  76  percent  of the  centers.  The 
setices  added  at  the  largest  number  of centers  were  HIV  counseling  and  testing, 
smoking-cessation  programs,  and  classes  in parenting  and  childbirth. 
The  range  of  ancillary  services--such  as  home  visiting  and  transportation-
increased  at  37  percent  of the  centers. 
Sixty-five  percent  of the  centers  offered  on-site  assistance  with  enrollment  in 
Medicaid  in  1990,  an  increase  from  23 percent  in  1988.  Eighty  percent  of the 
centers  offered  on-site  assistance  with  enrollment  in the  Supplemental  Food 
Program  for  Women,  Infants,  and  Children  in  1990,  an  increase  from  68 percent 
in  1988. 
Total  revenues  for  urban  centers  increased  31 percent  between  1988  and  1990; 
this  includes  an  18 percent  increase  in Section-330  grant  funding  and  a 59 percent 
increase  in  Medicaid  reimbursements.  Sixty-five  percent  of the  centers  reported 
that  the  amount  of funding  available  for  perinatal  services  has  increased  since 
1988. 
Despite  these  increases  in capacity,  &mand  for perinatal  semices  at  urban  centers  hus 
continued  to grow  and  many  clienfi  still  do  not  receive  the  optimal  coordinated  package 
of care  in a time$J fizshkm 
* Six percent  of the  urban  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  89 percent  of  the  urban  centers;  34 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  Service.  This  may,  in part,  reflect  variations  in the  definition  of 
management
case  among  centers. 
~	 on  average,  51  percent  of each  centers  prenatal  clients  entered  care  in the  first 
trimester  of  pregnancy  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. 
ii  on  average,  26 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. 
	 Thirty-six  percent  of  the  centers  did  not  offer  prenatal  appointments  at  times 
convenient  for  working  women. 
Several  major  corwrai.rm  seriously  lirnif the capa@y  of urban  cenlm  to provide  perinatal 
care. 
Medical  staff  shm-ta~es.  Medical  staff  shortages,  in part  as a result  of cuts  in the 
National  Health  Service  Corps  in the  1980s,  present  serious  problems  at  59 
percent  of centers.  Although  the  number  of  prenatal  clients  increased  an  average 
of  23  percent  at  the  centers,  the  number  of obstetricians,  family  physicians,  and 
certified  nurse  midwives  increased  an  average  of  12 percent.  Twenty-four  percent 
of centers  reported  that  at  least  1 obstetrician,  family-physician,  or  nurse-midwife 
position  had  been  vacant  for  longer  than  1 year. 
Medical  malt-mctice  insurance.  The  high  cost  of medical  malpractice  insurance 
has  been  a serious  drain  on  resources  at  56  percent  of the  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  (FTCA)  to  health  care  providers  at  the  centers. 
Medicaid  POIicies  and  procedures.  Seventy-six  percent  of the  centers  report 
serious  problems  stemming  from  Medicaid  policies  and  procedures--such  as a 
burdensome  application  process,  low  reimbursement  rates,  a limited  range  of 
covered  services,  or  limited  eligibility. 
Inadequate  health  insurance.  On  average,  21 percent  of each  centers  perinatal 
clients  were  uninsured  in  1990.  At  9 percent  of the  centers  more  than  50 percent 
of  the  perinatal  clients  were  uninsured. 
Unsatisfactory  community  supp ort.  Seventy-nine  percent  of the  centers  report 
serious  problems  stemming  from  unsatisfactory  coordination  of  perinatal  services 
m the  community,  a lack  of other  local  providers  willing  to  treat  uninsured  and 
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. 
Limited  space.  Limited  space  seriously  hinders  the  provision  of services  at  64 
percent  of  the  centers.  In addition,  limited  collocation  of sewices  on  site 
seriously  restricts  the  comprehensiveness  of  care  at  23  percent  of the  centers. 
... 
111  COMPANION  REPORTS 
This  is one  of three  reports  on  the  capacity  of the  community  health  centers  to 
provide  perinatal  care.  Another  report,  7%e Perinatal  Service Capacity of the Federal& 
Funded  Community  Healtil  Cen[en:  Rural  Centers (OEI-01-90-0233  1),  examines  recent 
trends  in the  perinata]  care  capacity  of rural  community  health  centers. 
The  third  report,  T4e Penna[al  Service Capacity of the Federally Funded  Community 
Health  Centen:  An  Overview (OEI-01-90-02332),  summarizes  and  compares  data  on 
the  perinatal  care  capacities  of the  urban  and  rural  centers.  It also  presents 
information  on  two  areas  of special  policy  interest:  Medicaid  reimbursements  to 
CHCS  and  Comprehensive  Perinatal  Care  Program  funding  of the  centers. 
That  report  identifies  four  major  constraints  that  limit  the  perinatal  care  capacity  of 
the  community  health  centers:  inadequate  staffing,  the  high  cost  of medical 
malpractice  insurance,  ineffective  ties  between  the  centers  and  the  Medicaid  program, 
and  unsatisfactory  relationships  between  the  centers  and  other  community  providers. 
To  enable  the  centers  to  meet  increasing  demand  for  services,  these  limitations  must 
be  addressed  in  the  near  term  by a cooperative  effort  involving  government  at  the 
Federal,  State,  and  local  levels,  as well  as  non-governmental  organizations.  The  third 
report  offers  a recommendation  that  the  Public  Health  Semite  (PHS)  and  the  Health 
Care  Financing  Administration  (HCFA)  work  with  the  Assistant  Secretary  for  Planning 
and  Evaluation  (ASPE)  to  draft  and  implement  a  plan  of  action  that  addresses  the 
identified  limitations.  The  report  also  includes  formal  comments  on  the  draft  reports 
from  PHS,  HCF~  and  ASPE. 
iv  TABLE  OF  CONTENTS

~oWcrmN  . .  . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 
I	
Purpose  . . . . . . . . . . . . . .
. . . . . . .OO.  . . . . . . . . ..O.
 . . . . . . . . . . . . . . . . . .  1

Background  . . . . . . . . . . . . . . . .

. . . . . . . . . .
 . . . . . . . . . . . . . . . . . . .$..  . . .  1

Companion  Reports  . . . . . . . . . . . . . . . .

. . . ..O  . . . . . . . . . . . . . . . . . . . . . . .  2

Methodolo~  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

FmINGS 
The  capaci~  ofurban  communi~  health  centers  to  provide

perinatal  care  hasincreased  inseveral  respects  since  1988  . . . . . . . . . . . . . . . .  4

Despite  these  increases  incapaci~,  demand  forperinatal  semicesat

urban  centers  continues  to  grow  and  many  clients  still  do  not

receive  the  optimal  coordinated  package  ofcare  in a timely  fashion  . . . . . . . . .  7

Several  major  constraints  seriously  limit  the  capaci~  ofurban  centers 
to  provide  perinatal  care  . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . .
. .  12

~NCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...19

APPEN131~ 
&  Federal  Support  for  Perinatal  Care  at  Communi~  Health  Centers  . . . . . . . .  A-] 
B:  Methodolo~  . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . ..  B-1

C:  Urban  Sumey  Resp(>nses  . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .  c-1

D:  Notes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  D-1
 INTRODUCTION 
PURPOSE 
This  report  describes  recent  trends  in the  perinatal  service  capacity  of urban  community 
health  centers  funded  under  Section  330  of the  Public  Health  Service  Act. 
BACKGROUND 
Birth Outcames  in Urban  America:  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  infants  born  alive  in the  nation.

In  the  1950s,  the  U.S.  ranked  5th  among  the  worlds  nations  in lowest  infant  mortality;

today  it ranks  23rd.  The  rate  for  black  infants  continues  to  be  double  that  for  white

infants.1  Infant  mortality  is particularly  acute  in the  nations  urban  areas,  where

poverty,  unemployment,  substance  abuse,  and  AIDS  have  taken  a severe  toll.  The  22

largest  U.S.  cities  account  for  14 percent  of  all  live  births,  yet  19 percent  of all  infant

deaths.~

Perinatal  Care:  A  pregnant  woman  with  no  prenatal  care  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  Semite  (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  intewentions  and  follow-up  .3  A full  course  of care  is especially  vital  for

women  at  risk  because  of  medical  or  social  factors.

Several  obstacles,  however--including  rising  medical  malpractice  insurance  costs,

inadequate  health  insurance  coverage,  a decreasing  supply  of obstetrical  providers,  and

a  lack  of  physicians  willing  to  treat  low-income  women--limit  the  availability  and

accessibility  of perinatal  care.q  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  was  twice  that,s

Community  Health  Centers:  Community  health  centers  (CHCS)  are  key  providers  of

perinatal  services  to  high-risk  women  in medically  undersexed  areas  across  the  nation.

The  CHC  program  was  established  in  1965 to  address  the  comprehensive  health  needs

of  the  nations  medically  undeserved.  The  centers  were  expected  to  provide  not  only

the  convenience  of a one-door  facility,  instead  of a city-wide  scattering  of  services,  but

also  improved  care  and  a better  relationship  between  the  providers  and  recipients  of

health  services.*

1
 Federal  administration  of  the  CHC  program  was  consolidated  in  1975  under  Section 
330  of the  Public  Health  Service  Act.  The  total  number  of centers,  however,  has  not 
been  maintained  at  the  level  originally  envisioned.  Moreover,  the  program  was  cut 
substantially  in  the  early  1980s;  the  number  of grantees  fell  from  867  in  1981  to  530  n 
1983,  a 39 percent  decrease.8  In  1991,  PHS  funded  212  urban  community  health 
center  grantees,  which  represented  40  percent  of  all  Section-330  grantees.9  In  1992, 
PHS  funded  a total  of 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,  and  the 
Supplemental  Food  Program  for  Women,  Infants,  and  Children. 
In  recent  years,  funding  for  the  centers  has  increased,l  and  several  initiatives  have 
been  implemented  to  expand  center  services  and  improve  access  to  care.  These 
include  supplemental  funding  through  the  Comprehensive  Perinatal  Care  Program 
(ePCP),  expanded  Medicaid  coverage  for  pregnancy  care,  increased  Medicaid 
reimbursement  for  center  setvices  through  the  Federally  Qualified  Health  Center 
provisions  of the  Omnibus  Budget  Reconciliation  Acts  of  1989  and  1990,  and  Healthy 
Start  grants  to  support  community  coordination  of perinatal  care.  (For  more 
information  on  Federal  programs  see  appendix  A.) 
Little  information  is available,  however,  on  the  extent  to  which  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.  In  this  report,  we  examine  recent  trends  in the  capacity  of urban 
centers  to  provide  these  services. 
COMPANION  REPORTS 
This  is one  of  three  reports  on  the  capacity  of  the  community  health  centers  to 
provide  perinatal  care.  Another  report,  The Perinatal  Service Capaciy  of the Federally 
Funded  Communiy  Healtil  Centers:  Rural  Cen/em  (OEI-O 1-90-02331),  examines  recent 
trends  in the  perinatal  care  capacity  of rural  community  health  centers. 
The  third  report,  77ZePerinataf Service Capacity of the Federally Funded  Community 
Health  Centers:  An  Overview (OEI-01-90-02332),  summarizes  and  compares  data  on 
the  perinatal  care  capacities  of the  urban  and  rural  centers.  It also  presents 
information  on  two  areas  of special  policy  interest:  Medicaid  reimbursements  to 
CHCS  and  Comprehensive  Perinatal  Care  Program  funding  of  the  centers. 
That  report  identifies  four  major  constraints  that  limit  the  perinatal  care  capacity  of 
the  community  health  centers,  To  enable  the  centers  to  meet  increasing  demand  for 
services,  these  limitations  must  be  addressed  in the  near  term  by a cooperative  effort 
involving  government  at  the  Federal,  State,  and  local  levels,  as well  as  non-
2
 governmental  organizations.  That  report  offers  a recommendation  that  the  Public

Health  Service  (PHS)  and  the  Health  Care  Financing  Administration  (HCFA)  work

with  the  Assistant  Secretary  for  Planning  and  Evaluation  (ASPE)  to  draft  and

implement  a plan  of action  that  addresses  the  identified  limitations.  The  report  also

includes  formal  comments  on  the  draft  reports  from  PHS,  HCF&  and  ASPE.

METHODOLOGY

This  report  is based  on  information  gathered  from  a mail  survey;  site  visits  to  several

urban  community  health  centers;  discussions  with  PHS  administrators,  State  officials,

and  infant  health  experts;  and  a review  of the  relevant  literature  and  PHS  data.1*

We  sent  the  mail  survey  to  a]] 212  urban  centers  that  received  Section-330  funds  in

June  1991;  178 (84  percent)  responded.  Our  findings  are  based  primarily  on  the

responses  of  those  167 urban  centers  (79  percent  of  all  urban  centers)  that  offered

services  on  site  during  the  1988-91  period.  (For  detailed  methodology  see

appendix  B.)

Our  review  was  conducted  in accordance  with  the  Interim  Standards for  Inspections
issued  by  the  Presidents  Council  on  Integrity  and  Efficiency.

3
 FINDINGS

THE  CAPACITY  OF  URBAN  COMMUNITY  HEALTH  CENTERS  TO  PROVIDE 
PERINATAL  CARE  HAS  INCREASED  IN SEVERAL  RESPECTS  SINCE  1988. 
+	 %  ruunber of premxal  clients  served  by the centers  rose 23 percent  between  1988  and 
19%9, firma an  average  of 477 per  center  to s86.  ?he  number  of bti  to cen$er cti 
we  17 pement  during  the  same  pew  fmm  an  avemge  of 32b per  center  to 374. 
Survey  reyxmdents  reported  a total  of 8~560  prenatal  clknzs  and  51,826  births  in 
2990. 
Seventy-eight  percent  of  the 
F&we  1 
centers  reported  that  the  size  of 
Average Numbs  of Prenatal Clients 
their  prenatal  client  caseloads  1988, 1989, and 1990 
5s6 
grew  between  1988  and  1990 
(see  figure  1).  Caseloads  grew 
555 
more  at  those  centers  that 
sewed  smaller  caseloads  in 
1988,  those  that  did  not  receive 
Comprehensive  Perinatal  Care 
Program  (CPCP)  funding,  and 
those  that  served  prenatal  client 
populations  that  were  more 
than  half  Medicaid-enrolled  in 
1*  19s9  1990 
1990.2  Yc!as 
ti:OIOmd  Ulnn C5nmnmitylimkh Caws, Jim@19!?1. 
N-U5 
Caseloads  grew  95  percent  between  1988  and  1990  at  centers  that  served  fewer  than 
200  clients  in  1988,  25  percent  at  centers  that  served  between  200  and  999  clients,  and 
.5 percent  at  centers  that  served  1000  or  more  prenatal  clients.13 
Caseloads  grew  35 percent  at  centers  that  did  not  receive  CPCP  grants,  and  22 
percent  at  centers  that  did  receive  these  grants.  The  average  caseload  size,  however, 
was  larger  at  CPCP-funded  centers.14  Caseloads  grew  35 percent  at  centers  in which 
more  than  half  of the  perinatal  population  was  Medicaid-enrolled  in  1990,  and  4 
percent  at  centers  in which  less  than  half  of the  perinatal  population  was  Medicaid
enroiled.  The  average  caseload  size,  however,  was  smaller  at  centers  with  perinatal 
populations  that  were  more  than  half  Medicaid-enrolled  in  1990.]5 
4  .	 w  rnnge  of perinutd  service  irneusd  at  76 percenf  of the  cen@x  i%  seties 
*at  the  kugest  number  of cem  were HW  combg  and  tatig 
mking+watin  program,  and  classes  in pareruing  and  cmti 
Mediud  and Health  Promotion  SeMeeX  Between  1988  and  1990  there  was  an 
increase  in the  percentage  of centers  prowding  each  of a representative  range  of 
perinatal  medical  and  health  promotion  services,  either  on  site  or  off  site  through  paid 
referrals  or  contracts.lG 
HIV  counseling  and  testing  semices  and  smoking-cessation 
programs  were  added  at  the  largest  percentage  of centers  (see  figure  2). 
r
1 
Figure 2
Percentage  of Centers  that proti~  each  Perinati  Service 
Either  On Site or Off Site, 1988 and  1990 
Percenhge  of CenterS Provitig  Each Service 
SOWU  OIG Swey  of UrbWI CunnItiqI  Health  f?en~  June  1991. 
N= 167 
Services  on site:  At  the  same  time,  62 percent  of the  centers  added  at  least  1 medical 
or  health  promotional  service  on  site.  The  services  added  on  site  at  the  largest  number 
of  centers  were  family  planning,  health  education,  nutritional  services,  and  HIV 
counseling  and  testing.  In  1990,  more  than  90 percent  of centers  offered  each  of these 
semices  on  site  (see  appendti  C  for  survey  responses). 
5
 The range  of ancillary  serviaw-such  as home  visiting  and  transpomuion-weasexl  at 
	
37 pexent  of the  centers. 
Thirty-seven  percent  of all  the  centers  added  at  least  one  service  that  facilitates  access 
to  perinatal  care  between  1988  and  1990.17  Home-visiting  setices  were  added  at 
the  largest  percentage  of centers,  and  child  care  during  appointments  was  added  at  the 
smallest  percentage  of centers  (see  figure  3).  - --
II

Kgure 3

Percentage of Centers that Rovided

Each hCi.kily  Service, 1988 and 1990

1 
1~ 
fuud?a@dlspcabxa 
I 
I 
S@-jive  percent of the  centerx oflered  on-site  assistance  with  enrdnent  in Medkakl 
	
in  1990,  an  increase  from  23 pement  in 198&  Eighty percent  of the  centezs  offered  on-
site  &timce  with  enrdbnent  in the  Supplemental  Food  Program  for  Womq  lnfa~ 
and  Children  (JV7C) in  1990,  an  increme  from  68 penznt  in  1988. 
A  larger  percentage  of CPCP-funded  centers  than  other  centers  provided  on-site 
assistance  with  Medicaid  and  WIC  enrollment.  In  1990,  70 percent  of CPCP-funded 
centers  provided  assistance  with  Medicaid  enrollment  and  84 percent  provided 
assistance  with  WIC.  By contrast,  only  50 percent  of  the  other  centers  provided 
assistance  with  Medicaid  enrollment  and  69 percent  of them  provided  assistance  with 
WIC.* 
Between  1988  and  1990,  however,  a larger  percentage  of centers  that  did  not  receive 
CPCP  funds  added  on-site  assistance  with  Medicaid  enrollment.19 
6
 Total  revenua  for  the &an  centem  weased  31 pexen/  between  1988  and  l~;  ti 
	
incti  an  18 percent  increase  in Section-330  grant jhnding  and  a 59 percent  increase 
in Medicaki  reirnbursementx  S&y-five  penznt  of the  centers  reported  that  the  amount 
of @ding  available  for perinatd  services  has  increased  since  198tl 
The  PHS  Section-330  grant  represented  39 percent  of total  revenues  for  these  centers 
in  1988  and  35  percent  in  1990.  Medicaid  reimbursements  amounted  to  20 percent  of 
total  revenues  in  1988 and  25 percent  in  1990.n 
Increased  funding  for  perinatal  services  was  correlated  with  increased  capacity.  As 
one  administrator  reported,  center  capacity  had  grown  as  a result  of increased 
funding  from  multiple  sources.  Some  centers  reported  that  implementation  of the 
Federally  Qualified  Health  Centers  mandate  had  resulted  in increased  Medicaid 
reimbursements,  which  had  been  used  to  improve  and  expand  center  semices.  Many 
of  the  centers  we  visited  drew  a direct  link  between  the  Medicaid  eligibility  expansions 
and  an  increased  capacity  to  care  for  more  women.  Some  centers  reported  that  they 
were  finally  receiving  reimbursement  for  women  they  would  have  otherwise  served, 
but  for  whom,  in the  past,  they  would  not  have  received  reimbursement. 
DESPITE  THESE  INCREASES  IN CAPACITY,  DEMAND  FOR  PERINATAL 
SERVICES  AT  URBAN  CENTERS  HAS CO NTINUED  TO  GROW  AND  MANY 
CLIENTS  STILL  DO  NOT  RECEIVE  THE  OPTIMAL  COORDINATED 
PACKAGE  OF  CARE  IN A TIMELY  FASHION. 
	 Six percent of the  urban  centerx reprted  that  they provided  no petital  services  on & 
between  1988  and  1991.  Our study  did  not  examine  the  extent  to which  these  centm 
made  alternative  perindal  care  arrangements  for  their  clienfi. 
Eleven  of the  urban  centers  that  responded  to  our  survey  did  not  offer  perinatal 
services  on  site  from  1988 to  1991.21  Nine  of these  indicated  that  they  referred 
clients  to  hospitals  or  other  providers  for  perinatal  services.  Four  expressed  an 
interest  in offering  perinatal  services,  but  noted  that  budgetary  constraints  or  the 
inability  to  recruit  obstetric  providers  prevented  them  from  doing  so.  One 
administrator  voiced  a common  sentiment  when  he  stated:  there  is a tremendous 
need  in our  community  for  perinatal  services,  but  we  cannot  afford  to  offer  them. 
7
 w Demand for  sewictx  increased  at 89 percent of the  urban  centem;  34 percent  of these 
cerzltm  repmzi  their capacity  to meet  ti  growing  dkmund  dher  &creased  or 
remained  the same. 
Several  centers  reported  that  they  were  overwhelmed  by demand.  Many  have  been 
periodically  forced  to  turn  away  new  perinatal  clients  because  they  do  not  have  the 
capacity  to  serve  them. 
Fifty-two  percent  of  the  centers  reported  that  Medicaid  eligibility  expansions  had 
seriously  increased  demand  for  perinatal  services,  and  48 percent  reported  that 
Medicaid  presumptive  and  continuous  eligibility  provisions  had  done  S0.22  Centers 
also  explained  increased  demand  as  a result  of the  downturn  in the  economy.  A 
growing  number  of  unemployed  women  have  neither  the  income  nor  the  health 
insurance  to  afford  private  medical  care,  and  therefore  seek  subsidized  care  at  the 
centers.  Reflecting  the  perceptions  of several  administrators  we  interviewed,  one 
reported  that  demand  has  increased  due  to  the  drug  epidemic,  an  increase  in teen 
pregnancy,  and  an  increase  in the  number  of older  women  having  children. 
Also  contributing  to  the  increase  in demand  is the  diminishing  number  of community 
providers  who  are  willing  to  treat  low-income  and  Medicaid  patients.  one  center  we 
visited  was  the  sole  provider  of obstetric  care  in its  service  area.  Many  centers 
reported  that,  although  there  were  private  obstetricians  in their  service  areas,  none 
would  care  for  Medicaid  or  uninsured  women.  One  administrator  summarized 
comments  made  by  many  we  visited  when  he  noted:  Our  center  is experiencing  the 
effects  of  the  withdrawal  of  private  physicians  from  the  Medicaid  program,  with  a 
tremendous  overflow  of  patients. 
w Fifiy-six percent  of urban  centezs  reported  that  they  do  not  coordinate  as pati  of their 
perinatal  case-management  efforts,  all of the health  and  social  services  recommended 
by the  Fublk  Health  Service.  l%k  may,  in paq  rqilect  variations  in the  di$iition  of 
case management  among  centem 
According  to  the  PHS,  perinatal  care  should  include  risk  assessment;  health 
promotion;  and  medical,  nutritional,  and  psychosocial  services  and  follow-up.x  To 
maximize  the  accessibility,  quality,  and  comprehensiveness  of services,  the  PHS 
requires  centers  to  coordinate  care  through  case  management.z4 
Most  centers  provide  some  of the  services  recommended  by the  PHS,  but  56 percent 
of  them  do  not  coordinate  all of  these  services  as  part  of  a comprehensive 
case-management  system.  Forty-five  percent  reported  that  they  do  not  coordinate 
discharge  planning  and  24 percent  reported  that  they  do  not  coordinate  delivery 
services  as  part  of  their  ~ase-management  efforts  (see  figure  4). 
8
 1, 
I 
Pigure 4 
Percentage of Centers that DO NOT  Case Manage  Each  Perinatal  Service 
I 
-w  *  ~45% 
o%  10%  m%  30%  40%  50%  60% 
Percentage of Centers that DO NOT Case Mansge Each Service 
II 
l~-su=-- 
There  is no  common  definition  of what  case  management  entails.  One  center  director

expressed  the  view  of many  we  met  when  he  said:  case  management  means  a million

different  things  to  different  people.  Thus,  centers  might  coordinate  the  delivery  of

services  and  not  refer  to  such  coordination  as  case  management.

Nonetheless,  23 percent  of the  centers  reported  that  limited  case  management

seriously  constrains  their  capacity  to  provide  comprehensive  care,  and  10 percent

reported  that  it has  become  a greater  problem  since  1988.  Nineteen  percent  of the

centers  provided  case  management  only  for  particular  groups  of clients,  such  as  teens,

substance  abusers,  or  women  identified  as high-risk.  An  administrator  at  one  center

summarized  a common  problem  when  he  explained  that  his  limited  social  services  staff

can  only  afford  to  give  intensive  services  to  those  most  in need.  This  center  was

unable  to  provide  case  management  for  clients  referred  to  other  providers  for  care.

Other  centers  reported  that  staff  who  provide  case-management  services  often  lose

track  of  high-risk  clients  when  they  refer  them  elsewhere  for  services.

Centers  reported  several  problems  that  indicate  inadequate  coordination  of care.  The

timely  transfer  of medical  records  to  delivery  facilities  is a problem  at  25 percent  of

the  centers,  and  the  transfer  of records  to  other  facilities  is a problem  at  31  percent.

Further,  centers  reported  that  they  do  not  reschedule  appointments  for  an  average  of

29 percent  of  the  perinatal  clients  who  miss  them.  Follow-up  care  is also  a problem:

on  average,  29 percent  of  each  centers  prenatal  clients  and  26 percent  of  their  infants

did  not  receive  follow-up  care  at  the  centers  within  the  first  8 weeks  after  birth  in

1990,Z 
9
 Athough  the  CPCP  was  intended,  in part,  to  support  centers  case-management

efforts,  we  found  that  CPCP-funded  centers  were  no  more  likely  than  other  centers  to

provide  case  management  for  all the  services  recommended  by the  PHS.

On  averag<  51 pe~ent  of each  centers prenatal  clierm  entered  care  in the fmt 
	
tri.rnater of pregnancy in 1990. Nationally, 76 pement of all womq  62 pexent of 
rnirwr@  wome~  and  58 pexent  of wornen  in Healthy  Stati  project  areas  entered  care 
during  the fit  trimester.% 
The  PHS  had  set  a goal  to  achieve  90 percent  first-trimester  enrollment  for  all women 
by the  year  1990.  This  goal  was  not  met,  and  has  now  been  set  for  the  year  2000.  on 
average,  39  percent  of each  centers  1990  prenatal  clients  did  not  enter  care  until  the 
second  trimester  and  10 percent  did  not  enter  care  until  the  third.  This  compares  with 
1989  national  rates  of  18 percent  of women  entering  in the  second  trimester  and  4 
percent  in the  third.27  Although  the  CPCP  was  intended,  in part,  to  encourage 
earlier  entry  into  care,  responses  to  our  survey  indicate  that  there  was  no  significant 
difference  between  CPCP-funded  centers  and  other  centers  with  regard  to  the 
percentage  of  perinatal  clients  who  entered  care  in the  first  trimester.  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. 
Several  centers  reported  that  motivating  women  to  seek  early  prenatal  care  is among 
their  biggest  problems.  Women  with  inadequate  health  insurance  sometimes  delay 
entry  into  care  in an  attempt  to  minimize  the  costs  associated  with  care.  Staff  at 
several  centers  we  visited  agreed  with  one  administrator  who  explained  that  some 
women  who  have  had  children  before  believe  that  they  are  experts  in  perinatal  care, 
and  do  not  consult  with  physicians.  Teenagers,  who  sometimes  try  to  conceal  their 
pregnancies,  are  apprehensive  about  prenatal  appointments.  Cultural  biases  against 
medical  intervention  lead  some  immigrant  women  to  avoid  care. 
Additional  barriers  to  care  were  suggested:  staff  at  one  center  explained  late  entry 
into  care  as  a  factor  of  language  barriers  and  the  fear  of deportation  of women  who 
are  not  legal  residents.  The  staff  at  another  center  explained  that  many  of their 
clients  are  so overwhelmed  by  life crises,  including  drugs,  poverty,  mental  illness,  and 
hopelessness,  that  perinatal  care  is not  a priority. 
Although  sumey  responses  indicate  that  most  centers  conduct  outreach,  several  centers 
indicated  that  their  efforts  are  minimal.  One  administrator  explained  what  was 
apparent  at  many  centers  we  visited  when  he  reported  that,  because  his  center  was 
already  ovemhelmed  by demand,  outreach  efforts  had  been  temporarily  suspended. 
10

  	 On  averagg  26 pement  of each  centds  fiht-trirnester  erudkx  received  fewer  than  9 
prenatal  viri.m. Ow study  did  not  examine  the extent  W which  these patienk3  may  have 
received  care  ekwhere. 
The  American  College  of Obstetricians  and  Gynecologists  recommends  that  women 
entering  care  in the  first  trimester  receive  a minimum  of  9 prenatal  visits.m  on 
average,  however,  26 percent  of each  centers  first-trimester  enrollees  did  not  receive 
at  least  9 prenatal  visits  in  1990.  Although  the  CPCP  was  intended,  in part,  to 
encourage  more  prenatal  visits,  there  was  no  significant  difference  between  CPCP-
funded  centers  and  other  centers  with  regard  to  the  percentage  of first-trimester 
enrollees  who  received  at  least  9 visits  in either  1988  or  1990. 
Women  with  limited  financial  resources  and  inadequate  insurance  coverage  often 
minimize  the  number  of their  prenatal  visits,  especially  when  care  is billed  per  visit 
instead  of as  a package  for  the  full  course  of the  pregnancy.  one  center  administrator 
reported  a problem  common  to  many  centers  when  he  explained  that  long  waits,  both 
between  scheduled  appointments  and  in the  crowded  waiting  room,  discourage  women 
from  seeking  care. 
Difficulties  with  child  care  and  transportation  were  cited  as  resulting  in a reduced 
number  of  perinatal  visits  by many  with  whom  we  spoke.  At  one  center,  the  staff 
noted  that  an  inability  to  arrange  child  care  discourages  women  from  making  and 
keeping  appointments.  One  administrator  said  that  public  transportation  to  the  center 
was  very  time-consuming.  Another  administrator  reflected  a common  perception 
when  she  reported  that  these  women  must  constantly  address  basic  living  needs,  and 
so  lack  interest  in  prenatal  care.  Drug  abuse  was  cited  at  several  centers  as  another 
factor  that  diminishes  womens  interest  in prenatal  care. 
~  17@-six  percent  of the  centers  did not ofier prenatal  appointments  at times  convenient 
for  wotig  women. 
Availability of Prenatal  Appointments:  In  1990,  36  percent  of the  centers  provided  no

scheduled  prenatal  appointments  in the  early  morning,  in the  evening,  or  on  Saturdays.

Such  restricted  appointment  hours  may  force  working  women  to  choose  between  work

and  prenatal  care.

Waiting Times:  Thirty-five  percent  of  the  urban  centers  have  waiting  times  for  initial

prenatal  visits  of  two  to  four  weeks  and  five  percent  have  waiting  times  for  initial  visits

of  more  than  one  month.  Long  waits  for  initial  appointments  can  cause  adverse

effects.  If a woman  tests  positive  for  pregnancy  in  her  second  month  and  then  must

wait  four  weeks  for  her  first  prenatal  appointment,  she  may  enter  care  in her  second

trimester.  The  implications  of such  waits  are  more  problematic  when  pregnancy  is

detected  later  and  when  the  mother  is at  high  risk,  as  many  center  clients  are.

11
 In addition,  20  percent  of  the  centers  reported  that  office  waiting  times  grew  longer

between  1988  and  1990.  One  center  administrator  said  that  long  waiting  periods  in

clinic  may  be  one  reason  patients  neglect  prenatal  care.  Another  administrator

reported  that  the  most  common  client  complaints  concerned  office  waiting  times  and  a

crowded  waiting  room.  These  comments  are  consistent  with  the  perceptions  of many

we  inter-viewed.

sEVm/u  MAJOR  CON~ 
SERIOUSLY  LIMIT  THE  CAPAC~  OF 
WAN  CENTERS  TO  PROVIDE  PERINATM  C-. 
Mdcai  stiff  shortagq  in pan  as a result  of cti  in the National  HeaLth Service  Coqx 
	
in the  19804  preseru  seriou  problems  at 59 pexent  of centem 
Although  demand  for  perinatal  services  increased  23 percent  at  urban  centers,  the 
number  of full-time  equivalent  obstetricians,  family  physicians,  and  certified  nurse 
midwives  rose  only  12 percent  (see  append~  C for  survey  responses).  Forty-seven 
percent  of  the  centers  reported  that  at  least  1 of these  clinical  positions  was  currently 
vacant  (see  table  1); and  24  percent  reported  that  at  least  1 of  these  positions  had 
been  vacant  for  over  1 year.  In addition,  37 percent  of the  centers  reported  that 
medical  staff  shortages  have  become  more  severe  since  1988,  and  28 percent  cited 
high  medical  staff  turnover  as  a serious  problem. 
Table  1

Percentage  of Centers  Reporting  at Least  One Clinical Provider  Position Vacant?g

!i~,  Nurse Midwife  c:  t:?  ::z- 
11% 
6% 
Source:  OTG Survey of Urban  Community  Health  Centers,  June  1991 
N=167 
Recruitment  and Retention  Problems:  Centers  have  historically  faced  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.  One  survey

respondent  reflected  the  view  of several  center  clinicians  with  whom  we  spoke  when

he  noted  that  providers  who  care  for  poor  pregnant  women  put  themselves  at risk  of

burn-out  and  bankruptcy.

12 A shortage  of staff  means  more  frequent  on-call  rotations,  which  in turn  makes  a 
center  less  attractive  to  prospective  employees.  Insufficient  support  from  the  wider 
medical  establishment  also  contributes  to  reluctance  on  the  part  of providers  to  accept 
positions  at  centers  where  they  might  not  be  assured  staff  privileges  at  local  hospitals 
or  adequate  backup  from  local  providers.  Unattractive  facilities  and  locations  in high-
crime  areas  also  hinder  recruitment  efforts. 
National  Health  Service  (2xps:  Centers  have  historically  relied  upon  the  National 
Health  Service  Corps  for  a large  percentage  of their  providers,  but  this  program 
experienced  major  funding  cuts  during  the  1980s.  Several  center  administrators  with 
whom  we  spoke  reported  that  they  have  often  been  unable  to  retain  corps  providers 
beyond  their  obligated  terms  of service  and  have  found  it difficult  to  replace  them. 
(See  appendix  A for  more  information.) 
Staffing  Models:  Obstetricians  are  in short  supply,  and  many  are  unwilling  to  work  in 
community  health  center  settings.  They  are  also  the  most  expensive  providers  to 
support:  Their  salaries  and  medical  malpractice  insurance  premiums  are  substantially 
higher  than  those  of other  providers.  The  medical  director  of one  site  we  visited 
expressed  a view  common  among  experts  when  he  remarked  that  nurse  midwives, 
physician  assistants,  and  nurse  practitioners  are  the  future  of  inner  city  care  because 
of their  lower  cost.  Family-physician  and  certified-nurse-midwife  models  of care  also 
pose  problems:  The  supply  of family  physicians  and  nurse  midwives  is limited;  many 
obstetricians  do  not  believe  that  family  physicians  or  certified  nurse  midwives  should 
perform  deliveries  and  are  reluctant  to  provide  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. 
%  cost  of medical  malpractice  insurance  has  been  a serious  &ain  on  r~oumes  at  56 
 
percent  of the  centem 
Twenty-eight  percent  of the  centers  indicated  that  the  cost  of  medical  malpractice

insurance  has  become  a more  serious  limitation  since  1988.  A substantial  increase  in

commercial  medical  liability  insurance  rates  and  cutbacks  in the  National  Health

Service  Corps  have  resulted  in dramatically  increased  expenditures  on  medical  liability

coverage  for  all  centers.  In  1990,  insurance  premiums  amounted  to  an  estimated  10

percent  of all  centers  total  Federal  grant  funding--or  4.4  percent  of  center

revenues.w

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.

13
 Concerns  about  restricted  staff  productivity  and  increasing  costs  were  echoed  by many 
of  the  survey  respondents  and  center  administrators  with  whom  we  spoke.  One 
centers  insurance  carrier  placed  a cap  on  the  number  of  deliveries  its family 
physicians  could  perform  each  year.  A recent  change  in insurance  coverage  for 
midwives  led  to  a substantial  increase  in another  centers  insurance  rates.3~ 
Escalating  malpractice  costs  led  another  center  to  ask,  what  can  be  done  to  control 
malpractice  costs  for  providers  willing  to volunteer  time  at  the  center? 
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  the  centers.32 
w	 Seventy-six  perceru  of the  centers  reprt  sericm  problems  stemming  fmm  Mdcaid 
policies  and  procedurm--such  as a burdensome  application  process,  bw  reimbursement 
mtes,  a limiled  range  of covered  services,  or limited  eligibil@ 
On  average,  67  percent  of each  centers  perinatal  clients  were  enrolled  in  Medicaid  in 
1990.33  Despite  recent  changes  in the  Medicaid  system  intended  to  increase  access 
to  care,  however,  many  Medicaid-related  factors  continue  to  hinder  the  centers  ability 
to  provide  comprehensive,  timely  care  (see  table  2). 
I  Table  2  1 
~  Percentage  of Centers  Citing Each  of the Following  I 
Medicaid  Factors  as a Serious  Limitation 
~~ Burdensome  application  procedures  !  56%  II 
#  Inadequate  reimbursement  rates  I  47%  II 
~  Slow  reimbursement  process  43%  I 
Restrictive  eligibility  criteria  41% 
I,  Limited  range  of covered  services  /  38T0  ~ 
Source:  C)IG Survey of Urban  Community  Health  Centers,  June  1991 
N=167 
Application  Process:  The  process  of applying  for  Medicaid  benefits  is burdensome 
and  confusing  to  both  centers  and  their  clients.  As  one  center  administrator  noted, 
the  complexity  of the  process  frequently  leads  to  patients  failure  to  follow  through 
with  procedures  for  obtaining  benefits.  The  process  is so  time-consuming,  another 
reported,  that  the  experience  of women  receiving  Medicaid  cards  in their  third 
trimester  is very  common.  Several  centers  reported  similar  problems.  A  number  of 
State  Medicaid  agencies  had  not  begun  to  place  eligibility  workers  at  centers,  even 
though  recent  Federal  law  had  required  them  to  begin  doing  so.~ 
14

  According  to  a prior  OIG  report,  only  26 States  had  adopted  presumptive  eligibility  as

of  June  1991.35  Our  research  indicates,  however,  that  even  some  States  that  had

adopted  this  option  were  not  using  it aggressively.  At  one  center  we  visited--in  a State

that  had  officially  implemented  presumptive  eligibility--a  State  eligibility  worker  in the

clinic  had  never  heard  of  it.  An  administrator  at  another  center  noted  that  even

workers  in the  central  welfare  office  were  not  familiar  with  this  option.  Such

confusion  among  State  welfare  employees  was  reported  by many  of the  center

administrators  with  whom  we  spoke.  Several  respondents  also  reported  that  the

presumptive  eligibility  process  was  so  frustrating  that  many  women  miss  medical

appointments.  Some  centers  have  encountered  difficulty  finding  other  providers  who

accept  presumptive  eligibility  clients  on  referral.

Reimbursement  The  staff  at  several  of the  centers  we  visited  noted  that  many

necessary  services  are  not  covered  by  Medicaid.  One  administrator  reported  that  it is

not  possible  to  bill  for  all  services  rendered  nor  to  collect  reimbursements  that  will

offset  expenses;  another  commented  that  most  specialty  semices  are  grant  funded-

we  would  not  have  them  without  grants.

The  Federally  Qualified  Health  Center  (FQHC)  provisions  of the  Omnibus  Budget

Reconciliation  Acts  of  1989  and  1990  called  on  the  States  to  begin  paying  cost-based

reimbursement  to  CHCS  as  of April  1, 1990.  According  to  PHS  records,  however,  only

27 States  and  the  District  of Columbia  had  begun  paying  higher  FQHC-Medicaid  rates

as  of  May  1991.  Most  of  these  payments  were  at  interim  rates .%  Since  our  survey,

additional  States  may  have  begun  to  implement  these  provisions.

EligiiiMy  Many  centers  reported  that  Medicaid  eligibility  requirements  are  still  too

restrictive.  Staff  at  one  center  echoed  a common  concern  when  they  reported  that

centers  are  expected  to charge  clients  who  cant  pay.  Further,  according  to  OIG

research,  three  States  have  not  yet  dropped  an  asset  test  for  eligibility.37

~  On  average,  21 percent  of cenler perinulal  clients  were uninsured  in 1990. 
At  33  percent  of  the  centers  more  than  25 percent  of the  perinatal  clients  were 
uninsured.  At  9 percent  of  the  centers  more  than  50 percent  of the  clients  were 
uninsured.  These  clients  received  services  at  reduced  rates,  according  to  a sliding 
scale. 
w  Seventy-nine  perceru  of the  centen  reprt  serious problems  stemming  @m 
unsati$actoiy  coordinalwn  of perinatal  services  in the commun  ity, a tick  of other  ikal 
pmvidm  willing  to treat  uninsured  and publicly  insured  wornq  dificu.i@  an-anging 
obstetric  backup  for  center  stafl  and for  consultation  for  high-tik  ctints,  or dim 
obtaining  hospital  pnvikges for  center  stafi 
15
 Community  Coordination:  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.% 
Twenty-six  percent  of the  centers,  however,  do  not  participate  in perinatal  care 
consortia.  Ten  percent  of  the  centers  cited  limited  relationships  with  local  community 
and  government  organizations  as  a factor  that  seriously  hinders  the  provision  of 
services.  Centers  reported  wide  differences  in consortia  membership  (see  table  3). 
Table  3 
Percentage  of Centers  Reporting  the Participation  of Each  of the 
Following in a Cmnxnunity Perinatal  Care  Consortium 
~ Teaching  hospitals  1 54%  I  Government  social  services  349Z0 
Local  health  departments	 i  53%  ~  Private-practice  physicians
~  ,~
\ 
~  Other  health  clinics  ~ 4396  ~  Nonteaching  hospitals  25% 
I 
II Private  nonprofit  groups   42%  II Local  schools  I 20%  II 
I  !
State  health  departments  I  35%  ~~Other  10% 
1 
i 
Source:  OIG  Survey of Urban  Community  Health  Centers,  June  1991 
N=167 
Many  centers  indicated  that,  although  they  participate  in perinatal  care  consortia, 
these  involve  minimal  activity  and  have  limited  results.  Several  centers  noted  that  they 
participate  in consortia  addressing  only  specific  problems--most  commonly,  substance 
abuse.  Eighty  percent  reported  that  their  consortium  activities  do  not  include  local 
schools;  74 percent  that  they  do  not  include  private-practice  physicians;  and  65 percent 
that  they  do  not  include  State  health  departments.39 
The  Imczd Medical  Establishment:  Sixty-one  percent  of the  centers  reported  that  a 
lack  of  other  local  providers  willing  to  treat  low-income  and  uninsured  women 
seriously  limits  the  comprehensiveness  of center  care;  35  percent  reported  that  this 
shortage  has  become  a more  severe  problem  since  1988. 
The  PHS  notes  that  a key  element  in the  quality  and  continuity  of care  is the 
integration  of  the  clinical  staff  into  the  larger  medical  community  . . . to  assure  follow-
up  of  referred  care  and  the  availability  of timely  and  quality  consultations.4 
Centers  indicated,  however,  that  they  Fdce serious  difficulties  arranging  both  backup 
and  referrals.  Thirty-one  percent  of the  centers  reported  serious  difficulty  arranging 
obstetric  backup  for  certified  nurse  midwives  and  22  percent  reported  such  problems 
for  family  physicians.  Twenty-one  percent  cited  difficulty  arranging  consultation  for 
high-risk  clients  as  a serious  limitation. 
16
 Many  of thecenter  administrators  weintetiewed  reported  that  they  are  constrained

by negative  attitudes  on  the  part  of providers,  hospitals,  and  public  agencies  toward

low-income  pregnant  women.  Consistent  with  this  concern,  one  center  administrator

noted  that  his  centers  biggest  problem  is the  provision  or  identification  of referral/

ancillary  semices  for  patients,  particularly  for  the  uninsured.  Another  administrator

noted  that,  even  when  Medicaid  rates  went  up,  private  doctors  didnt  come  back  to

the  business  of  treating  poor  women.  Similarly,  the  director  of another  center  said

that  she  had  experienced  great  difficulty  convincing  local  doctors  to  provide  backup

coverage  and  to  take  center  referrals.  Ultimately,  she  reminded  doctors  and  the  local

for-profit  hospital  that  they  would  be  further  burdened  with  nonpaying  patients  if they

did  not  do  their  part  in facilitating  the  centers  provision  of care.

Hospital  Admitting  Privileges:41  The  PHS  recommends  that,  to assure  continuity  of

care,  center  physicians  should  have  admitting  privileges  and  medical  staff  membership

at  one  or  more  hospitals.42  Centers,  however,  reported  many  difficulties  arranging

admitting  privileges.  Fifteen  percent  reported  a decrease  between  1988  and  1990  in

the  percentage  of staff  providers  with  such  privileges.  Thirty-nine  percent  indicated

that  difficulty  obtaining  admitting  privileges  for  staff  obstetricians,  family  physicians,  or

nurse  midwives  is a serious  limitation  to  care.

Inconsistent  and  restrictive  hospital  protocols  for  nurse-midwife  practice  were  cited  as

a problem  by  many  center  administrators.  Thirty-three  percent  of the  centers  cited

difficulty  obtaining  privileges  for  nurse  midwives  as  a serious  problem.  One

administrator  reported  that  each  hospital  in the  community  has  a different  protocol  for

nurse-midwife  practice.  Another  noted  that,  although  a local  hospital  allows  midwives

to  deliver,  it has  very  stringent  requirements  for  obstetric  backup;  the  center  is limited

by  its  inability  to  retain  such  backup.

Some  hospitals  are  reportedly  reluctant  to  extend  privileges  to  any  providers  whose

patients  might  become  a financial  drain:  one  center  noted  that  a local  hospital  allows

center  physicians  to  deliver  only  patients  with  Medicaid  or  private  insurance  coverage;

another  noted  that  no  local  hospital  takes  uninsured  patients.

w L&z&d  space  seriourly  hinders  the provirwn  of services  at 64 pexent  of the  centers. 
In additiq  limited  coilocalwn  of services  on site  seriously  restricts  the 
comprehensiveness  of care  at 23 pe~ent  of the  centers. 
Thirty-eight  percent  of the  centers  reported  that  inadequate  space  has  become  a more 
serious  problem  since  1988.  Illustrating  the  ways  in which  inadequate  space  can 
hinder  service  delivery,  one  administrator  indicated  that  the  small  number  of 
examination  rooms  at  that  center  limits  its providers  productivity.  The  center  had 
temporarily  stopped  accepting  new  prenatal  clients  because  of the  lack  of space. 
Another  center  had  struggled  for  years  to  increase  its  clinical  staff  capacity;  having 
recently  done  so,  it must  still  limit  the  number  of clients  served  because  of space 
constraints.  Still  another  noted  that,  in a recent  survey  of  patient  satisfaction,  the 
17
 most  common  complaints  were  long  waiting  times  and  congestion  in the  waiting  room. 
State  PrimaV  Care  officials  who  had  recently  visited  this  center  remarked  that  it was 
so crowded  that  we  had  to  go  in through  the  employees  entrance. 
Fifty-nine  percent  of the  centers  reported  that  no  other  public  organizations,  aside 
from  Medicaid  or  WIC,  and  no  private  groups  provided  services  on  site  in  1990. 
Those  centers  that  cited  limited  space  as a serious  problem  were  significantly  more 
likely  than  other  centers  to  cite  limited  collocation  of semices  on  site  as  a serious 
constraint. 
18
 CONCLUSION

Section-330-funded  community  health  centers  play  an  important  role  in the  provision 
of  perinatal  care  in urban  areas  across  the  country.  In this  report  we  have  stressed 
three  themes  concerning  their  performance  of this  role. 
First,  the  centers  capacity  to  provide  perinatal  services  has  increased  substantially 
since  1988.  In  terms  of the  number  of clients  served,  the  range  of services  offered, 
and  budgetary  resources,  the  centers  have  demonstrated  considerable  growth. 
Second,  increased  demand  has  accompanied  the  growth  in capacity.  As  a result,  many 
center  clients  still  do  not  receive  all  the  setices  recommended  by the  Public  Health 
Service.  Limitations  are  particularly  apparent  in the  scope  of case-managed  services 
offered  by the  centers  and  in the  proportion  of women  who  receive  care  during  the 
first  trimester  of  pregnancy. 
Finally,  there  are  several  basic  factors  that  constrain  the  centers  ability  to  provide 
more  services  in a more  timely  manner  to  more  women.  These  constraints, 
documented  in many  previous  studies  as well  as  in ours,  include  staffing  problems, 
Medicaid  policies  and  procedures,  medical  malpractice  insurance,  relationships  with 
other  medical  providers,  and  clinic  space. 
19
 APPENDIX  A

FEDEIUL  SUPPORT  FOR  PERINATAL  CARE 
AT  COMMUNITY  HEALTH  CENTERS 
The  Federal  Government  supports  the  perinatal  services  provided  by community 
health  centers  both  directly  through  Section-330  grants  and  indirectly  through  other 
mechanisms,  including  Medicare  and  Medicaid  reimbursements,  Maternal  and  Child 
Health  grants,  supplemental  nutrition  programs  and  targeted  funds.  In  recent  years, 
several  initiatives  have  been  implemented  to  improve  center  perinatal  sewices  and  the 
access  of women  to  those  semices,  including  the  following: 
Medicaid  Expansions:  Congress  has  mandated  several  changes  in the  Medicaid 
program.  These  include  (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 eligibility  eligibility  for  coverage  is wow  guaranteed 
throughout  pregnancy  and  the  postpartum  period,  regardless  of  income  changes; 
(3)  pr=mptiw  eligiiihty  eligibility  for  temporary  coverage,  limited  to  a maximum  of 
61 days  for  ambulato~  sewices  only,  is 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. 
Federal& Qualified  Heal[/l Cen[en  (FQHC):  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. 
7he  Comprehensive  Perina[al Care Program (CPCP):  In  1988,  the  PHS  launched  this 
initiative  to  improve  birth  outcomes  by encouraging  earlier  entry  into  care  and  more 
perinatal  visits.  The  CPCP  provides  supplemental  funding  for  enhanced  services, 
including  improved  outreach  and  case  management.  Funds  were  first  awarded  in 
1989.  In  FY  1991,  290  of  the  urban,  rural,  and  migrant  health  centers  received  a total 
of $33  million  in CPCP  supplemental  funding;43  80 percent  of the  urban  respondents 
to  our  survey  that  offered  perinatal  services  received  CPCP  funding  for  at  least  1 year 
between  1988  and  1991.  In fiscal  years  1992  and  1993,  $44.7  million  was  appropriated 
for  CPCP.44 
Healthy  Start:  In September  1991,  HHS  awarded  competitive  grants  to  15 
communities  on  the  basis  of  their  proposals  for  coordinated  community  programs  to 
improve  maternal  and  infant  health  care. 
A-1
 Several  other  ongoing  Federa]  efforts  play  important  roles  in  the  centers  provision  of 
perinatal  care,  including: 
National  Health  Setvice  Corps (NHSC):  The  PHSoffers  both  scholarships  and 
educational  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  incommuni~  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. 
Supplemental  Food  Program  for  Women,  Infants,  and  Children  ( WIC):  The 
Department  of  Agriculture  provides  vouchers  through  this  program  to  address  the 
nutritional  needs  of  pregnant  and  lactating  women  and  their  infants. 
A -2
 APPENDIX  B

METHODOU3GY

We  obtained  information  for  this  report  through  a mail  survey  of Section-330  grantees,

site  visits  to  several  centers,  a series  of interviews,  and  a review  of relevant  literature

and  data.

Mail Survey  We  sent  a mail  survey  of perinatal  sexvices  to  all  community  health

centers  receiving  Section-330  funding  as  of June  1991.  Of  the  212  urban  centers,  178

(84  percent)  responded,  including  centers  in every  HHS  region  and  every  State  and

territory  in which  urban  centers  are  located,  with  the  exception  of Washington,  D.C.

A  review  of geographic  and  demographic  information  suggests  no  significant

differences  between  respondents  and  nonrespondents.

Of  the  178 urban  respondents,  11 (6  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  167 centers  (79  percent  of all

urban  centers)  that  offered  services  on  site  in at  least  1 year  during  the  1988-91

period.

Of  the  167 respondents  that  provided  services  on  site  during  the  study  period,  133

(80  percent)  were  CPCP-funded.  For  the  purposes  of this  report,  a CPCP-funded

center  is any  center  that  received  CPCP  grant  funding  at  any  time,  regardless  of the

year  in which  the  initial  grant  was  awarded.

Not  all  respondents  provided  complete  information.  We  calculated  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  (such  as  CPCP-funded  centers  and  other  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  eight  urban  centers:  three  in

Massachusetts,  two  in Connecticut,  and  one  each  in Texas,  Wisconsin,  and  Oregon.

The  team  toured  these  facilities  and  interviewed  management  and  clinical  staff.  We

chose  these  centers  based  on  discussions  with  regional  PHS  staff  and  with

consideration  of geographic  representation  and  community  size.  Of  the  eight  centers,

seven  had  received  CPCP  funding.

B-1
 Intemiews:  ~estudy  team  held  discussions  with  (l)officials  in PHS's  Bureau  of 
Primary  Health  Care  (BPHC)  (then  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. 
B-2
 APPENDIX  C

URBAN SURVEY  RESPONSES 
The  Office  of  Inspector  General  survey  was  mailed  to  212  urban  community  health  centers  in

May  1991.  Of  the  178 (84  percent)  that  responded,  11 provided  no  perinatal  services  on  site

during  the  1988-91  period.  Below  we  present  the  frequencies  and  mean  responses  for  those

167 centers  that  did  provide  services  at some  point  during  this  period.  Not  all centers

answered  every  question.  The  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  perinatal  semices  on  site  in each  year:

1988:  Yes=152  No=15 
1989:  Yes=159  NO=8 
1990:  Yes=165  No=2 
1991:  Yes=164  No=3 
A  CASELOAD  1988  1989  1990 
1. Please  indicate: 
MEAN  (N) 
a.	 the  number  of women  who  received  prena[al 
care  at your  center:  481  (126)  530  ( 149)  558  (157) 
b.	 the  percentage  of  these  clients  who  were 
high-rislq  as defined  by your  center:  37%  (92)  39%  (115)  39%  (128) 
c.	 the  percentage  of  these  clients  who  were 
low-risk  as defined  by your  center:  49%  (88)  48%  (109)  49%  (125) 
d.	 the  number  of births  to your  centers 
clients:  321  (120)  354  (135)  362  (143) 
2.	 Of  the  women  who  gave  birth  in your  service 
area,  what  percentage  received  prenatal  care 
at your  center?  25%  (71)  29%  (81)  32%  (79) 
c-1  B. COMMUNITY COORDINATION 
1. Does  your  center  currently  participate  in a consortium  of perinatal  care  providers? 
Yes  =  123  No  =44  If YES,  please  continue. 
2. Which  of  the  following  participate  in the  consortium?  (Please  check  all that  apply): 
a. state  health  department:  58  f. nonteaching  hospitals:  41 
b. local  health  department:  88  g. private-practice  physicians:  44 
c. health  clinics:  72  h. gov.  social  setvice  agencies:  56 
d. schools:  34  i. non-profit  organizations:  69 
e.  teaching  hospitals:  90  j. other:  16 
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  of  MEAN(N) 
a. clinic  sites  operated  by your  center:  1.95  (159)  2.01  (161)  2.06  (164) 
b.	 clinic  sites  at which  prenatal  care 
was  provided:  1.50  (158)  1.57  (161)  1.59  (165) 
2.	 On  how  many  days  a week  did  your  center

provide  scheduled  prenatal  appointments

either  before 8AM  or  after  6PM?  1.01  (153)  1.15  (157)  1.25  (162)

3. On  how  many  Saturdays  a month  did

your  center  provide  scheduled

prenatal  appointments?  0.48 (151)  0.45  (154)  0.50  (159)

D. Funding 
1. Compared  with  1988, the  amount  of funding  available  for  perinatal  care  at your  center  in 1990 
was: 
Larger= 109  Smaller=21  Unchanged=30 
2. Please  indicate  the  percentage  of your  centers  1990  perinatal  clients  covered  by: 
a. Private  insurance:  6.95%  (148)  c. Medicaid:  67.30%  (152) 
b. No  insurance:  20.70%  ( 149)  d. Other:  4.00%0 (155) 
c-2  3.	 To  what  extent  have  the  fo]]owing  factors  resulted  in increased  demand  for  perinatal  semices 
at your  center  over  the  past  three  years? 
Not at alU  Moderately/ 
Somewhat  Substantially 
a. Medicaid  eligibility  expansions:  62  87 
b.	 Medicaid  presumptive  and 
continuous  eligibility  provisions:  68  81 
E. 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:  140  c. Non-English  speakers:  92 
b. Substance  abusers:  78  d. Other:  51 
2.	 At  which  of  the  following  locations  does  your  center  currently  conduct  perinatal  outreach? 
(Please  check  all that  apply) 
a.	 Community  d. Schools:  109 
centers:  98  e.  Welfare  offices:  52 
b. Shops:  27  f. Churches:  59 
c.	 Door-to-door  in the  g. Other:  66 
neighborhood:  43 
3.	 Through  which  of the  following  media  does  your  center  currently  conduct  perinatal  outreach? 
(Please  check  all that  apply) 
a. Television:  34  d. Radio:  45 
b. Newspapers:  69  e. Other:  49 
c. Pamphlets:  132 
4. Compared  with  1988,  your  centers  outreach  efforts  in  1990 were: 
Greater= 114  Smaller=11  l%e same=32 
5. Compared  with  1988, your  centers  outreach  efforts  in  1990 yielded: 
More clients=124  Fewer clients=7  lhe  same numberof clients=20 
c-3  F. PERINATAL  SERVICES 
1. Please  indicate  which  of  the  following  semices  were  provided  by your  center.  If these  were 
offered  on site,  please  circle  On.  If these  were  offered  off site--either  through  contract,  affiliation, 
or  paid  referral--please  circle  O& 
1988  1989  1990 
a. Ultrasound:  0n=42  on=51  on=57 
Off=lol  Offloo  OH=  103 
b. Amniocentesis:  On=6  on=5  00=7 
0E=136  Off=  143  m=  147 
c. Genetic  counseling:  on=14  on=17  on=22 
off=l19  Off=  124  Off=  126 
d. Non-stress  testing:  on=35  00=48  on=50 
OE=98  0ff=90  off=95 
e.  Dental  care:  On=lll  on=l14  on=l15 
01T=32  0Ef=36  off=43 
f. Nutritional  services:  on=135  on=139  on=154 
off=
14  off=17  0H=9 
h. Health  education:  on=139  on=147  0n=158 
Off=lo  0H=8  0H=6 
i. Birthing  classes:  0n=84  on=95  on=lo6 
0E=54  OE=54  (M=52 
j. Parentinghfant  care  classes:  0n=87  On=98  On=lzl 
otT=45  Off-=43  0iT=32 
k. Family  planning:  on=lso  0n=154  on=160 
0H=2  0ff=3  off=3 
1. Smoking  cessation  programs:  0n=52  0n=58  on=75 
0tT=65  0ff=66  0E=65 
m. Substance  abuse  treatment:  0n=25  0n=28  on=44 
off=  102  off=  104  OtT= 103 
n. HIV  counselinghesting:  0n=81  011=117  on=143 
off=47  0E=29  Off=  18 
2. Compared  with  1988,  the  range  of  perinatal 
semices  offered  by your  center  in  1990 was: 
Greater=  127  Smaller=6  Unchanged=30 
3.	 Were  perinatal  clients  enrolled  on-site  at  the  center 
in the  following  programs? 
a.	 Medicaid:  Yes=38  Yes=63  Yes=108 
No=117  No=94  No=56 
b.	 WIC:  Yes=l13  Yes=  123  Yes=134 
No=43  NO=36  No=31 
c-4  1988  1%9  1990 
4. Did  other  government  or  private  social  setice 
organizations  provide  services  on-site  at your 
center?  Yes=42  Yes=49  Yes=66 
No=113  No=11O  No=99 
5. Did  your  center  facilitate  access  to  perinatal 
care  by providing  the  following  semices? 
a. Transportation  to  and  from  appointments:  Yes=74  Yes=89  Yes=97 
No=80  No=71  No=67 
b. Translation  for  non-English  speaking  clients:  Yes=120  Yes=127  Yes=133 
No=32  No=30  No=28 
c. Child  care  during  center  appointments:  Yes=ll  Yes=14  Yes=19 
No=145  No=147  No=146 
d. Home  visits:  Yes=76  Yes=lo3  Yes=l15 
No=78  No=58  No=50 
G. STAFFING 
1988  1989  1990 
1. How  many  full-time equivalents  of each 
of  the  following  provided  perinatal  services 
on-site  at  the  center?  (N=  167) 
a. Obstetricians:  0.89  0.99  0.93 
b. Family  physicians:  0.64  0.72  0.75 
c. Certified  nurse  midwives:  0.28  0.33  0.35 
d. Nurse  practitioners:  0.57  0.65  0.67 
e.  Physician  assistants:  0.17  0.19  0.21 
2. Please  indicate  below:  (i)  the  number  of your  perinatal  provider  positions  which  are  currently 
vacant;  (ii)  the  number  which  have  been  vacant  for  more  that  six months;  and  (iii)  the  number 
which  have  been  vacant  for  more  than  one  year.  (N=  167) 
(i)  (ii)  (iii) 
Numberof  More than  More than 
Vacanaes  six months  one year 
a. Obstetrician:  0.41  0.34  0.20 
b. Family  physician:  0.25  0.20  0.13 
c. Certified  nurse  midwife:  0.14  0.11  0.07 
3.	 Compared  with  1988,  the  percentage  of your  perinatal  providers  with  admitting  privileges  at 
local  hospitals  in  1990 was: 
Larger =44  SmaUer=24  Unchanged =91  H. TIMING  OF  CARE 
1. Please  indicate  the  percentage  of your  centers  1990  prenatal  clients  who  entered  care  in the: 
a. Fh_st trimester:  50.8%  (N=  156) 
b. Second  trimester:  39.1%  (N=154) 
c. Third  trimester:  10.3%  (N=139) 
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?  69.3%  (67)  7190  (94)  74%  (108) 
3. What  percentage  of your  centers  prenatal 
clients  returned  for  postpartum  visits 
during  the  first  eight  weeks  after  delivery?  66%  (84)  66.4%  (121)  71%  (142) 
4. What  percentage  of  all infants  born  to  center 
prenatal  clients  returned  for  newborn  visits 
during  the  first  four  weeks  after  birth?  69.5%  (79)  69.7%  (1 10)  73.9%  (128) 
I. 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:  47 
on  a walk-in  basis:  105  One-two weeks:  12 
More than 
two weeks:  3 
2. If the  pregnancy  test  were  negative,  would  she  be  referred  to  family  planning  services? 
Yes=150  NO=16 
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:  75 
provided  in conjunction  Two-four  weeks:  58 
with  the  pregnancy  test:  26  One-two  months:  7 
More  than 
two  months:  1 
4.  Compared  with  1988,  waiting  room  waiting  times  at  perinatal  appointments  in  1990  were 
generally: 
Shorter=  56  Longer=33  The sarne=68 
C-6  J. CASE  MANAGEMENT 
1. Does  your  center  currently  provide  case  management  to  promote  the  coordination  of services 
for  perinatal  clients? 
Yes=161  NO=6  If YES,  please  continue. 
2. Case  management  at your  center  is primarily  conducted  by (please  check  only  one): 
The  clients  primary  care  doctor:  4 
The  clients  primary  care  nurse:  23 
The  appointments  secretary:  o 
A multidisciplinary  team:  69 
A center  employee  whose  main 
responsibility  is case  management 
for  perinatal  clients:  59 
Other:  6 
3. Case  management  at your  center  is provided  for  (please  check  only  one): 
Ail  perinatal  clients:  129 
All  high-risk  perinatal  clients:  22 
Only  certain  groups  of 
perinatal  clients:  16 
4. Case  management  of  perinatal  clients  at your  center  comprises  (please  check  all that  apply): 
a. Risk  assessment:  155 
b. Planning  of care:  152 
c.	 Assessment  of  adequacy  and 
appropriateness  of services:  134 
d. Client  advocacy:  146 
e.	 Contact  with  other  organizations 
to  arrange  for  services  / 
schedule  appointments:  159 
f.	 Assistance  with  papemork  related  to 
WIC,  Medicaid,  and  other  programs:  154 
g. Discharge  planning:  92 
Coordination  of 
h.	 Medical  sewices  provided 
on-site  at  the  center:  153 
i.	 Medical  services  provided 
off-site:  129 
c-7  Continued: 
j.  Delivery  setices:  127 
k.	 Social  services  provided 
on-site  at  the  center:  143 
1.	 Social  services  provided 
off-site:  117 
m.  Nutritional  setices:  155 
n.  Health  education:  153 
0.  Other:  26 
5.	 Compared  with  1988,  the  percentage  of all center  perinatal  clients  case  managed  by your  staff 
in  1990 was: 
Larger=  140  Smaller=3  Unchanged=  11 
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  delivecy:  Yes=41  No=120 
For  other  care:  Yea=52  No=1O3 
7.	 Please  estimate  the  percentage  of  cases  in  which  your  center  contacts  perinatal  clients  to 
reschedule  missed  appointments: 
71%  (N=151) 
8.	 Please  indicate  the  manner  in which  you  contact  clients  to  reschedule  missed  appointments 
(please  check  all that  apply): 
Mail=  156  Phone=  161  Home  visit=112  Other=  15 
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=153  NO=6 
C-8
 K  LIMITATIONS  TO CARE  Please indicate the degree to which each of the following factors 
limits yourcenters  ability  to  provide  perinatal  services: 
Not at W
 Moderately/ 
Somewhat  sub6tantiauy

1. Shortage  of medical  staff  67  95 
2. Shortage  of nonmedical  staff.  112  47 
3. High medical  staff turnover:  113  44 
4. High  nonmedical  staff turnover:  135  22 
Difficulty  obtaining  admitting  privileges 
at local hospitals  for: 
5. obstetricians:  132  13 
6. family physicians:  118  21 
7. certified  nurse  midwives:  81  40 
8. High cost of malpractice  insurance:  68  88 
Difficulty  obtaining  malpractice  insurance  for: 
9. obstetric  providers:  120  27 
10. all providers:  124  22 
Difficulty  arranging  medical  backup  for: 
11. OB supervision  of certified  nurse  midwives/ 
nurse  practitioners:  97  43 
12. OB supervision  of family physicians:  99  28 
13. coverage  during  center  staff vacations, 
holidays,  and weekends:  97  59 
14. consultation  for high-risk  patients:  123  32 
15. Limited  relationships  with  local 
community  and government  organizations:  146  16 
16. Lack of other  providers  in the community 
willing  to treat  uninsured  or publicly 
insured  women:  63  98 
Non-acceptance  of certified  nurse  midwives/ 
nurse  practitioners: 
17. by the medical  community:  101  46 
18. by patients:  133  6 
19. Inadequate  center  funding:  59  101 
20. Difficulties  related  to funding  obtained 
from  many different  sources:  83  71 
Medicaid-related  problems: 
21. slow reimbursement  process:  93  69 
22. inadequate  reimbursement  rates:  86  75 
23. limited  range  of covered  services:  99  60 
24. restrictive  eligibility  criteria:  95  65 
25. burdensome  application  procedures:  72  91 
26. Limited  case management:  119  36 
27. Limited  collocation  of setvices:  111  33 
28. Limited  space:  58  102 
10  9 
29. Other 
c-9  Which  of  these  factors  have  become  LESS  SERIOUS  or  MORE  SERIOUS  limitations  since 
1988? 
More

Serious  serious

1. Shortage  of medical  staffi  60  23 
2. Shortage  of nonmedical  staff  19  21 
3. High  medical  staff turnover:  17  14 
4. High  nonmedical  staff turnover:  5  21 
Difficulty  obtaining  admitting  privileges 
at local hospitals  for: 
5. obstetricians:  5  20 
6. family physicians:  11  12 
7. certified  nurse  midwives:  14  10 
8. High cost of malpractice  insurance:  43  11 
Difficulty  obtaining  malpractice  insurance  for: 
9. obstetric  providers:  16  12 
10. all providers:  9  11 
Difficulty  arranging  medical  backup  for: 
11. OB supervision  of certified  nurse  midwives/ 
nurse  practitioners:  27  13 
12. OB supervision  of family physicians:  14  13 
13. coverage  during  center  staff vacations, 
holidays,  and weekends:  31  13 
14. consultation  for high-risk  patients:  20  18 
15. Limited  relationships  with  local 
community  and government  organizations:  6  28

16. Lack of other  providers  in the community 
willing to treat  uninsured  or publicly 
insured  women:  56  9 
Non-acceptance  of cz?rtified nurse  midwivtxl 
nurse  practitioners: 
17.by the medical  community:  11  24 
18. by patients:  3  20 
19.Inadequate  center  funding:  40  22 
20.	 Difficulties  related  to funding  obtained 
from  many different  sources:  36  12 
Medicaid-related  problems: 
21. slow reimbursement  process:  30  30

22. inadequate  reimbursement  rates:  31  44

23. limited  range  of covered  services  23  34

24. restrictive  eligibility  criteria:  30  52

25. burdensome  application  procedures:  37  37

26. Limited  case management:  16  41 
27. Limited  collocation  of services:  12  19 
28. Limited  space:  61  21 
29. Other  6 1 
c-lo  L  CONCLUSION 
1. Over the past three  years, demand for perinatal  care  at your center  has: 
Increased=  149  Decre&A=7  Not changed=8 
2. Over  the  past  three  years,  your  centers  capacity  to  address  the  demand  for  perinatal  care  in 
your  service  area  has: 
Ineread=lo6  Decreased=36  Not changed=22 
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 
years  to  improve  its ability  to  respond  to  perinatal  care  needs  in your  service  area? 
C-II
 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 
recent  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.  NCHS,  1988.  These  are  the  most  recent  data  available. 
3.  U.S.  Public  Health  Semite  (PHS),  Healthy  People 2000:  National  Health

Promotion  and Dkease  Prevention  Objectives,  Washington,  D. C.,  1990,  p.  366.

PHS,  Caring for  Our Future:  The Content  of Prenatal  Care:  A  Repoti  of the

PHS  Expert Panel on lhe Content  of Prenatal  Care, Washington,  D. C.,  1989,  p.  2.

4.  Sarah  S. Brown,  editor:  Institute  of Medicine,  Prenatal  Care: Reaching  Mothens 
Reaching  Infants,  National  Academy  Press,  Washington,  D. C.,  1988,  p.  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  services  had  discontinued  such  care.  (American  Academy  of Family 
D-1
 Physicians,  Family  Physicians  and  Obstetrics:  A  Professional  Liability  Study, 
1987.) 
5.  NCHS,  Advance  Report  on  Final  Natality  Statistics,  1989, MonthZy VW 
Statistics	 Report, vol.  80,  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.  iv.  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.	 Cohesion  Sought  in  Medical  Aids:  Antipoverty  Funds  Used  for  Centralized 
Services,  771e New  York Times, May  22,  1966. 
7.	 Alice  Sardell,  The  U.S. 13rpenrnent in Social Medicine:  Z4e Community  Heahh 
Center Program, 1965-1986,  University  of Pittsburgh  Press,  Pittsburgh,  PA  1988, 
p. 66. 
8.	 Bonnie  Lefkowitz,  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. 
9.	 As  of June  1991,  PHS  also  funded  302  rural  community  health  centers.  The 
capacity  of  these  centers  to  provide  perinatal  services  is addressed  in the  OIG 
inspection  report  The Perinatal Service Capacity  of The Federally Funded 
Community  Health  Centers:  Rural  Centem  (OEI-01-90-02331).  Some 
community  health  centers  received  both  Section-330  funds  and  Section-329 
funds  for  care  provided  to  migrant  workers;  an  additional  71 centers  received 
only  Section  329  funding. 
10.	
Section-330  funding  was  $435  million  in FY  1989,  $457  million  in FY  1990,  and 
$478  million  in FY  1991.  (Health  Resources  and  Services  Administration 
(HRSA)  FY  1993 Justification  of Appropriations,  vol.  1, p.  63.) 
For  FY  1992,  $532  million  was  appropriated.  The  FY  1993  appropriation  is 
$559  million.  (BPHC  and  the  Assistant  Secretary  for  Management  and  Budget 
[ASMB].) 
11.	 The  Public  Health  Semite  provided  us with  financial  data  that  they  collected 
from  the  centers  through  the  Bureaus  Common  Reporting  Requirements 
reports  and  with  financial  and  user  data  that  they  collected  from  CPCP 
applicants  through  the  Perinatal  User  Profile  reports, 
D-2
 13  Unless  otherwise  noted,  all of the  differences  between  groups  (such  as  CPCP-
lL.	
funded  centers  and  other  centers)  cited  in this  report  a~e statistically  significant 
at  the  .05  level. 
13.	 Centers  that  served  fewer  than  200  prenatal  clients  in  1988  served  an  average 
of  110 in  1988  and  215  in  1990.  Centers  that  sewed  between  200  and  999 
clients  in  1988  served  an  average  of 465  in  1988  and  581  in  1990.  Centers  that 
seined  1,000  or  more  clients  in  1988  sened  an  average  of  1,886  in  1988  and 
1,971  in  1990. 
14.	 In  1988--before  CPCP  funds  were  awarded--those  centers  that  eventually 
received  funding  sened  an  average  of 526  clients;  the  other  centers  seined  an 
average  of  231.  In  1990,  the  CPCP-funded  centers  sewed  an  average  of  641 
clients;  other  centers  seined  an  average  of  311. 
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  served  in  1988.  Also

according  to  this  report,  in  1989,  CPCP-funded  centers  provided  services  to  13.4

percent  of all  pregnant  teens  age  15 or younger  in the  United  States.  The

BPHCS  CPCP  data,  however,  does  not  permit  a comparison  of CPCP-funded

centers  and  other  centers.

15.	 These  centers  served  an  average  of 372  prenatal  clients  in  1988  and  504  in 
1990.  Centers  with  perinatal  populations  that  were  less  than  half  Medicaid-
enrolled  served  an  average  of 811  clients  in  1988  and  845  in  1990. 
16.	 Our  survey  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. 
17.	 Our  survey  inquired  about  the  provision  of four  services  that  facilitate  access  to 
care:  translation,  transportation,  home  visiting,  and  child  care  during 
appointments. 
18.	 Some  centers  are  able  to  complete  enrollment  on  site.  Other  centers  only 
distribute  forms  or  provide  assistance  in completing  them.  In  such  cases, 
applicants  must  complete  the  enrollment  process  at  the  appropriate  State 
offices.  Some  centers  reported  that  staff  sometimes  accompany  clients  to  the 
State  offices  to  facilitate  the  process.  Some  centers  complete  all  nutritional 
assessment  and  paperwork  for  WIC  on  site,  but  clients  must  obtain  vouchers  at 
a different  location. 
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 19.  There  wasa  163percent  increase  inthenumber  of CPCP-funded  centers  that 
provided  Medica~d  enrollment  assistance  on  site.  There  wasa433  percent 
increase  in the  number  of centers  without  CPCP  funding  that  provided  this 
service.  In  1988,  35  CPCP-funded  centers  and  3 other  centers  provided  on-site 
assistance  with  Medicaid  enrollment.  By  1990,  92 CPCP-funded  centers  and  25 
other  centers  offered  this  service. 
20.  Bureaus  Common  Reporting  Requirements  (BCRR)  Database,  BPHC,  PHS. 
This  database  contains  self-reported  financial  and  user  data  from  Section  330 
grantees.  We  derived  the  percentage  change  in center  revenues  from  data  for 
those  146 urban  centers  (82  percent  of urban  survey  respondents,  or  72 percent 
of all  urban  grantees)  that  both  responded  to  our  sumey  and  provided  financial 
data  to  BPHC  through  the  BCRR  form  for  the  years  1988,  1989,  and  1990. 
Total  reported  revenues  for  these  146 centers  increased  from  $415  million  in 
1988  to  $544  million  in  1990.  PHS  Section-330  grants  to  these  centers 
increased  from  $163  million  in  1988  to  $193  million  in  1990.  Medicaid 
reimbursements  to  these  centers  increased  from  $84  million  in  1988  to  $134 
million  in  1990.  These  centers  received  additional  revenues  from  MCH  block 
grants,  Section-329  and  -340  grants,  WIC  grants,  Title  X grants,  Title  XVIII 
Medicare  payments,  Title  XX  payments,  other  third  party  payments,  patient 
collections,  State  and  local  revenues,  and  donations. 
21.  We  excluded  these  11 centers  from  the  calculation  of the  statistics  presented  in 
the  body  of this  report  (see  appendix  B for  detailed  methodology). 
22.  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. 
23.  PHS,  Caring for  Our Future,  p. 2. 
PHS,  Healthy  People 2000, p.  366. 
In  our  survey,  we  used  the  terms  health  education  for  health  promotion  and 
social  sewices  for  psychosocial  services. 
24.  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. 
25.  Inadequate  insurance,  limited  financial  resources,  long  waits  for  appointments, 
an  inability  to  arrange  child  care,  and  time-consuming  transportation  all 
discourage  women  from  returning  to  the  center.  In  addition,  in some 
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 immigrant  communities,  women  are  discouraged  from  leaving  their  homes  for 
at  least  one  month  after  delivery.  Some  women  may  receive  follow-up  care 
from  other  providers,  but  it is unclear  to what  extent  the  centers  track  these 
women  after  delivery. 
26.	 NCHS,  1992.  The  1989  data  for  national  rates  of entry  into  care  are  the  most 
recent  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. 
27.	 NCHS,  Montidy  VI[al Stattitics  Repoti,  1991, p. 43.  These  1989  data  are  the 
most  recent  available. 
28.	 ACOG,  S[andard-sfor  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 
semices  that  they  deliver  conform  to  the  Standards for  Obstetnc-Gynecolo@c 
Services (Perinatal  Care:  How  to  Establish  Perinatal  Services  in Community 
Health  Centers,  PHS,  1985,  p. 96.) 
A  1989  PHS  report,  Caring for  Our Future:  The Content  of Prenatal  Care, 
suggests  slightly  different  guidelines.  This  report  recommends  that  healthy 
women  receive  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). 
29.	 Nonresponses  may  have  resulted  in an  underestimate  of  the  percentage  of 
centers  with  such  vacancies. 
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 30.  U.S.  General  Accounting  Office,  Medical  Malpractice:  Data  on  Claims  Needed 
to Evaluate  Health  Centers Insurance Alternatives  @IRD-91-98),  Washington, 
D. C.,  May  1991,  p.  1.  These  data  are  for  all Section-330  grant  recipients. 
31.  The  clinics  midwives  had  originally  been  covered  under  its  general  liability 
policy,  but  must  now  be  insured  individually. 
32.  P.L.  102-501.  Under  the  FfC~  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. 
33.  On average,  seven  percent  of  each  centers  perinatal  clients  were  privately 
insured  and  four  percent  were  covered  by  other  mechanisms  in  1990. 
34.  The  Omnibus  Budget  Reconciliation  Act  of  1990  required  States  to  locate 
eligibility  workers  at  sites  other  than  AFDC  enrollment  sites,  including  CHCS, 
as  of July  1991. 
Several  administrators  speculated  that  States  lacked  the  funds  needed  to 
implement  outstationing  of eligibility  workers.  At  one  center,  a State  eligibility 
worker  was  stationed  on  site,  but  her  effectiveness  was  limited  because  she  was 
unable  to  access  the  regional  Medicaid  database  and  was  not  allowed  to  make 
long-distance  telephone  calls  to  the  agency  office. 
35.  OIG,  Medicaid  Expansions for Prenatal Care:  State  and Local  Implementation 
(OEI-06-90-00160),  January  1992,  appendix  E. 
36.  Bonnie  Lefkowitz,  BPHC,  PHS,  written  communication  to  OIG,  December  24, 
1991. 
37.  OIG,  Draft  report  Medicaid  Expansions for Prenatal  Care: State  Update 
(OEI-06-90-00161),  May  1992. 
At  one  site  we  visited,  where  only  5 percent  of the  perinatal  clients  were 
covered  by  Medicaid  and  70 percent  were  uninsured  (most  clients  were  working 
poor  and  failed  the  asset  test),  the  director  noted  that  grant  funds  are  necessary 
to  subsidize  sliding  scale  fees. 
38.  P. E.,  pp.  4-5. 
39.  Centers  report  a range  of coalition  activities,  including  formulation  of 
recruitment  and  retention  strategies;  sharing  of services;  use  of  a common 
medical  record;  on-line  appointment,  registration,  and  data  transfer  with  local 
hospitals;  coordination  of referrals;  improved  communication;  telephone 
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 hotlines;  public  forums  forperinatal  issues;  media  relations;  contact  with 
legislators;  consultation  with  governmental  agencies;  and  community  education. 
40.  P. E.,  p.  18. 
41.	 Our  survey  only  addressed  admitting  privileges.  During  interviews,  center  staff 
reported  hospital  restrictions  on  the  delivery  privileges  of certified  nurse 
midwives  and  family  physicians. 
42.  P. E.,  p.  19. 
43.  HRS~  FY  1993 Justification  of Appropriations,  vol.  1, p. 61. 
44.  BPHC  and  ASMB  data. 
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