Depafiment of Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
TI-IE PERINATAL SERVICE CAPACITY 
OF THE FEDERALLY  FUNDED 
COMMUNTY HEALTH  CENTERS: 
RURAL  CENTERS 
DECE~ER 1992  OEI-01-90-02331 
I  OFFICE  OF  INSPECrOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human 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 Sexvices, the 
Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting  audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE  OF  INVESTIGATIONS
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF  EVALUATION  AND  INSPECITONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public. The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-todate information on the efficiency, vulnerability, 
and effectiveness of departmental programs.  This report was prepared in the Boston regional 
office under the direction of Mark R. Yessian, Ph. D., Regional Inspector General, and Martha 
B. Kvaal, Deputy Regional Inspector General. Project staffi 
REGION  HEADQUARTERS 
Dana L. Miller, Frojec[ Leader  Maruta Zitans 
Timothy J. Corbett  Barbara Tedesco 
Madelaine T. Tully 
Deborah  Skahan 
For additional copies of this repo~ please contact the Boston regional office at 617/565-1050.  E X E C U T I V E   S U M M A RY

PURPOSE 
This report describes recent trends in the perinatal service capacity of rural community 
health centers funded under Section 330 of the Public Health Sewice Act. 
BACKGROUND 
The high infant mortality rate in the United States continues to be a cause for 
concern.  The  Public  Health  Service  (PHS)  recommends  timely,  high-quality  perinatal 
care  as  an  effective  way  to  lower  the  infant  mortality  rate  and  ensure  healthier

newborns.  A  number  of  obstacles,  however--including  a  decreasing  supply  of

obstetrical  providers,  rising  medical  malpractice  insurance  costs,  and  inadequate  health

insurance
 coverage--prevent many women from obtaining perinatal services in a timely 
fashion.

Attention has increasingly focused on the role of community health centers as key

providers
 of perinatal services to high-risk women in medically underserved areas 
across the nation. Many of these women are difficult to reach and do not appreciate

the importance of prenatal care.  In 1991, PHS funded 302 rural centers; these

represented 60 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 Semite 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 address the perinatal care needs of the women they seine. To examine the 
capacity of rural centers to provide perinatal care, we conducted a mail survey of all 
rural centers receiving Section-330 funds as of June 1991 (to which 84 percent

responded); visited 1 center; conducted a telephone interview with representatives of

another center; held discussions with PHS administrators, State officials, and infant

health experts; and reviewed the relevant literature and data. our findings are based 
primarily on information reported by the centers to us and to PHS.

FINDINGS

i%e capacity of rural commun ity health centen to provide painatd care ha increased in 
several reqxcls tie 198& 
	 The number of prenatal clients served by the centers rose 20 percent between 
1988 and 1990, from an average of 261 per center to 312.  The number of 
births to center clients rose 21 percent during the same period, from an average 
i  of 194 per center to 235. Survey respondents reported a total of 52,597 
prenatal clients and 36,316 births in 1990. 
The range of perinatal services increased at 61 percent of centers. The sewices 
added at the largest number of centers were HIV testing and counseling, 
smoking-cessation programs, and classes in parenting and childbirth. 
The range of ancillary services--such as home visiting and transportation-
increased at 28 percent of the centers. 
Forty-eight percent of centers offered on-site assistance with enrollment in 
Medicaid in 1990, an increase from 25 percent in 1988. Fifty-three percent of 
centers offered on-site assistance with enrollment in the Supplemental Food 
Program for Women, Infants, and Children in 1990, an increase from 49 
percent in 1988. 
Total revenues for the rural centers increased 20 percent between 1988 and 
1990; this includes a 19 percent increase in Section-330 grant funding, and a 42 
percent increase in Medicaid reimbursements. Thirty-eight percent of survey 
respondents reported that the amount of funding available for perinatal semices 
has increased since 1988. 
Despite the increases in capacity, demand for perinatal senzices at mral centm has 
continued to gmw and many cliimts still & not receive the optirnd coordinated packzge
of care in a timely fashion 
Twenty percent of the centers reported that they provided no perinatal services 
on site between 1988 and 1991. Our study did not examine the extent to which 
these centers made alternative perinatal care arrangements for their clients. 
Demand for semices increased at 75 percent of the centers; 42 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 sewices recommended by 
the Public Health Setice. This may, in part, reflect variations in the definition 
of case management among centers. 
On average, 59 percent of each centers prenatal clients entered care during the 
first trimester in 1990. Nationally, 76 percent of all women, 62 percent of 
minority women, and 58 percent of women in Healthy Start project areas 
entered care during the first trimester. 
ii  On average 18 percent of each centers first-trimester enrollees received fewer 
b 
than 9 prenatal visits.  Our study did not examine the extent to which these 
patients may have received care elsewhere. 
	 Thirty-eight percent of centers did not offer prenatal appointments at times 
convenient for working women. 
Rural cen&m idimti@d several major comtrainls that saiously hit their capacity to provide 
peiinatal  care 
Medical staff shortages. Medical staff shortages, in part as a result of cuts in 
the National Health Service Corps in the 1980s, present serious problems at 67 
percent of centers.  Although the number of prenatal clients increased an 
average of 20 percent at the centers, the number of obstetricians, family 
physicians, and certified nurse midwives decreased an average of 1 percent. 
Twenty-eight percent of rural centers reported that at least 1 of these positions 
had been vacant for longer than 1 year. 
Medical malpractice insurance. The high cost of medical malpractice insurance 
has been a serious drain on resources at 55 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 (mCA) to health care providers at the centers. 
Medicaid PO Iicies and procedures. Seventy percent of 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. 
Inadecmate health insurance. On average, 17 percent of each centers perinatal 
clients were uninsured in 1990. At 9 percent of the centers more than 50 
percent of the clients were uninsured. 
Unsatisfactow community coordination. Seventy-three percent of the centers 
report serious problems stemming from unsatisfactory coordination of perinatal 
services in 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 48 
percent of the centers.  In addition, limited collocation of semices on site 
seriously restricts the comprehensiveness of care at 28 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, The Perinatal Service Capacity of the Federally 
Funded Community Health Centen:  Urban Centers (OEI-01-90-02330) examines recent 
trends in the perinatal care capacity of urban community health centers. 
The third report, 771e Perinatal Sewice Capacity of the Federally Funded Community 
Health Centem: 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   areas of special policy interest: Medicaid reimbursements to 
two
CHCS and Comprehensive Perinatal Care Program funding of the centers. 
That report identifies four major constraints that limit the perinatal 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 semices, 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 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 comments on the draft reports received 
from PHS, HCF~ and ASPE. 
iv 
.  TABLE  OF  CONTENTS

EX ECUTlvE SUMMARY 
tNTRODUCIION  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  ...* .  .  .  1 
Purpose . . . . . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  1 
Background . .
 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  1 
                            
Companion Reports  2 
                                                                                    

Methodology . . . . .
 3 
-.                                                                                          
FINDINGS 
The capacity of rural community health centers to provide

perinatal care has increased in several respects since 1988 . . . . . . . . . . . . . . . . .
 4 
Despite these increases in capacity, demand for perinatal setices at 
rural centers has continued to grow and many clients still do not 
receive the optimal coordi ]ated package of care in a timely fashion. . . . . . . . . .  7

Rural centers identified se /era] maior constraints that seriouslv limit 
their capacity toprovideperinatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . ...12 
CONCLUSION  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  ...*. .  .  .  19

APPENDICES 
k  Federal Support for Perinatal Care at Community Health Centers . . . . . . . .  A-1

B:  Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  B-1

c:  Rural Sumey Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  c-1

D:  Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  D-1
 INTRODUCTION

PURPOSE 
This report describes recent trends in the perinatal semice capacity of rural community 
health centers funded under Section 330 of the Public Health Semite Act. 
BACKGROUND 
Birth Outcomes in the United States: The high rate of infant mortality in the United 
States continues to be a cause for concern. Each year, approximately 40,()()0 infants 
die before their first birthday--almost 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 mortali~, 
today it ranks 23rd. The rate for black infants continues to be double that for white 
infants.l 
Perinatal Care in Rural America: A pregnant woman with no prenatal care is three 
times more likely to have d baby born at low birthweight--a key indicator of the risk of 
infant death--than a woman with adequate care. The Public Health Service (PHS) 
recommends timely, high-quality care before, during, and after birth as an effective 
way to lower the infant mortality rate and ensure healthier infants. Such perinatal 
care should include early and continuing risk assessment; health promotion; and 
medical, nutritional, and psychosocial interventions and follow-up.2 A full course of 
care is especially vital for women at risk because of medical or social factors. 
In 1989, however, 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.3 
Rural women face especially significant barriers to care, including poverty, isolation, 
inadequate medical insurance, and a lack of transportation. A shortage of health 
professionals in rural areas--particularly a lack of obstetrical providers--exacerbates 
these problems.  Although 28 percent of Americans live outside of urban areas, they 
are sewed by only 13 percent of the nations doctors;4 more than 1,400 rural counties 
have no obstetricians at all.s  A lack of resources and inadequate insurance further 
limit access to care. About one-third of rural childbearing women live below the 
poverty level--5 percent more than in urban areas--and about 4.7 million rural families 
have no health insurance of any kind.G  Although recent Medicaid expansions have 
increased the number of pregnant women who are eligible for coverage, States have 
found that many obstetrical providers are unwilling to accept Medicaid-enrolled 
clients. 
1  Rural  Community  Health Centers: Community health centers (CHCS) are key 
providers of perinatal services to high-risk women in the nations rural areas. The 
CHC program was established in 1965 to meet the comprehensive health needs of 
the  nations  medically  undersexed.  Federal  administration  of the program  was  consolidated

in 1975 under Section 330 of the Public Health Service Act. In 1991, PHS funded 514

centers,  60  percent  of  which  were  located  in  rural  areas.  There  are  roughly  1,380

medically  underserved  rural  areas,  however,  and  many  of  these  are  not  seined  by  centers;

about  2,100  counties  in  the  United  States  still  have  provider  shortages.8 More than one-
third  of  the  States  have  5  or  fewer  community  health  centers.9 In 1992, PHS funded a 
total of 549 centers. 
The Federal government supports the semices 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 Sewice Corps, the Supplemental 
Food Program for Women, Infants, and Children, and the Rural Health Clinic Program. 
In recent years, funding for the centers has increased,10 and several initiatives have been 
implemented to expand center semices and improve access to care. These include: 
supplemental funding through the Comprehensive Perinatal Care Program (CPCP), 
expanded Medicaid coverage for pregnancy care, increased Medicaid reimbursement for 
center semices 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 serve. 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 rural centers 
to provide these senices. 
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 Capacity of the Federally Funded 
Community Health Cen[ers:  Urban Cenlen (OEI-01-90-02330) examines recent trends in
the perinatal care capacity of urban community health centers. 
The third report, T4e Perina[al Service Capacity of the Federally Funded Community 
Health Centezs: 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 CPCP 
funding of the centers. 
2
 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-
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 comments received from PHS, HCF& and ASPE on the draft reports. 
METI-IoDoImGY 
This report is based on information gathered from a mail survey of rural community 
health centers; a site visit to one rural center; a telephone intetiew with another 
center; discussions with PHS administrators, State officials, and infant health experts; 
and a review of the relevant literature and PHS data.ll 
We sent the mail su~ey to all community health centers receiving Section-330 funds as 
of June 1991. Of the 302 rural centers, 253 (84 percent) responded. Our findings are 
based primarily on the responses of those 202 rural centers (67 percent of all rural 
centers) that offered perinatal services on site during the period 1988-91. (See 
appendix B for detailed methodology.) 
Our review was conducted in accordance with the Inlerirn Slandards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
3
 FINDINGS

THE CAPACITY OF RURAL COMNKNTY HEALTH CENTERS TO PROVIDE 
PERINATAL CARE HAS INCREASED IN SEVERAL RESPECTS SINCE 1988. 
 % number of prenatal ciienLY served by the centen rose 20 pement between 1988 and 
19W, fmm an average of 261 per center to 312 The number of b% to cen&r c&n@ 
we 21 percenl during the same pew finm an average of 194 per cenler to 235. 
Survey reqpondenfs repti a total of 5~597 prenatal clien/s and 3~316 births in 
Iwo. 
Sixty-three percent of the centers  Figure 1 
Average Number of Prenatal Clienis 
reported  that  the  size  of  their  1988.1989, and 1990 
prenatal  client  caseloads  grew 
between 1988 and 1990 (see figure  w  I 
)! 
I 
1). Caseloads grew more at those  J 400{
I 
centers  that  sewed  smaller  u  I 
caseloads in 1988, those that did not  294
I_
receive  Comprehensive  Perinatal  261 
Care Program (CPCP) funding, and 
those  that  seined  prenatal  client 
populations  that  were  more  than 
half Medicaid-enrolled in 1990.12  1 
lW 
solmxoms lmmyafmualcmmmlayHcabheh&  1991. 
N-151 
Caseloads grew 173 percent between 1988 and 1990 at centers that sewed fewer than 
75 clients in 1988, 23 percent at centers that served between 75 and 249 clients, and 
11 percent at centers that sewed 250 or more prenatal clients.13 
Caseloads grew 25 percent at centers that did not receive CPCP grants, and 18 
percent at centers that did receive these grants.  The average caseload size, however, 
was larger at CPCP-funded centers. 14 Caseloads grew 28 percent at centers in which 
more than half of the perinatal population was Medicaid-enrolled in 1990, and 12 
percent at centers in which less than half was Medicaid-enrolled. The average 
caseload size, however, was smaller at centers with perinatal populations that were 
more than half Medicaid-enrolled in 1990.1s 
4
   The range of painatal sewices increased at 61 pement of centeKs. The services 
added at the liqyxt number of centm were HIV testing and counsebg 
Smotig<matin program, and chsses in parenting and childb~ 
Between 1988 and 1990, there was an 
Medical and Health Promotion SeM(XS: 
increase in the percentage of centers protiding each of a representative range of 
either on site or off site through paid 
perinatal medical and health promotion services, 
referrals or contracts. 16 HIV counseling and  testing  and parenting classes were added
at the largest percentage of centers (see figure 2). 
F@re 2 
Percentage of Centers that Provided each Peri.nata.l Service 
Either On Site or Off Site, 1988 and 1990 
8 
E 
$ 
3 
+! 
& 
by 1990 
Percentage of Centers Providing Each Service 
Source: OIG Survey of Rural Cmununity Health Center% June 1991. 
N-202 
Sewices on site: At the same time, 42 percent of the centers added at least 1 medical 
or health promotion service on site.  The semices added on site at the largest number 
of centers were family planning, health education, and nutrition SeIViCeS In 1990~ 
more than 80 percent of centers offered each of these services on site (see appendk C 
for suwey responses). 
5
   The mnge of a&~ semices--such as home visiting and tzaqortation--increased 
at 28 pemenf of the cenhxs. 
Twenty-eight percent of the centers added at least one service that facilitates access to 
perinatal care between 1988 and 1990.17 Home-visiting semices were added at the 
largest percentage of centers, and child care during appointments was added at the 
smallest percentage of centers (see figure 3). 
Figure 3 
Percentage of Center8 that Provided 
Each AXiC~ SeMce, 1988 and 1990 
Trans&tiaI far naMhi@b Spakem 
HaIW Wits 
4, 
IL 
 
bI  uliklca rc dining Ap@mnmm  c1  :wzm
k  ,
0%  20%  40%  60s  m% 
la)% 
sameoIQ sweyaf Ru4dcnmwniy HeaM-JulE 1991. 
N-2U2 
  Fo@+ght pement of cetiem  offered on-de assistance with eruulknent in Medicakl 
in 1990, an increase fmm 25 pexeti in 198& Fifi-three  penxru of centem offkred 
on-de dtance tih enrollment in the Suppbnentd  Food -am for Womq 
Infa~ and Chikken (JV7C) in 1990,  an ihcrease @m 49 percent  in 198& 
A larger percentage of CPCP-funded centers than other centers provided on-site 
assistance with WIC enrollment. In 1990, 62 percent of the CPCP-funded centers 
provided assistance with WIC, while only 46 percent of other centers did S0.18 
There was no significant difference between the percentage of CPCP-funded centers 
and other centers that offered on-site assistance with Medicaid enrollment in 1990. 
Between 1988 and 1990, however, on-site assistance with Medicaid enrollment was 
added at a larger percentage of CPCP-funded centers.19 
6
   Total revenues for the nual centm increased 20 percent between 1988 and 199Q; 
ti includes a 19 pexent increase in Section-330 grant funding and a 42 pment 
increase in Medicaid reimbmements.  l%irty-eight  penxnt of SUWey  respondents
repti that the amounf of @ding avaikble for painatal  services has increased
since 198& 
The PHS Section-330 grant represented 44 percent of total revenues for these centers 
in both 1988 and 1990. Medicaid reimbursements amounted to 11 percent of total 
revenues in 1988 and 13 percent in 1990.m 
Increased funding for perinatal services was correlated with increased capacity. 
Seventy-two percent of centers that reported increased funding for perinatal services 
also reported increased capacity, while only 40 percent of those that reported a 
decrease or no change in perinatal funding also reported increased capacity. 
Several centers noted that additional revenues, especially through the CPCP, enabled 
them to enhance their perinatal services.  One administrator illustrated the potential
impact of the supplemental revenues when he explained: Our CPCP funding began 
in 1990. We got an additional family practitioner that year. Now we have two 
providers instead of just one.  Another center further demonstrated the possible 
benefits of the funding, reporting greatly expanded semices through the addition of a 
case manager, of an obstetric specialist, and of a double-wide trailer to house an 
obstetric clinic--a much improved space. 
DESPITE THESE INCREASES IN CAPACITY, DEMAND FOR PERINATAL 
SERVICES AT RURAL CENTERS HAS CONITN_UED TO GROW AND MANY 
CLIENTS STILL DO NOT RECEIVE THE OPTIMAL COORDINATED 
PACKAGE OF CARE IN A TTMELY FASHION. 
b  7kenty percent of lhe centm repotied that they provided no petitd seties on site 
between  1988 and 1991. Our studjv did not examine the exteti to whidz these 
centers made alternative perinatal care awangements for their cZients. 
Fifty-one centers reported that they did not offer perinatal care between 1988 and 
1991.2* Forty-seven percent of these indicated that they would like to provide perinatal 
services but that a lack of obstetric providers or hospital privileges prevented them 
from doing so.  Illustrating these circumstances, one administrator wrote that, due to 
lack of support services for our physicians and the lack of available delivery facilities, 
all perinatal clients are referred to four surrounding county health departments. 
Many centers indicated that they provide referral and support selvices, but the 
distances some patients must travel for such care are considerable. Several centers 
said that they refer women more than 50 miles away.  For example, one administrator 
7
 remarked that closure of a hospital unit 50 miles away forces us to send all obstetric 
patients 100 miles away.  Another remarked that the local hospital closed in 
1987. We now refer women to the local health department and hospital 26 miles 
away. 
According to a recent survey, women who traveled outside of their communities for 
perinatal semices were more likely to experience complications during delivery, stay 
longer in the hospital, and need more expensive neonatal semices.22 In addition, a 
prior OIG survey of rural hospital closings found that people who must travel more 
than 10 miles for health care experience limited access to medical and emergency 
semices. 
b  Demand for services increased at 75 pewen& of the centers; 42 pecenf of these 
centm repoti their capady to meet thik growing demand either decreased or 
remaind the same 
An additional 16 percent of the centers reported that demand for services had not 
changed since 1988. Of these, 19 percent reported that capacity to meet demand had 
decreased. 
Illustrating these statistics, a center noted that between August 1989 and July 1990, 
the floodgates were opened and any prenatal patient who wanted care from our CHC 
was seen and delivered. This caused problems, however, because the doctor was 
absent from the clinic too often, and eventually the program had to be curtailed. 
Another center reported that the demand for perinatal care has increased but the 
number of our health providers has remained the same, not allowing us to see more 
perinatal patients; and another stated that between 1988 and 1990 the number of 
prenatal women seeking care at our clinic continually increased. By mid-1990 the 
demand for care exceeded our capacity. Presently the demand for perinatal care is 
nearly double our capacity. 
Several factors account for increasing demand at centers. Fifty-three percent of the 
centers reported that Medicaid eligibility expansions had seriously increased demand 
for perinatal semices, and 46 percent reported that Medicaid presumptive and 
continuous eligibility provisions had done Sow 
Decreases in the availability of private health care and in private physician 
participation in Medicaid have also increased demand at centers. An administrator 
explained that fewer providers accept Medicaid, while at the same time eligibility has 
increased resulting in higher demand.  Another remarked that demand at his center 
increased when the private obstetric provider left the area. These comments are 
consistent with reports from other centers. 
8
 Sixty-eight  pement of the centers repti that thq do not cooniina~ as pa?t of their 
E 
@natal  case-management  flortiq all of the hedh and d sewices 
recommended  by  the  RAlic Health Servke. This may, in pu~ rejkct variatiims h 
the&jinul o n of case rnunagement  among centem 
According to the PHS, perinatal care should include risk assessment; health 
promotion; and medical, nutritional, and psychosocial services and follow-up.fi To 
maximize the accessibility, quality, and comprehensiveness of services, the PHS 
requires centers to coordinate care through case management. 
Most centers provide some of the services recommended by the PHS, but 68 percent 
of them do not coordinate all of these services as part of a comprehensive 
case-management system.  Fifty-three percent reported that they did not coordinate 
discharge planning and 42 percent reported that they did not coordinate delivery 
services as part of their case-management efforts (see figure 4). 
Figure 4 
Percentage of Centers that DO NOT Case Manage Each Perinatal Semite 
RiAA.wxnmt~ 18% 
Wti  ~  - 22% 
AmbtmawithwIc-~% 
HaltbEAK-ial-~% 
~-i=-~- =% 
~ s-i- M-SiCO~ 27% 
- =V= ~~~ ~45% 
- =-off-si~~ 38% 
~w--~42% 
~p-- 53% 
o%  10%  30%  40%  so%  60% 
Percentage of Centers that DO NOT Case Manage Each Service 
SOlucc: 01(3 Slnvcy of Rm81 community Health Gmal& h 1991. 
N-202 
There is no commonly accepted definition of what case management entails; centers 
may coordinate the delivery of services and not refer to such coordination as 
case management. 
Nonetheless, 29 percent of the centers reported that limited case management 
seriously constrains their capacity to provide comprehensive care; and 8 percent 
reported that it has become a greater problem since 1988. Thirteen percent reported 
that they provided no case management at all. 
9
 Centers reported several problems that indicate inadequate coordination of care. The 
timely transfer of medical records to delivery facilities is a problem at 17 percent of 
the centers, and the transfer of records to other facilities at 16 percent. Further, 
centers reported that they do not reschedule appointments for an average of 40 
percent of perinatal clients who miss them.  Follow-up care is also a problem: on 
average, 26 percent of each centers prenatal clients and 28 percent of their infants did 
not receive follow-up care at the centers within the first 8 weeks after birth in 1990.27 
The CPCP was intended, in part, to support centers case-management efforts. CPCP-
funded centers were significantly more likely than other centers to provide case 
management for all the services recommended by the PHS. Fifty percent of CPCP-
funded centers included all of these services in their case-management efforts, while 
only 14 percent of other centers did so. Eighteen percent of CPCP-funded centers 
cited limited case management as a serious limitation to care, while 47 percent of 
other centers reported the same concern. 
  On avemge, 59 percent of each centerh prenatal clients entered care in the @t 
titer of pr~ncy in 1990. Natiimally, 76 pe~ent of all wow  62  percent  of
minority womq and 58 percent of women in Healthy Stati project areas entered 
care cluing the jiit ttiter. B 
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, 31 percent of each centers  1990 prenatal clients did not enter care until the 
second trimester and 10 percent did not enter until the third. This compares with 
1989 national rates of 18 percent of women entering care in the second trimester and
4 percent in the third.29 
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 clients who 
entered care in the first trimester in 1990. Our study does not allow a comparison of 
CPCP grant recipients and other centers with regard to trends over time in first-
trimester entry into care. 
According to several center administrators, transportation problems hinder early entry 
into care. Thirty percent of centers noted that patients had difficulty traveling to the 
center and to delivery sites.  One administrator explained the difficulties caused by 
rural isolation:  Even though we improved access through multiple sites, there are 
many clients who have no transportation. . . . The fact that our delivery site and after-
hours clinic is located 30 to 60 miles away from our clients leads to a high degree of 
stress and anxiety for them. 
10
 Twenty percent of centers reported that poverty and cultural barriers also hinder early 
entry into care.  Several noted that clients often do not recognize the importance of 
prenatal care. 
  On aven.zgq 18 percent of each center3 fimt-titer enmlks received freer than 9 
prenatal  vkits. Our study did not wrnine the extent ti which these patients may 
have received care ekwhere. 
The American College of Obstetricians and Gynecologists recommends that women 
entering prenatal care in the first trimester receive a minimum of 9 visits.n On 
average, however, 18 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, sumey 
responses indicate that 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. 
Centers reported that transportation problems and poor education prevent women 
from making and keeping a sufficient number of prenatal appointments. Some centers 
have begun offering gifts to encourage women to enter care early and attend all 
scheduled appointments; one center offered $25 to clients who kept all of their 
perinatal appointments. 
  ~-eight piment  of  centen  do not offer prenatal appointmenfi at times 
convenient for wotig women. 
In 1990, 38 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. 
Twenty-one percent of the rural centers have waiting times of two to four weeks for 
initial prenatal visits and three percent have waiting times for initial visits of more than 
one month. Long waits for prenatal appointments can have adverse results. 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. 
In addition, 13 percent of the centers reported that office waiting times have grown 
longer since 1988. Long waiting times at the centers may discourage women from 
making and keeping appointments, 
11
 RURAL  CENTERS  IDENTIFIED  SEVERAL  MAJOR CONS~ THAT 
SERIOUSLY LIMIT THEIR CAPACITY TO PROVIDE PERINATAL CARE.

  Medical staff shonagq in part as a result of cuts in the National Health Service 
COP in the 1980$ praent serious pmbleww at 67 ~xent of centem 
Although the average number of prenatal clients increased about 20 percent at 
centers, the average number of full-time-equivalent obstetricians, family physicians, 
and certified nurse midwives decreased 1 percent from 1988 to 1990. (See appendix C 
for survey responses.) 
Additionally, 52 percent of the centers reported that at least 1 obstetrician, family-
physician, or certified nurse-midwife position was currently vacant (see table 1), and 28 
percent reported that at least 1 of these positions had been vacant for longer than 1 
year. Thirty-nine percent of the centers also reported that medical staff shortages 
have become more severe since 1988, and 32 percent cited high medical staff turnover 
as a serious problem. 
Table 1 
Percentage of Centers Reporting at Least One Clinical Provider Position Vacant?l 
Staff Position  Currently  Vacant more  Vacant more 
amt  ~  m  k  onth  m ne = 
~
Obstetrician-Gynecologist  2170  17%  10% 
Family Physician  39%  I  3370  19% 
Nurse Midwife  13%  10%  5% 
Source: OIG Sutvey of Rural Community Health Centers, June 1991 
N =202 
Many centers reported that current staffing levels are insufficient to meet client needs. 
One center noted that the demand for semices continues to grow, but with no 
additional providers, the demand is not met with a corresponding supply. Another 
complained that, despite incredible population growth in the area, the provider 
population isnt increasing. 
of those centers that have reduced perinatal services in recent years, a large number 
cited staffing problems as the primary cause:  one noted that its decrease in perinatal 
services is proportional to a decrease in providers;  and another that its recent loss of 
an obstetrician has definitely hampered our ability to provide perinatal services.  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. 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.  Some centers cited unattractive clinic 
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.  Some centers cited unattractive clinic 
facilities and poor client populations as barriers to recruitment efforts. 
Recruitment efforts at many rural centers are further hindered by their geographic 
isolation. Some prowders are apprehensive about working in small communities 
where they will have little support from and contact with a broader medical 
establishment. One center administrator reported great difficulty convincing 
prospective employees that the community was not the worst place in the world to 
work, play, and live.  Such recruiting challenges were reported by other administrators 
with whom we spoke. 
A limited supply of providers further exacerbates recruitment efforts. As one hospital 
administrator explained:  Without a supply of trained practitioners from which to 
draw, the incentives created by many communities in the form of buildings, loan 
forgiveness, etc., are largely futile.  Similarly, program grant monies are only of use 
when the practitioners are available.  Other centers echoed this view. One 
administrator reported that his center had been working with a local hospital to jointly 
recruit an obstetrician, but they had not yet met with success; another noted that, in 
attempting to replace a physician who had just left the center, they had used search 
firms, State offices, and other agencies and individuals to find a replacement, all to no 
avail. 
National Health SeMce Corps: Centers have historically relied upon the NHSC for a 
large percentage of their providers, but this program experienced major funding cuts 
during the 1980s. (See appendix A for more information.) Center administrators 
reported that they have often been unable to retain corps providers beyond their 
obligated terms of semice and that they have found it difficult to replace these 
providers. Exempli&ing problems that the centers encounter retaining NHSC 
physicians, one center reported that it had lost an NHSC obstetrician to buy-out by a 
private hospital. 
Staffing Models: Most rural centers rely more heavily on family physicians than 
obstetricians. Centers report significant problems, however, recruiting family
-. .  .  **. *  n:__ A_  ---..JAfi 
fiL.+ntAp 09rp  fine r~nter  administrator  For those centers that are interested in employing obstetricians, recruitment is often

an insurmountable challenge because of the high salaries and insurance premiums they

require.
 one administrator explained the underlying economic dynamic and its 
impact: When a scarcity of anything exists, it becomes a sellers market. Obstetricians

can name their price and structure their work in accord with their preferences. The

strain and stress that this places on the CHC can easily be underestimated.

E  % cwt of medical malpractice insumnce has been a setius dmin on resoumx at 
55 pement of the eaten. 
Twenty-four 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 of the 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.s2 
These costs have made it difficult for centers to expand staff, 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. 
The variety of medical malpractice problems is exemplified by comments from three 
centers. One center reported that its perinatal services had been discontinued due to 
a lack of funding for excessively high malpractice premiums. Another center noted 
that its malpractice insurance carrier had threatened to cancel coverage for the entire 
clinic if the center did not suspend its contractual agreement with a private 
obstetrician. Still another reported that, although it had been able to locate providers 
willing to work at the center, it was unable to arrange liability coverage. 
In late 1992, Congress took initial steps to address this problem by passing legislation 
that extends medicai malpractice liability protection under the Federal Tort Claims 
Act (FTCA) to health care providers at the centers.33 
  Seventy pexent of centen repti serious problems stemmingfiom M2dicaid poti 
and procedures--such as a bur&nsome application process, low reimbwement  mtq 
a ilmikxi range of covered services, or limited eli~ility. 
On average, 67 percent of each centers perinatal clients were enrolled in Medicaid in 
1990.~ 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). 
14  Table 2 
Percentage of Centers Citing Each of the Following 
Medicaid Factors as a Serious Limitation 
Burdensome application procedures  52% 
1! 
Inadequate reimbursement rates  1  52%  II 
/1 1  II
1! Restrictive eligibility criteria  44% 
L---
Limited range of covered services  4170 
Slow reimbursement process  39940 
Source: OIG Survey of Rural Community Health Centers, June 1991 
N=202 
Application Process:  According to a prior OIG report, only 26 States had

implemented presumptive eligibility as of June 1991.35 
our research indicates, 
however, that even some States that had adopted this option had not begun to use it

aggressively. Further, according to the centers, a number of State Medicaid agencies

had not begun outstationing eligibility workers on site.

Reimbursement: The Federally Qualified Health Center (FQHC) provisions of the 
1989 and 1990 omnibus Budget Reconciliation Acts 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. 
An administrator at the site we visited noted that the State had begun reimbursing 
that center at FQHC rates, but that even these new rates did not fully cover the cost 
of care. Concerns about continuing inadequate reimbursement rates were voiced by 
several survey respondents.  Centers also reported long delays between the provision 
of services and the receipt of payment from Medicaid.37 
Some centers may already have been receiving higher Medicaid reimbursement rates 
as a result of the Rural Health Clinic Act of 1977. To quali@ for higher rates under 
this act, a center must be located in a rural area that has a shortage of either health 
professionals or services.  Additionally, the center must be staffed by one or more 
eligible certified nurse midwives, nurse practitioners, or physician assistants whose 
practice is within the scope of State law and regulations.x (See appendix A for more 
information on Federal programs that support perinatal care at the centers.) 
Eligibility Many centers reported that Medicaid eligibility requirements are still too 
restrictive. According to OIG research, three States had not yet dropped an asset test 
for eligibility.39 Several centers indicated, however, that eligibility expansions have 
15  resulted in increased client caseloads. Consistent with several reports we received, 
staff at one center noted that the number of women on Medicaid had risen as the 
local economy had deteriorated. 
On avemgq 17 percent of each cc-> perinutal clients were uninsured in 19%2 
F 
At 25 percent of the centers, 25 percent or more of the perinatal clients were 
uninsured. At 9 percent of the centers, more than 50 percent of the clients were 
uninsured. These clients received sewices at reduced rates, according to a sliding 
scale. 
*  Seven@wee  paent of the centers repti serious ptublerm stemmingfmm 
.
-k coordinatwn of petital services in h commwdy, a tick of other local 
pmh wiUing to treat unimured and publicly insured wo~ dim anungiitg 
obsteti backup for center staff and for comuhtion for high-tik clk~ or di 
obtaining hospital privileges for center stafi 
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.40 
Forty-two percent of the centers, however, do not participate in perinatal care 
consortia. Centers reported wide differences in consortia memberships (see table 3). 
Table 3 
Percentage of Centers Reporting the Participation of Each of the 
Following in a Community Perinatal Care Consortium 
Local  health  departments  I  42%  Other health clinics  22% 
Private-practice physicians  3470  Nonteaching hospitals  21% 
State health departments  24%  Local schools  16% 
Government social services  24%  Teaching hospitals  16% 
Nonprofit groups  23%  ~~  Other  4% 
Source: OIG Survey of Rural Community Health Centers, June 1991 
N =202 
Eighty-four percent reported that their consortium activities do not include teaching 
hospitals, 84 percent that they do not include local schools, 79 percent that they do 
16
 not include nonteaching hospitals, and 76 percent that they do not include State health 
departments.41 
The Local Medical Establishment: Fifty-eight 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; 30 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.42 Centers 
reported, however, that they face serious difficulties arranging both backup and

referrals. Forty percent of the centers reported serious difficulty arranging obstetric

backup for certified nurse midwives; 34 percent reported such problems for family

physicians.
 Thirty-six percent reported that difficulty arranging consultation for high-
risk clients is a serious limitation.

A number of centers reported that there are simply no other providers to whom

women can be referred. A variety of related problems were reported by center staff.

One center noted that the closest obstetrician serving Medicaid patients was 50 miles 
away, while another reported that women had to travel 120 miles for high-risk

obstetric consultations. Another center reported that, because the local private

obstetricians wont cover our family physician for anything but very low-risk

pregnancies, we must turn away a high number of patients who would want care at

our facility.  Another noted that women at or below the poverty level couldnt get

appointments with private physicians in our area.  Another center director cited turf

consciousness on the part of local private-practice obstetricians as a major problem. 
These doctors refused to provide backup for center staff and would only deliver 
women who came directly to them for care.

Hospital Admitting Privileges:43  The PHS recommends that, to assure continuity of 
care, center physicians should have admitting privileges and medical staff membership 
at one or more hospitals.a  Centers, however, reported many difficulties arranging 
admitting privileges.  Twenty-one percent reported a decrease between 1988 and 1990 
in the percentage of staff providers with such privileges. 
Thirty-one percent reported that difficulty obtaining admitting privileges for staff 
obstetricians, family physicians, or certified nurse midwives is a serious limitation to 
care. Twenty-nine percent of the centers cited difficulty obtaining privileges for 
certified nurse midwives as a serious problem.  Fourteen percent cite serious 
difficulties obtaining privileges for center family physicians. For example, one 
administrator noted that the local hospital had recently extended delivery privileges to 
the centers family physicians--a first in that community--but the physicians are still 
unable to perform deliveries because they have been unable to arrange for obstetric 
backup.  Difficulties with admitting privileges have been compounded by more basic problems 
with the availability of hospital care in rural areas.  Many centers have been adversely 
affected by rural hospital closings. Those rural hospitals that have remained open 
have experienced problems similar to those of CHCS in retaining obstetric staff and 
maintaining delivery setices.  Additionally, some hospitals are reluctant to provide 
care for poor women.  One center explained the dynamic that leads hospitals to refuse 
poor clients:  The private for-profit hospital was unable to recoup the costs of 
indigent care they were providing for our patients and refused to continue delivery 
services for our countys indigent or Medicaid women, forcing us to close our 
program. 
E  Limited space serioudy hindem  the pmvikm of senices at 48 pem?nt of the centers. 
In additiorq limited collocation of sewices on site seriously rekcts the 
comprehenszveness of care at 28 pement of the centem 
Twenty-three percent of the centers reported that inadequate space has become a 
more serious problem since 1988. Those centers that reported an increase in demand 
since 1988 were significantly more likely to cite limited space as having become a 
more serious limitation to care. Several centers remarked that, because clinical staff 
capacity has increased, now space is a major barrier. Consistent with comments 
made by administrators across the country, one medical director noted that the 
limited physical space of the current medical facilities prevents the centers two 
OB/GYN providers from providing care simultaneously. 
Sixty-two percent of the centers reported that no other public organizations, aside 
from Medicaid or WIC, and no private groups provided sewices on site in 1990. 
Those centers that cited limited space as a serious problem were significantly more 
likely to cite limited collocation of services on site as a serious limitation. 
18
 CONCLUSION

Section-330-funded community health centers play an important role in the provision 
of perinatal care in rural 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 services recommended by the Public Health 
Semite. Limitations are particularly apparent in the scope of case-managed setices 
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 semices 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

FEDERAL SUPPORT FOR PERINATAL  CARE 
AT  COMMUNITY  HEALTH  CENTERS 
The Federal Government supports the perinatal sewices 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 services and the 
access of women to those sewices, 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 now guaranteed 
throughout pregnancy and the postpartum period, regardless of income changes; 
(3) presumptive eligi%ili~. eligibility for temporary coverage, limited to a maximum of 
61 days for ambulatory services 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. 
Federally Qualified Heahh Centem (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. 
The Rural Heahh Clinic Program:  The Rural Health Clinic Sewices Act of 1977 
provides cost-related Medicaid reimbursement for services at rural centers in health 
manpower shortage areas or medically underserved areas. Qualifying centers are 
staffed by at least one certified nurse midwife, nurse practitioner, or physician assistant 
whose practice must be within the scope of State law and regulations. Until the 
passage of this act, these providers were not eligible for Medicaid reimbursement in 
some States. Because of several problems with regulation, certification, and 
reimbursement, however, far fewer centers than expected had availed themselves of 
reimbursement under the act. 
T%e Comprehensive Perinalal 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, $33 million was provided in CPCP supplemental funding;45 51 
percent of the rural respondents to our survey that offered perinatal services received 
A -1
 CPCP funding for at least 1 year between 1988 and 1991. In fiscal years 1992 and 
1993, $44.7 million was appropriated for the CPCP.fi 
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. 
Several other ongoing Federal efforts play important roles in the centers provision of 
perinatal care, including: 
National Health Service Corps (NHSC): The PHS offers 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 in community health centers. After substantial 
cuts in program size in the early 1980s, the NHSC received increased funding in 
1990; the number of loan repayment candidates is limited, however, and most 
scholarship recipients will not be available for service until the mid-1990s. 
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

METHODOLOGY 
We obtained information for this report through a mail survey of Section-330 grantees, 
a site visit to one center, telephone conversations with representatives of another 
center, a series of intemiews, and a review of relevant literature and data. 
Mail Survey We sent a mail survey of perinatal semices to all Section-330 grant 
recipients in June 1991. Of 302 rural centers, 253 (84 percent) responded, including 
centers in every HHS region and every State and territory in which rural centers are 
located, with the exception of the U.S. Virgin Islands. A review of the geographic and 
demographic information that was available suggested no significant differences 
between respondents and nonrespondents. 
Of the 253 rural respondents, 51 (20 percent) provided no perinatal services on site at 
all during the 1988-91 period.  The numbers and percentages in the body of this 
report, unless otherwise noted, reflect the responses of those 202 centers (67 percent 
of all rural centers) that offered semices on site in at least 1 year during the 1988-91 
period. 
Of the 202 respondents that provided semices on site during the study period, 102 (51 
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 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 a site visit to one rural center in Ohio and its 
two satellite clinics. The team toured the facility and interviewed management and 
clinical staff. The study team also conducted a conference-call interview of 
administrative and clinical staff at a center in Mississippi. We chose these centers 
based on discussions with regional PHS staff and with consideration of geographic 
representation and community size. 
B-1

  .  Intewiews: The study team held discussions with (1) officials in PHSS Bureau of 
Prima~ Health Care (BPHC) (then called the Bureau of Health Care Deli}e~ 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 Sewice 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

RURAL SURVEY RESPONSES 
The Office of Inspector General survey was mailed to 302 rural community health centers in 
May 1991. Of the 253 (84 percent) that responded, 51 provided no perinatal services on site 
during the 1988-91 period. Below we present the frequencies and mean responses for those 
202 centers that did provide se~ices 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 services on site in each year: 
1988:  Yes=179  No=23 
1989:  Yes=182  No=20 
1990:  Yes=187 No=15 
1991:  Yes=185  No=17 
A CASELOAD  1988  1989  1990 
1. Please indicate: 
MEAN  (N) 
a. the number of women who received prenafaf 
care at your center:  261  (157)  272  (174)  278 (188) 
b. the percentage of these clients who were 
high-risk as defined by your center:  27%  (130)  29%  (144)  29%  (160) 
c. the percentage of these clients who were 
low-risk  as defined by your center: 60%  (129)  61%  (146)  61% (154) 
d. the number of births to your centers 
clients:  195  (139)  206  (161)  218  (167) 
2. Of the women who gave birth in your service 
area,  what  percentage  received  prenatal  care 
at your center?  45%  (128)  46%  (137)  49%  (135) 
c -1  B. COMMUNITY COORDINATION 
1. Does your center currently participate in a consortium of perinatal  care  providers? 
YeS=l17  No=85  If YES, please continue. 
2. Which of the following participate in the consortium? (Please check all that apply): 
a. state  health  department:  4 9  f. nonteaching  hospitals:  43 
b.  local  health  department:  85  g. private-practice physicians:  69 
c. health clinics:  44  h. gov. social setice agencies:  48 
d. schools:  33  i.  non-profit  organizations:  47 
e. teaching hospitals:  32  j.  other:  8 
3. On the last page of this sumey, briefly describe the coordination of consortium activities and 
your centers involvement. 
C. CLINIC SITES AND HOURS  1988  1989  1990 
1. Please indicate the number OE  MEAN  (N) 
a. clinic sites operated by your center:  2.5  (192)  2.6  (192)  2.6 (193) 
b. clinic sites at which prenatal care 
was provided:  1.8  (199)  1.9  (198)  1.9  (l%) 
2. On how many days a week did your center 
provide  scheduled  prenatal  appointments 
either before 8AM or after 6PM?  0.97  (191)  0.99  (190)  1.1  (189)
3. On how many saturdays a month did 
your  center  provide  scheduled

prenatal  appointments?  0.59  (189)  0.62  (188)  0.66  (188)

D.  Funding 
1. Compared with 1988, the amount of funding available for perinatal care at your center in 1990 
was: 
Larger= 76  Smallcr=26  Unchanged=84 
2. Please indicate the percentage of your centers 1990 perinatal clients covered by: 
a. Private insurance:  13.1%  (170)  c. Medicaid:  S.6% (167) 
b. No insurance:  17.4%  (172)  d.  Other:  2.3% (175) 
c -2  3. To what extent hwe the following factors resulted in increased demand for perinatal semices 
at your center over the past three years? 
Not at W  Moderately/ 
Somewhat  Substantially 
a. Medicaid  eligibility  expansions:  72  107 
b. Medicaid presumptive and 
continuous eligibility provisions:  82  93 
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:  170  c. Non-English speakers:  65 
b.  Substance  abusers:  55  d.  Other:  55 
2. At which of the following locations does your center currently conduct perinatal  outreach? 
(Please check all that apply) 
a. Community	 d. Schools:  129 
centers:  81  e. Welfare offices:  68 
b. Shops:  20  f. Churches:  48 
c.  Door-to-door  in  the	 g. Other:  62 
neighborhood:  33 
3. Through which of the following media does your center currently conduct perinatal  outreach? 
(Please check all that apply) 
a. Television:  27  d. Radio:  59 
b.  Newspapers:  111  e.  Other:  48 
c.  Pamphlets:  151 
4. Compared with 198S, your centers outreach efforts in 1990 were: 
Greater= 118  Smaller= 16  The same=55 
5. Compared with 1988, your centers outreach efforts in 1990 yielded: 
More clients= 121  Fewer clients= 16  The same number of clients=37 
c -3  F. PERINAT~ SERVI~ 
1. Please indicate which of the following seMces were provided by your center. If these were 
--either through contract, affiliation, 
offered on site, please circle On. If these were offered off site
or paid referral~-please circle Off. 
1988  1989  1990
On=42  orl=50  On=5 6 
a. Ultrasound: 
Off= 129  Off= 124  Off= 123 
on= 9  0U=9  on=13  
b. Amniocentesis:  Off= 150  0ff=152  off= 150 
0n=36  0Q=36  on=37
c. Genetic  counseling: 
Off=l18  off= 120  off= 121 
on=36  0n=38  on=45 
d. Non-stress  testing: 
m= 122  off= 120  0ff=l16 
on=90  0n=85  on=91 
e. Dental  care: 
0ff=78  off=86  off=88 
Orl=lso  on=157  0n=167 
f. Nutritional  services: 
0ff=29  0ff=25  Off= 18 
on=168  On=172  0n=181 
h.  Health  education: 
off= 17  off= 13  off= 10 
on=77  0n=84  0n=90 
i. Birthing classes: 
0E=79  off=73  off=74 
0n=76  0n=83  0n=102 
j. Parenting/infant care classes: 
OE=75  off=73  off=64 
&=176  0n=176  0n=183 
k. Family planning:  off= 10  off= 10  Off=lo 
0n=85  0n=84  0n=90 
1. Smoking cessation programs: 
off=57  off=60  Off=63 
on=38  0n=34  0n=35 
m.  Substance  abuse  treatment: 
0ff=l18	 0ff=123  off= 130 
0n=98  0n=l13  0n=135 
n.  HIV  counseling/testing: 
0ff=58  0ff=52  0ff=38 
2. Compared with 1988,  the range of perinatal 
services offered by your center in 1990 was: 
Greater= 123  Smaller=24  Unchangd=49 
3. Were perinatal  clients enrolled on-site at the center 
in the following programs? 
yes=51  Yes=72  yes=97 
a. Medicaid: 
No=139	 No=119  No=IOO 
yes=99  Yes=lo7  Yes=lo7
b. WIC: 
No=93  No=88  No=90 
c -4  1988  1989  1990 
4. Did other government or private social sexvice 
organizations provide services on-site at your 
center?	 Yes=56  Yes=59  Yes=72 
No=134  No=132  No=125 
5. Did your center facilitate access to perinatal 
care by providing the following services? 
a.	 Transportation  to  and  from  appointments:  Yes=87  Yes=loo  Yes=l14 
No=1O3  No=93  No=83 
b.	 Translation  for  non-English  speaking  clients:  Yes=85  Yes=88  Yes=97 
NO=81  NO=80  No=71 
c. Child  care  during  center  appointments:  Yes=19  Yes=20  YesXl 
No=171  No=172  No=165 
d,  Home visits:  Yes=85  Yes=lol  Yes=l15
No=1O6  No=92  NO=81 
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  =202) 
Obstetricians:  0.45  0.45  0.43 
: Family physicians:  1.44  1.40  1.41 
c.  Certified nurse midwives:  0.19  0.18  0.22 
d. Nurse  practitioners:  0.56  0.59  0.65

e. Physician assistants:  0.39  0.42  0.45

2.
 Please indicate below: (i) the number of your perinatal provider positions which are currently 
vacant; (ii) the number which have been va-cant for more that six months; and (iii) the number

which have been vacant for more than one year. (N=202) 
(i)  (ii)  (iii) 
Number of  More than  More than 
vacancies  six months  one year 
a. Obstetrician:  0.25  0.21  0.12 
b. Family physician:  0.54  0.47  0.47 
c. Certified nurse midwife:  0.13  0.10  0.05 
3. Compared with 1988, the percentage of your perinatal providers with admitting privileges at 
local hospitals in 1990 was: 
Ixger=49  Smaller= 21  Unchanged=97 
c -5  H. TIMING OF CARE 
l. Please indicate the percentage  ofyourcenters 1990 prenatal clients whoentered care in the: 
58.7%  (181) 
a. First  trimester: 
30.8%  (180) 
b.  Second  trimester: 
9.9%  (163) 
c. Third trimester: 
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 
79.1%  (1  13)  79.8%  (124)  81.9%0  (147) 
medical visits? 
3. What percentage of  your  centers  prenatal 
clients  returned  for  postpartum  visits  69.3% (121) 72% (142)  73.9% (161) 
during the first eight weeks after delivery? 
4. What percentage of all infants born to center 
prenatal  clients  returned  for  newborn  visits 
66.3%  (121)  69.7%  (138)  71.8%  (158) 
during the first four weeks after birth? 
L APPOmE~ FOR CARE 
1.  If  a  woman  called  today  to  schedule  a  pregnancy  test,  how  long  would  she  wait  for  an 
appointment? 
Less  than  one  week:  66 
Pregnancy  tests  are  offered 
123  One-two  weeks:  8 
on a walk-in basis: 
More  than 
two weeks:  2
would she be referred to family planning services? 
2. If the pregnancy test were negative, 
Yes=178  No=19 
how long would she wait for her first prenatal visit? 
3. If the pregnancy test were positive, 
Less than two weeks: 118 
The first perinatal visit is 
Two-four  weeks:  42 
provided  in  conjunction 
33	 One-two  months:  2 
with the pregnancy test: 
More  than 
two months:  3 
4.  Compared  with  1988,  waiting  room  waiting  times  at  perinatal  appointments  in	 1990  were 
generally: 
Shorter= 65  Longer=26  me same=94 
C-6 
  J. CASE MANAGE~NT 
1.  Does your center currently provide case management  topromote thecoordination  ofsetices 
for perinatal  clients? 
Yes=176  No=26  If-,  please  continue. 
2. Case management at your center is primarily conducted by (please check only one): 
28 
The clients primary care doctor:

14 
The clients primary care nurse:

2 
The  appointments  secretary:

54 
A multidisciplinary team:

A center employee whose main 
responsibility is case management 
67 
for perinatal clients: 
12 
Other: 
3. Case management at your center is provided for (please check only one): 
143 
All perinatal  clients: 
21 
All high-risk perinatal clients: 
Only certain groups of 
13
perinatal  clients: 
4. Case management of perinatal clients at your center comprises (please check all that apply): 
165 
a. Risk assessment: 
162 
b. Planning of care: 
c. Assessment of adequacy and 
144 
appropriateness  of services: 
131 
d. Client advocacy: 
e.  Contact  with  other  organizations 
to arrange for scmices / 
163 
schedule  appointments: 
f. Assistance with paperwork related to 
145 
WIC, Medicaid, and other programs: 
94 
g. Discharge planning: 
Coordination  OC 
h. Medical	 semices  provided 
158 
on-site at the center: 
i. Medical services piovided 
147 
off-site: 
c -7  Continued: 
j.  Delivery  semiccs:  118 
k. Social services provided 
on-site at the center:  110 
1. Social set-vices provided 
off-site:  126 
m.  Nutritional  se~ices:  158 
n.  Health  education:  162 
o.  Other:  27 
5. Compared with 1988, the percentage of all center perinatal clients case managed by your staff 
in 1990 was: 
kger= 126  Smaller= 14 Unchanged =33 
6. Does your center often encounter problems assuring the timely transfer of medical records to 
and from facilities to which perinatal  clients are referred?
For delivery:  Yes=35  No=142 
For  other  care:  Yes=32  No=141 
7.  Please  estimate  the  percentage  of  cases  in  which  your  center  contacts  perinatal  clients  to 
reschedule  missed  appointments: 
6 0 %  (N=158) 
8.  Please  indicate  the  manner  in  which  you  contact  clients  to  reschedule  missed  appointments 
(please check all that apply): 
Mail= 149  Phone=  168  Home  visit=95  Other= 10 
9. Are perinatal clients at your center routinely attended by either the same primary medical 
provider or the same provider team at eachperinatal visit? 
Yes=168  No=7 
C-8
 K LIMITATIONS TO CARE Please indicate the degree to which each of the following factors 
limits your centers ability to provide perinatal serwces: 
Not at all/  Moderately/ 
Somewhat  Subwultially 
1. Shortage of medical staff  65  132 
2. Shortage of nonmedicd staff  138  48 
3. High medical staff turnover:  127  61
4. High nonmedical staff turnover:  168  16 
Difficulty obtaining admitting privileges 
at local hospitals for: 
5. obstetricians:  144  18 
6. family physicians:  157  25 
7. certified nurse midwives:  97  43 
8. High cost of malpractice insurance:  82  102 
Difficulty obtaining malpractice insurance for: 
9. obstetric providers:  135  35 
10. all providers:  156  29 
Difficulty arranging medical backup for: 
11. OB supervision of certified nurse midwives/ 
nurse  practitioners:  88  59 
12. OB supervision of family physicians:  110  57 
13. coverage during center staff vacations, 
holidays, and weekends:  99  84 
14, consultation for high-risk patients:  117  67 
15. Limited relationships with local 
community and government organizations:  172  15 
16. Lack of other providers in the community 
willing to treat uninsured or publicly 
insured women:  79  108 
Non-acceptance of certified nurse midwives/ 
nurse  practitioners: 
17. by the medical community:  103  62 
18. by patients:  144  15 
19. Inadequate center funding:  80  109 
20. Difficulties related to funding obtained 
from many different sources:  104  76 
Medicaid-related  problems: 
21. slow reimbursement process:  114  72 
22. inadequate reimbursement rates:  89  95 
23. limited range of covered services:  107  75 
24. restrictive eligibility criteria:  104  81 
25. burdensome application procedures:  91  97 
26. Limited case management:  127  58 
27. Limited collocation of services:  131  50 
28. Limited space:  98  91 
29. Other  27  19 
c -9  Which Of these factors have become LESS SERIOUS  or MORE  SERIOUS  limitations  since 
1988? 
More 
serious  serious 
40  13 
1. Shortage of medical staff: 
12  11 
2. Shortage of nonmedial staff 
17  14 
3. High medical staff turnover: 
5  12 
4. High nonmedicd staff turnover: 
Difficulty obtaining admitting privileges 
at local hospitals for: 
6  10 
5. obstetricians: 
6  10 
6. family physicians: 
6  10 
7. certified nurse midwives: 
24  7 
8. High cost of malpracti~ insurana: 
Difficulty obtaining malpractiu insurance for: 
8 7 
9. obstetric providers: 
7 8 
10. all providers: 
Difficulty arranging medical backup for: 
11. OB supervision of certified nurse midwives/ 
14  8 
nurse  practitioners: 
15  7 
12. OB supervision of family physicians: 
13. coverage during center staff vacations, 
22	 9 
holidays, and weekends: 
17  7
14. consultation for high-risk patients: 
15. Limited relationships with local 
3  20 
community and government organizations: 
16. Lack of other providers in the community 
willing to treal uninsured or publicly 
27  9 
insured women: 
Non-acceptan@ of certified nurse midwives/ 
nurse  practitioners: 
8  13 
17. by the medical community: 
3  14 
18. by patients: 
24  11 
19. Inadequate center funding: 
20. Difficulties related to funding obtained 
16  5 
from many different sources: 
Medicaid-relatd problems: 
12  18 
21. slow reimbursement process: 
13  23 
22. inadequate reimbursement rates: 
10  17 
23. limited range of covered services 
9  29 
24. restrictive eligibility criteria: 
13  21 
25. burdensome application procedures: 
8  22 
26. Limited case management: 
5  16 
27. Limited collocation of services: 
23  11 
28. Limited space: 
2 1 
29. Other 
c - lo  L CONCLUSION 
1. Over the past three years, demand for perinatal care at your center has: 
Inereased=152  Dexxd=15  Not changed =32 
2. Over the past three years, your centers capacity to address the demand for perinatal  care in 
your semice area has: 
Lrlcreased=  104  Decreascd=52  Not changed =42 
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 sewice area? 
C-n

  APPENDIX  D

NOTES 
1.  National Center for Health Statistics (NCHS), 1992. The 1989 U.S. infant 
mortality rate was 9.8 deaths per 1,000 live births. The provisional rate for 
1990 is 9.1 deaths per 1,000; and the provisional rate for 1991 is 8.9 per 1,000. 
These rates represent considerable improvement over the 1950 rate of 29.2, but 
the pace of improvement has slowed in recent years and has not been 
experienced equally by all segments of the population. According to the most 
recently published international data, the 1988 U.S. infant mortality rate for 
whites alone places the nation 17th lowest in the world, while the rate for 
blacks alone places it 36th. Native Americans and Puerto Ricans also have 
infant mortality rates considerably higher than the national average. 
2.  U.S. Public Health Service (PHS), Healthy People 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 the Content of Prenatal Care, Washington D.C., 1989, p. 2. 
3.  NCHS, Advance Report on Final Natality Statistics, 1989, A40nthZy Htal 
Sta/zktic.s  Repon, vol. 40, no. 8, Supplement, December 12, 1991, p. 43. These 
1989 data are the most current available. 
Alan Guttmacher Institute, Prenatal Care in the United States, New York, N. Y., 
1987, vol. I, p. 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. 
4.  Bruce Behringer, President, National Rural Health Association; Executive 
Director, Virginia Primary Care Association; Testimony before the U.S. House 
Committee on the Budget Task Force on Human Resources, October 3, 1991, 
p. 1. 
5.  Laura Summer, Limited Access: Health Care for the Rural Poor, Center on 
Budget and Policy Priorities, Washington, D. C., 1991, p. 16. 
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 
D-1  Corporation,  Professional Liability and Its Effects: Report of a 1990 Suwey of 
ACOGs Membership, Washington, D. C., September 1990.) The ACOG 
repeated this survey 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 
Physicians,  Family Physicians and Obstetrics:  A Professional Liability Study, 
1987.) 
6.  March of Dimes, Infant Survival in Rural America, White Plains, N. Y., 
August 1991, p. 3. 
Summer, pp. 27-29. 
7.  Deborah Lewis- Idema, Increasing Provider Participation, National Governors 
Association, Washington, D. C., 1988, pp. 21-22. 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. 
Office of Inspector General (OIG), Medicaid Expansions for Prenatal Care: 
State and Local Implementation (OEI-06-90-0016), January 1992, pp. 8-9. 
8.  PHS, HRSAS Long-Range Plan to Improve Access to Primary Health Care 
for Underserved Populations. July 1990, unpublished, p. 10. 
9.  National Association of Community Health Centers, Mothen, Infants, and 
Community and Migrant Health Centen, Washington, D. C., December 1989, 
table 4. 
10.  Section-330 funding was $435 million in FY 1989, $457 million in FY 1990, and 
$478 million in FY 1991. (Health Resources and Semites 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. (Bureau of Primary Health Care [BPHC] and the Assistant 
Secretary for Management and Budget [ASMB].) 
11.	 The Public Health Service 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. 
12.	 Unless otherwise indicated, the differences between groups (such as CPCP 
grantees and other centers) that are noted in this report are statistically 
significant at the .05 level. 
D -2  13.  Centers that semedfewer than 75prenatal clientsin 1988 served anaverageot 
32 in 1988 and 88 in 1990. Centers that served between 75 and 249 clients in 
1988 seined an average of 149 in 1988 and 184 in 1990. Centers that sexved 
250 or more clients in 1988 served an average of 562 in 1988 and 623 in 1990. 
14.  In 1988--before CPCP funds were distributed--those centers that eventually 
received CPCP funding served an average of 365 clients; the other centers 
seined an average of 134. In 1990, the CPCP-funded centers served an average 
of 431 clients; other centers served an average of 167. 
According to an internal PHS draft report, CPCP 1990 Data Report: Moving 
Ahead, CPCP-funded centers seined 33,938 pregnant teens in 1990, which they 
report is more than triple the number seined 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. PHSS CPCP data, 
however, does not permit a comparison of CPCP-funded centers and other 
centers. 
15.  These centers served an average of 223 prenatal clients in 1988 and 286 in 
1990. Centers with prenatal populations that were less than half Medicaid-
enrolled sewed an average of 270 clients in 1988 and 302 in 1990. 
16.  Our suwey inquired about the provision of a representative range of perinatal 
medical and health-promotion semices:  ultrasound, amniocentesis, genetic 
counseling, non-stress testing, dental care, nutritional services, health education, 
childbirth classes, parenting/infant-care classes, fami~y planning, 
smoking-cessation programs, substance-abuse treatment, and HIV 
counseling/testing. 
17.  Our survey inquired about the provision of four semices that facilitate access to 
care: translation. transportation, home visiting, and child care during 
appointments. 
18.  Some centers were able to complete enrollment on site. Other centers only 
distributed forms or provided assistance in completing them. In such cases, 
applicants had to complete the enrollment process at the appropriate State 
offices. Some centers completed all nutritional assessment and paper-work for 
WIC on site, but clients had to obtain vouchers at a different location. 
19.  There was a 126 percent increase in the number of CPCP-funded centers and a 
44 percent increase in the number of other centers that provided on-site 
assistance with Medicaid enrollment. In 1988, 19 CPCP-funded centers and 18 
other centers provided on-site assistance with Medicaid enrollment, compared 
with 43 CPCP-funded centers and 26 other centers in 1990. 
D-3
 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 increase incenter revenues from data for 
those 214 rural centers (71 percent of all rural grantees) that provided financial 
data to BPHC through the BCRR form for the years 1988, 1989, and 1990. 
Some of these centers did not respond to our survey. 
Total reported revenues for these 214 centers increased from $215 million in 
1988 to $259 million in 1990. Public Health Service Section-330 grants to these 
centers increased from $95 million in 1988 to $113 million in 1990. Medicaid 
reimbursements to these centers increased from $23 million in 1988 to $33 
million in 1990. These centers received additional revenues from MCH block 
grants, Public Health Service 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 51 centers from calculations of the statistics presented in the 
body of this report (see appendix B for detailed methodology). 
22.  Thomas S. Nesbitt, Frederick A. Connell, L. Gary Hart, and Roger A. 
Rosenblatt, Access to Obstetric Care in Rural Areas: Effect on Birth 
Outcomes, America~l Journal of Public Health, July 1990, vol. 80, no. 7, 
pp. 814-819. 
This study compared communities in which 67 percent or more of pregnant 
women traveled outside of their community for obstetric care (high outflow) 
and communities in which fewer than 33 percent of pregnant women travelled 
outside of their communities for obstetric care (low outflow). The sumey found 
that women who lived in high-outflow communities had a 34 percent higher 
occurrence of complications during delivery and higher medical costs for 
themselves and their infants than those from low-outflow communities. Medical 
costs were twice as high overall for high-outflow communities ($2,103 versus 
$1,046), and four times as high for Medicaid patients ($4,627 versus $1,014). 
23.  OIG, Effects of 1988 Rural Hospi~al Closures on Access lo Medical Care (OEI-
04-89-00742), August 1990, pp. 4, 7. 
Forty percent of residents who lived within 10 miles of a recently closed 
hospital, and for which a replacement was more than 10 miles away, said that 
they had a serious problem getting hospital care and attributed it to hospital 
closure. Similarly, 42 percent of those who had to travel more than 10 miles 
for emergency care reported a serious problem with access. 
24.  In reporting responses to survey questions that solicited information on a scale, 
D -4
 we combined responses of moderately and substantially and reported them 
as seriously or serious. 
25.  PI-IS, Caring for Our Future, p. 2. 
PHS, Healthy People 2000, p. 366. 
In our sumey, we used the terms health education for health promotion and 
social setices for psychosocial services. 
26.  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. 
27.  Inadequate insurance, limited financial resources, long waits for appointments, 
an inability to arrange child care, and time-consuming transportation all 
discourage women from returning for care. Some women may receive follow-
up care from other providers, but it is unclear to what extent centers track 
these women after delivery. 
28.  NCHS, 1992. These 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. 
29.  NCHS, Monthly Vital Statzkics Repoti, 1991, p. 43. These 1989 data are the 
most recent available. 
30.  American College of Obstetricians and Gynecologists (ACOG), S/andards for 
Obstetric-Gynecological Services, Washington, D. C., 7th cd., 1989, p. 16. 
The PHS has required that all centers, regardless of size, must assure that the 
services that they deliver conform to the Standards for Obstelnsc-GynecoloNc 
D-5  Services (Perinatal Care: How to Establish Perinatal Semites in Community 
Health Centers, PHS, 1985 p. 96). 
A 1989 PHS report, Caring for Our Future: me Content of Prenatal Care, 
suggested slightly different guidelines.  This report recommends that healthy 
women receive a minimum of nine prenatal visits during a first pregnancy and 
seven prenatal visits during subsequent pregnancies (p. 50). The report 
suggests that women at risk, because of either psychosocial or physical factors, 
might require more prenatal visits (p. 71). Psychosocial and physical risk 
factors include: inadequate personal support systems, single marital status, 
adolescence, advanced age, high stress and anxiety, less than high school 
education, low income, inadequate housing, inadequate nutritional resources, 
communication barriers, smoking, alcohol abuse, and illicit drug use (p. 79). 
31.  Nonresponses may have resulted in an underestimate of the percentage of 
centers with such vacancies. 
32.  U.S. General Accounting Office, Medical Malpractice: Data on Claims Needed 
to Evaluate Health Centen Insurance Alternatives (HRD-91 -98), Washington, 
D. C., May 1991, p. 1. These data are for all Section-330 grant recipients. 
33.  P.L. 102-501. Under the 17C& 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. 
34.  On average, 13 percent of each centers perinatal clients were privately insured 
and 2 percent were covered by other mechanisms in 1990. 
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.  One center reported waits of more than 12 months for Medicaid 
reimbursement. 
38.  P.L. 95-210. Tile Rural Health Clinic Services Act. 
The Rural Health Clinic Se~ices Act was amended in the Omnibus budget 
Reconciliation Act of 1989 to include certified nurse midwives as eligible 
program participants, and to provide reimbursement for clinical social work 
services. 
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 39.  OIG, Medicaid Ekpan.sions for Prenatal Care: An Update 
(OEI-06-90-O0161),  May 1992. 
40.  P. E., pp. 4-5. 
41.  Centers report a range of coalition activities, including: high-risk referrals and 
consultations, coverage for delivery, case management and support services, 
integration of WIC setices, support for breast-feeding women, setices to 
migrant populations, and outreach. 
42.  P. E., p. 18. 
43.  Our sumey addressed only admitting privileges.  During intemiews, center staff 
reported hospital restrictions on the delivery privileges of certified nurse 
midwives and family physicians. 
44.  P. E., p. 19. 
45.  HRS~ FY 1993 Justification of Appropriations, vol. 1, p. 61. 
46.  BPHC and ASMB data. 
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