Department of Health and Human Setices 

OFFICE OF 

INSPECTOR GENERAL 

AN OVER~W 

DECE~ER 1992 

— 
OFFICE OF INSPECrOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Semites’ (HHS) 

programs as well as the health and welfare of beneficiaries sexved by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by three OIG operating components: the Office of Audit Semites, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management problems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’S 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 OIG’S 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 OIG’S Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. This report was prepared in the Boston regional 

office under the direction of Mark R. Yessian, Ph.D., Regional Inspector General, and Martha 

B. Kvaal, Deputy Regional Inspector General. Project staffi 

Dana L. Miller, Projecr Leader Maruta Zitans 

Timothy J. Corbett Barbara Tedesco 

Madelaine T. Tully 

Deborah Skahan 

For additional copies of this repo~ please contact the Boston regional office at 617/565-1050. 
Depatiment of Health and Human Sefices 

OFFICE OF 

INSPECTOR GENERAL 

AN OVER~W 
EXECUTIVE SUMMARY 

PURPOSE 

This report describes recent trends in the perinatal service capacity of the community 

health centers funded under Section 330 of the Public Health Service Act. 

BACKGROUND 

Community health centers (CHCS) play an important role in reducing infant mortality 

by delivering comprehensive perinatal care to high-risk women in medically undersexed 

areas across the nation. Many of these women are difficult to reach and do not 

appreciate the importance of prenatal care. In 1991, the Federal government supported 

services at 514 CHCS through Public Health Service (PHS) Section-330 grants, PHS 

Section-329 and -340 grants for migrant workers and the homeless, Medicare and 

Medicaid reimbursements, Maternal and Child Health grants, and the National Health 

Service Corps. 

In recent years the Federal government has made an increasing investment in the 

centers. Little information is available, however, on the extent to which the centers are 

able to meet the perinatal care needs of the women they serve. To examine the capacity 

of the centers to provide perinatal care, we conducted a mail sumey of all CHCS; 

inte~iewed center staff and management; held discussions with PHS administrators, State 

officials, and infant health care experts; and reviewed relevant literature and data. Our 

sumey was completed in June 1991. our findings are based primarily on information 

reported by the centers to us and to PHS. 

FINDINGS 

Increased Capacity The capacity of the community health centers to provide perinatal 

care increased in several respects between 1988 and 1990: 

� Prenatal caseloads increased an average of 22 percent. 

� The range of medical and health promotional services increased at 68 percent of 

the centers. The services added at the largest number of centers were HIV 

testing and counseling, smoking-cessation programs, and classes in parenting and 

childbirth. 

F The range of ancillary services--such as home visiting and transportation--increased 

at 32 percent of the centers. 

F Total center revenues increased 27 percent. 

i 
Increased Demand: Despite these increases in capacity, demand for perinatal services 

has continued to grow, and many center clients still do not receive the optimal 

coordinated package of care in a timely fashion. 

Fourteen percent of the centers reported that they provided no perinatal services 

on site between 1988 and 1991. Our study did not examine the extent to which 

these centers made alternative perinatal care arrangements for their clients. 

Demand for services increased at 82 percent of the centers; 39 percent of these 

centers reported their capacity to meet this growing demand either decreased or 

remained the same. 

Many centers reported that they do not coordinate, as part of their perinatal 

case-management efforts, all of the health and social services recommended by the 

Public Health Semite. This may, in part, reflect variations in the definition of 

“case management” among centers. 

On average, 55 percent of each center’s prenatal clients entered care during the 

first trimester in 1990. Nationally, 76 percent of all women, 62 percent of minority 

women, and 58 

during the first 

On average, 21 

percent of women in Healthy Start project areas entered care 

trimester. 

percent of each center’s first-trimester enrollees received fewer 

than 9 prenatal visits. Our study did not examine the extent to which these 

patients may have received care elsewhere. 

Limitations to Care: Centers identified several major constraints that seriously limit their 

capacity to provide perinatal care. Among these are: 

_ Medical staff shortages, in part as a result of cuts in the National Health 

Setice Corps in the 1980’s, present serious problems at 63 percent of centers. 

Although the number of prenatal clients increased an average of 22 percent at the 

centers, the number of obstetricians, family physicians, and certified nurse 

midwives increased an average of 5 percent. 

Medical Mahxwtice Lnsurance. The high cost of medical malpractice insurance 

has been a serious problem at 56 percent of centers. In late 1992, Congress took 

initial steps to address this problem by passing legislation (P.L. 102-501) that 

extends medical malpractice liability protection under the Federal Tort Claims Act 

(ITCA) to health care providers at the centers. 

Communiw-Provider Relations. Seventy-six percent of the centers report serious 

problems stemming from inadequate coordination of perinatal services in the 

community, a lack of other local providers willing to treat uninsured and 

ii 
publicly insured women, difficulty arranging obstetric backup for center staff and 

for consultation for high-risk clients, or difficulty obtaining hospital privileges for 

center staff. 

Health Insurance. On average, 19 percent of each center’s perinatal clients were 

uninsured in 1990. At 9 percent of centers, more than half of the perinatal clients 

were uninsured. 

Medicaid Funding: Medicaid is an important source of revenue for the centers’ perinatal 

semices. 

On average, 67 percent of each center’s perinatal clients were enrolled in 

Medicaid in 1990. 

Medicaid reimbursements to centers increased, as a percentage of total revenues, 

from approximately 17 percent in 1988 to 21 percent in 1990. 

Nonetheless, 73 percent of the centers reported serious problems with Medicaid-­

burdensome application procedures, inadequate and/or slow reimbursement, 

restrictive eligibility criteria, or a limited range of covered services. 

Only 56 percent of centers reported that they offered on-site assistance with 

enrollment in Medicaid, even though recent Federal law required that the States 

outstation workers to do so. 

Only 27 States and the District of Columbia had begun to implement cost-based 

reimbursement to the CHCS by May 1991, as called for in the Federally Qualified 

Health Centers mandate. 

Comprehensive Perinatal Care Program (CPCP): The CPCP provided supplemental 

funds for enhanced perinatal services to approximately two-thirds of the centers for at 

least one year between 1988 and 1991. 

� Eighty percent of centers that received CPCP funds expanded their range of 

perinatal services between 1988 and 1990, compared with 50 percent of other 

centers. 

� A larger percentage of CPCP grant recipients than of other centers coordinate all 

of the PHS-recommended health and social services through their perinatal casemanagement efforts. 

� Responses to our survey indicated no significant differences between CPCP grant 

recipients and other centers in the percentage of clients who entered care in the 

first trimester in 1990. We did not gather information on changes over time in 

first-trimester enrollment. 

... 

111 
� Responses to our survey indicated no significant differences between CPCP grant 

recipients and other centers in the percentage of first-trimester enrollees who 

received at least nine prenatal visits in 1988 or 1990. 

Urban-Rural Comparisons: Between 1988 and 1990, the capacity of urban and rural 

centers to provide perinatal care increased in terms of prenatal caseload size, the range 

of services offered, and overall revenues. The increases were greater for urban centers 

than for rural centers. 

* A greater percentage of rural centers (20 percent) than urban centers (6 percent) 

offered no perinatal services on site between 1988 and 1991. Our study did not 

examine the extent to which these centers made alternative perinatal care 

arrangements for their clients. Rural centers with perinatal programs offered 

more timely care than urban centers. 

> Urban and rural centers identified the same factors as serious limitations to their 

ability to provide perinatal care. Limited space was a problem for a greater 

percentage of urban centers, and staff shortages were a problem for a greater 

percentage of rural centers. 

KEY AREAS FOR ACIION 

In recent years, government at all levels has looked to the CHCS to play a more 

prominent role in providing perinatal care to poor, high-risk women. As the data in this 

report suggest, the capacity of centers to provide perinatal services has increased in 

several important respects since 1988. More women are being served and a wider range 

of services is being offered. Many centers, however, are burdened by major problems 

that limit their ability to meet the heightened expectations they face. The problems are 

pervasive and suggest vulnerabilities that cannot be effectively addressed by the centers 

alone. 

In part, the difficulties facing centers reflect problems of access and cost in the nation’s 

health care system and are dependent for resolution on broad reforms in that system. 

Nonetheless, there are important actions policy makers can take now to strengthen the 

capacity of centers to provide care. The data in this report suggest four critical areas 

that warrant immediate attention. Policy makers at all levels of government--Federal, 

State, and local--need to: 

E Address the staffing needs of the centers. If community health centers are to 

meet the increasing demand for services, they need to be better able to attract, retain, 

and utilize clinicians. Thus, it is vital to identify cost-effective steps to (1) ensure an 

adequate supply of clinicians, (2) develop more effective incentives for clinicians trained 

with public funds to locate in undersexed areas, and (3) ease undue restrictions on the 

credentialing of certified nurse midwives, nurse practitioners, and physician assistants. 

iv 
� Assure that recent legislation effectively relieves the centers of the high cost of 

medical malpractice insurance. The high cost of malpractice insurance, particularly for 

clinicians providing perinata] care, has limited the centers’ ability to offer services. In 

late 1992, Congress took initial steps to address this problem by extending medical 

malpractice liability protection under the Federal Tort Claims Act (ITCA) to health care 

providers at the centers. It is necessary to monitor this new arrangement to ensure that 

it effectively addresses the centers’ concerns. 

� Continue to imprwe ties between the centers and the Medicaid program. An 

effective link between centers and the Medicaid program is vital given the high 

proportion of Medicaid-insured women served by the centers and the expanded 

Medicaid coverage now available for their prenatal care. It is particularly crucial to 

ensure that the law requiring outstationing of Medicaid eligibility workers at CHCS 

and the law ensuring cost-based reimbursement to centers as Federally Qualified 

Health Centers (FQHC) are both fully implemented and working optimally. 

Continue to strengthen relationships with other health and social seMce 

p~oviders. To be more comprehensive and efficient, the perinatal services offered by 

centers must be more effectively linked with those of other providers in the 

community. It is particularly important to increase the number of providers willing to 

serve Medicaid patients, to simpli~ enrollment, to facilitate referrals among programs, 

and to ensure that center clinicians have staff privileges at hospitals in their 

communities. 

RECOMMENDATION 

The Assistant Secretary for Health the Administrator of the Health Care Financing 

Administratio~ and the Assistant Secretary for Planning and Evaluation should 

develop a plan of action to address the key areas outlined above. 

The PHS and HCFA should, individually and collaboratively, develop plans of action 

that incorporate specific targets and concrete steps to ensure that the key areas for 

action are addressed. The ASPE should review these plans and assure that they are 

compatible and adequate to meet the nation’s health goals for the year 2000 to reduce 

infant mortality rates and increase access to perinatal care. The ASPE should 

coordinate activities and monitor implementation of the plans. 

The PHS cannot effectively address these problems alone. Other Departmental 

components, State and local government agencies, and nongovernmental organizations 

must be involved in planning and implementation. of particular importance is 

cooperation between public health and health care financing agencies at both the 

Federal and State levels. 

Only through concerted action to address the key problem areas identified above can 

the potential for the community health centers be more fully realized. Strategies for 

improving perinatal care, such as expanded insurance coverage and aggressive 

v 
outreach programs, will be successful only to the extent that centers can provide 

sufficient clinical services linked effectively with other health and social semtices. 

Unless the serious problems affecting the community health center system are 

addressed, the centers’ capacity to meet increased demand and heightened 

government expectations will continue to be strained and the system will remain 

vulnerable. 

COMMENTS ON THE DRAFT’ REPORT 

We received formal comments on our draft report from the Public Health Sewice 

(PHS), the Office of the Assistant Secretary for Planning and Evaluation (ASPE), and 

the Health Care Financing Administration (HCFA). These comments are reproduced 

in appendix C. 

The PHS and ASPE concurred with our recommendation and proposed steps to 

implement it. The HCFA did not concur with our recommendation. The HCFA 

suggested that the key areas for action we identified are being addressed by current 

efforts in the Department and that the implementation of our recommendation could 

result in a duplication or delay of these ongoing efforts. 

We continue to believe that the development and implementation of an interagency 

action plan by PHS, ASPE, and HCFA is critical to the strengthening of the 

community health centers’ perinatal care capacity. The participation of HCF& which 

plays a vital role in support of the community health centers’ provision of perinatal 

care, is important to this effort. 

We recognize that PHS, ASPE, and HCFA are involved in ongoing initiatives that 

address concerns about infant mortality and perinatal care. We urge PHS, ASPE, and 

HCFA to consider these current activities as resources upon which to draw in 

developing a comprehensive plan that incorporates both specific targets and concrete 

steps to ensure that the key areas for action are addressed. We hope the interagency 

effort will provide an opportunity to further involve State and local policy makers in a 

concerted plan to support the centers’ provision of perinatal care. 

We have revised our draft reports to reflect additional comments we received from 

PHS, ASPE, and HCFA. 

vi 
TABLE OF CONTENTS


EXE~ SU19WY 

1


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


FINDINGS


4


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


.5


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


7


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


9


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


10


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


..11


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


16


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


. 17


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


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


APPENDI= 

A-1


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


. B-1


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


c-1


c: Detailed Cc>mments on the Draft Report . . . . . . . . . . . . . . . . . . . . . . . 

. . D-1


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


vii 
INTRODUCTION 

PURPOSE 

This report describes recent trends in the perinatal service capacity of the community 

health centers funded under Section 330 of the Public Health Service Act. 

BACKGROUND 

Birth Outcomes in the United States: The high rate of infant mortality in the United 

States continues to be a cause for concern. Each year, approximately 40,000 infants 

die before their first birthday--about 1 percent of all live births in the nation. In the 

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

1991, it ranked 23rd. The rate for black infants continues to be double that for white 

infants. ] 

Perinatal Care: A pregnant woman with no prenatal cm-e is three times more likely to 

have a baby born at low birthweight--a key indicator of the risk of infant death--than a 

woman with adequate care. The Public Health Service (PHS) recommends timely, 

high-quality care before, during, and after birth as an effective way to lower the infant 

mortality rate and ensure healthier infants. Such perinatal care’ should include early 

and continuing risk assessment; health promotion; and medical, nutritional, and 

psychosocial intementions and follow-up.2 

Several factors, however--including financial, geographic, and cultural barriers--prevent 

many women from obtaining timely perinatal care.3 Rising medical malpractice 

insurance costs, inadequate health insurance coverage, a decreasing supply of obstetric 

providers, and a lack of physicians willing to treat low-income women are among the 

factors that have further limited the accessibility of perinatal care.4 In 1989, almost 

170,000 American women received no prenatal care until the third trimester, and 

another 86,000 received no care at all during pregnancy. Thirteen percent of whites 

received inadequate care; the proportion of blacks and Hispanics is twice that.5 

Community Health Centers: Community health centers (CHCS) play an important 

role in reducing infi~nt mortality by delivering comprehensive perinatal care to highrisk women in medically undersexed areas across the nation. Many of these women 

are difficult to reach and do not appreciate the importance of prenatal care. 

The CHC program was established in 1965 to meet the health care needs of the 

nation’s medically undeserved. Federal administration of the program was 

consolidated in 1975 under Section 330 of the Public Health Semite Act. The total 

number of centers, however, has not been maintained at the level originally 

envisioned.6 The number of grantees was cut substantially in the early 1980’s--from 

867 in 1981 to 530 in 1983, a 39 percent decrease.’ At the time of our survey, in 

1 
1991, PHSfunded 514centers; 60 percent of these sened predominantly rural 

populations, and 40 percent served predominantly urban populations.8 As of 

December 1992, PHS funded 549 centers. 

The Federal government supports the services provided by community health centers 

through PHS Section-330 grants as well as through Medicare and Medicaid 

reimbursements, Maternal and Child Health grants, PHS Section 329 and 340 grants 

for migrant workers and the homeless, the National Health Service COrpS,9 the 

Supplemental Food Program for Women, Infants, and Children (WIC),10 and the

11 r 

‘ ‘--­ ill~~lfl[[~~[~~gg~h: 

yiMitiij6fffq L8t 

Mu ~w 

rime 

~-r wI~Ls3USMOL~~.. 9LIqZUGP0W=JCe2- IUC T----– # . –=-- 4.3 ~Llq ~Jlrrrnrfi.. { . . – . . 

for migrant workers and the homeless, the NZIWMZH~~iii~fi”;=;t }=%’=21~-~1’~‘w= 

Supplemental Food Program for Women, Infants, and Children (WIC),1° and the 

Rural Health Clinic Programll. In recent years, funding for the centers has 

increased,12 and several initiatives have been implemented to expand center services 

and imrmwe access to care. These include: 

Medicaid Expansions: Since 1982, Congress has enacted several changes in the 

Medicaid program, including mandated and optional changes in eligibility requirements 

and other measures, intended to improve the availability of perinatal care.13 

Federally Qualified Health Centen Legklation: The Omnibus Budget Reconciliation 

Acts of 1989 and 1990 require State Medicaid programs to cover a core set of services 

provided by community health centers and to reimburse centers for the reasonable 

cost of covered services. 

The Comprehensive Perinatal Care Program (CPCP): The CPCP provides 

supplemental funding to some CHCS for enhanced perinatal setices, including 

improved outreach and case management. Funds were first awarded in 1989.14 

Healthy Start: In September 1991, HHS awarded competitive grants to 15 

communities in support of coordinated programs to reduce infant mortality rates. 

Although there has been increasing Federal interest in perinatal care and the 

community health centers, little information is available on the extent to which the 

centers are able to address the perinatal care needs of the women they seine. A clear 

understanding of the centers’ current capacity to provide perinatal care is vital to 

further planning and program design. 

This report presents an ove~iew of recent trends in the perinatal service capacity of 

the Section-330-funded centers, and summarizes and compares data on urban and 

rural centers. It also presents information on two areas of special policy interest: 

Medicaid reimbursements to the centers, and CPCP funding of the centers. 
COMPANION REPORTS 

This is one of three reports on the capacity of the community health centers to 

provide perinatal care. Two companion reports address the provision of perinatal 

services at urban and rural centers: 7%e Perinatal Service Capacity of the Federally 

Funded Community Health Centem: Urban Centers, 0EI-01-90-02330, and Z4e 

Perinatal Service Capacity of h Federally Funded Community Heahh Centem: Rural 

Cen[en, OEI-01-90-0233 1.15 

METHODO~Y 

To examine the capacity of the community health centers to provide perinatal care, we 

conducted a mail sumey of Section-330-funded centers, interviewed staff and 

management at 10 centers; held discussions with PHS administrators, State officials, 

and infant health care experts; and reviewed relevant literature and data. 

We sent the mail suwey to all 514 community health centers receiving Section-330 

funds in June 1991; of these, 431 (84 percent) responded. Our findings are based 

primarily on the responses of those 369 centers (72 percent of all centers) that 

reported that they offered perinatal services on site during the 1988-91 period. (See 

appendix A for a detailed methodology.) 

Our review was conducted in accordance with the Interim Slandards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

3 
FINDINGS


INCREASED CAPACITY: 7he capacity of the commundy health centem to pmide 

peri.natal care increasd between 1988 and 19X) in terms of prenatal casehad ~ the 

range of services offm~ and jhiing. 

� Caseloads: The number of prenatal clients served by the centers rose 22 percent 

between 1988 and 1990, from an average of 359 per center to 436. The number of 

births to center clients rose 19 percent during the same period, from an average of 

253 per center to 300. Centers reported a total of 140,157 prenatal clients and 88,142 

births in 1990. 

E Setices: The range of perinatal services increased at 68 percent of the centers. 

The services added at the largest number of centers were HIV counseling and testing, 

smoking-cessation programs, and classes in parenting and childbirth. 16 The range of 

ancillary services increased at 32 percent of the centers. Home-visiting services were 

added at the largest percentage of the centers and child care during appointments was 

added at the smallest percentage (see figure 1). 

Figure 1 

Percentage of Centers that Provided 

Each Perinatal Service, Including Ancillary Services 

Either On Site or Off Site, 1988 and 1990 

F~9 

.	

8 

E 

: 

i! 

2 

T~ 

ti’ -~ •1 1988 

3 

2

u 

- - ChildCare m addedby 1990 

! 1 I 1 1 

o% 20% 40% 60% 80% 100% 

Percentageof Centers ProvidingEach Senrice 

Source:OIGSurvey of Comnmnity Health Centers, June 1991. 

N-369 

4

Sixty-five percent of the centers offered on-site assistance with enrollment in the 

Supplemental Food Program for Women, Infants, and Children (WIC) in 1990, an 

increase from 57 percent in 1988.17 

� Revenues: Total revenues for all center services increased 27 percent between 

1988 and 1990; this includes an 18 percent increase in Section-330-grant funding.18 

Fifty percent of the centers reported that the amount of funding available for perinatal 

senices had increased since 1988. 

INCREASED DEMAND: Despite these increases in capacity, demand for perinatal 

services has continued to grew, and many center clients still do not receive the optimal 

coordinate package of care in a timely filshion 

� Availability of setices: Sixty-two (14 percent) of the centers that responded to 

our survey provided no perinatal setices on site from 1988 to 1991.19 While these 

centers are required to ensure that clients receive services elsewhere, our study did not 

examine the extent to which centers did so. Twenty-nine (47 percent) of the centers 

that did not provide on-site perinatal semices indicated that they would have liked to, 

but noted that budgetary constraints, a lack of obstetric providers, and an inability to 

obtain hospital privileges prevented them from doing so. 

� Demand for services: Eighty-two percent of the centers that offered perinatal 

care reported an increase in the demand for sewices since 1988. Of these, 39 percent 

reported that their capacity to address this demand had either decreased or remained 

the same. An additional 12 percent of the centers reported that demand for perinatal 

semices had not changed since 1988. Of these, 17 percent reported that capacity to 

meet demand had decreased. 

Several centers reported that they were overwhelmed by demand and have been 

periodically forced to turn away new perinatal clients because they lack the capacity to 

seine them. Centers attributed increased demand for services to several factors, 

including: Medicaid eligibility expansions, and presumptive and continuous eligibility 

provisions; a diminishing number of community providers willing to treat low-income 

and Medicaid patients; and increasing unemployment rates among center clients. 

Many unemployed women have neither the income nor the health insurance to afford 

private medical care, and therefore seek subsidized care at the centers. 

� Case management: According to PHS, perinatal care should include risk 

assessment; health promotion; and medical, nutritional, and psychosocial services and 

follow-up.20 To maximize the accessibility, quality, and comprehensiveness of services, 

PHS requires centers to provide case-management services.21 

Although centers may provide some of the senices recommended by PHS, 63 percent 

of the centers reported that they do not provide case management for all of these 

sewices (see figure 2). 

5 
Figure 2 

Percentage of Centers that DO NOT Case Manage Each Perinatal SeMce 

m~titi 13% 

Health E&carion -~ 14% 

Nutritional Services -~ 15% 

ASSiStmccwithWC 

Medical Semites On-Sit.c 

Medical Services Off-Site -1 2s% 

Social Saivcesi On-Site i 31% 

social Services Off-Site -I 34% 

Delivery Se$v&g -I 34% 

Discharge Planning so% , o% 10% 30% 40% so% 60% 

Percentage of Centers th DO NOT Case Manage Each Service 

!kunx. 010SUIVCy ofcommunityHealthcenm he 1991. 

N-369 

There is no commonly accepted definition of case management, and the process has 

been implemented differently at different centers. Centers might coordinate the 

delivery of semices and not refer to such coordination as case management. 

Centers reported several problems, however, that indicate inadequate coordination of 

care: 

o	 Missed appointments are not rescheduled for an average of 35 percent of each 

center’s perinatal clients. 

o	 The timely transfer of medical records to and from facilities for delivery and 

other semices is a problem at 27 percent of the centers. 

o	 Follow-up care within the first 8 weeks after birth was not provided for an 

average of 27 percent of each center’s prenatal clients in 1990. 

� Timing of care: On average, 55 percent of each center’s prenatal clients entered 

care during the first trimester of pregnancy in 1990. Nationally, 76 percent of all 

women, 62 percent of minority women, and 58 percent of women in federally 

designated Healthy Start project areas entered care during the first trimester.zz 

These rates compare with a PHS goal of 90 percent of all women by the year 2000.X 

� Number of visits: The American College of Obstetricians and Gynecologists 

recommends that women entering care in the first trimester receive a minimum of 9 

prenatal visits.24 On average, however, 21 percent of each center’s first-trimester 

enrollees received fewer than 9 prenatal visits at the center. Our study did not 

examine the extent to which these patients may have received care elsewhere. 

6

� Availability of appointments: Thirty-seven percent of thecenters did not offer 

prenatal appointmentsat times convenient forworking women in 1990. Restricted 

appointment hours may force working women to choose between work and prenatal 

care. 

� Waiting times: At 27 percent of the centers, waits for initial prenatal visits are 

2 to 4 weeks; at 4 percent, waits are more than 1 month. Long waits for initial 

appointments can have adverse effec~s. If a woman tests positive for pregnancy in her 

second month and then must wait 4 weeks for her first prenatal appointment, she may 

enter care in her second trimester. The implications of such waits are even more 

problematic when pregnancy is detected later and when the mother is at high risk, as 

many center clients are. 

sixteen percent of the centers reported that office waiting times grew longer between 

1988 and 1990. Centers reported that long office waits may discourage women from 

making and keeping appointments. 

LIMITATIONS TO CARE: 7% centem &&m@Zedseveral major constnints that 

seriously limit their capacity to pmvkii? painatal care. 7kse inchuie medical staff 

shortage+ medical malpractice insumnce cmtis, unsatii$actq community suppo~ kited 

spacq and inadequate “ health insumnce of center clientk 

� Medical staff shortages: Medical staff shortages are so severe that they 

seriousl~ hinder the provision of perinatal sexvices at 63 percent of the centers. 

While the number of perinatal clients served by the centers increased an average of 

22 percent between 1988 and 1990, the number of full-time equivalent (FTE) 

obstetricians, family physicians, and certified nurse midwives increased an average of 5 

percent. Twenty-six percent of the centers reported that at least 1 obstetrician, familyphysician, or nurse-midwife position had been vacant for longer than 1 year (see table 

1). 

Table 1 

Percentageof Centers Reporting at Least One C1.iniealProviderPmition Vacan# 

Currently Vacant more Vacant more 

Stafl Position Vacant than SixMonths than one year 

Obstetrician-Gynecologist 26~o 22% 13% 

II FamilyPhysician II 31% I 26fZo I 15% II 

II Nurse Midwife 11 13% I 1170 I 6% II 

Source: OIG Swvey of Community HealthCenters, June 1991 

N=369 

Centers face serious problems recruiting and retaining medical staff. The work is 

demanding, and wages and benefits are generally not comparable to those in the 

private sector. Although the National Health Service Corps used to supply a large 

7 
percentage ofcenter providers, funding forthecorps was seriously cut in the 1980’s. 

In recent years the corps has produced a decreasing number of providers.27 

Obstetricians are in short SUpply, and many are unwilling to work in community health 

centers. They are also the most expensive providers to support: Their salaries and 

medical malpractice insurance premiums are substantially higher than those of other 

providers. Family-physician and certified-nurse-midwife models of care also pose 

problems: The supply of family physicians and nurse midwives is limited; many 

obstetricians are reluctant to provide supervision and backup services for them; and 

many hospitals will not extend delivery privileges to them. Thus, these more 

affordable staffing models are impractical for many centers. 

� Malpractice insurance costs: The cost of medical malpractice insurance has been 

a serious drain on resources at 56 percent of the centers. The cost of medical 

malpractice insurance has become a more serious limitation since 1988 at 27 percent 

of the centers.n 

These costs have made it difficult for centers to expand their staffs, since scarce funds 

must be spent on insurance instead of salaries. Centers that contract for care have 

had difficulty paying the rising wages necessary to meet the insurance costs of private 

physicians. One center reported that it has been unable to obtain coverage at any 

cost . 

In late 1992, Congress took initial steps to address this problem by passing legislation 

that extends medical malpractice liability protection under the Federal Tort Claims 

Act (ITCA) to health care providers at the centers.29 

� Unsatisfactory community support: The PHS expects that centers be “active 

participants in their community’s health care system. . . . This typically means 

fostering partnerships and participating in consortia and task forces addressing the 

area’s health care issues.”~ These consortia should include local health departments, 

social services departments, hospitals, and other public and private health care 

providers. Thirty-five percent of the centers, however, do not participate in perinatal 

care consortia. 

Inadequate coordination of perinatal services in the community, insufficient support 

from the local medical establishment, or limited hospital privileges31 seriously restrict 

the provision of services at 76 percent of the centers. Unsatisfactory community 

support is indicated by several problems cited as serious impediments to the delivery 

of care: 

o 

0 

0 

a lack of other local providers willing to treat uninsured and 

publicly-insured women (59 percent); 

difficulty arranging obstetric backup for family physicians, certified nurse 

midwives, or nurse 

difficulty arranging 

practitioners (35 percent); 

medical consultation for high-risk clients (29 percent); 

8 
o difficulties obtaining admitting or delivery privileges for staff obstetricians, 

family physicians, or nurse midwives (35 percent); and 

o a decrease between 1988 and 1990 in the percentage of staff providers with 

hospital admitting privileges (19 percent). 

� Mted space: Limited space seriously hinders the provision of sewices at 

55 percent of the centers. This problem has become more serious since 1988 at 

31 percent of the centers. In addition, limited collocation of setices on site seriously 

restricts the comprehensiveness of care at 26 percent of the centers. Centers that 

cited limited space as a serious problem more frequently cited limited collocation of 

semices as a serious limitation. 

� Inadequate health insurance: An average of 19 percent of each center’s perinatal 

clients were uninsured in 1990. At 29 percent of the centers, 25 percent or more of 

the perinatal clients were uninsured. At 9 percent of the centers, more than 

50 percent were uninsured. These clients received semices free of charge or at 

reduced rates, according to a sliding scale. 

MEDICAID FUNDING: iUedica&i fiuuiing for petital care at the centm has increased 

in recent yea~ but centzm repti that Medicad policia and pmcedures-inchding a 

burdensome application process, inadequate “ reimhuxement rota, a reistited mnge of 

covered servicq and limited eli’ility--are among the facton that serixdy inhibit the 

pmvkion of care at mmt centem 

� Medicaid reimbursements: Medicaid reimbursements to the centers increased 

approximately 56 percent between 1988 and 1990.32 As a percentage of total center 

revenues, they increased from approximately 17 to 21 percent. 

� Medicaid+mrolled clients as a portion of perinatal caseload: An average of 

67 percent of each center’s perinatal clients were Medicaid-enrolled in 1990. At 

50 percent of the centers, at least 71 percent of these clients were Medicaid-insured. 

� Medicaid limitations: Medicaid eligibility expansions or presumptive and continuous 

eligibility provisions resulted in an increase in demand for perinatal services at 57 percent 

of the centers, but difficulties with Medicaid policies and procedures--including 

burdensome application procedures, inadequate and/or slow reimbursement, restrictive 

eligibility criteria, or a limited range of covered services--seriously limit the provision of 

perinatal care at 73 percent of the centers (see table 2). 

9 
Table 2 

Percentage of Gnters Citing Each of the Following 

Medicaid Factors as a Serious Limitation 

I 

Burdensome application procedures 1 5470 

II Inadequate reimbursement rates I 4970 II I 

Restrictive eligibility criteria I 42$Z0 II 

11 Slow reimbursement process i 41% II 

II Limited range of covered services ! 40% II 

Source OIG Survey of Community Health Centers, June 1991 

N=369 

Several recent Medicaid reforms have been designed to increase access to perinatal 

care. These had not yet been fully implemented at the time of our survey: 

o Only 56 percent of centers offered assistance with Medicaid enrollment on 

site, even though Federal law required that the States outstation workers to 

do S0.33 

o Only 27 States and the District of Columbia had begun to implement costbased reimbursement to CHCS as of May 1991, even though the Federally 

Qualified Health Center provisions of the Omnibus Budget Reconciliation 

Acts of 1989 and 1990 called on the States to do so by April 1, 1990.~ 

COMPREHENWVE PERINATAL CARE PROGRAM (CKT): 7%e CPCP p~vidt?d 

supplemental jiuuis for enhanced petitid servhx to approximately two-thinh of the 

centem for at least one year between 198/3 and 1991. A bger pemntage of centm that 

received CPCP fiuds than of those that did not expanded their range of semices between 

1988 and 1990. CPCP gmnt recipients conduct more extensive case management than 

other centem There were no significant ~krences, howeve~ between gnmt recipik~ and 

other centen in either the penzntage of ciknts who entered care in the jht Oimester in 

1990 or the pacentage of these who received at ikast nine prenatal visits. 

� Caseload size: In 1988, before CPCP funds were awarded, those centers that 

eventually received CPCP funds served an average of 454 prenatal clients, compared 

with an average of 156 sewed by other centers. In 1990, CPCP-funded centers served 

an average of 547 prenatal clients; other centers served an average of 201.35 Thus, 

CPCP-funded centers seined considerably more clients than other centers, but there is 

no significant difference between CPCP-funded centers and other centers in the rate 

at which caseload size grew between 1988 and 1990.M 

~ Semites: CPCP funds were intended, in part, to support increased perinatal 

services at the centers,37 and 80 percent of the CPCP-funded centers reported that 

10 
the range of perinatal semices increased between 1988 and 1990. Half of the other 

centers reported that the range of services increased. 

E Case management: CPCP funds were also intended to support better 

coordination of care for perinatal clients,w and 46 percent of the CPCP-funded 

centers provide case management for all of the sefices recommended by PHS. 

Twenty-two percent of the other centers provide case management for all of these 

services. 

In addition, 70 percent of the funded centers participated in perinatal care consortia; 

58 percent of the other centers did S0.39 

� Timing of care: The CPCP was further intended to support early entry into care 

and more prenatal visits.w Responses to our survey, however, indicate that CPCPfunded centers and other centers did not differ significantly in terms of either the 

percentage of center clients that entered care in the first trimester in 1990, or the 

percentage of first-trimester enrollees that received nine or more prenatal visits in 

1988 or 1990. Our study does not allow a comparison of CPCP grant recipients and 

other centers with regard to trends over time in first-trimester entry into care. 

URBAN-RURAL COMPARISONS: Urban centers exhibited greater painatd care 

capacity in terms of prenatal casekuui S@ the mnge of semiax Offi?r@ and revenuex 

Rural centen provided more timely perinatal care. Urban and mml centm identified the 

same factom as setiu limitations to the pmvkion of painatal care. 

* Caseloads: Urban centers served more prenatal clients and experienced greater 

caseload growth than rural centers. Prenatal caseloads at urban centers increased an 

average of 23 percent between 1988 and 1990, from 477 to 586. Prenatal caseloads at 

rural centers grew an average of 20 percent, from 261 to 312. 

* SeMWs: Only 6 percent of the urban centers that responded to our survey did 

not offer any perinatal services on site between 1988 and 1990; 20 percent of the rural 

centers did not do so. Of those that did offer sewices, a greater percentage of urban 

(78 percent) than rural (63 percent) centers reported that the range of perinatal 

semices they provided, either on or off site, increased between 1988 and 1990. 

A higher proportion of urban centers offered on-site assistance with enrollment in 

both Medicaid and WIC in 1990. Sixty-six percent of urban centers offered on-site 

assistance with enrollment in Medicaid and 81 percent offered on-site assistance with 

enrollment in WIC; 49 percent of rural centers offered on-site assistance with 

enrollment in Medicaid and 54 percent offered on-site assistance with enrollment in 

WIC. 

E Case management: 

percent) centers provide 

A greater percentage of urban (44 percent) than rural (32 

case management for all the services recommended by PHS. 

11 
A greater percentage of urban (34 percent) than rural (18 percent) centers, however, 

also often encounter problems with the timely transfer of medical records to and from 

referral facilities for setices other than delivery. 

� Revenues: Total revenues for all services at urban centers increased 31 percent 

between 1988 and 1990; total revenues for all setices at rural centers increased 20 

percent. Section-330 funding increased approximately 18 percent at urban and rural 

centers alike. This funding represented 3S percent of total 1990 revenues for urban 

centers and 44 percent for rural centers. Medicaid reimbursements increased 59 

percent at urban centers and 42 percent at rural centers. These reimbursements 

represented 25 percent of total 1990 revenues for urban centers, and 13 percent for 

rural centers.4* 

� Timing of care: Rural centers, on average, provided more timely prenatal care 

than urban centers. Seventy-six percent of the rural centers conducted initial prenatal 

visits for their clients within 2 weeks of a positive pregnancy test, compared with 60 

percent of the urban centers. On average, 59 percent of each rural center’s clients, 

and 51 percent of each urban center’s clients, entered care in the first trimester in 

1990. In addition, an average of 82 percent of the first-trimester enrollees at rural 

centers and 74 percent at urban centers received at least 9 prenatal visits in 1990. 

� Limitations: Urban and rural centers alike reported that their provision of 

perinatal care is seriously inhibited by several factors, including medical staff shortages, 

medical malpractice insurance costs, unsatisfactory community support, limited space, 

and inadequate health insurance. There were significant differences between urban 

and rural centers involving space and staffing. 

Limited space seriously restricts the provision of perinatal care at a greater percentage 

of urban (64 percent) than rural (48 percent) centers, and has become a more serious 

problem since 1988 at a greater percentage of urban (38 percent) than rural (24 

percent) centers. 

Staff shortages present serious limitations to care at a larger percentage of rural than 

of urban centers.42 At rural centers there was a 1 percent decrease in the number of 

FTE obstetricians, family physicians, and certified nurse midwives between 1988 and 

1990; at the same time there was a 20 percent increase in the size of the prenatal 

client caseload. At urban centers there was a 12 percent increase in the number of 

FTE providers and a 23 percent increase in the size of the prenatal caseload. 

Difficulty arranging backup for obstetric supervision of family physicians is a serious 

limitation to the provision of care at a greater percentage of rural (34 percent) than 

urban (22 percent) centers. Consultation for high-risk patients is also a serious 

problem at a greater percentage of rural (36 percent) than urban (21 percent) centers. 

In addition, high medical-staff turnover has become a more serious limitation to the 

provision of perinatal care since 1988 at a greater percentage of rural (18 percent) 

than urban centers (11 percent) (see table 3.). 

12 
Table 3 

Section-330-Funded Urban and Rural Community Health Centem Compared 

~~+ ~ 

Average increase in the number of prenatal client.sat each center, 1988to 1990: 23% / 2070 

SERVICES 

Percentage of survey rm~ ndents that did not offer any perinatal semkes on site 

between 1988 and 1991: -E 69Z0 20% 

Percentage of centers that reported an increase in demand for perinatal services: 

R 

899Z0 75% 

Percentage of the above centers that reported that capacity to meet this demand 

had decreased or remained the same: 3470 42?Z0 

Percents e of centers that re orted that the range of perinatal services had 

increas J between 1988 and 1’990: 78% 63% 

Percentage of centers that offered on-site assistance with Medicaid enrollment in 66?Z0 4970 

1990: 

Percentage of centers that offered on-site assistance with WIC enrollment in 1990: I 81% I 54% 

CASE MANAGEMENT 

Percentage of centers that re orted that they provide case management for all 

services recommended by P r-?S: m 

REVEhJUE@ 

Percentage increase in total center revenues between 1988 and 1990: 

E 

3170 2070 

PHS Section-330 grants as a percentage of total center revenues in 1990: 35% 4470 

Medicaid reimbursements as a percentage of total center revenues in 1990: 259Z0 13% 

TIMING OF CARE ~~ 

Percentage of centers that offered an initial prenatal visit within two weeks 

of a positive pregnancy test: 

~ 

6070 76% 

Percentage of each center’s clients enrolled during the first trimester: 51% 59?Z0 

Percentage of each center’s first-trimester enrollees who received at least 

nine prenatal visits: 74% 82?Z0 

LIMITATIONS 

Percentage of centers that reported serious medical staff shortages: 

FE 

59$Z0 67?ZOC 

Percentage change in the number of full-time-equivalent obstetricians, family 

physicians, and certified nurse midwives at centers between 1988 and 1990: 12% -l%c 

Percentage of centers that reported serious difficulties stemming from high 

~ract]ce insurancecosts: 56?40 559Zod 

Percentage of centers that experienced serious problems as a result of Medicaid 

Dolicies and Procedures: 76% 7090d 

Percentage of centers that reported serious roblems with communit 

coordination, community supp ort, or limit J 

‘- ~k 

hospital admitting privi egesPercentage of centers that reported serious space limitations: 

Source: OIG Sumwy of Community Health Centers, June 1991 

N= 167 for Urban Centers; N=202 for Rural Centers 

a These were not included in the calculation of other statistics presented in the this report (see appendix A for methodology). 

b These data were prowded by the Public Health Semke (see note 20). Statistical significance was not determined. 

c The differences noted are statistically significant at the 0.1 kwel. 

d The differences noted are not s[atisticalty significant. 

13 
KEY AREAS FOR ACTION 

In recent years, government at all levels has looked to the community health centers 

to play a more prominent role in providing perinatal care to poor, high-risk women. 

The growing financial investment in centers reflects heightened expectations for their 

performance. These expectations rest on the assumptions of many policy makers that 

centers are able to meet the growing demand for comprehensive, timely perinatal 

semices. 

As the data in this report suggest, the capacity of centers to provide perinatal services 

has increased substantially since 1988. More women are being served, a wider range 

of services is being offered, and total revenues for all center services have increased. 

At the same time, there is reason for concern about the capacity of the community 

health centers to deliver all that is expected of them. The findings of this report, 

based on the most current and comprehensive data available, confirm that many 

centers are burdened by major problems that limit their capacity to provide care. 

These difficulties reflect problems of access and cost in the nation’s health care 

system, and, as such, are, in part, dependent for resolution on broader national 

reforms. 

Independent of such reforms, however, we believe there are important actions that 

policy makers can take now to strengthen the capacity of centers to provide care. The 

data in this report suggest four areas in particular that warrant immediate attention. 

Below we identi$ these four critical areas and offer suggestions for action. 

Federal, State, and local policy makers should take steps to: 

� Address the staffing needs of the centers. 

If community health centers are to serve more women, reach them earlier in their 

pregnancies, and provide adequate care, they need a sufficient supply of obstetricians, 

family physicians, certified nurse midwives, and nurse practitioners. 

Centers need to be better able to attract, retain, and utilize various types of clinical 

staff who are skilled in providing perinatal care; who are motivated to seine poor, 

high-risk women; and who are allowed to practice, without undue restriction, 

consistent with their training and experience. Thus, it is vital for policy makers to 

identify cost-effective steps they can take to: 

(1) ensure an adequate supply of those types of clinicians needed to provide 

perinatal services in ambulatory primary care settings such as centers;43 

(2) develop more effective incentives for clinicians trained with public funds 

to locate in underserved areas. In this regard, it is particularly important 

14 
that the revitalized National Health Service Corps maximize its potential 

for addressing staffing needs through its loan repayment program, 

support training for an appropriate mix of clinical disciplines, and ensure 

that its recruitment and placement policies enhance the attractiveness of 

the program to young clinicians; and 

(3) ease undue restrictions on the credentialing of certified nurse midwives, 

nurse practitioners, and physician assistants to allow their fuller 

participation in perinatal sexvice delivery. 

� Assure that recent legislation effectively relieves the centers of the high cost of 

medical malpractice insurance. The high cost of malpractice insurance, particularly for 

clinicians providing perinatal care, has limited the centers’ ability to offer services. 

In late 1992, Congress took initial steps to address this problem by passing legislation 

that extends medical malpractice liability protection under the Federal Tort Claims 

Act (FT’CA) to health care providers at certain Federally supported health care clinics, 

including Section-330-funded community health centers.~ Under the FI’C~ center 

providers will be defended by the Justice Department in any malpractice litigation, and 

any judgments will be paid out of a Justice Department fund, into which the centers 

will pay annual contributions. This extension will be in effect for a trial period of 

three years, after which the financial benefits of the arrangement will be assessed. 

This coverage is intended to help alleviate the burden on the centers of malpractice 

insurance costs. It is necessary to monitor this new arrangement to ensure that it 

effectively addresses the centers’ concerns. 

� Continue to improve ties between the centers and the Medicaid program. An 

effective link between centers and the Medicaid program is vital given the high 

proportion of Medicaid-insured women sewed by the centers and the expanded 

Medicaid coverage now available for their prenatal care. It is crucial for public health 

and Medicaid officials to take steps to: 

(1) continue to expedite the application and eligibility determination 

processes for Medicaid to improve the access of high-risk women to 

more timely perinatal care. In this regard, it is particularly important to 

simpiify the application forms, to streamline enrollment procedures, and 

to ensure that eligibility workers are outstationed at the centers; and 

(2) ensure that the Federally Qualified Health Centers mandate, which 

allows centers to be reimbursed for reasonable costs, has been fully 

implemented and is working optimally. 

Steps such as these are consistent with the current directions of the Department’s 

Interagency Committee on Infant Mortality and with the recommendations and 

15 
suggestions of other studies including two recent OIG reports on Medicaid coverage 

for prenatal care.45 

� Continue to strengthen relationships between the centers and other health and 

social seMce providers in the community. 

The perinatal semices offered by the centers must be linked more effectively with 

those of other health and social service agencies. This coordination must go beyond 

the mere sharing of information to include effective working relationships for referral 

of clients and delivery of services.% It is particularly important to search for ways to 

increase the number of obstetric providers who are willing to seine Medicaid 

patients.47 

Moreover, strategies to locate multiple programs at a single site and to provide 

eligibility determination, complete program enrollment, and the delivery of services at 

a single site deseme further emphasis. Other strategies warranting continued attention 

are those that encourage more extensive use of common application forms and generic 

eligibility workers. 

It is particularly important to link centers and hospitals more effectively. Centers must 

rely on hospitals to provide inpatient care, including delivery services, for their 

patients; yet many centers have difficulty securing hospital privileges for their 

physicians and certified nurse midwives. Such privileges are critical for delivering the 

comprehensive, continuous care that the centers’ high-risk perinatal clients need. 

Thus, it is important for policy makers to identify ways to ensure that center physicians 

and midwives who meet appropriate requirements for licensure and training have staff 

membership at hospitals in their communities. This membership should encompass 

both admitting and delivery privileges. At present, the National Health Semite Corps 

statute requires hospitals, as a condition of their participation in Medicare, to grant 

privileges to corps physicians. This approach might be used to obtain privileges for 

other clinical staff.w Alternative approaches to explore include linking the licensure 

or tax-exempt status of hospitals to their guarantees of broader privileges for center staff. 

16 
RECOMMENDATION 

The Assistant Secretary for Healt4 the Administrator of the Health Care Financing 

Administration and the Assistant Secretq for Planning and Evaluation should 

develop a plan of action to address the key areas outlined abave. 

The PHS and HCFA should, individually and collaboratively, develop plans of action 

that incorporate specific targets and concrete steps to ensure that the key areas for 

action are addressed. The ASPE should review these plans and assure that they are 

compatible and adequate to meet the nation’s goals for the year 2000 to reduce infant 

mortality rates and increase access to perinatal care. The ASPE should coordinate 

activities and monitor implementation of the plans. 

The PHS cannot effectively address these problems alone. Other Departmental 

components, State and local government agencies, and nongovernmental organizations 

must be involved in planning and implementation. Of particular importance is 

cooperation between public health and health care financing agencies at both the 

Federal and State levels. 

Only through concerted action to address the key problem areas identified above can 

the potential for the community health centers be more fully realized. Strategies for 

improving perinatal care, such as expanded insurance coverage and aggressive 

outreach programs, will be successful only to the extent that centers can provide 

sufficient clinical services linked effectively with other health and social semices. 

Unless the serious problems affecting the community health center system are 

addressed, the centers’ capacity to meet increased demand and heightened 

government expectations will continue to be strained and the system will remain 

vulnerable. 
COMMENTS ON THE DRAFT REPORT


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


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


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


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


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


of the agencies’ comments in appendix C.


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


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


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


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


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


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


recommendation.


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


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


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


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


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


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


Agriculture’s Food and Nutrition Sewice, which administers the WIC program.


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


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


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


already in progress to meet the Secretary’s Program Directions.


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


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


The HCFA expressed concern that implementation of our recommendation could


result in a duplication or delay of these ongoing efforts.


l%e development and implementation of an interagency action plan by PHS, ASPE, and 

HCFA is critical to the strengthening of the community health centem’ perinatal care 

capaci~. We are pleased that ASPE and PHS have agreed with our recommendation for 

an interagency effort to address the key areas for action that we identified. 

We continue to believe that the participation of HCFA, which plays a vital role in suppoti 

of the community health centen ’provkion of pen”natal care, is important to thti effort, 

and we urge that HCFA reconsider its position. 

18

We recognize that PHS, ASPE, and HCFA are involved in ongoing inihahves that address 

concerns about infant mortality and pen-natal care. We uige PHS, ASPE, and HCFA to 

consider these current activities as resources upon which to draw in developing a 

comprehensive plan that incorporates bo~h specific targets and concrete steps to ensure 

that the key areas for action are atiressed. We suggest that the drafting and 

implementation of such a plan be used as an opportunity to bn”ngsharper focus to efforts 

addressing pemistent problems, and that the agencies not duplicate or delay current work 

We hope the interagency effort will also provide an oppo~nity to further involve State 

and locat’policy maken in a concerted plan to suppon the centem ’provision of perinatal 

care. 

Technical Comments 

Medical Malpmctice Liability 

After our draft report was released, Congress passed legislation (P.L. 102-501) that 

extends medical malpractice liability protection under the Federal Tort Claims Act 

(FTCA) to health care providers at certain Federally supported health care clinics, 

including Section-330-funded community health centers. Under the FT’C~ center 

providers will be defended by the Justice Department in any malpractice litigation, and 

judgments will be paid out of a Justice Department fund, into which the centers will 

pay annual contributions. This liability protection will be provided for three years, at 

which time the financial benefits of the arrangement will be assessed. 

We have revked our report to reflect the new legislation. We believe that the centem’ 

medical malpractice insurance concerns warrant continued attention, and we u~e PHS, 

ASPE, and HCFA to incorporate into their action plan an effort to monitor the 

implementation of the law and assess the cente~’ expen”encewith the new arrangement. 

Methodology 

The HCFA expressed concern that our report might be based on incomplete 

information because we did not intetiew representatives of HCFA or State Medicaid 

agencies. 

Our report focuses on trends in the community health centen’ capaci~ to provide 

perinatal care. As a bask for our findings, we relied primarily on information reported by 

the centens. A comprehensive assessment of the Department k efforts relevant to infant 

mortality and peri”natalcare would be beyond the scope of this report. We have revised 

our report to indicate more explicitly the focus and methodology of our study. 

19

The Implemenuwn of Rec& Me&a&i Refonru 

The HCFA cites information on the outstationing of Medicaid eligibility workers and 

the implementation of FQHC cost-based reimbursement that is more recent than that 

in our report. 

Our information on the outsta~ioning of Medicaid eligibility workers came from centen’ 

responses to our suIvq in June 1991. our information on the implementation of FQHC 

cost-based reimbursement to the centen was provided by PHS and was accurate as of 

May 1991. 

We expect that progress s}lould have been made in both areas since the time of our study. 

771ecenters cited several additional Medicaid factors as serious limitations to their 

prowkion of perinatal care, however, and we continue to believe that the ties between the 

centers and the Medicaid program need to be improved. 

20 
APPENDIX A 

METHoDoImGY 

We obtained information for this report through a mail sumey of all community health 

centers receiving Section-330 funds as of June 1991, site visits to several centers, a 

series of intewiews, and a review of relevant literature and data. our findings are 

based primarily on the centers’ responses to our survey. 

Mail Survey We sent a mail survey of perinatal services to all Section-330 grant 

recipients in June 1991. Of 514 centers, 431 (84 percent of rural and 84 percent of 

urban centers) responded, including centers in every HHS region and every State and 

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

U.S. Virgin Islands. A review of geographic and demographic information suggests no 

significant differences between respondents and nonrespondents. 

of the 431 respondents, 62 (14 percent) provided no perinatal services on site during 

the 1988-91 period. The numbers and percentages in the body of this report, unless 

otherwise noted, reflect the responses of those 369 centers (72 percent of all centers) 

that offered semices on site in at least 1 year during the 1988-91 period. 

Of the 369 respondents that provided semices on site during the study period, 235 (64 

percent) received CPCP funds. For the purposes of this report, a “CPCP-funded” 

center is any center that received CPCP grant funding at any time during the past 3 

years, regardless of the year in which its initial grant was awarded. 

Not all respondents provided complete information. We calculated the trends 

presented in the body of this report from the responses of those centers that provided 

the relevant information for all years. 

Unless otherwise noted, the statements in the body of this report that compare groups 

of centers (for example, rural and urban centers) reflect statistical significance at the 

.05 level. In reporting responses to survey questions that solicited information on a 

scale, we combined responses of “moderately” and “substantially” and reported them as 

“seriously” or “serious.” 

Site Visits: The study team conducted site visits to nine centers: three in 

Massachusetts, two in Connecticut, and one each in Texas, Wisconsin, Ohio, and 

Oregon. The team toured these facilities and interviewed management and clinical 

staff. The study team also conducted a telephone interview with administrative and 

clinical staff at a center in Mississippi. We choose the centers based on discussions 

with regional PHS staff and with consideration of geographic representation and 

community size. Of the ten centers, seven had received CPCP funding. 

A -1 
Intetiews: The study team held discussions with (1) officials in PHS’S Bureau of 

Primary Health Care (BPHC) (at that time called the Bureau of Health Care Delivery 

and Assistance), both in headquarters and in those regional offices responsible for the 

oversight of site-visit centers; (2) State primary care association and cooperative 

agreement staff in those States and regions in which site-visit centers are located; and 

(3) infant and community health experts, including staff at the Children’s Defense 

Fund, the National Commission to Prevent Infant Mortality, and the National 

Association of Community Health Centers. 

Literature and Data Review: The team reviewed extensive literature in the areas of 

infant and community health. The Public Health Service provided us with financial 

data that were collected from the centers through the Bureau’s Common Reporting 

Requirements reports, and with financial and user data that were collected from CPCP 

applicants through the Perinatal User Profile reports. 
APPENDIX B 

URBAN AND RURAL SURVEY RESPONSES 

The Office of Inspector General suwey was mailed to 514 community health centers in May 

1991. Of the 431 (84 percent) that responded, 62 provided no perinatal sexvices on site during 

the 1988-91 period. Below we present the frequencies and mean responses for those 369 

centers that did Drovide sefices at some point . during — this period. Not all centers answered

every question. ‘me number of respondents to each 

appropriate. 

Any discrepancies between the responses below and 

report are a result of the methods used in aggregating 

appendix C for a discussion of statistical methodology. 

field (N) is indicated in parentheses as 

the data presented in the body of this 

data and calculating trends. Please see 

Number of centers that offered pcrinatal sexvices on site in each year: 

1988: Yes=331 No=33 

1989: Yes=341 No=26 

1990: Yes=352 No=16 

1991: YeS=349 NO=18 

A CASELOAD 1988 

1. Please indicate: 

a. the number of women who received prenalal 

care at your center: 359 (283) 

b. the percentage of these clients who were 

high-risk as defined by your center: 31% (222) 

c. the percentage of these clients who were 

d. 

2. 

low~ris~ as ~efined by your center: 55% (217) 

the number of births to your center’s 

clients: 253 (259) 

Of the women who gave birth in your setice 

area, what percentage received prenatal care 

at your center? 37% (199) 

1989 

MEAN(N) 

391 (323) 

33% (259) 

55% (255) 

273 (296) 

40% (218) 

1990 

406 (345) 

33% (288) 

56% (279) 

310 (284) 

43% (214) 

B-1 
B. COMMUNITY COORDINATION 

1. Does your center currently participate in a consortium of perinatal care providem? 

Yes =240 No =128 If YES, please continue. 

2. ~ich of the following participate in the consortium? (Please check all that apply): 

a. state health department: 107 f. nonteaching hospitals: 84 

b. local health department: 173 g. private-practi~ physicians: 113 

c. health clinics: 116 h. gov. social setvice agencies: 104 

d. schools: 67 i. non-profit organizations: 116 

e. teaching hospitals: 122 j. other: 24 

3. On the last page of this survey, briefly describe the coordination of consortium activities and 

your center’s involvement. 

C. CLINIC SITES AND HOURS 1988 1989 1990 

1. 

a. 

b. 

2. 

Please indicate the number OE MEAN (N-) 

clinic sites operated by your center: 2.2 (351) 2.3 (353) 2.4 (357) 

clinic sites at which prenatal care 

was provided: 1.7 (357) 1.7 (359) 1.8 (361) 

On how many days a week did your center 

provide scheduled prenatal appointments 

either before 8AM or after 6PM? 1.0 (344) 1.1 (347) 1.2 (351) 

3. On how many Saturdays a month did 

your center provide scheduled 

prenatal appointments? 0.5 (340) 0.5 (342) 0.6 (347) 

D. Funding 

1. Compared with 1988,the amount of funding available for 

was: 

Larger= 185 Smaller=47 Unchanged= 114 

perinatal care at your center in 1990 

2. Please indicate the percentage of your center’s 1990 perinatal clients covered by: MEAN ~ 

a. Private insurance: 10.3% (318) c. Medicaid: 66.9%0 (319) 

b. No insurance: 18.9% (321) d. Other: 3.1% (330) 

B-2 
3. To what extent have the following factors resulted in increased demand for perinatal services 

at your center over the past three years? 

Not at all/ Moderately/ 

Somewhat substantially 

a. Medicaid eligibility expansions: 134 194 

b. Medicaid presumptive and 

continuous eligibility provisions: 150 174 

IZ PERINATAL OUTREACH 

1. To which of the following groups does your center currently target specific perinatal outreach 

efforts? (Please check all that apply) 

a. Teenagers: 310 c. Non-English speakers: 157 

b. Substance abusers: 133 d. Other: 106 

2. At which of the following locations does your center currently conduct perinatal outreach? 

(Please check all that apply) 

a. Community d. Schools: 238 

centers: 179 e. Welfare offices: 120 

b. Shops: 47 f. Churches: 107 

c. Door-to-door in the g. Other: 128 

neighborhood: 76 

3. Through which of the following media does your center currently conduct perinatal outreach? 

(Please check all that apply) 

a. Television: 61 d. Radio: 104 

b. Newspapers: 180 e. Other: 97 

c. Pamphlets: 283 

4. Compared with 1988, your center’s outreach efforts in 1990 were: 

Greater= 232 SmaUcr=27 ‘Thesame=87 

5. Compared with 1988, your center’s outreach efforts in 1990 yielded: 

More clients=245 Fewer clients=23 The same number of clients=57 

B-3 
F. PEIUNATfi SERV’IL~ 

1. Please indicate which of the following services were provided by your center. If these were 

offered on site, please circle On. If these were offered off site--either through contract, affiliation, 

or paid referrall-pleme circle OK 

a. Ultrasound: 

b. Amniocentesis: 

c. Genetic counseling: 

d. Non-stress testing: 

e. Dental care: 

t. Nutritional setices: 

h. Health education: 

i. Birthing classes: 

j. Parenting/infant care classes: 

k. Family planning: 

1.Smoking cessation programs: 

m. Substance abuse treatment: 

n. HIV counseling/testing: 

1988 1989 1990 

~.~ On=lol orl=l13 

0ff=230 off=224 0ff=226 

On=ls on=14 on=20 

01x=286 off=295 0ff=297 

Orl=so orl=53 on=59 

~=237 0ff=244 0ff=247 

on=71 on.~ on=95 

0ff=220 off=210 off=211 

on=201 on=199 on=206 

Off=llo OEi= 122 0il=131 

0n=285 orl=2% 0n=312 

0E=43 0fi=42 Off=27 

011=307 on=319 on=339 

0ff=27 0ff=21 0fl=16 

0n=161 on=179 On=l% 

off= 133 Off= 127 Off= 126 

0n=163 0Q=181 0n=223 

off= 120 0H=116 Off=% 

011=326 on=330 on=343 

0ff=12 0ff=13 0ff=13 

on=137 0n=142 0n=165 

Off= 122 Off= 126 Off= 128 

0n=63 0n=62 on=79 

off=220 0H=227 0ff=233 

on=179 0u=230 0n=278 

off= 105 0ff=81 0ff=56 

2. Compared with 1988, the range of perinatal 

semices offered by your center in 1990 was: 

Greater= 250 Smaller=30 Unchangd=79 

3. Were perinatal clients enrolled on-site at the center 

in the following programs’] 

a. Medicaid: yes=89 yes=135 Yes=205 

No=256 No=213 No=156 

b. WIC: yes=212 Yes=230 Yes=241 

No=136 No=124 No=121 

B-4

1988 1989 1990 

4. Did other government orprivate social setice 

organizations	 provide sewica on-site at your 

center? 

5. Did your center facilitate access to perinatal 

care by providing the following services? 

a. Transportation to and from appointments: 

b. Translation for non-English speaking clients: 

c. Child care during center appointments: 

d. Home visits: 

G. STAFFING 

1. How many full-timeequivalenfi of each 

of the following provided perinatal services 

on-site at the center? 

Yes=98 Y~=108 Yes= 138 

No=247 No=242 No=224 

Yes=161 yes=186 yes=211 

NO=183 No=164 No=150 

Yes=205 Yes=215 Yes=230 

No=113 No=11O No=99 

yes=30 yes=34 yes=47 

No=316 No=319 No=311 

Yes=161 yes=204 Yes=230 

;0=184 No=150 No=131 

1988 1989 1990 

MEAN (N=369) 

0.64 0.70 0.66 

1.08 1.09 1.11 

0.23 0.25 0.28 

0.56 0.62 0.66 

0.29 0.31 0.34 

a. 

b. 

c. 

d. 

e. 

L. 

obstetricians: 

Family physicians: 

Certified nurse midwives: 

Nurse practitioners: 

Physician assistants: 

Please indicate below: (i) the number of your perinatal provider positions which are currently 

vacant; (ii) the number which have been vacant for more that six months; and (iii) the number 

MEAN (N=369) which have been vacant for more than one 

a. Obstetrician: 

b. Family physician: 

c. Certified nurse midwife: 

year 

(i) 

Number of More than More than 

vacancies six months one year 

0.33 0.27 0.16 

0.41 0.35 0.20 

0.14 0.11 0.06 

(ii) (iii) 

3.	 Compared with 1988, the percentage of your perinatal providers with admitting privileges at 

local hospitals in 1990 was: 

Larger=93 Smaller=67 Unchangd= 188 

B-5 

7 
H. TIMING OF CARE 

1. Please indicate the percentage of your center’s 1990 prenatal clients who entered care in the: 

w 

a. First trimester: 55.0% (N=337) 

b. Second trimester: 34.6% (N=334) 

c. Third trimester: 10.1% (N=302) MEAN (n) 

1988 1989 1990 

2. Of those clients who entered care during the 

first trimester, and carried to term, what 

percentage received at least nine prenatal . 

medical visits? 75% (183) 

3. What percentage of your center’s prenatal 

clients returned for postpartum visits 

during the first eigh~ weeks after delivery? 68% (205) 

4. What percentage of all infants born to center 

r)renatal clients returned for newborn visits 

~uring the first four weeks after birth? 68% (200) 

76% (218) 

70% (263) 

70% (248) 

79% (255) 

73% (303) 

73% (286) 

1. APPOINTMENTS FOR CARE 

1. If a woman called today to schedule a pregnancy test, how long would she wait for an 

appointment? 

Pregnancy tests are offered Less than one week: 113 

on a waik-in basis: 228 One-two weeks: 20 

More than 

two weeks: 5 

2. If the pregnancy test were negative, would she be referred to family planning services? 

Yes=328 No=35 

3. If the pregnancy test were positive, how long would she wait for her first prenatal visit? 

The first perinatal visit is 

provided in conjunction 

with the pregnancy test: 

4. Compared with 1988, waiting 

generally: 

59 

room waiting 

Less than two weeks: 193 

Two-four weeks: 100 

One-two months: 9 

More than 

two months: 4 

times at perinatal appointments in 1990 were 

Shorter= 121 Longer=59 The same= 162 

B-6 
J. CASE MANAGEMENT 

1. Does your center currently provide case management to 

for perinatal clients? 

Yes=337 No=32 If YES, please continue. 

2. Case management at your center is primarily conducted 

The client’s primary care doctor: 32 

The client’s primary care nurse: 37 

The appointmen~ secretary: 2 

A multidisciplina~ team: 123 

A center employee whose main 

responsibility is case management 

for perinatal clients: 126 

Other: 18 

promote the coordination of services 

by (please check only one): 

3. Case management at your center is provided for (please check only one): 

All perinatal clients: 272 

All high-risk perinatal clients: 43 

Only certain groups of 

perinatal clients: 23 

4. Case management of perinatal clients at your center comprises (please check all that apply): 

a. Risk assessment: 

b. Planning of care: 

c. Assessment of adequacy and 

appropriateness of setices: 

d. Client advocacy: 

e. Contact with other organizations 

to arrange for services / 

schedule appointments: 

f. Assistance with paperwork related to 

WIC, Medicaid, and other programs: 

g. Discharge planning: 

Coordination of 

h. Medical services provided 

on-site at the center: 

i. Medical sexwices provided 

off-site: 

320 

314 

278 

277 

322 

299 

186 

311 

276 

B-7 
Continued: 

j. Delivery services: 245 

k. Social sewices provided 

on-site at the center: 253 

1. Social semices provided 

off-site: 243 

m. Nutritional services: 313 

n. Health education: 315 

0. Other: 

5. Compared with 1988, the percentage of all center perinatal clients case managed by your staff 

in 1990 was: 

L.arger=266 SmalIer=17 Unchanged=44 

6. Does your center often encounter problems assuring the timely transfer of medical records to 

and from facilities to which perinatal clients are referred? 

For delivery: Yes=76 No=262 

For other care: Yes=84 No=244 

7. Please estimate the percentage of cases in which your center contacts perinatal clients to 

reschedule missed appointments: 

~m 

65% (N=309) 

8. Please indicate the manner in which you contact clients to reschedule missed appointments 

(please check all that apply): 

Mail= 305 Phone= 329 Home visit= 207 Other= 25 

9. Are perinatal clients at your center routinely attended by either the same primary medical 

provider or the same provider team at each perinatal visit? 

Yes=321 No=13 

B-8 
K LIMITATIONS ~ CARE Please indicate the degree to which each of the following factors 

limits your center’s ability to provide perinatal setvices: 

Not at W Moderately/ 

Somewhat substantially 

1. Shortage of medical staff 

2. Shortage of nonmedical staff 

3. High medical staff turnover: 

4. High nonmedical staff turnover: 

Difficulty obtaining admitting privileges 

at local hospitals for: 

5. obstetricians: 

6. family physicians: 

7. certified nurse midwives: 

8. High cost of malpractice insurance: 

Difficulty obtaining malpractice insurance for: 

9. obstetric providers: 

10. all providers: 

Difficulty arranging medical backup for: 

11. OB supervision of certified nurse midwives/ 

nurse practitioners: 

12. OB supewision of family physicians: 

13. coverage during center staff vacations, 

holidays, and weekends: 

14. consultation for high-risk patients: 

15. Limited relationships with local 

community and government organizations: 

16. Lack of other providers in the community 

willing to treat uninsured or publicly 

insured women: 

Non-acceptance of cer~ified nurse midwives/ 

nurse practitioners: 

17. by the medical community: 

18. by patients: 

19. Inadequate center funding: 

20. Difficulties related to funding obtained 

from many different sources: 

Medicaid-related problems: 

21. slow reimbursement process: 

22. inadequate reimbursement rates: 

23. limited range of covered services: 

24. restrictive eligibility criteria: 

25. burdensome application procedures: 

26. Limited case management: 

27. Limited collocation of services: 

28. Limited space: 

29. Other 

132 227 

250 95 

240 105 

303 38 

276 31 

275 46 

178 83 

150 190 

255 62 

280 51 

185 102 

209 85 

1% 143 

240 99 

318 

142 

31 

206 

204 108 

277 21 

139 210 

187 147 

207 

175 

206 

199 

163 

246 

242 

156 

37 

141 

170 

135 

146 

188 

94 

83 

193 

28 

B-9 
mich of these factors have become LESS SERIOUS or MORE SERIOUS limitations since 

1988? More 

serious serious 

1. Shortage of medical staff 

2. Shortage of nonmedi~l staff 

3. High medical staff turnover: 

4. High nonmedid staff turnover: 

139 49 

43 44 

51 45 

15 45 

Difficulty obtaining admitting privileges 

at local hospitals for: 

5. obstetricians: 

6. family physicians: 

7. certified nurse midwives: 

40 

33 

29 

17 

23 

26 

25 91 8. High cost of malpractiu insuranu: 

Difficulty obtaining malpractim insuran~ for: 

9. obstetric providers: 

10. all providers: 

27 

27 

32 

21 

Difficulty arranging medical backup for: 

11. OB supervision of certified nurse midwivti/ 

nurse practitioners: 

12. OB supetision of family physicians: 

13. coverage during center staff vacations, 

holidays, and weekends: 

14. consultation for high-risk patients: 

29 

28 

55 

45 

31 

33 

76 

54 

15. Limited relationships with local 

community and government organizations: 

16. Lack of other providers in the community 

willing to treat uninsured or publicly 

insured women: 

69 12 

28 111 

Non-acceptanm of certified nurse midwivti/ 

nurse practitioners: 

17. by the medical community: 

18. by patients: 

50 

48 

27 

8 

89 44

19. Inadequate center funding: 

20. Difficulties related to funding obtained 

from many different sources: 

69 22

Medicaid-related problems: 

21. slow reimbursement process: 

22. inadequate reimbursement rates: 

23. limited range of covered servim 

24. restrictive eligibility criteria: 

25. burdensome application procedures: 

66 

90 

69 

110 

80 

54 

57 

44 

49 

63 

86 

52 

43 

2 

32 

22 

107 

8 

26. Limited case management: 

27. Limited collocation of services: 

28. Limited space: 

29. Other 

B-10 
L CONCLUSION 

1. Over the past three years, demand for perinatal care at your center has: 

Imxeasd=201 Decreased =22 Not changed=40 

2. Over the past three years, your center’s capacity to address the demand for perinatal care in 

your setvice area has: 

Inereawxl=210 Dtxxead=88 Not changed=64 

OPEN-ENDED QUESTIONS: [Center responses are not included here]: 

3. What are the three most significant barriers to delivering perinatal care that your center has 

faced in the past three years? 

4. What special projects, initiatives, or programs has your center undertaken over the past three 

yms to improve its ability to respond to perinatal care needs in your setvice area? 

B-n 
APPENDIX C 

DETAILED COMME~ ON THE DRAFI’ REPORT 

h th~s appendti, we present the complete comments on the draft repofi received from 

the Public I-lea\th Setice (PHS), the Office of the Assistant Secretaq for Planning 

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

Public Health Sewice 

Assistant Secretary for Planning and Evaluation 

Health Care Financ~ng Admlnlstratlon 

Page C-2 

Page C-5 

Page C-6 

c-1 
--

,. ,11*1 <,, 

+ ‘>,. ...

* 

~ (

i’ DEPART,’tlENTOF HWLTII & HUALNJ SERVICES f%bficHeakh SeM”ce 

*3 -; 

’56>

‘~,ilc~ Memorandum 

C3:e � NOV ~ w 

~fom - ~~ssi~tant secret s.-y for Health 

Office of Inspec:cr General Reports on the Perinatal Service 

‘Ub’mqCapacity of the Federally Funded Community Health Centers, 

OEI-01-90-02330, OEI-01-90-(12331, and OEI-01-90-02332 

To Acting Inspector General, OS 

Attached are the Public Health Servi-ce (PHS) conmen~s on the 

subject Inspector General reports- We concur with the 

recommendation for PHS, in coordination with the Health Care 

Financing ~%dmini~tration and the Assistant Secretaq for 

?lanning and Evaluation, to develop and hnplement a plan of 

action to address the key areas for action identified in these 

reports. Our coxmenta discuss some of the actions planned or 

underway to Lnprove perinatal services in the community health 

center~ . 

k (’)+WW-’ 

ames O. Mason, M.D., DroP”~” 

v 

~Attacbunent 

C-2 
PUBLIC !~ZALT1iSERVTCE {PHS\ COMMENTS ON THE OFFICE OF INSPECTOR 

GENERAL (OIG\ 2EPORTS ON THE PERINATAL SERVICE CAPACITY 

OF THE FEDE?ALLY FUNDED COMKUNITY HEALTH CENTERS, 

OE1-01-90-02330, OEI-01-90-02331, AND OEI-01-90-02332 

The OIG reports sm~arize the results of an inspection which 

revealed that the per~natal capacity of the co~~lty health 

centers (CHC) inc~cased in several respects between 1988 and 

1990. However, OIG reports that the inspection also revealed 

that the demand for ~e~~ices also i~cre~sed apd ~ny clients do 

not receive the optimal coordinated package of care in a t~ely 

fashion. The reports note t-hat several key constraints limit the 

perinatal capacity of the CHCS. OIG suggests that a cooperative 

effort involving government at the Federal, State, and local 

levels , as well as non-governmental organizations is needed tO 

acidxessi these find~ng8. 

The OIG report desc~lbes many programs ud lniti.atf-ves Of the


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


which is part Of the PHS’ Health Resources and Services


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


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


follow, we will refer to the organizatiorl responsible for


managing the CIIC program by this new title.


OIG Recommendation


We recoxmnend that PHS, the Health Care Pinancing Administration 

(HCFA), and the Assistant Secretary for planning and Evaluation 

(ASPE) develop and iii,plementa plan of action to: (1) address 

the staffing needs of the CHCS, (2) relieve the CHCS of the high 

co~ts of medical malpractice insurance, (3) improve ties between 

the CHCS and the-xedi.caici pragram, and (4) strengthen 

relationships between the CHCS and other health and social 

service providers in the co~~ityc 

PHS Comments


We concur with this recommendation. We are particularly 

appreciative of the OIG recommendation to bring together agencies 

throughout the Department of Health and Human Semites that can 

work with BPHC on i.nproving perinatal services in CHCS. 

Furthermore, 13PHC is prepared to take the lead on development on 

the plan recommended k~ OIG. we consider it critical that the


plan be the result of a process that includes the participation 

of Departmental agencies and other affected parties (e.g. , State 

and local govenm,ent agencies, grantees) . 

The lEISA and the 21{SInteragency Committee on Infant Mortality 

(ICIM) are prep~r~d tO “~orkwith other agencies throughout the 

Department of ~IeaL:hand Human Semites to address the key issues 

c-3 
2


identified in the OIG report and improve perinatal se~~ces in 

the CHCS. HRSA plans to take the following actions to Implement 

this recommendation: 

1.	 In the Autuii of i992, convene an internal work group to 

outline the steps and develop an implementation plan that 

describe the direction BPHC and its p~09~~s f~~l ‘ake ‘n 

addressing the OIG report’s recomendation~ 

implementation plan will be developed to co+.ncidewith 

discussion affecting Fiscal Year 1993 fmdlng= 

2.	 In collaboration with the ICIM, convene a meeting of 

Departmental representatives who can review BPHC’S plan and 

help formulate step8 involving offices external to BPHC* 

Agencies asked to participate will include other l?HS 

components? XPE~ ~~c~h~ the Office of the Msistmt . for
 . 

Secretaq for Management and Budget, the AtinistrntlOn 

Childzen and Families, and the Depa~ent of Agriculture’s 

WIC Program.


The KRSA plans this meeting before the end of to convene 

produce a plan with admhistrative calendar year 1992 and


hnrovments and action steps to coincide with the budget


an; legislative cycle.


We concur that X5PZ approve and nonitor this plan once it 

has been apprcved by the Assistmt Secretaq for Health­ . CongreSs In a directly related matter, before adjoum>ng the 

passed ~egi~lation {i?.~. 6183) which extends Federal Tort Clahs 

fict (FTCA) protection for three years 

to health care providers 

employed by certain Federally-funded health care entlties~ 

including CHCS. The FTCA coverage is paid for by a Judqent Fund 

in the U.S. Treasury, and the Depar~ent of Justice handlee theThe 

cases with help frcn the General Counsel of each Deparment” 

bill requires annual contributions from the relevant progr~f 

e.g., CHCS, to the Juaqent Fund, baaed on the prior year’s 

experience. There are riaxi.mm limits to the annual 

contributions . At the time these comments were prepared, the 

President had not signed this bill. 

C-4

�������� ‘f, ~+‘ , 

. 

~ 

: DEPARTMENT OF HEALTH & HUMAN SERVICES offkaofthas~ 

:

. 

,

-0‘*,b>I,.,,a Washington, D.C.20201 

JLJL161W 

TO: 

FROM : 

SUBJECT : 

Thank you 

copies of 

Richard P. Kusserow 

Inspector General 

Assistant Secretary for Planning and Evaluation 

OIG Draft Reports on the Perinatal SeNice capacity of 

the Federally Funded Community Health Centers, OEI-Ol90–02330; OEI-01-90-02331; and QEI-G1-90-02332 

for submitting for my review and comment the draft 

the subject reports. The reports provide useful 

information on issues pertaining to peiinatal senice capacity 

Community Health Centers [CHCS). 

I support the recommendation that the Assistant Secreta~ fOr 

Health and the Administrator of the Health Care Financing 

in 

Administration develop a plan of action to address the key areas 

outlined in these reports, and that the Assistant Secretary for 

Planning and Evaluation review such a plan to assure that our 

national objectives to reduce infant mortality rates and increase 

access to perinatal care are met by the year 2000. The role of 

CHCS is increasingly important in our efforts to achieve health 

care refom and provide better access to undersexed communities. 

We look fonard to workin~ with PHS and HCFA to assure ‘hat ‘Ur 

limited health care resou~ces are used as effectively as 

possible. 

We intend to incorporate this action plan into the actions 

already in progress in the Secretary’s Program Directions plan to 

improve pre- and perinatal care. 

lf you have any questions, please phone Elise Smith on 690-1870. 

. 

c-5 
Date 

h ‘rem () 

5Ublecl 

DEPARTAIENTOF HEALTH & HUhlAN SERVICES’ 

Health Care 

financing Administration 

n*ln?Ann 

““Z7’4L 

\Villim Toby, Jr.’ 

.Aicting Adminktrator 

Office of Lnspector General (OIG) Draft Reports 

the FederaLIy Funded Communltv Health Centers, / 

Memorandum 

on the PerinaEl Setice 

OEI-01-90-02330, OEI-01-90-02331, and OEI-01-90-02332 

TO 

Bryan B. Ltitchell 

Principal Deputy Inspector General 

Capacity of 

. We have rcvicwcci the three above-referenceci reports on perinatal scnnce 

capacityof fedcr~y-findeci Urban community health Ce-nters, mral cornmuni~ health 

centers, and all co~unity health centers. 

We agree bat tic icdcraily-funded community and migrant healthcenters 

(C~4HCs) plav an important role in national strategies to reduce infant mortality, and 

that Nledicaid “rcunburscmcnt and strong relationships between C/MHCS and s~~c 

Medicaid programs are essential. In fac~ beause of our stiong belief in this objective, 

we aiready have a varlc~ of actions underway in concefi witi the Health Resources 

and Setices A~inis~aLOn and with the A&tant Secretav for planning and 

Evaluation (ASPE) to address better program coordination. L)vlanyof these activities 

~0 beyond the Icgal authorities mentioned in the OIG reportNot all of the issues mentioned in the report relate toprogramcoordination.A 

number of tic issues need to bc addressed directly by the Public ~ealti Senice (PHS) 

and the QMI-Ics, such as Staffingand spaceneeds. 

Partlybecause of the delay in collecting information and incorporating those 

data JDIOt.hc OIG rCPo~ ~nd, partly as a result of the methodology used as the basis 

[or the recommendations in the repoz we bebe~”e the OIG overlooked a broad Variety 

of steps the Dcpar~cnt IS taking to address the chief concerns identified in the 

reports. [n addition, the reports fail to recognize the elements of the President’s 

Hcaiti Care Reform plan that are responsive, albeit on a broader bask, to some of the 

issues raked in the audits. Limits on malpractice insurance are one exampie of Such 

an eIemen L 

C-6 
Conscquentl}’, ~vc do notsupport the recommendation for a new initiative on 

the part of the Dcp”2~cnt lnvol~ting ASpE, pHS and HCFA to address these 

concerns since wc hcllcve hat such a recommendation duphcates efforts that are 

aircadv under \vav. ~ese ~~ent cffo~ are a comb~ation of HCFA’S Medicaid 

innovations dea~g w~~ OuVcach, s~etied e~gibfi~ dete~tiations. new 

reimbursement approaches, special HCFA-PHS cooper~~e efforts, and special 

responses to tie Secrew’s progr~ ~xtiatives w~ic~ are ~e~g conducted under the 

overnight of ASPE. -

~ttacbed foryourconsideration areour detaded comments. Thank you for the 

opportunl~ to review and comment on these draft reports. please advise us ~ you 

agree ~~~ our position on he repom’ reco~endations at your earfimt convenience. 

Attachment 
~’omrncnts of [hc Heaith Care Financ]ng Administration (HCF4] 

on ~(flcc of Inspector C~cnerai (OIG’) Draft Repo~ 

on the Pcrlnntal Semcc Capacity of the 

Federnil\’ F-tlncicd Communltv Health Centers 

0EI-fil-(jO-~12330. 0[31- 01-90-02331, and OEI-01-90-02332 

OIG Rccommcndation 

The Assistant Secrctaw for Health, the Admkkrator of tie Heal~ Care 

Financing Administration,and the Assistant Secretary for Planning and 

Evaluation should develop a plan of action to address the key areas outlined 

above. 

HCFA Response 

~~e be~icve that OIG has ldcnt]ficd pertinent problems that community and 

migrant heaith centers iCNHC) face when delivering perinatil care to low 

Income. high risk women. However, since I-ICFA and the Public Health 

ScWIcc (PfiS) arc already l~orking together to resolve many of these issues, 

we cannot commit to dc~’cioping a new initiative which may duplicate or delay 

ongoing efforts. The following arc activities already undemay: 

o Under the Deparment’s Interagenm Committee on 

Infant Nlortaliw (on which the Assistant Secretary for 

Planning and Evaiuatlon (ASPE) is also represented), 

the Directors of HCFA’S ,Medicaid Bureau and PHS’S 

Bureau of Health Care Delivery and Assistance co-chair 

an ACCCSS\J’ork Group. Its agenda includes streamlined 

eligibility and outstatloning eligibility workers at 

C/MHCs. 

o	 HCF:\ has an ]ntcragcnc~ agreement with the Health Resources 

and Scmlccs ,\dmlnl;tratlon-concerning federally qualified health 

centers (FQHCs’) (I.e., [cderallv-finded C/MHCs). Reguiar 

meetings nrc held to plan and assess progress in achieving mutuai 

perlnatai care stratcglcs and Medicaid coordinated care initiatives. 

0	 The Secrcum”s. “Program Directions’, monitored by ASPE. inciude 

several primary and pcrlnatai care Initiatives involving C/MHCS and 

Jfedicald c!cmcnts. 

Insummam, Jvc bclic~e [hc reports do not adequately address current issues 

and or dcpnrtrncn~l plann]ng and implementation initiatives. 

c-s 
Page 2 

General Comments 

The following comments arc directed to the summary repofl: The PerinataI 

Service Capaci~ of the Federally Funded Community Health centers 

(OEI-01-90-02332). 

1.	 Discussions on pages v, 10, and 16 imply that little is being done about 

outstationed eligibility workers. In contras~ the National Governors’ 

Asoaation 1992 repor~ Outstationin p Medicaid Eli~ibiliN Workers at 

~ sQted* “~ost of the s~dY c~Hcs repofl that oufi~tioning 

also has improved the centers’ fiscal condition, at least as it pertains to 

the delivery of perinat.al sewices . . . . In general, the s~dy C~HCS are 

very satisfied with their outstationing arrangements . . . .“ 

Discussions on pages v, 10, and 16 imply that only half the States have 

implemented the FQHC reimbursement provisions. All States are 

implementing the provisions, and ail but one State plan amendment has 

been approved. 

2.	 The following commen~ relate to the Key Areas for Action on pages iv 

and v: 

o 

o 

Addressthes(affin~eedsofcenters­
OIG did not consider the 

five-point plan in the President’s budget which calls for e~anding 

C/MHCs and increasing funding for the Nationai Health Senice 

corps. 

In addition, States set credentiaiing criteria. The Federai


government does not play a large role in this area.


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


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


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


particularly affected by this problem. while immediate fixes may


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


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


President has addressed the issue of heaith care liability in his


proposai for CamprchensiVe heaith reform and in subsequent draft


legislation submitted to Congress on Juiy 2.


c-9 
Page 3 

0	 Improve the tics between the centers and the Medicaid pro~ram -

A modci auuiica~on form for Maternal and Child Assistance 

Programs &s dcveioped by the Administration for Children and 

Famdies. HCFA, PHS, and the Food and Nutrition Sefice of the 

Department of Agriculture, and was published in the Federal 

Register on December 9, 1991. 

Also, tic Medicaid program already gives States the option to use a 

shortened application form, implement an expedited eligibility 

program for women and children, and outstation eligibility workers. 

In addition, HCFA is working closely with PHS to implement the 

FQHC mandate. HCFA has distributed lists of FQHCS tO the 

States, and issued policyand retiew guidelines. 

o	 Stren~then relationships be~een the centers and other heakh and 

soclai sewce prowders In the communi~ - HCFA beiieves that 

coordinated care is the best route to increasing access to providers. 

HCFA is aiready working with PHS on how to best integrate 

FQHCS into coordinated care ne~orks. 

In addition, the Omnibus Budget and Reconciliation Act of 1989 

requires States to raise Medicaid obstetric/pediatric paymenfi to 

ensure that access to services by Medicaid recipients is comparable 

to the general population in the same area. This mandate should 

have the effect of strengthening the relationships between the 

centers
and individual providers in their community. 

3.	 ~- Although the reports address financing and Medicaid 

issues, no intewiewswere held with officials in State Medicaid agencies 

or central and regional offices of HCFA. Based on these incomplete 

data. we suggest that OIG include a Medicaid-related discussion in the 

report and arrange an Information gathering conference with HCFA. 

c-lo 
APPENDIX D 

1. 

2. 

3. 

4. 

NOTES 

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. 

U.S. Public Health Service (PHS), Healthy People 2(900: National Health 

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

PHS, Caring for Our Future: 7%e Content of Prenatal Care: A Repo~ of the 

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

Sarah S. Brown, editor: Institute of Medicine, Prenatal Care: Reaching Mothen 

Reaching Infants, National Academy Press, Washington, D. C., 1988, p. 4. 

Deborah Lewis-Idema, Increasing Provider Participation, National Governors’ 

Association, Washington, D. C., 1988, pp 20-23. An increasing number of 

physicians who practice obstetrics are unwilling to accept low-income or 

Medicaid-insured patients because of high malpractice premiums and low 

Medicaid reimbursement rates. 

In September 1990, the American College of Obstetricians and Gynecologists 

(ACOG) reported that, as a result of the risk of malpractice, 12 percent of its 

members had discontinued their obstetric practices, 24 percent had reduced or 

eliminated services to high-risk women, and 10 percent had decreased the 

number of deliveries they performed. Average obstetric premiums rose 248 

percent between 1982 and 1989. (ACOG, prepared by Opinion Research 

Corporation, “Professional Liability and Its Effects: Report of a 1990 Survey of 

ACOG’s Membership,” Washington, D.C., September 1990.) The ACOG 

repeated this sumey in September 1992, and found no statistically significant 

differences from the prior survey. 

In addition, as of 1987, 64 percent of family physicians who once provided 

obstetric semices had discontinued such care. (American Academy of Family 

Physicians, “Family Physicians and Obstetrics: A Professional Liability Study,” 

1987.) 

D-1 
5. 

6. 

‘7. 

8. 

9. 

10. 

11. 

NCHS, “Advance Report on Final Natality Statistics, 1989,” Monthly Htal 

Statistics Repoti, vol. 40, no. 8, Supplement, December 12, 1991, p. 43. These 

1989 data are the most current available. 

Alan Guttmacher Institute, Prenatal Care in the United States, New York, N.Y., 

1987, vol. I, p. vi. Adequacy of care is a function of time of entrance into care 

and number of visits. During the period 1984-86, 24 percent of women entered 

care after the first trimester, 24 percent had fewer than 9 visits, and 34 percent 

received less than adequate care. 

Alice Sardell, 771eU.S. Experiment in Social Medicine: l%e Community Health 

Center Program, 1965-1986, University of Pittsburgh Press, Pittsburgh, P& 1988, 

p. 66. 

Bonnie Lefkowit~ Bureau of Primary Health Care (BPHC), PHS, “The 

Institutionalization of Community Health Centers,” speech to the American 

Public Health Association, November 13, 1983, p. 4. This number represents 

consolidation as well as elimination of grantees. 

All of these centers received Section-330 community health center grants. 

Some also received Section-329 funds for care provided to migrant workers; an 

additional 71 centers received only Section-329 funding. 

Through the National Health Service Corps (NHSC), PHS offers scholarships 

and loan repayment to health providers who commit to work in designated 

Health Professional Shortage Areas for a given period. A large percentage of 

corps providers have traditionally worked in community health centers. After 

substantial cuts in program size in the early 1980’s, 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-1990’s. 

The Department of Agriculture provides vouchers through this program to 

address the nutritional needs of pregnant and lactating women and their 

infants. 

The Rural Health Clinic Services Act of 1977 provides cost-related Medicaid 

reimbursement for semices at rural centers in Health Professional Shortage 

Areas or Medically Underserved Areas. Qualifying centers must be staffed by 

at least one certified nurse midwife, nurse practitioner, or physician assistant, 

whose practice must be within the scope of State law and regulation. Prior to 

passage of this act, these providers were not eligible for Medicaid 

reimbursement in some States. Because of problems with regulation, 

certification, and reimbursement, however, far fewer centers than expected had 

availed themselves of reimbursement under the act. 

D-2 
12. Section 330 funding was $435 million in FY 1989, $457 million in FY 1990, and 

$478 million in FY 1991 (Health Resources and Sexvices Administration 

(HRSA) FY 1993 Justification of Appropriations, vol. 1, p. 63.) 

Section 330 funding for FY 1992 was $532 million. The FY 1993 appropriation 

is $559 million. (BPHC and the Assistant Secretary for Management and 

Budget [ASMB].) 

13. Congress has provided for: (1) expanded eligibility: States are now mandated 

to extend coverage to all pregnant women below 133 percent of the Federal 

poverty level, and have the option of extending coverage to women between 

133 and 185 percent of the poverty level; (2) continuous eligiii.lity eligibility 

for coverage is now guaranteed throughout pregnancy and the postpartum 

period, regardless of income changes; (3) presumptive eligibility States have 

the option of granting temporary coverage based solely on self-reported 

income; (4) expanded coverage: case management services are now 

reimbursable; and (5) outstationing States must place eligibility workers at 

locations other than AFDC enrollment sites, including CHCS. 

14. CPCP funding was $30 million in FY 1990 and $33 million in FY 1991. (HRSA 

FY 1993 Justification of Appropriations, vol. 1.) 

In fiscal years 1992 and 1993, $44.7 million was appropriated for the CPCP. 

(BPHC and ASMB data.) 

Eighty percent of urban and 51 percent of rural centers that responded to our 

survey and offered perinatal services had received CPCP funding at some point 

during the 1988-1991 period. 

15. The HHS Office of Inspector General (OIG) has addressed the issue of 

perinatal care for underserved women in several prior studies: Medicaid 

Expansions for Prenatal Care: State and Local Implementation 

(OEI-06-90-O0160), January 1992; Comprehensive Perinatal Care Program 

(OEI-01-90-00460), November 1990; Access to Medicaid-Covered Prenatal Care 

(OE1-06-90-00162), October 1990; Evaluation of the Boston Healthy Baby 

Program (OAI-01-88-01420), July 1989; and Local Management and 

Implementation Strategies to Reduce Infant Mortality (OA1-01-88-01420), July 

1989. 

16. Our sumey inquired about the provision of a representative range of perinatal 

medical and health-promotion services: ultrasound, amniocentesis, genetic 

counseling, non-stress testing, dental care, nutritional services, health education, 

childbirth classes. parenting/infant-care classes, family planning, 

smoking-cessation programs, substance-abuse treatment, and HIV 

counseling/testing. Our survey also inquired about the provision of four ancillary 

D-3 
services that facilitate access to care: translation, transportation, home visiting, 

and child care during appointments. 

17.	 Some centers completed enrollment on site. Other centers only began the 

enrollment process at the center and applicants had to complete it at the 

appropriate State offices. In some instances, centers completed all nutritional 

assessment and WIC paperwork on site, but clients had to obtain vouchers at a 

different location. 

18. Bureau’s Common Reporting Requirements (BCRR) Database, BPHC, PHS. 

This database contains self-reported financial and caseload data from Section 

330 grantees. We derived the percentage change in center revenues from data 

for those 146 urban centers that both responded to our sumey and provided 

financial data to BPHC through the BCRR form for 1988 and 1990; and for 

214 rural centers that provided financial data to BPHC through the BCRR 

form for 1988 and 1990. Some of these rural centers did not respond to our 

survey. 

Total reported revenues for these 360 centers increased from $630 million in 

1988 to $803 million in 1990. Urban center revenues increased from $415 

million to $544 million; rural center revenues increased from $215 million to 

$259 million. 

PHS Section 330 grants increased from $258 million in 1988 to $305 million in 

1990. Urban centers received $163 million in 1988 and $193 million in 1990, 

while rural centers received $95 million and $113 million. 

Medicaid reimbursements to these centers increased from $107 million in 1988 

to $167 million in 1990. At urban centers, Medicaid reimbursements increased 

from $84 million to $134 million. At rural centers, reimbursements increased 

from $23 million to $33 million. 

These centers received additional revenues from: Maternal and Child Health 

block grants, PHS Section 329 and 340 grants for migrant workers and the 

homeless, WIC grants, Title X grants, Title XVIII Medicare payments, Title 

XX payments, other third party payments, patient collections, State and local 

revenues, and donations. 

19.	 We excluded these 62 centers from the calculations of the statistics presented in 

the body of this report (see appendix A for detailed methodology). 

20. PHS, Caring for Our Future, p. 2. 

H-IS, Healthy People 2000, p. 366. 

D-4

In our survey, we used the terms “health education” for “health promotion” and 

“social services” for “psychosocial services.” 

21. BPHC, PHS, “Program Expectations,” (hereafter P.E.), May 1, 1991, p. 21. 

This document outlines both requirements of law and regulation and 

Departmental priorities for the centers. 

BPHC, PHS, “Regional Program Guidance Memorandum 84-52,” May 15, 1984. 

22. NCHS, 1992. These 1989 data are the most current available. The average of 

62.2 percent for minority women was calculated from rates for Mexican 

American, Puerto Rican, Cuban, Central and South American, other Hispanic, 

Chinese, Japanese, Filipino, Hawaiian, other Asian, American Indian/Alaskan 

Native, and Black women. 

The BPHC provided the rate for women in federally designated Healthy Start 

project areas. The BPHC calculated this rate from information reported by the 

15 projects for a time period between 1984 and 1989. The project areas are: 

Aberdeen, South Dakota (rates are for the Northern Plains Native American 

populations in North Dakota, South Dakota, and Nebraska); Baltimore, 

Maryland; Birmingham, Alabama; Boston, Massachusetts; Chicago, Illinois; 

Cleveland, Ohio; Detroit, Michigan; Lake County, Indiana; New orleans, 

Louisiana; New York, New York; Oakland, California; the Pee Dee region, 

South Carolina; Philadelphia, Pennsylvania; Pittsburgh, Pennsylvania; and 

Washington, D.C. 

23. PHS, Healthy People 2000, p. 381. 

24. ACOG, Standards for Obstetric-Gynecologi”cal Services, 7th cd., Washington, 

D. C., 1989, p. 16. 

The PHS has required that “all centers, regardless of size, must assure that the 

services that they deliver conform to the Sfandards for Obsle&ic-Gynecologz”c 

Services” (“Perinatal Care: How to Establish Perinatal Services in Community 

Health Centers,” PHS, 1985, p. 96). 

A 1989 PI-IS report, Caringfor Our Future: Tile Content of Prenatal Care, 

suggests slightly different guidelines. This report recommends that healthy 

women receive a minimum of nine prenatal visits during a first pregnancy and 

seven prenatal visits during subsequent pregnancies (p. 50). The report 

suggests that women at risk, because of either psychosocial or physical factors, 

might require more prenatal visits (p. 71). Psychosocial and physical risk 

factors include: inadequate personal support systems, single marital status, 

adolescence, advanced age, high stress and anxiety, less than high school 

education, low income, inadequate housing, inadequate nutritional resources, 

communication barriers, smoking, alcohol abuse, and illicit drug use (p. 79). 

D-5 
25. 

26. 

27. 

28. 

29. 

30. 

31. 

32. 

33. 

34. 

In reporting responses to survey questions that solicited information on a scale, 

we have combined responses of “moderately” and “substantially” and have 

reported them as “seriously” or “serious.” 

Nonresponses may have resulted in an underestimate of the percentage of 

centers with such vacancies. 

See note 9. 

A substantial increase in commercial medical liability insurance rates and 

cutbacks in the National Health Service Corps program have resulted in 

dramatically increased expenditures on medical liability coverage for the 

centers. 

According to the U.S. General Accounting Office, insurance premiums in 1990 

amounted to an estimated 10 percent of the centers’ total Federal grant 

funding--or 4.4 percent of center revenues (Medical Malpractice: Data on 

Claims Needed to Evaluate Health Centers) Insurance Alternatives, I-IRD-91-98, 

Washington, D.C., May 1991, p. l.). 

P.L. 102-501. Under the ITC& center providers will be defended by the 

Justice Department in any medical malpractice litigation, and judgments will be 

paid out of a Justice Department fund, into which the centers will pay annual 

contributions. This liability protection will be provided for three years, after 

which time the financial benefits of the arrangement will be assessed. 

P. E., pp. 4-5. 

our survey questions addressed only admitting privileges. During interviews, 

center staff reported hospital restrictions on the delivery privileges of certified 

nurse midwives and family physicians. 

See note 18. 

The Omnibus Budget Reconciliation Act of 1990 mandated that States locate 

eligibility workers at sites other than AFDC enrollment sites, including CHCS, 

by July 1991. 

Bonnie Lefkowitz, BPHC, PHS, written communication to OIG, December 24, 

1991. 

In addition, only 26 States had adopted presumptive eligibility as of June 1991 

(Medicaid Expansions for Rrenatal Care: State and Local Implementation, 

appendix E). 

According to the OIG report, Medicaid Expansions for Prenatal Care: An 

D-6 
Updale (OEI-06-90-O0161), three States still used an asset test to determine 

35. 

36. 

37. 

38. 

39. 

40. 

41. 

42. 

43. 

Medicaid eligibility as of January 1992. 

According to an internal BPHC draft report, “CPCP 1990 Data Report: 

Moving Ahead,” CPCP-funded centers served 33,938 pregnant teens in 1990, 

which they report is more than triple the number sexved in 1988. AlSO 

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

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

BPHC’S CPCP data, however, does not permit a comparison of CPCP-funded 

centers and other centers. 

Unless otherwise noted, the differences between groups (for example, CPCPfunded centers and other centers) cited in this report are statistically significant 

at the .05 level. 

BPHC, PHS, “Supplemental Grants for the Development of a Comprehensive 

Perinatal Care Program in Community and Migrant Health Centers, 

Application Guidance,” undated document, p. 9. 

BPHC, PHS, “Supplemental Grants,” p. 1. 

Of those centers that did participate in consortia, a larger percentage of CPCP 

grant recipients than of other centers reported collaboration with schools, 

hospitals, private-practice physicians, government social-semice agencies, and 

nonprofit organizations. 

BPHC, PHS, “Supplemental Grants,” p. 9. 

We did not calculate the statistical significance of the difference between 

urban and rural center revenues. For more information on center 

revenues, see note 18. 

The difference between the percentage of urban centers and the percentage of 

rural centers that reported medical staff shortages as a serious limitation to the 

provision of perinatal setices was statistically significant at the .1 level. 

Additionally, the difference between the 1 percent decrease in FTE provider 

staff at rural centers and the 12 percent increase in FTE provider staff at urban 

centers is statistically significant at the .1 level. 

PHS, Seventh Report to the President and Congress on the Status of Health 

Penonnel in the United States, March 1990. 

Robert M. Politzer, Donna L. Harris, Marilyn H. Gaston, and Fitzhugh Mullan, 

“Primary Care Physician Supply and the Medically Undersexed,” Journal of the 

American Medical Association, July 3, 1991, vol. 266, no. 1, pp. 104-109. 

D-7 
John E. Verby, J. Paul Newell, Susan A. Andersen, and Walter M. Swentko, 

“Changing the Medical School Curriculum to Improve Patient Access to 

Primary Care,” Journal of the American Medical Association, July 3, 1991, 

vol. 266, nO. 1, p. 110-113. 

44. P.L. 102-501. 

45. See the OIG reports, Access to Medicaid-Covered Prenatal Care (OEI-06-90-

00162), October 1990, and Medicaid Expansions for Prenatal Care: State and 

Local Implementation (OE1-06-90-00160), January 1992. 

46. For an analysis of one city’s experience, see OIG reports Evaluation of the 

Boston Healthy Baby Program (OE1-01-88-01420), July 1989, and Local 

Management and Implementation Stratep”esto Reduce Infant Mortality 

(OEI-01-88-01420), July 1989. 

47. For a description of various State approaches to reducing Medicaid’s 

administrative burden on physicians, see the OIG report, Medicaid Hassle: 

S/a/e Responses to Physician Complaints (OEI-O1-92-OO1OO),March 1992. 

48. Sara Rosenbaum and Marilynn Sager, “Unlocking the Hospital Doors: Medical 

Staff Membership and Physicians Who Serve the Poor,” Yale Law & Policy 

Review, vol. 9, no. 1 (1991). 

D-8