Depafiment of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

TI-IE PERINATAL SERVICE CAPACITY 

OF THE FEDERALLY FUNDED 

COMMUNTY HEALTH CENTERS: 

RURAL CENTERS 

DECE~ER 1992 OEI-01-90-02331 

I 
OFFICE OF INSPECrOR GENERAL 

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

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

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

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

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

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

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

correct them. 

OFFICE OF AUDIT SERVICES 

The 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-todate information on the efficiency, vulnerability, 

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

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

B. Kvaal, Deputy Regional Inspector General. Project staffi 

REGION 

Dana L. Miller, Frojec[ Leader 

Timothy J. Corbett 

Deborah Skahan 

Madelaine T. Tully 

For additional copies of this repo~ please contact 

HEADQUARTERS 

Maruta Zitans 

Barbara Tedesco 

the Boston regional office at 617/565-1050. 
EXECUTIVE SUMMARY


PURPOSE 

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

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

BACKGROUND 

The high infant mortality rate in the United States continues to be a cause for 

concern. The Public Health Service (PHS) recommends timely, high-quality perinatal 

care as an effective way to lower the infant mortality rate and ensure healthier


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


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


insurance


fashion.


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

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


providers


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


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


represented 60 percent of all Section-330 centers. The Federal government provides


additional support for the centers through PHS Section-329 and -340 grants for


migrant workers and the homeless, Medicare and Medicaid reimbursements, Maternal


and Child Health grants, and the National Health Semite Corps.


of perinatal services to high-risk women in medically underserved areas 

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


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


are able to address the perinatal care needs of the women they seine. To examine the 

capacity of rural centers to provide perinatal care, we conducted a mail survey of all 

rural centers receiving Section-330 funds as of June 1991 (to which 84 percent


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


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


health experts; and reviewed the relevant literature and data. our findings are based 

primarily on information reported by the centers to us and to PHS.


FINDINGS


i%e capacity of rural commun ity health centen to provide painatd care ha increased in 

several reqxcls tie 198& 

�	 The number of prenatal clients served by the centers rose 20 percent between 

1988 and 1990, from an average of 261 per center to 312. The number of 

births to center clients rose 21 percent during the same period, from an average 

i 
of 194 per center to 235. Survey respondents reported a total of 52,597 

prenatal clients and 36,316 births in 1990. 

The range of perinatal services increased at 61 percent of centers. The sewices 

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

smoking-cessation programs, and classes in parenting and childbirth. 

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

increased at 28 percent of the centers. 

Forty-eight percent of centers offered on-site assistance with enrollment in 

Medicaid in 1990, an increase from 25 percent in 1988. Fifty-three percent of 

centers offered on-site assistance with enrollment in the Supplemental Food 

Program for Women, Infants, and Children in 1990, an increase from 49 

percent in 1988. 

Total revenues for the rural centers increased 20 percent between 1988 and 

1990; this includes a 19 percent increase in Section-330 grant funding, and a 42 

percent increase in Medicaid reimbursements. Thirty-eight percent of survey 

has increased since 1988. 

respondents reported that the amount of funding available for perinatal semices 

Despite the increases in capacity, demand for perinatal senzices at mral centm has 

continued to gmw and many cliimts still & not receive the optirnd coordinated packzge

of care in a timely fashion 

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

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

these centers made alternative perinatal care arrangements for their clients. 

Demand for semices increased at 75 percent of the centers; 42 percent of these 

centers reported their capacity to meet this growing demand either decreased 

or remained the same. 

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

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

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

of “case management” among centers. 

On average, 59 percent of each 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 percent of women in Healthy Start project areas 

entered care during the first trimester. 

ii 
b On average 18 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. 

�	 Thirty-eight percent of centers did not offer prenatal appointments at times 

convenient for working women. 

Rural cen&m idimti@d several major comtrainls that saiously hit their capacity to provide 

peiinatal care 

Medical staff shortages. Medical staff shortages, in part as a result of cuts in 

the National Health Service Corps in the 1980’s, present serious problems at 67 

percent of centers. Although the number of prenatal clients increased an 

average of 20 percent at the centers, the number of obstetricians, family 

physicians, and certified nurse midwives decreased an average of 1 percent. 

Twenty-eight percent of rural centers reported that at least 1 of these positions 

had been vacant for longer than 1 year. 

Medical malpractice insurance. The high cost of medical malpractice insurance 

has been a serious drain on resources at 55 percent of the centers. In late 

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

(P.L. 102-501) that extends medical malpractice liability protection under the 

Federal Tort Claims Act (mCA) to health care providers at the centers. 

Medicaid PO Iicies and procedures. Seventy percent of centers report serious 

problems stemming from Medicaid policies and procedures--such as a 

burdensome application process, low reimbursement rates, a limited range of 

covered services, or limited eligibility. 

Inadecmate health insurance. On average, 17 percent of each center’s perinatal 

clients were uninsured in 1990. At 9 percent of the centers more than 50 

percent of the clients were uninsured. 

Unsatisfactow community coordination. Seventy-three percent of the centers 

report serious problems stemming from unsatisfactory coordination of perinatal 

services in the community, a lack of other local providers willing to treat 

uninsured and publicly insured women, difficulty arranging obstetric backup for 

center staff and for consultation for high-risk clients, or difficulty obtaining 

hospital privileges for center staff. 

Limited space. Limited space seriously hinders the provision of services at 48 

percent of the centers. In addition, limited collocation of semices on site 

seriously restricts the comprehensiveness of care at 28 percent of the centers. 

. . . 111 
COMPANION REPORTS 

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

provide perinatal care. Another report, The Perinatal Service Capacity of the Federally 

Funded Community Health Centen: Urban Centers (OEI-01-90-02330) examines recent 

trends in the perinatal care capacity of urban community health centers. 

The third report, 771e Perinatal Sewice Capacity of the Federally Funded Community 

Health Centem: An Overview (OEI-01-90-02332), summarizes and compares data on 

the perinatal care capacities of the urban and rural centers. It also presents 

information on two areas of special policy interest: Medicaid reimbursements to 

CHCS and Comprehensive Perinatal Care Program funding of the centers. 

That report identifies four major constraints that limit the perinatal capacity of the 

community health centers: inadequate staffing, the high cost of medical malpractice 

insurance, ineffective ties between the centers and the Medicaid program, and 

unsatisfactory relationships between the centers and other community providers. 

To enable the centers to meet increasing demand for semices, these limitations must 

be addressed in the near term by a cooperative effort involving government at the 

Federal, State, and local levels, as well as non-governmental organizations. The third 

report offers a recommendation that the Public Health Service (PHS) and the Health 

Care Financing Administration (HCFA) work with the Assistant Secretary for Planning 

and Evaluation (ASPE) to draft and implement a plan of action that addresses the 

identified limitations. The report also includes comments on the draft reports received 

from PHS, HCF~ and ASPE. 

iv 

. 
TABLE OF CONTENTS


EX ECUTlvE SUMMARY 

tNTRODUCIION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...* . . . 

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Background . .
 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � � � � � � � � � � � � � � �

Companion Reports � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ���


Methodology . . . . .
 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � -. 

FINDINGS 

The capacity of rural community health centers to provide


perinatal care has increased in several respects since 1988 . . . . . . . . . . . . . . . . .


Despite these increases in capacity, demand for perinatal setices at 

rural centers has continued to grow and many clients still do not 

receive the optimal coordi ]ated package of care in a timely fashion. . . . . . . . . . 

Rural centers identified se /era] maior constraints that seriouslv limit 

1 

1 

1 

2 

3 

4 

7


their capacity toprovideperinatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . ...12 

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...*. . . . 19


APPENDICES 

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


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


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


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

INTRODUCTION


PURPOSE 

This report describes recent trends in the perinatal semice capacity of rural community 

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

BACKGROUND 

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

States continues to be a cause for concern. Each year, approximately 40,()()0 infants 

die before their first birthday--almost 1 percent of all infants born alive in the nation. 

In the 1950’s, the U.S. ranked 5th among the world’s nations in lowest infant mortali~, 

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

infants.l 

Perinatal Care in Rural America: A pregnant woman with no prenatal care is three 

times more likely to have d baby born at low birthweight--a key indicator of the risk of 

infant death--than a woman with adequate care. The Public Health Service (PHS) 

recommends timely, high-quality care before, during, and after birth as an effective 

way to lower the infant mortality rate and ensure healthier infants. Such perinatal 

care should include early and continuing risk assessment; health promotion; and 

medical, nutritional, and psychosocial interventions and follow-up.2 A full course of 

care is especially vital for women at risk because of medical or social factors. 

In 1989, however, almost 170,000 American women received no prenatal care until the 

third trimester, and another 86,000 received no care at all during pregnancy. Thirteen 

percent of whites received inadequate care; the proportion of blacks and Hispanics 

was twice that.3 

Rural women face especially significant barriers to care, including poverty, isolation, 

inadequate medical insurance, and a lack of transportation. A shortage of health 

professionals in rural areas--particularly a lack of obstetrical providers--exacerbates 

these problems. Although 28 percent of Americans live outside of urban areas, they 

A lack of resources and inadequate insurance further 

limit access to care. About one-third of rural childbearing women live below the 

poverty level--5 percent more than in urban areas--and about 4.7 million rural families 

are sewed by only 13 percent of the nation’s doctors;4 more than 1,400 rural counties 

have no obstetricians at all.s 

have no health insurance of any kind.G Although recent Medicaid expansions have 

increased the number of pregnant women who are eligible for coverage, States have 

found that many obstetrical providers are unwilling to accept Medicaid-enrolled 

clients.’ 

1 
Rural Community Health Centers: Community health centers (CHCS) are key 

providers of perinatal services to high-risk women in the nation’s rural areas. The 

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

the nation’s medically undersexed. Federal administration of the program was consolidated


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


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


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


about 2,100 counties in the United States still have provider shortages.8 More than onethird of the States have 5 or fewer community health centers.9 In 1992, PHS funded a 

total of 549 centers. 

The Federal government supports the semices provided by community health centers 

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

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

migrant workers and the homeless, the National Health Sewice Corps, the Supplemental 

Food Program for Women, Infants, and Children, and the Rural Health Clinic Program. 

In recent years, funding for the centers has increased,10 and several initiatives have been 

implemented to expand center semices and improve access to care. These include: 

supplemental funding through the Comprehensive Perinatal Care Program (CPCP), 

expanded Medicaid coverage for pregnancy care, increased Medicaid reimbursement for 

center semices through the Federally Qualified Health Center provisions of the Omnibus 

Budget Reconciliation Acts of 1989 and 1990, and Healthy Start grants to support 

community coordination of perinatal care. (For more information on Federal programs 

see appendix A.) 

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

address the perinatal care needs of the women they serve. A clear understanding of the 

centers’ current capacity to provide perinatal care is vital to further planning and 

program design. In this report, we examine recent trends in the capacity of rural centers 

to provide these senices. 

COMPANION REPORTS 

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

perinatal care. Another report, The Perinatal Service Capacity of the Federally Funded 

Community Health Cen[ers: Urban Cenlen (OEI-01-90-02330) examines recent trends in

the perinatal care capacity of urban community health centers. 

The third report, T4e Perina[al Service Capacity of the Federally Funded Community 

Health Centezs: An Overview (OEI-01-90-02332), summarizes and compares data on the 

perinatal care capacities of the urban and rural centers. It also presents information on 

two areas of special policy interest: Medicaid reimbursements to CHCS and CPCP 

funding of the centers. 

2

That report identifies four major constraints that limit the perinatal care capacity of 

the community health centers. To enable the centers to meet increasing demand for 

services, these limitations must be addressed in the near term by a cooperative effort 

involving government at the Federal, State, and local levels, as well as nongovernmental organizations. That report offers a recommendation that the Public 

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

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

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

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

METI-IoDoImGY 

This report is based on information gathered from a mail survey of rural community 

health centers; a site visit to one rural center; a telephone intetiew with another 

center; discussions with PHS administrators, State officials, and infant health experts; 

and a review of the relevant literature and PHS data.ll 

We sent the mail su~ey to all community health centers receiving Section-330 funds as 

of June 1991. Of the 302 rural centers, 253 (84 percent) responded. Our findings are 

based primarily on the responses of those 202 rural centers (67 percent of all rural 

centers) that offered perinatal services on site during the period 1988-91. (See 

appendix B for detailed methodology.) 

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

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

3

FINDINGS


THE CAPACITY OF RURAL COMNKNT’Y HEALTH CENTERS TO PROVIDE 

PERINATAL CARE HAS INCREASED IN SEVERAL RESPECTS SINCE 1988. 

� % number of prenatal ciienLY served by the centen rose 20 pement between 1988 and 

19W, fmm an average of 261 per center to 312 The number of b% to cen&r c&n@ 

we 21 percenl during the same pew finm an average of 194 per cenler to 235. 

Survey reqpondenfs repti a total of 5~597 prenatal clien/s and 3~316 births in 

Iwo. 

Sixty-three percent of the centers 

reported that the size of their 

prenatal client caseloads grew 

between 1988 and 1990 (see figure 

1). Caseloads grew more at those 

centers that sewed smaller 

caseloads in 1988, those that did not 

receive Comprehensive Perinatal 

Care Program (CPCP) funding, and 

those that seined prenatal client 

populations that were more than 

half Medicaid-enrolled in 1990.12 

Figure 1 

Average Number of Prenatal Clienis 

1988.1989, and 1990 

w I 

)! I 400{ J

u I 

I 

1 

261 

294

I_lW 

solmxoms lmmyafmualcmmmlayHcabheh& 1991. 

N-151 

Caseloads grew 173 percent between 1988 and 1990 at centers that sewed fewer than 

75 clients in 1988, 23 percent at centers that served between 75 and 249 clients, and 

11 percent at centers that sewed 250 or more prenatal clients.13 

Caseloads grew 25 percent at centers that did not receive CPCP grants, and 18 

percent at centers that did receive these grants. The average caseload size, however, 

was larger at CPCP-funded centers. 14 Caseloads grew 28 percent at centers in which 

more than half of the perinatal population was Medicaid-enrolled in 1990, and 12 

percent at centers in which less than half was Medicaid-enrolled. The average 

caseload size, however, was smaller at centers with perinatal populations that were 

more than half Medicaid-enrolled in 1990.1s 

4

� The range of painatal sewices increased at 61 pement of centeKs. The services 

added at the liqyxt number of centm were HIV testing and counsebg 

Smotig<matin program, and chsses in parenting and childb~ 

Medical and Health Promotion SeM(XS: Between 1988 and 1990, there was an 

increase in the percentage of centers protiding each of a representative range of 

perinatal medical and health promotion services, either on site or off site through paid 

and parenting classes were added referrals or contracts. 16 HIV counseling and testing 

at the largest percentage of centers (see figure 2). 

F@re 2 

Percentage of Centers that Provided each Peri.nata.l Service 

Either On Site or Off Site, 1988 and 1990 

8 

“E 

$ 

3 

+! 

& 

by 1990 

Percentage of Centers Providing Each Service 

Source: OIG Survey of Rural Cmununity Health Center% June 1991. 

N-202 

Sewices on site: At the same time, 42 percent of the centers added at least 1 medical 

of centers were family planning, health education, and nutrition SeIViCeS” In 1990~ 

or health promotion service on site. The semices added on site at the largest number 

more than 80 percent of centers offered each of these services on site (see appendk C 

for suwey responses). 

5

� 

� 

The mnge of a&~ semices--such as home visiting and tzaqortation--increased 

at 28 pemenf of the cenhxs. 

Twenty-eight percent of the centers added at least one service that facilitates access to 

perinatal care between 1988 and 1990.17 Home-visiting semices were added at the 

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

smallest percentage of centers (see figure 3). 

Figure 3 

Percentage of Center8 that Provided 

Each AXiC~ SeMce, 1988 and 1990 

Trans&tiaI far naMhi@b Spakem 

HaIW Wits 

IL 

4, 

I 

b uliklcarc dining Ap@mnmm c1 � :wzm

k , 0% 20% 40% 60s m% la)% 

sameoIQ sweyaf Ru4’dcnmwniy“ HeaM-JulE 1991. 

N-2U2 

Fo@+ght pement of cetiem 

in 1990, an increase fmm 25 pexeti in 198& Fifi-three penxru of centem offkred 

offered on-de assistance with eruulknent in Medicakl 

on-de dtance tih enrollment in the Suppbnentd Food -am for Womq 

Infa~ and Chikken (JV7C) in 1990, 

A larger percentage of CPCP-funded centers than other centers provided on-site 

an ihcrease @m 49 percent in 198& 

assistance with WIC enrollment. In 1990, 62 percent of the CPCP-funded centers 

provided assistance with WIC, while only 46 percent of other centers did S0.18 

There was no significant difference between the percentage of CPCP-funded centers 

and other centers that offered on-site assistance with Medicaid enrollment in 1990. 

Between 1988 and 1990, however, on-site assistance with Medicaid enrollment was 

added at a larger percentage of CPCP-funded centers.19 

6

� Total revenues for the nual centm increased 20 percent between 1988 and 199Q; 

ti includes a 19 pexent increase in Section-330 grant funding and a 42 pment 

increase in Medicaid reimbmements. l%irty-eight penxnt of SUWey respondents

repti that the amounf of @ding avaikble for painatal services has increased

since 198& 

The PHS Section-330 grant represented 44 percent of total revenues for these centers 

in both 1988 and 1990. Medicaid reimbursements amounted to 11 percent of total 

revenues in 1988 and 13 percent in 1990.m 

Increased funding for perinatal services was correlated with increased capacity. 

Seventy-two percent of centers that reported increased funding for perinatal services 

also reported increased capacity, while only 40 percent of those that reported a 

decrease or no change in perinatal funding also reported increased capacity. 

Several centers noted that additional revenues, especially through the CPCP, enabled 

them to enhance their perinatal services. One administrator illustrated the potential

impact of the supplemental revenues when he explained: “Our CPCP funding began 

in 1990. We got an additional family practitioner that year. Now we have two 

providers instead of just one.” Another center further demonstrated the possible 

benefits of the funding, reporting greatly expanded semices through the “addition of a 

case manager, of an obstetric specialist, and of a double-wide trailer to house an 

obstetric clinic--a much improved space.” 

DESPITE T’HESE INCREASES IN CAPACITY, DEMAND FOR PERINATAL 

SERVICES AT RURAL CENTERS HAS CONITN_UED TO GROW AND MANY 

CLIENTS STILL DO NOT RECEIVE THE OPTIMAL COORDINATED 

PACKAGE OF CARE IN A TTMELY FASHION. 

b 7kenty percent of lhe centm repotied that they provided no petitd seties on site 

between 1988 and 1991. Our studjv did not examine the exteti to whidz these 

centers made alternative perinatal care awangements for their cZients. 

Fifty-one centers reported that they did not offer perinatal care between 1988 and 

1991.2

* Forty-seven percent of these indicated that they would like to provide perinatal 

services but that a lack of obstetric providers or hospital privileges prevented them 

from doing so. Illustrating these circumstances, one administrator wrote that, “due to 

lack of support services for our physicians and the lack of available delivery facilities, 

all perinatal clients are referred to four surrounding county health departments.” 

Many centers indicated that they provide referral and support selvices, but the 

distances some patients must travel for such care are considerable. Several centers 

said that they refer women more than 50 miles away. For example, one administrator 

7

remarked that “closure of a hospital unit 50 miles away forces us to send all obstetric 

patients 100 miles away.” Another remarked that “the local hospital closed in 

1987. We now refer women to the local health department and hospital 26 miles 

away.” 

According to a recent survey, women who traveled outside of their communities for 

perinatal semices were more likely to experience complications during delivery, stay 

longer in the hospital, and need more expensive neonatal semices.22 In addition, a 

prior OIG survey of rural hospital closings found that people who must travel more 

than 10 miles for health care experience limited access to medical and emergency 

semices.” 

b Demand for services increased at 75 pewen& of the centers; 42 pecenf of these 

centm repoti their capady to meet thik growing demand either decreased or 

remaind the same 

An additional 16 percent of the centers reported that demand for services had not 

changed since 1988. Of these, 19 percent reported that capacity to meet demand had 

decreased. 

Illustrating these statistics, a center noted that between August 1989 and July 1990, 

“the floodgates were opened and any prenatal patient who wanted care from our CHC 

was seen and delivered. This caused problems, however, because the doctor was 

absent from the clinic too often, and eventually the program had to be curtailed.” 

Another center reported that “the demand for perinatal care has increased but the 

number of our health providers has remained the same, not allowing us to see more 

perinatal patients;” and another stated that “between 1988 and 1990 the number of 

prenatal women seeking care at our clinic continually increased. By mid-1990 the 

demand for care exceeded our capacity. Presently the demand for perinatal care is 

nearly double our capacity.” 

Several factors account for increasing demand at centers. Fifty-three percent of the 

centers reported that Medicaid eligibility expansions had seriously increased demand 

for perinatal semices, and 46 percent reported that Medicaid presumptive and 

continuous eligibility provisions had done Sow 

Decreases in the availability of private health care and in private physician 

participation in Medicaid have also increased demand at centers. An administrator 

explained that “fewer providers accept Medicaid, while at the same time eligibility has 

increased resulting in higher demand.” Another remarked that demand at his center 

increased when the private obstetric provider left the area. These comments are 

consistent with reports from other centers. 

8

E Sixty-eight pement of the centers repti that thq do not cooniina~ as pa?t of their 

@natal case-management flortiq all of the hedh and d sewices 

recommended by the RAlic Health Servke. This may, in pu~ rejkct variatiims h 

the&jinulo“ “ n of “case rnunagement” among centem 

According to the PHS, perinatal care should include risk assessment; health 

promotion; and medical, nutritional, and psychosocial services and follow-up.fi To 

maximize the accessibility, quality, and comprehensiveness of services, the PHS 

requires centers to coordinate care through case management.” 

Most centers provide some of the services recommended by the PHS, but 68 percent 

of them do not coordinate all of these services as part of a comprehensive 

case-management system. Fifty-three percent reported that they did not coordinate 

discharge planning and 42 percent reported that they did not coordinate delivery 

services as part of their case-management efforts (see figure 4). 

Figure 4 

Percentage of Centers that DO NOT Case Manage Each Perinatal Semite 

RiAA.wxnmt~ 18% 

Wti ~ - 22% 

AmbtmawithwIc-~% 

HaltbEAK-ial-~% 

~-’i=-~- =% 

~s-i-M-SiCO~ 27% 

-=V’= ~~~45% 

-=-off-si~~ 38% 

~w--~42% 

~p--53% 

o% 10% 30% 40% so% 60% 

Percentage of Centers that DO NOT Case Manage Each Service 

SOlucc: 01(3 Slnvcy of Rm81 community Health Gmal& h 1991. 

N-202 

There is no commonly accepted definition of what case management entails; centers 

may coordinate the delivery of services and not refer to such coordination as 

case management. 

Nonetheless, 29 percent of the centers reported that limited case management 

seriously constrains their capacity to provide comprehensive care; and 8 percent 

reported that it has become a greater problem since 1988. Thirteen percent reported 

that they provided no case management at all. 

9

� 

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

timely transfer of medical records to delivery facilities is a problem at 17 percent of 

the centers, and the transfer of records to other facilities at 16 percent. Further, 

centers reported that they do not reschedule appointments for an average of 40 

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

average, 26 percent of each center’s prenatal clients and 28 percent of their infants did 

not receive follow-up care at the centers within the first 8 weeks after birth in 1990.27 

The CPCP was intended, in part, to support centers’ case-management efforts. CPCPfunded centers were significantly more likely than other centers to provide case 

management for all the services recommended by the PHS. Fifty percent of CPCPfunded centers included all of these services in their case-management efforts, while 

only 14 percent of other centers did so. Eighteen percent of CPCP-funded centers 

cited limited case management as a serious limitation to care, while 47 percent of 

other centers reported the same concern. 

On avemge, 59 percent of each centerh prenatal clients entered care in the @t 

titer of pr~ncy in 1990. Natiimally, 76 pe~ent of all wow 62 percent of

minority womq and 58 percent of women in Healthy Stati project areas entered 

care cluing the jiit ttiter. B 

The PHS had set a goal to achieve 90 percent first-trimester enrollment for all women 

by the year 1990. This goal was not met, and has now been set for the year 2000. on 

average, 31 percent of each center’s 1990 prenatal clients did not enter care until the 

second trimester and 10 percent did not enter until the third. This compares with 

1989 national rates of 18 percent of women entering care in the second trimester and

4 percent in the third.29 

Although the CPCP was intended, in part, to encourage earlier entry into care, 

responses to our survey indicate that there was no significant difference between 

CPCP-funded centers and other centers with regard to the percentage of clients who 

entered care in the first trimester in 1990. Our study does not allow a comparison of 

CPCP grant recipients and other centers with regard to trends over time in firsttrimester entry into care. 

According to several center administrators, transportation problems hinder early entry 

into care. Thirty percent of centers noted that patients had difficulty traveling to the 

center and to delivery sites. One administrator explained the difficulties caused by 

rural isolation: “Even though we improved access through multiple sites, there are 

many clients who have no transportation. . . . The fact that our delivery site and afterhours clinic is located 30 to 60 miles away from our clients leads to a high degree of 

stress and anxiety for them.” 

10

� 

Twenty percent of centers reported that poverty and cultural barriers also hinder early 

entry into care. Several noted that clients often do not recognize the importance of 

prenatal care. 

On aven.zgq 18 percent of each center3 fimt-titer enmlks received freer than 9 

prenatal vkits. Our study did not wrnine the extent ti which these patients may 

have received care ekwhere. 

The American College of Obstetricians and Gynecologists recommends that women 

entering prenatal care in the first trimester receive a minimum of 9 visits.n On 

average, however, 18 percent of each center’s first-trimester enrollees did not receive 

at least 9 prenatal visits in 1990. 

Although the CPCP was intended, in part, to encourage more prenatal visits, sumey 

responses indicate that there was no significant difference between CPCP-funded 

centers and other centers with regard to the percentage of first-trimester enrollees 

who received at least 9 visits in either 1988 or 1990. 

Centers reported that transportation problems and poor education prevent women 

from making and keeping a sufficient number of prenatal appointments. Some centers 

have begun offering gifts to encourage women to enter care early and attend all 

scheduled appointments; one center offered $25 to clients who kept all of their 

perinatal appointments. 

� ~-eight piment of centen do not offer prenatal appointmenfi at times 

convenient for wotig women. 

In 1990, 38 percent of the centers provided no scheduled prenatal appointments in the 

early morning, in the evening, or on Saturdays. Such restricted appointment hours 

may force working women to choose between work and prenatal care. 

Twenty-one percent of the rural centers have waiting times of two to four weeks for 

initial prenatal visits and three percent have waiting times for initial visits of more than 

one month. Long waits for prenatal appointments can have adverse results. If a 

woman tests positive for pregnancy in her second month and then must wait four 

weeks for her first prenatal appointment, she may enter care in her second trimester. 

The implications of such waits are more problematic when pregnancy is detected later 

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

In addition, 13 percent of the centers reported that office waiting times have grown 

longer since 1988. Long waiting times at the centers may discourage women from 

making and keeping appointments, 

11

� 

RURAL CENTERS IDENTIFIED SEVERAL MAJOR CONS~ THAT 

SERIOUSLY LIMIT THEIR CAPACITY TO PROVIDE PERINATAL CARE.


Medical staff shonagq in part as a result of cuts in the National Health Service 

COP in the 1980’$ praent serious pmbleww at 67 ~xent of centem 

Although the average number of prenatal clients increased about 20 percent at 

centers, the average number of full-time-equivalent obstetricians, family physicians, 

and certified nurse midwives decreased 1 percent from 1988 to 1990. (See appendix C 

for survey responses.) 

Additionally, 52 percent of the centers reported that at least 1 obstetrician, familyphysician, or certified nurse-midwife position was currently vacant (see table 1), and 28 

percent reported that at least 1 of these positions had been vacant for longer than 1 

year. Thirty-nine percent of the centers also reported that medical staff shortages 

have become more severe since 1988, and 32 percent cited high medical staff turnover 

as a serious problem. 

Table 1 

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

~

Staff Position Currently Vacant more Vacant more 

‘amt ~ “m ‘k ‘onth ‘m ‘ne ‘= 

Obstetrician-Gynecologist 2170 17% 10% 

Family Physician 39% I 3370 19% 

Nurse Midwife 13% 10% 5% 

Source: OIG Sutvey of Rural Community Health Centers, June 1991 

N =202 

Many centers reported that current staffing levels are insufficient to meet client needs. 

One center noted that “the demand for semices continues to grow, but with no 

additional providers, the demand is not met with a corresponding supply.” Another 

complained that, despite “incredible population growth in the area, the provider 

population isn’t increasing.” 

of those centers that have reduced perinatal services in recent years, a large number 

cited staffing problems as the primary cause: one noted that its “decrease in perinatal 

services is proportional to a decrease in providers;” and another that its recent loss of 

an obstetrician “has definitely hampered our ability to provide perinatal services.” 
Recruitment and Retention Problems: Centers have historically faced serious 

problems recruiting and retaining medical staff. The work is demanding and wages 

and benefits are generally not comparable to those in the private sector. A shortage 

of staff means more frequent on-call rotations, which in turn makes a center less 

attractive to prospective employees. Insufficient support from the wider medical 

establishment also contributes to reluctance on the part of providers to accept 

positions at centers where they might not be assured staff privileges at local hospitals 

or adequate backup from local providers. Some centers cited unattractive clinic 

establishment also contributes to reluctance on the part of providers to accept 

positions at centers where they might not be assured staff privileges at local hospitals 

or adequate backup from local providers. Some centers cited unattractive clinic 

facilities and poor client populations as barriers to recruitment efforts. 

Recruitment efforts at many rural centers are further hindered by their geographic 

isolation. Some prow”ders are apprehensive about working in small communities 

where they will have little support from and contact with a broader medical 

establishment. One center administrator reported great difficulty convincing 

prospective employees that the community was “not the worst place in the world to 

work, play, and live.” Such recruiting challenges were reported by other administrators 

with whom we spoke. 

A limited supply of providers further exacerbates recruitment efforts. As one hospital 

administrator explained: “Without a supply of trained practitioners from which to 

draw, the incentives created by many communities in the form of buildings, loan 

forgiveness, etc., are largely futile. Similarly, program grant monies are only of use 

when the practitioners are available.” Other centers echoed this view. One 

administrator reported that his center had been working with a local hospital to jointly 

recruit an obstetrician, but they had not yet met with success; another noted that, in 

attempting to replace a physician who had just left the center, they had “used search 

firms, State offices, and other agencies and individuals to find a replacement, all to no 

avail.” 

National Health SeMce Corps: Centers have historically relied upon the NHSC for a 

large percentage of their providers, but this program experienced major funding cuts 

during the 1980’s. (See appendix A for more information.) Center administrators 

reported that they have often been unable to retain corps providers beyond their 

obligated terms of semice and that they have found it difficult to replace these 

providers. Exempli&ing problems that the centers encounter retaining NHSC 

physicians, one center reported that it had lost an NHSC obstetrician to “buy-out by a 

private hospital.” 

Staffing Models: Most rural centers rely more heavily on family physicians than 

obstetricians. Centers report significant problems, however, recruiting family -. **. * “n:__ A_ ---..JAfi fiL.+ntAp . . 09rp fine r~nter administrator 
� 

For those centers that are interested in employing obstetricians, recruitment is often


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


require.


impact: “When a scarcity of anything exists, it becomes a seller’s market. Obstetricians


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


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


one administrator explained the underlying economic dynamic and its 

E % cwt of medical malpractice insumnce has been a setius dmin on resoumx at 

55 pement of the eaten. 

Twenty-four percent of the centers indicated that the cost of medical malpractice 

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

commercial medical liability insurance rates and cutbacks in the National Health 

Service Corps have resulted in dramatically increased expenditures on medical liability 

coverage for all of the centers. In 1990, insurance premiums amounted to an 

estimated 10 percent of all centers’ total Federal grant funding--or 4.4 percent of 

center revenues.s2 

These costs have made it difficult for centers to expand staff, since scarce funds must 

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

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

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

cost. 

The variety of medical malpractice problems is exemplified by comments from three 

centers. One center reported that its perinatal services had been discontinued due to 

“a lack of funding for excessively high malpractice premiums.” Another center noted 

that its malpractice insurance carrier had threatened to cancel coverage for the entire 

clinic if the center did not suspend its contractual agreement with a private 

obstetrician. Still another reported that, although it had been able to locate providers 

willing to work at the center, it was unable to arrange liability coverage. 

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

that extends medicai malpractice liability protection under the Federal Tort Claims 

Act (FTCA) to health care providers at the centers.33 

Seventy pexent of centen repti serious problems stemmingfiom M2dicaid poti 

and procedures--such as a bur&nsome application process, low reimbwement mtq 

a ilmikxi range of covered services, or limited eli~ility. 

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

1990.~ Despite recent changes in the Medicaid system intended to increase access to 

care, however, many Medicaid-related factors continue to hinder the centers’ ability to 

provide comprehensive, timely care (see table 2). 

14 
Table 2 

Percentage of Centers Citing Each of the Following 

Medicaid Factors as a Serious Limitation 

Burdensome application procedures 52% 

1! Inadequate reimbursement rates 1 52% II 

/

1! Restrictive eligibility criteria 

1

44% 1 II

L--- Limited range of covered services 4170 

Slow reimbursement process 39940 

Source: OIG Survey of Rural Community Health Centers, June 1991 

N=202 

Application Process: According to a prior OIG report, only 26 States had


implemented presumptive eligibility as of June 1991.35 


however, that even some States that had adopted this option had not begun to use it


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


had not begun outstationing eligibility workers on site.


our research indicates, 

Reimbursement: The Federally Qualified Health Center (FQHC) provisions of the 

1989 and 1990 omnibus Budget Reconciliation Acts called on the States to begin


paying cost-based reimbursement to CHCS as of April 1, 1990. According to PHS


records, however, only 27 States and the District of Columbia had begun paying higher


FQHC-Medicaid rates as of May 1991. Most of these payments were at interim 

rates.% Since our survey, additional States may have begun to implement these 

provisions. 

An administrator at the site we visited noted that the State had begun reimbursing 

that center at FQHC rates, but that even these new rates did not fully cover the cost 

of care. Concerns about continuing inadequate reimbursement rates were voiced by 

several survey respondents. Centers also reported long delays between the provision 

of services and the receipt of payment from Medicaid.37 

Some centers may already have been receiving higher Medicaid reimbursement rates 

as a result of the Rural Health Clinic Act of 1977. To quali@ for higher rates under 

this act, a center must be located in a rural area that has a shortage of either health 

professionals or services. Additionally, the center must be staffed by one or more 

eligible certified nurse midwives, nurse practitioners, or physician assistants whose 

practice is within the scope of State law and regulations.x (See appendix A for more 

information on Federal programs that support perinatal care at the centers.) 

Eligibility Many centers reported that Medicaid eligibility requirements are still too 

restrictive. According to OIG research, three States had not yet dropped an asset test 

for eligibility.39 Several centers indicated, however, that eligibility expansions have 

15 
resulted in increased client caseloads. Consistent with several reports we received, 

staff at one center noted that the number of women on Medicaid had risen as the 

local economy had deteriorated. 

F On avemgq 17 percent of each cc-> perinutal clients were uninsured in 19%2 

At 25 percent of the centers, 25 percent or more of the perinatal clients were 

uninsured. At 9 percent of the centers, more than 50 percent of the clients were 

uninsured. These clients received sewices at reduced rates, according to a sliding 

scale. 

* Seven@wee paent of the centers repti serious ptublerm stemmingfmm .

-kcoordinatwn of petital services in h commwdy, a tick of other local 

pmh wiUing to treat unimured and publicly insured wo~ dim anungiitg 

obsteti backup for center staff and for comuhtion for high-tik clk~ or di” 

obtaining hospital privileges for center stafi 

Community Coordination: The PHS expects that centers be “active participants in 

their 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.40 

Forty-two percent of the centers, however, do not participate in perinatal care 

consortia. Centers reported wide differences in consortia memberships (see table 3). 

Other 4% 

Source: OIG Survey of Rural Community Health Centers, June 1991 

N =202 

Eighty-four percent reported that their consortium activities do not include teaching 

hospitals, 84 percent that they do not include local schools, 79 percent that they do 

Table 3 

Percentage of Centers Reporting the Participation of Each of the 

Following in a Community Perinatal Care Consortium 

Local health departments I 42% Other health clinics 22% 

Private-practice physicians 3470 Nonteaching hospitals 21% 

State health departments 24% Local schools 16% 

Government social services 24% Teaching hospitals 16% 

Nonprofit groups 23% ~~ 

16

not include nonteaching hospitals, and 76 percent that they do not include State health 

departments.41 

The Local Medical Establishment: Fifty-eight percent of the centers reported that a 

lack of other local providers willing to treat low-income and uninsured women


seriously limits the comprehensiveness of center care; 30 percent reported that this


shortage has become a more severe problem since 1988.


The PHS notes that “a key element in the quality and continuity of care is the


integration of the clinical staff into the larger medical community . . . to assure followup of referred care and the availability of timely and quality consultations.”42 Centers 

reported, however, that they face serious difficulties arranging both backup and


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


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


physicians.


risk clients is a serious limitation.


Thirty-six percent reported that difficulty arranging consultation for highA number of centers reported that there are simply no other providers to whom


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


One center noted that the closest obstetrician serving Medicaid patients was 50 miles 

away, while another reported that women had to travel 120 miles for high-risk


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


obstetricians won’t cover our family physician for anything but very low-risk


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


our facility.” Another noted that “women at or below the poverty level couldn’t get


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


consciousness” on the part of local private-practice obstetricians as a major problem. 

These doctors refused to provide backup for center staff and would only deliver 

women who came directly to them for care.


Hospital Admitting Privileges:43 The PHS recommends that, “to assure continuity of 

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

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

admitting privileges. Twenty-one percent reported a decrease between 1988 and 1990 

in the percentage of staff providers with such privileges. 

Thirty-one percent reported that difficulty obtaining admitting privileges for staff 

obstetricians, family physicians, or certified nurse midwives is a serious limitation to 

care. Twenty-nine percent of the centers cited difficulty obtaining privileges for 

certified nurse midwives as a serious problem. Fourteen percent cite serious 

difficulties obtaining privileges for center family physicians. For example, one 

administrator noted that the local hospital had recently extended delivery privileges to 

the center’s family physicians--a first in that community--but the physicians are still 

unable to perform deliveries because they have been unable to arrange for obstetric 

backup. 
Difficulties with admitting privileges have been compounded by more basic problems 

with the availability of hospital care in rural areas. Many centers have been adversely 

affected by rural hospital closings. Those rural hospitals that have remained open 

have experienced problems similar to those of CHCS in retaining obstetric staff and 

maintaining delivery setices. Additionally, some hospitals are reluctant to provide 

care for poor women. One center explained the dynamic that leads hospitals to refuse 

poor clients: “The private for-profit hospital was unable to recoup the costs of 

indigent care they were providing for our patients and refused to continue delivery 

services for our county’s indigent or Medicaid women, forcing us to close our 

program.” 

E Limited space serioudy hindem 

In additiorq limited collocation of sewices on site seriously rekcts the 

the pmvikm of senices at 48 pem?nt of the centers. 

comprehensz”veness of care at 28 pement of the centem 

Twenty-three percent of the centers reported that inadequate space has become a 

more serious problem since 1988. Those centers that reported an increase in demand 

since 1988 were significantly more likely to cite limited space as having become a 

more serious limitation to care. Several centers remarked that, because clinical staff 

capacity has increased, “now space is a major barrier.” Consistent with comments 

made by administrators across the country, one medical director noted that “the 

limited physical space of the current medical facilities prevents the center’s two 

OB/GYN providers from providing care simultaneously.” 

Sixty-two percent of the centers reported that no other public organizations, aside 

from Medicaid or WIC, and no private groups provided sewices on site in 1990. 

Those centers that cited limited space as a serious problem were significantly more 

likely to cite limited collocation of services on site as a serious limitation. 

18

CONCLUSION


Section-330-funded community health centers play an important role in the provision 

of perinatal care in rural areas across the country. In this report we have stressed 

three themes concerning their performance of this role. 

First, the centers’ capacity to provide perinatal services has increased substantially 

since 1988. In terms of the number of clients served, the range of services offered, 

and budgetary resources, the centers have demonstrated considerable growth. 

Second, increased demand has accompanied the growth in capacity. As a result, many 

center clients still do not receive all the services recommended by the Public Health 

Semite. Limitations are particularly apparent in the scope of case-managed setices 

offered by the centers and in the proportion of women who receive care during the 

first trimester of pregnancy. 

Finally, there are several basic factors that constrain the centers’ ability to provide 

more semices in a more timely manner to more women. These constraints, 

documented in many previous studies as well as in ours, include staffing problems, 

Medicaid policies and procedures, medical malpractice insurance, relationships with 

other medical providers, and clinic space. 

19

APPENDIX A


FEDERAL SUPPORT FOR PERINATAL CARE 

AT COMMUNITY HEALTH CENTERS 

The Federal Government supports the perinatal sewices provided by community 

health centers both directly through Section-330 grants and indirectly through other 

mechanisms, including Medicare and Medicaid reimbursements, Maternal and Child 

Health grants, supplemental nutrition programs, and targeted funds. In recent years, 

several initiatives have been implemented to improve center perinatal services and the 

access of women to those sewices, including the following: 

Medicaid Expansions: Congress has mandated several changes in the Medicaid 

program. These include (1) expanded eligibility States are now mandated to extend 

coverage to all pregnant women below 133 percent of the Federal poverty level, and 

have the option of extending coverage to women between 133 and 185 percent of the 

poverty level; (2) continuous eligibility: eligibility for coverage is now guaranteed 

throughout pregnancy and the postpartum period, regardless of income changes; 

(3) presumptive eligi%ili~. eligibility for temporary coverage, limited to a maximum of 

61 days for ambulatory services only, is based solely on self-reported income; 

(4) expanded coverage: case-management services are now reimbursable; and 

(5) outstationing States must place eligibility workers at locations other than AFDC 

enrollment sites, including CHCS. 

Federally Qualified Heahh Centem (FQHC): The Omnibus Budget Reconciliation Acts 

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

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

cost of covered services. 

The Rural Heahh Clinic Program: The Rural Health Clinic Sewices Act of 1977 

provides cost-related Medicaid reimbursement for services at rural centers in health 

manpower shortage areas or medically underserved areas. Qualifying centers are 

staffed by at least one certified nurse midwife, nurse practitioner, or physician assistant 

whose practice must be within the scope of State law and regulations. Until the 

passage of this act, these providers were not eligible for Medicaid reimbursement in 

some States. Because of several problems with regulation, certification, and 

reimbursement, however, far fewer centers than expected had availed themselves of 

reimbursement under the act. 

T%e Comprehensive Perinalal Care Program (CPCP): In 1988, the PHS launched this 

initiative to improve birth outcomes by encouraging earlier entry into care and more 

The CPCP provides supplemental funding for enhanced services, 

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

1989. In FY 1991, $33 million was provided in CPCP supplemental funding;45 51 

perinatal visits. 

percent of the rural respondents to our survey that offered perinatal services received 

A -1

CPCP funding for at least 1 year between 1988 and 1991. In fiscal years 1992 and 

1993, $44.7 million was appropriated for the CPCP.fi 

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

communities on the basis of their proposals for coordinated community programs to 

improve maternal and infant health care. 

Several other ongoing Federal efforts play important roles in the centers’ provision of 

perinatal care, including: 

National Health Service Corps (NHSC): The PHS offers both scholarships and 

educational loan repayment to health providers who commit to work in designated 

Health Professional Shortage Areas for a given period. A large percentage of corps 

providers have traditionally worked in community health centers. After substantial 

cuts in program size in the early 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. 

Supplemental Food Program for Women, Infants, and Children ( WIC): The 

Department of Agriculture provides vouchers through this program to address the 

nutritional needs of pregnant and lactating women and their infants. 

A -2

APPENDIX B


METHODOLOGY 

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

a site visit to one center, telephone conversations with representatives of another 

center, a series of intemiews, and a review of relevant literature and data. 

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

recipients in June 1991. Of 302 rural centers, 253 (84 percent) responded, including 

centers in every HHS region and every State and territory in which rural centers are 

located, with the exception of the U.S. Virgin Islands. A review of the geographic and 

demographic information that was available suggested no significant differences 

between respondents and nonrespondents. 

Of the 253 rural respondents, 51 (20 percent) provided no perinatal services on site at 

all during the 1988-91 period. The numbers and percentages in the body of this 

report, unless otherwise noted, reflect the responses of those 202 centers (67 percent 

of all rural centers) that offered semices on site in at least 1 year during the 1988-91 

period. 

Of the 202 respondents that provided semices on site during the study period, 102 (51 

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

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

which the initial grant was awarded. 

Not all respondents provided complete information. We calculated trends presented 

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

relevant information for all years. 

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

of centers (such as CPCP-funded and other centers) reflect statistical significance at 

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

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

as “seriously” or “serious.” 

Site Visits: The study team conducted a site visit to one rural center in Ohio and its 

two satellite clinics. The team toured the facility and interviewed management and 

clinical staff. The study team also conducted a conference-call interview of 

administrative and clinical staff at a center in Mississippi. We chose these centers 

based on discussions with regional PHS staff and with consideration of geographic 

representation and community size. 

B - 1


— . 
Intewiews: The study team held discussions with (1) officials in PHS’S Bureau of 

Prima~ Health Care (BPHC) (then called the Bureau of Health Care Deli}’e~ and 

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

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

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

(3) infant and community health experts, including staff at the 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 Sewice 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. 

B - 2

APPENDIX C


RURAL SURVEY RESPONSES 

The Office of Inspector General survey was mailed to 302 rural community health centers in 

May 1991. Of the 253 (84 percent) that responded, 51 provided no perinatal services on site 

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

202 centers that did provide se~ices at some point during this period. Not all centers 

answered every question. The number of respondents to each field (N) is indicated in 

parentheses as appropriate. 

Any discrepancies between the responses below and the data presented in the body of this 

report are a result of the methods used in aggregating data and calculating trends. Please see 

appendix C for a discussion of statistical methodology. 

Number of centers that offered perinatal services on site in each year: 

1988: Yes=179 No=23 

1989: Yes=182 No=20 

1990: Yes=187 No=15 

1991: Yes=185 No=17 

A CASELOAD 

1. Please indicate: 

a. the number of women who received prenafaf 

care at your center: 

b. the percentage of these clients who were 

high-risk as defined by your center: 

c. the percentage of these clients who were 

low-risk as defined by your center:

d. the number of births to your center’s 

clients: 

2. Of the women who gave birth in your service 

area, what percentage received prenatal care 

at your center? 

1988 

261 (157) 

27% (130) 

60% (129) 

195 (139) 

45% (128) 

1989 

MEAN (N) 

272 (174) 

29% (144) 

61% (146) 

206 (161) 

46% (137) 

1990 

278 (188) 

29% (160) 

61% (154) 

218 (167) 

49% (135) 

c - 1 
B. COMMUNITY COORDINATION 

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

YeS=l17 No=85 If YES, please continue. 

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

a. state health department: 4 9 f. nonteaching hospitals: 43 

b. local health department: 85 g. private-practice physicians: 69 

c. health clinics: 44 h. gov. social setice agencies: 48 

d. schools: 33 i. non-profit organizations: 47 

e. teaching hospitals: 32 j. other: 8 

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

your center’s involvement. 

C. CLINIC SITES AND HOURS 1988 1989 1990 

MEAN (N) 

a. clinic sites operated by your center: 2.5 (192) 2.6 (192) 2.6 (193) 

1. Please indicate the number OE 

b. clinic sites at which prenatal care 

was provided: 1.8 (199) 1.9 (198) 1.9 (l%) 

2. On how many days a week did your center 

provide scheduled prenatal appointments 

either before 8AM or after 6PM? 0.97 (191) 0.99 (190) 1.1 (189)

3. On how many saturdays a month did 

your center provide scheduled


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


D. Funding 

was: 

Larger= 76 Smallcr=26 

1. Compared with 1988, the amount of funding available for perinatal care at your center in 1990 

Unchanged=84 

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

a. Private insurance: 13.1% (170) c. Medicaid: S.6% (167) 

b. No insurance: 17.4% (172) d. Other: 2.3% (175) 

c - 2 
3. To what extent hwe the following factors resulted in increased demand for perinatal semices 

at your center over the past three years? 

Not at W Moderately/ 

Somewhat Substantially 

a. Medicaid eligibility expansions: 72 107 

b. Medicaid presumptive and 

continuous eligibility provisions: 82 93 

E. PERINATAL OUTREACH 

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

efforts? (Please check all that apply) 

a. Teenagers: 170 c. Non-English speakers: 65 

b. Substance abusers: 55 d. Other: 55 

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

(Please check all that apply) 

a. Community	 d. Schools: 129 

centers: 81 e. Welfare offices: 68 

b. Shops: 20 f. Churches: 48 

c. Door-to-door in the	 g. Other: 62 

neighborhood: 33 

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

(Please check all that apply) 

a. Television: 27 d. Radio: 59 

b. Newspapers: 111 e. Other: 48 

c. Pamphlets: 151 

4. Compared with 198S, your center’s outreach efforts in 1990 were: 

Greater= 118 Smaller= 16 The same=55 

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

More clients= 121 Fewer clients= 16 The same number of clients=37 

c - 3 
F. PERINAT~ SERVI~ 

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

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

or paid referral~-please circle Off. 

1990 1988 

a. 

b. 

Ultrasound: On=42 

Off= 129 

Amniocentesis: on= 9 

Off= 150 

1989 

orl=50 

Off= 124 

0U=9 

0ff=152 

On=5 6 

Off= 123 

on=1 3 

off= 150 

on=37 0n=36 0Q=36 

c. Genetic counseling: Off=l18 

on=4 5 

off= 120 off= 121 

d. Non-stress testing: on=36 

m= 122 

0n=38 

off= 120 0ff=l16 

0n=85 on=91 

e. Dental care: on=90 

0ff=78 off=86 off=88 

Orl=lso on=157 0n=167 

f. Nutritional services: 0ff=29 0ff=25 

on=168 On=172 0n=181 

Off= 18 

h. Health education: 

on=77 0n=84 0n=90 

off= 17 off= 13 off= 10 

i. Birthing classes: 0E=79 off=73 off=74 

0n=7 6 0n=8 3 0n=102 

j. Parenting/infant care classes: OE=75 off=73 off=64 

&=176 0n=176 0n=183 

k. Family planning: off= 10 off= 10 Off=lo 

0n=84 0n=9 0 

1. Smoking cessation programs: 0n=85 

off=57 off=60 Off=63 

0n=3 4 0n=3 5 

m. Substance abuse treatment: on=38 

0ff=l18	 0ff=123 

0n=l13 0n=135 

off= 130 

n. HIV counseling/testing: 0n=98 

0ff=58 0ff=52 0ff=38 

2. Compared with 1988, the range of perinatal 

services offered by your center in 1990 was: 

Greater= 123 Smaller=24 Unchangd=49 

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

in the following programs? 

a. Medicaid: yes=51 Yes=72 yes=97 

No=139	 No=119 No=IOO 

ye’s=99 Yes=lo7 Yes=lo7 b. WIC: 

No=93 No=88 No=90 

c - 4 
1988 1989 1990 

4. Did other government or private social sexvice 

organizations provide services on-site at your 

center?	 Yes=56 Yes=59 Yes=72 

No=134 No=132 No=125 

5. Did your center facilitate access to perinatal 

care by providing the following services? 

a.	 Transportation to and from appointments: Yes=87 Yes=loo Yes=l14 

No=1O3 No=93 No=83 

b.	 Translation for non-English speaking clients: Yes=85 Yes=88 Yes=97 

NO=81 NO=80 No=71 

c. Child care during center appointments: Yes=19 Yes=20 Yes’Xl 

No=171 No=172 No=165 

d, Home visits: Yes=85 Yes=lol Yes=l15

No=1O6 No=92 NO=81 

G. STAFFING 

1988 1989 1990 

1. How many full-time equivalents of each 

services 

on-site at the center? (N =202) 

of the following provided perinatal 

: 

Obstetricians: 0.45 0.45 0.43 

Family physicians: 1.44 1.40 1.41 

c. Certified nurse midwives: 0.19 0.18 0.22 

d. Nurse practitioners: 0.56 0.59 0.65


e. Physician assistants: 0.39 0.42 0.45


2.


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


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

which have been vacant for more than one year. (N=202) 

a. Obstetrician: 

b. Family physician: 

c. Certified nurse midwife: 

3. Compared with 1988, the 

local hospitals in 1990 was: 

(i) (ii) (iii) 

Number of More than More than 

vacancies six months one year 

0.25 0.21 0.12 

0.54 0.47 0.47 

0.13 0.10 0.05 

percentage of your perinatal providers with admitting privileges at 

Ixger=49 Smaller= 21 Unchanged=97 

c - 5 
H. TIMING OF CARE 

l. Please indicate the percentage ofyourcenter’s 1990 prenatal clients whoentered care in the: 

a. First trimester: 

b. Second trimester: 

c. Third trimester: 

58.7% (181) 

(180 ) 

9.9% 

30.8% 

(163) 

2. Of those clients who entered care during the 

first trimester, and carried to term, what 

percentage received at least nine prenatal 

medical visits? 

3. What percentage of your center’s prenatal 

clients returned for postpartum visits 

during the first eight weeks after delivery? 

4. What percentage of all infants born to center 

prenatal clients returned for newborn visits 

during the first four weeks after birth? 

1988 1989 1990 

79.1% (1 13) 79.8% (124) 81.9%0 (147) 

69.3% (121) 72% (142) 73.9% (161) 

66.3% (121) 69.7% (138) 71.8% (158) 

L APPOmE~ 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: 66 

on a walk-in basis: 123 One-two weeks: 8 

More than 

two weeks: 2

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

Yes=178 No=19 

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

The first perinatal visit is Less than two weeks: 118 

Two-four weeks: 42 

provided in conjunction 

with the pregnancy test: 33	 One-two months: 2 

More than 

two months: 3 

4. Compared with 1988, waiting room waiting times at perinatal appointments in	 1990 were 

generally: 

Shorter= 65 Longer=26 me same=94 

C - 6 

— 
1. 

J. CASE MANAGE~NT 

Does your center currently provide case management topromote thecoordination ofsetices 

for perinatal clients? 

Yes=176 No=26 If-, please continue. 

2. Case management at your center is primarily conducted by (please check only one): 

The client’s primary care doctor:


The client’s primary care nurse:


The appointments secretary:


A multidisciplinary team:


A center employee whose main 

responsibility is case management 

for perinatal clients: 

Other: 

28 

14 

2 

54 

67 

12 

clients: 

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

All perinatal 143 

All high-risk perinatal clients: 21 

Only certain groups of 13 perinatal clients: 

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 

d. Client advocacy: 

of services: 

e. Contact with other organizations 

to arrange for scmices / 

schedule appointments: 

f. Assistance with paperwork related to 

WIC, Medicaid, and other programs: 

g. Discharge planning: 

Coordination OC 

h. Medical	 semices provided 

on-site at the center: 

i. Medical services piovided 

off-site: 

165 

162 

144 

131 

163 

145 

94 

158 

147 

c - 7 
Continued: 

j. Delivery semiccs: 

k. Social services provided 

on-site at the center: 

1. Social set-vices provided 

off-site: 

m. Nutritional se~ices: 

n. Health education: 

o. Other: 

118 

110 

126 

158 

162 

27 

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

in 1990 was: 

kger= 126 Smaller= 14 Unchanged =33 

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

and from facilities to which perinatal clients are referred?

For delivery: Yes=35 No=142 

For other care: Yes=32 No=141 

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

reschedule missed appointments: 

60% (N=158) 

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

Phone= 168 Home visit=95 Other= 10 

(please check all that apply): 

Mail= 149 

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

provider or the same provider team at eachperinatal visit? 

Yes=168 No=7 

C - 8

K LIMITATIONS TO CARE Please indicate the degree to which each of the following factors 

limits your center’s ability to provide perinatal serwces: 

Moderately/ 

1. Shortage of medical staff 

2. Shortage of nonmedicd 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 supervision 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 certified 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 

Not at all/ 

Somewhat Subwultially 

65 132 

138 48 

127 61

168 16 

144 18 

25 

97 43 

157 

82 102 

135 35 

156 29 

88 59 

110 57 

99 

117 67 

84 

172 15 

79 108 

103 62 

144 15 

80 109 

104 76 

114 72 

89 95 

107 75 

104 81 

91 97 

127 58 

131 50 

98 91 

27 19 

c - 9 
Which Of these factors have become LESS SERIOUS 

1988? 

1. Shortage of medical staff: 

2. Shortage of nonmedial staff 

3. High medical staff turnover: 

4. High nonmedicd staff turnover: 

Difficulty obtaining admitting privileges 

at local hospitals for: 

5. obstetricians: 

6. family physicians: 

7. certified nurse midwives: 

8. High cost of malpracti~ insurana: 

Difficulty obtaining malpractiu insurance for: 

9. obstetric providers: 

10. all providers: 

Difficulty arranging medical backup for: 

11. OB supervision of certified nurse midwives/ 

nurse practitioners: 

12. OB supervision 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 treal uninsured or publicly 

insured women: 

Non-acceptan@ of certified 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-relatd 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 

or MORE SERIOUS limitations since 

More 

serious serious 

40 13 

12 11 

17 14 

5 12 

6 10 

6 10 

6 10 

24 7 

8 7 

7 8 

14 8 

15 7 

22	 9 

17 7

3 20 

2’7 9 

8 13 

3 14 

24 11 

16 5 

12 18 

13 23 

10 

9 29 

13 21 

17 

8 22 

5 16 

23 11 

2 1 

c-l o 
L CONCLUSION 

Inereased=152 Dexxd=15 

care in 

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

Not changed =32 

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

your semice area has: 

Lrlcreased= 104 Decreascd=52 Not changed =42 

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

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

faced in the past three years? 

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

years to improve its ability to respond to perinatal care needs in your sewice area? 

C-n


— 
APPENDIX D


1. 

2. 

3. 

4. 

5. 

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 2000: National Health 

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

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

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

NCHS, “Advance Report on Final Natality Statistics, 1989,” A40nthZy Htal 

Sta/zktic.s Repon, vol. 40, no. 8, Supplement, December 12, 1991, p. 43. These 

1989 data are the most current available. 

Alan Guttmacher Institute, Prenatal Care in the United States, New York, N. Y., 

1987, vol. I, p. iv. Adequacy of care is a function of time of entrance into care 

and number of visits. During the period 1984-86, 24 percent of women entered 

care after the first trimester, 24 percent had fewer than 9 visits, and 34 percent 

received less than adequate care. 

Bruce Behringer, President, National Rural Health Association; Executive 

Director, Virginia Primary Care Association; Testimony before the U.S. House 

Committee on the Budget Task Force on Human Resources, October 3, 1991, 

p. 1. 

Laura Summer, Limited Access: Health Care for the Rural Poor, Center on 

Budget and Policy Priorities, Washington, D. C., 1991, p. 16. 

In September 1990, the American College of Obstetricians and Gynecologists 

(ACOG) reported that, as a result of the risk of malpractice, 12 percent of its 

members had discontinued their obstetric practices, 24 percent had reduced or 

eliminated services to high-risk women, and 10 percent had decreased the 

number of deliveries they performed. Average obstetric premiums rose 248 

percent between 1982 and 1989. (ACOG, prepared by Opinion Research 

D - 1 
Corporation, “Professional Liability and Its Effects: Report of a 1990 Suwey of 

ACOG’s Membership,” Washington, D. C., September 1990.) The ACOG 

repeated this survey in September 1992, and found no statistically significant 

differences from the prior survey. 

In addition, as of 1987, 64 percent of family physicians who once provided 

obstetric services had discontinued such care. (American Academy of Family 

Physicians, “Family Physicians and Obstetrics: A Professional Liability Study,” 

1987.) 

6. 

August 1991, p. 3. 

March of Dimes, Infant Survival in Rural America, White Plains, N. Y., 

Summer, pp. 27-29. 

7. 

Association, Washington, D. C., 1988, pp. 21-22. An increasing number of 

physicians who practice obstetrics are unwilling to accept low-income or 

Medicaid-insured patients because of high malpractice premiums and low 

Medicaid reimbursement rates. 

Deborah Lewis- Idema, Increasing Provider Participation, National Governors’ 

Office of Inspector General (OIG), Medicaid Expansions for Prenatal Care: 

State and Local Implementation (OEI-06-90-0016), January 1992, pp. 8-9. 

8. PHS, “HRSA’S Long-Range Plan to Improve Access to Primary Health Care 

for Underserved Populations.” July 1990, unpublished, p. 10. 

9. National Association of Community Health Centers, Mothen, Infants, and 

Community and Migrant Health Centen, Washington, D. C., December 1989, 

table 4. 

10. Section-330 funding was $435 million in FY 1989, $457 million in FY 1990, and 

$478 million in FY 1991. (Health Resources and Semites Administration 

(HRSA) FY 1993 Justification of Appropriations, vol. 1, p. 63.) 

For FY 1992, $532 million was appropriated. The FY 1993 appropriation is 

$559 million. (Bureau of Primary Health Care [BPHC] and the Assistant 

Secretary for Management and Budget [ASMB].) 

11.	 The Public Health Service provided us with financial data that they collected 

from the centers through the Bureau’s Common Reporting Requirements 

reports, and with financial and user data that they collected from CPCP 

applicants through the Perinatal User Profile reports. 

12.	 Unless otherwise indicated, the differences between groups (such as CPCP 

grantees and other centers) that are noted in this report are statistically 

significant at the .05 level. 

D - 2 
13. 

14. 

15. 

16. 

17. 

18. 

19. 

Centers that semedfewer than 75prenatal clientsin 1988 served anaverageot 

32 in 1988 and 88 in 1990. Centers that served between 75 and 249 clients in 

1988 seined an average of 149 in 1988 and 184 in 1990. Centers that sexved 

250 or more clients in 1988 served an average of 562 in 1988 and 623 in 1990. 

In 1988--before CPCP funds were distributed--those centers that eventually 

received CPCP funding served an average of 365 clients; the other centers 

seined an average of 134. In 1990, the CPCP-funded centers served an average 

of 431 clients; other centers served an average of 167. 

According to an internal PHS draft report, “CPCP 1990 Data Report: Moving 

Ahead,” CPCP-funded centers seined 33,938 pregnant teens in 1990, which they 

report is more than triple the number seined in 1988. Also according to this 

report, in 1989, CPCP-funded centers provided services to 13.4 percent of all 

pregnant teens age 15 or younger in the United States. PHS’S CPCP data, 

however, does not permit a comparison of CPCP-funded centers and other 

centers. 

These centers served an average of 223 prenatal clients in 1988 and 286 in 

1990. Centers with prenatal populations that were less than half Medicaidenrolled sewed an average of 270 clients in 1988 and 302 in 1990. 

Our suwey inquired about the provision of a representative range of perinatal 

medical and health-promotion semices: ultrasound, amniocentesis, genetic 

counseling, non-stress testing, dental care, nutritional services, health education, 

childbirth classes, parenting/infant-care classes, fami~y planning, 

smoking-cessation programs, substance-abuse treatment, and HIV 

counseling/testing. 

Our survey inquired about the provision of four semices that facilitate access to 

care: translation. transportation, home visiting, and child care during 

appointments. 

Some centers were able to complete enrollment on site. Other centers only 

distributed forms or provided assistance in completing them. In such cases, 

applicants had to complete the enrollment process at the appropriate State 

offices. Some centers completed all nutritional assessment and paper-work for 

WIC on site, but clients had to obtain vouchers at a different location. 

There was a 126 percent increase in the number of CPCP-funded centers and a 

44 percent increase in the number of other centers that provided on-site 

assistance with Medicaid enrollment. In 1988, 19 CPCP-funded centers and 18 

other centers provided on-site assistance with Medicaid enrollment, compared 

with 43 CPCP-funded centers and 26 other centers in 1990. 

D - 3

20. 

21. 

22. 

23. 

24. 

Bureau’s Common Reporting Requirements (BCRR) Database, BPHC, PHS. 

This database contains self-reported financial and user data from Section-330 

grantees. We derived the percentage increase incenter revenues from data for 

those 214 rural centers (71 percent of all rural grantees) that provided financial 

data to BPHC through the BCRR form for the years 1988, 1989, and 1990. 

Some of these centers did not respond to our survey. 

Total reported revenues for these 214 centers increased from $215 million in 

1988 to $259 million in 1990. Public Health Service Section-330 grants to these 

centers increased from $95 million in 1988 to $113 million in 1990. Medicaid 

reimbursements to these centers increased from $23 million in 1988 to $33 

million in 1990. These centers received additional revenues from MCH block 

grants, Public Health Service Section-329 and -340 grants, WIC grants, Title X 

grants, Title XVIII Medicare payments, Title XX payments, other third party 

payments, patient collections, State and local revenues, and donations. 

We excluded these 51 centers from calculations of the statistics presented in the 

body of this report (see appendix B for detailed methodology). 

Thomas S. Nesbitt, Frederick A. Connell, L. Gary Hart, and Roger A. 

Rosenblatt, “Access to Obstetric Care in Rural Areas: Effect on Birth 

Outcomes,” America~l Journal of Public Health, July 1990, vol. 80, no. 7, 

pp. 814-819. 

This study compared communities in which 67 percent or more of pregnant 

women traveled outside of their community for obstetric care (high outflow) 

and communities in which fewer than 33 percent of pregnant women travelled 

outside of their communities for obstetric care (low outflow). The sumey found 

that women who lived in high-outflow communities had a 34 percent higher 

occurrence of complications during delivery and higher medical costs for 

themselves and their infants than those from low-outflow communities. Medical 

costs were twice as high overall for high-outflow communities ($2,103 versus 

$1,046), and four times as high for Medicaid patients ($4,627 versus $1,014). 

OIG, Effects of 1988 Rural Hospi~al Closures on Access lo Medical Care (OEI04-89-00742), August 1990, pp. 4, 7. 

Forty percent of residents who lived within 10 miles of a recently closed 

hospital, and for which a replacement was more than 10 miles away, said that 

they had a serious problem getting hospital care and attributed it to hospital 

closure. Similarly, 42 percent of those who had to travel more than 10 miles 

for emergency care reported a serious problem with access. 

In reporting responses to survey questions that solicited information on a scale, 

D - 4

25. 

26. 

27. 

28. 

29. 

30. 

we combined responses of “moderately” and “substantially” and reported them 

as “seriously or “serious.” 

PI-IS, Caring for Our Future, p. 2. 

PHS, Healthy People 2000, p. 366. 

In our sumey, we used the terms “health education” for “health promotion” and 

“social setices” for “psychosocial services.” 

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. 

Inadequate insurance, limited financial resources, long waits for appointments, 

an inability to arrange child care, and time-consuming transportation all 

discourage women from returning for care. Some women may receive followup care from other providers, but it is unclear to what extent centers track 

these women after delivery. 

NCHS, 1992. These 1989 data for national rates of entry into care are the 

most recent available. The average of 62.2 percent for minority women was 

calculated from rates for Mexican American, Puerto Rican, Cuban, Central and 

South American, other Hispanic, Chinese, Japanese, Filipino, Hawaiian, other 

Asian, American Indian/Alaskan Native, and Black women. 

The BPHC provided the rate for women in federally designated Healthy Start 

project areas. The BPHC calculated this rate from information reported by the 

15 projects for a time period between 1984 and 1989. The project areas are: 

Aberdeen, South Dakota (rates are for the Northern Plains Native American 

populations in North Dakota, South Dakota, and Nebraska); Baltimore, 

Maryland; Birmingham, Alabama; Boston, Massachusetts; Chicago, Illinois; 

Cleveland, Ohio; Detroit, Michigan; Lake County, Indiana; New Orleans, 

Louisiana; New York, New York; Oakland, California; the Pee Dee region, 

South Carolina; Philadelphia, Pennsylvania; Pittsburgh, Pennsylvania; and 

Washington, D.C. 

NCHS, Monthly Vital Statzkics Repoti, 1991, p. 43. These 1989 data are the 

American College of Obstetricians and Gynecologists (ACOG), S/andards for 

most recent available. 

Obstetric-Gynecological Services, Washington, D. C., 7th cd., 1989, p. 16. 

The PHS has required that “all centers, regardless of size, must assure that the 

services that they deliver conform to the Standards for Obstelnsc-GynecoloN”c 

D - 5 
Services” (“Perinatal Care: How to Establish Perinatal Semites in Community 

31. 

32. 

33. 

34. 

35. 

36. 

37. 

38. 

Health Centers,” PHS, 1985 p. 96). 

A 1989 PHS report, Caring for Our Future: me Content of Prenatal Care, 

suggested slightly different guidelines. This report recommends that healthy 

women receive a minimum of nine prenatal visits during a first pregnancy and 

seven prenatal visits during subsequent pregnancies (p. 50). The report 

suggests that women at risk, because of either psychosocial or physical factors, 

might require more prenatal visits (p. 71). Psychosocial and physical risk 

factors include: inadequate personal support systems, single marital status, 

adolescence, advanced age, high stress and anxiety, less than high school 

education, low income, inadequate housing, inadequate nutritional resources, 

communication barriers, smoking, alcohol abuse, and illicit drug use (p. 79). 

Nonresponses may have resulted in an underestimate of the percentage of 

centers with such vacancies. 

U.S. General Accounting Office, Medical Malpractice: Data on Claims Needed 

to Evaluate Health Centen’ Insurance Alternatives (HRD-91 -98), Washington, 

D. C., May 1991, p. 1. These data are for all Section-330 grant recipients. 

P.L. 102-501. Under the 17C& center providers will be defended by the 

Justice Department in any medical malpractice litigation, and judgments will be 

paid out of a Justice Department fund, into which the centers will pay annual 

contributions. This liability protection will be provided for three years, after 

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

On average, 13 percent of each center’s perinatal clients were privately insured 

and 2 percent were covered by other mechanisms in 1990. 

OIG, Medicaid Expansions for Prenatal Care: State and Local Implementation 

(OEI-06-90-00160), January 1992, appendix E. 

Bonnie Lefkowitz, BPHC, PHS, written communication to OIG, 

December 24, 1991. 

One center reported waits of more than 12 months for Medicaid 

reimbursement. 

P.L. 95-210. Tile Rural Health Clinic Services Act. 

The Rural Health Clinic Se~ices Act was amended in the Omnibus budget 

Reconciliation Act of 1989 to include certified nurse midwives as eligible 

program participants, and to provide reimbursement for clinical social work 

services. 

D - 6

39. 

40. 

41. 

42. 

43. 

44. 

45. 

46. 

OIG, Medicaid Ekpan.sions for Prenatal Care: An Update 

(OEI-06-90-O0161), May 1992. 

P. E., pp. 4-5. 

Centers report a range of coalition activities, including: high-risk referrals and 

consultations, coverage for delivery, case management and support services, 

integration of WIC setices, support for breast-feeding women, setices to 

migrant populations, and outreach. 

P. E., p. 18. 

Our sumey addressed only admitting privileges. During intemiews, center staff 

reported hospital restrictions on the delivery privileges of certified nurse 

midwives and family physicians. 

P. E., p. 19. 

HRS~ FY 1993 Justification of Appropriations, vol. 1, p. 61. 

BPHC and ASMB data. 

D-’l