Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

THE PERINATW SERVICE CAPACIH 

OF THE FEDEWLY FUNDED 

COMMU~H HEALTH CENTERS: 

URBAN CENTERS 

DECEMBER 1992

OFFICE OF INSPE~OR GENERAL 

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

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

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

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

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

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

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

correct them. 

OFFICE OF AUDIT SERVICES 

TheOIG’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 

TheOIG’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 INSPECTIONS 

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

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

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

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

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

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

B. Kvaal, Deputy Regional Inspector General. Project staff 

REGION HEADQUARTERS 

Dana L. Miller, Projecf Leader Maruta Zitans 

Timothy J. Corbett - Barbara Tedesco 

Madelaine T. Tully 

Deborah Skahan 

For additional copies of this repor$ please contact the Boston regional office at 617/565-1050. 
Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

THE PERINATAL SERVICE CAPACITY 

OF THE FEDERALLY FUNDED 

COMMtJNrIy HEALTH CENTERS: 

URBAN CENTERS


DECEMBER 1992 OEI-01-9W2330

EXECUTIVE SUMMARY 

PURPOSE 

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

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

BACKGROUND 

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


concern. The problem is particularly acute in the nation’s urban areas: the 22 largest


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


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


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


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


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


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


fashion.


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


the centers to us and to PHS.


FINDINGS 

7he capacily of urban cornrnun iy heahh centem to provkie pai.n.atd care has increa.wd h 

several rt.xpects since 1988. 

�	 The number of prenatal clients served by the centers rose 23 percent between 

1988 and 1990, from an average of 477 per center to 586. The number of births 

to center clients rose 17 percent during the same period, from an average of 320 

i 
percenterto 374. Sumeyrespondents reported atotalof 87,560 prenatal clients 

and 51,826 births in 1990. 

The range of perinatal services increased at 76 percent of the centers. The 

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

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

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

increased at 37 percent of the centers. 

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

Medicaid in 1990, an increase from 23 percent in 1988. Eighty percent of the 

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

Program for Women, Infants, and Children in 1990, an increase from 68 percent 

in 1988. 

Total revenues for urban centers increased 31 percent between 1988 and 1990; 

this includes an 18 percent increase in Section-330 grant funding and a 59 percent 

increase in Medicaid reimbursements. Sixty-five percent of the centers reported 

that the amount of funding available for perinatal services has increased since 

1988. 

Despite these increases in capacity, &mand for perinatal semices at urban centers hus 

continued to grow and many clienfi still do not receive the optimal coordinated package 

of care in a time$J fizshkm 

*� Six percent of the urban centers reported that they provided no perinatal services 

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

these centers made alternative perinatal care arrangements for their clients. 

�	 Demand for services increased at 89 percent of the urban centers; 34 percent of 

these centers reported their capacity to meet this growing demand either 

decreased or remained the same. 

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

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

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

“case management” among centers. 

~	 on average, 51 percent of each center’s prenatal clients entered care in the first 

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

of minority women, and 58 percent of women in Healthy Start project areas 

entered care during the first trimester. 

ii 
�	 on average, 26 percent of each 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-six percent of the centers did not offer prenatal appointments at times 

convenient for working women. 

Several major corwrai.rm seriously lirnif the capa@y of urban cenlm to provide perinatal 

care. 

Medical staff shm-ta~es. Medical staff shortages, in part as a result of cuts in the 

National Health Service Corps in the 1980’s, present serious problems at 59 

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

of 23 percent at the centers, the number of obstetricians, family physicians, and 

certified nurse midwives increased an average of 12 percent. Twenty-four percent 

of centers reported that at least 1 obstetrician, family-physician, or nurse-midwife 

position had been vacant for longer than 1 year. 

Medical malt-mctice insurance. The high cost of medical malpractice insurance 

has been a serious drain on resources at 56 percent 

Congress took initial steps to address this problem 

102-501 ) that extends medical malpractice liability 

Tort Claims Act (FTCA) to health care providers 

of the centers. In late 1992, 

by passing legislation (P.L. 

protection under the Federal 

at the centers. 

Medicaid POIicies and procedures. Seventy-six percent of the centers report 

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

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

covered services, or limited eligibility. 

Inadequate health insurance. On average, 21 percent of each center’s perinatal 

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

of the perinatal clients were uninsured. 

Unsatisfactory community supp ort. Seventy-nine percent of the centers report 

serious problems stemming from unsatisfactory coordination of perinatal services 

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

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

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

center staff. 

Limited space. Limited space seriously hinders the provision of services at 64 

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

seriously restricts the comprehensiveness of care at 23 percent of the centers. 

... 

111 
COMPANION REPORTS 

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

provide perinatal care. Another report, 7%e Perinatal Service Capacity of the Federal& 

Funded Community Healtil Cen[en: Rural Centers (OEI-01-90-0233 1), examines recent 

trends in the perinata] care capacity of rural community health centers. 

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

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

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

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

CHCS and Comprehensive Perinatal Care Program funding of the centers. 

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

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

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

and unsatisfactory relationships between the centers and other community providers. 

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

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

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

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

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

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

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

from PHS, HCF~ and ASPE. 

iv 
TABLE OF CONTENTS


~oWcrmN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. I	

Purpose . . . . . . . . . . . . . . . . . . . . .OO. . . . . . . . . ..O.
 . . . . . . . . . . . . . . . . . . 1


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


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


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


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


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


FmINGS 

The capaci~ ofurban communi~ health centers to provide


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


Despite these increases incapaci~, demand forperinatal semicesat


urban centers continues to grow and many clients still do not


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


Several major constraints seriously limit the capaci~ ofurban centers 

to provide perinatal care . . . . . . . . . . . . . .


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


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


APPEN131~ 

& Federal Support for Perinatal Care at Communi~ Health Centers . . . . . . . . A-] 

B: Methodolo~ . . . . . . . . . . . . . . . .


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


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


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


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

INTRODUCTION 

PURPOSE 

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

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

BACKGROUND 

Birth Outcames in Urban America: The high rate of infant mortality in the United


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


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


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


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


infants.1 Infant mortality is particularly acute in the nation’s urban areas, where


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


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


deaths.~


Perinatal Care: A pregnant woman with no prenatal care is three times more likely to


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


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


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


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


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


psychosocial intewentions and follow-up .3 A full course of care is especially vital for


women at risk because of medical or social factors.


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


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


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


accessibility of perinatal care.q In 1989, almost 170,000 American women received no


prenatal care until the third trimester, and another 86,000 received no care at all


during pregnancy. Thirteen percent of whites received inadequate care; the


proportion of blacks and Hispanics was twice that,s


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


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


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


of the nation’s medically undeserved. The centers were expected “to provide not only


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


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


health services.’*


1

Federal administration of the CHC program was consolidated in 1975 under Section 

330 of the Public Health Service Act. The total number of centers, however, has not 

been maintained at the level originally envisioned.’ Moreover, the program was cut 

substantially in the early 1980’s; the number of grantees fell from 867 in 1981 to 530 n 

1983, a 39 percent decrease.8 In 1991, PHS funded 212 urban community health 

center grantees, which represented 40 percent of all Section-330 grantees.9 In 1992, 

PHS funded a total of 549 centers. 

The Federal government supports the services provided by community health centers 

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

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

for migrant workers and the homeless, the National Health Service Corps, and the 

Supplemental Food Program for Women, Infants, and Children. 

In recent years, funding for the centers has increased,l” and several initiatives have 

been implemented to expand center services and improve access to care. These 

include supplemental funding through the Comprehensive Perinatal Care Program 

(ePCP), expanded Medicaid coverage for pregnancy care, increased Medicaid 

reimbursement for center setvices through the Federally Qualified Health Center 

provisions of the Omnibus Budget Reconciliation Acts of 1989 and 1990, and Healthy 

Start grants to support community coordination of perinatal care. (For more 

information on Federal programs see appendix A.) 

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

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

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

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

centers to provide these services. 

COMPANION REPORTS 

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

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

Funded Communiy Healtil Centers: Rural Cen/em (OEI-O 1-90-02331), examines recent 

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

The third report, 77ZePerinataf Service Capacity of the Federally Funded Community 

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

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

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

CHCS and Comprehensive Perinatal Care Program funding of the centers. 

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

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

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

involving government at the Federal, State, and local levels, as well as non2

governmental organizations. That report offers a recommendation that the Public


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


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


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


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


METHODOLOGY


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


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


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


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


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


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


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


appendix B.)


Our review was conducted in accordance with the Interim Standards for Inspections�

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


3

FINDINGS


THE CAPACITY OF URBAN COMMUNITY HEALTH CENTERS TO PROVIDE 

PERINATAL CARE HAS INCREASED IN SEVERAL RESPECTS SINCE 1988. 

+	 % ruunber of premxal clients served by the centers rose 23 percent between 1988 and 

19%9, firma an average of 477 per center to s86. ?he number of bti to cen$er cti 

we 17 pement during the same pew fmm an avemge of 32b per center to 374. 

Survey reyxmdents reported a total of 8~560 prenatal clknzs and 51,826 births in 

2990. 

Seventy-eight percent of the 

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 served prenatal client 

populations that were more 

than half Medicaid-enrolled in 

1990.’2 

F&we 1 

Average Numbs of Prenatal Clients 

1988, 1989, and 1990 

5s6 

555 

1* 19s9 1990 

Yc!as 

ti:OIOmd Ulnn C5nmnmitylimkh Caws, Jim@19!?1. 

N- U5 

Caseloads grew 95 percent between 1988 and 1990 at centers that served fewer than 

200 clients in 1988, 25 percent at centers that served between 200 and 999 clients, and 

.5 percent at centers that served 1000 or more prenatal clients.13 

Caseloads grew 35 percent at centers that did not receive CPCP grants, and 22 

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

was larger at CPCP-funded centers.14 Caseloads grew 35 percent at centers in which 

more than half of the perinatal population was Medicaid-enrolled in 1990, and 4 

percent at centers in which less than half of the perinatal population was Medicaidenroiled. The average caseload size, however, was smaller at centers with perinatal 

populations that were more than half Medicaid-enrolled in 1990.]5 

4 
.	 w rnnge of perinutd service irneusd at 76 percenf of the cen@x i% seties 

*at the kugest number of cem were HW combg and tatig 

mking+watin program, and classes in pareruing and cmti 

Mediud and Health Promotion SeMeeX Between 1988 and 1990 there was an 

increase in the percentage of centers prow”ding each of a representative range of 

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

referrals or contracts.lG HIV counseling and testing semices and smoking-cessation 

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

1 

Figure 2

rPercentage of Centers that proti~ each Perinati Service 

Either On Site or Off Site, 1988 and 1990 

Percenhge of CenterS Provitig Each Service 

SOWU OIG Swey of UrbWI CunnItiqI Health f?en~ June 1991. 

N= 167 

Services on site: At the same time, 62 percent of the centers added at least 1 medical 

or health promotional service on site. The services added on site at the largest number 

of centers were family planning, health education, nutritional services, and HIV 

counseling and testing. In 1990, more than 90 percent of centers offered each of these 

semices on site (see appendti C for survey responses). 

5

--

�	 The range of ancillary serviaw-such as home visiting and transpomuion-weasexl at 

37 pexent of the centers. 

Thirty-seven percent of all the centers added at least one service that facilitates access 

to perinatal care between 1988 and 1990.17 Home-visiting setices were added at 

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

smallest percentage of centers (see figure 3). -

II


Kgure 3


Percentage of Centers that Rovided


Each hCi.kil’y Service, 1988 and 1990


1 

1~ fuud?a@dlspcabxa 

I 

I 

�	 S@-jive percent of the centerx oflered on-site assistance with enrdnent in Medkakl 

in 1990, an increase from 23 pement in 198& Eighty percent of the centezs offered onsite &timce with enrdbnent in the Supplemental Food Program for Womq lnfa~ 

and Children (JV7C) in 1990, an increme from 68 penznt in 1988. 

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

assistance with Medicaid and WIC enrollment. In 1990, 70 percent of CPCP-funded 

centers provided assistance with Medicaid enrollment and 84 percent provided 

assistance with WIC. By contrast, only 50 percent of the other centers provided 

assistance with Medicaid enrollment and 69 percent of them provided assistance with 

WIC.’* 

Between 1988 and 1990, however, a larger percentage of centers that did not receive 

CPCP funds added on-site assistance with Medicaid enrollment.19 

6

�	 Total revenua for the &an centem weased 31 pexen/ between 1988 and l~; ti 

incti an 18 percent increase in Section-330 grant jhnding and a 59 percent increase 

in Medicaki reirnbursementx S&y-five penznt of the centers reported that the amount 

of @ding available for perinatd services has increased since 198tl 

The PHS Section-330 grant represented 39 percent of total revenues for these centers 

in 1988 and 35 percent in 1990. Medicaid reimbursements amounted to 20 percent of 

total revenues in 1988 and 25 percent in 1990.n 

Increased funding for perinatal services was correlated with increased capacity. As 

one administrator reported, center capacity had grown as a result of “increased 

funding from multiple sources.” Some centers reported that implementation of the 

Federally Qualified Health Centers mandate had resulted in increased Medicaid 

reimbursements, which had been used to improve and expand center semices. Many 

of the centers we visited drew a direct link between the Medicaid eligibility expansions 

and an increased capacity to care for more women. Some centers reported that they 

were finally receiving reimbursement for women they would have otherwise served, 

but for whom, in the past, they would not have received reimbursement. 

DESPITE THESE INCREASES IN CAPACITY, DEMAND FOR PERINATAL 

SERVICES AT URBAN CENTERS HAS CO NTINUED TO GROW AND MANY 

CLIENTS STILL DO NOT RECEIVE THE OPTIMAL COORDINATED 

PACKAGE OF CARE IN A TIMELY FASHION. 

�	 Six percent of the urban centerx reprted that they provided no petital services on & 

between 1988 and 1991. Our study did not examine the extent to which these centm 

made alternative perindal care arrangements for their clienfi. 

Eleven of the urban centers that responded to our survey did not offer perinatal 

services on site from 1988 to 1991.21 Nine of these indicated that they referred 

clients to hospitals or other providers for perinatal services. Four expressed an 

interest in offering perinatal services, but noted that budgetary constraints or the 

inability to recruit obstetric providers prevented them from doing so. One 

administrator voiced a common sentiment when he stated: “there is a tremendous 

need in our community for perinatal services, but we cannot afford to offer them.” 

7

w Demand for sewictx increased at 89 percent of the urban centem; 34 percent of these 

cerzltm repmzi their capacity to meet ti growing dkmund dher &creased or 

remained the same. 

Several centers reported that they were overwhelmed by demand. Many have been 

periodically forced to turn away new perinatal clients because they do not have the 

capacity to serve them. 

Fifty-two percent of the centers reported that Medicaid eligibility expansions had 

seriously increased demand for perinatal services, and 48 percent reported that 

Medicaid presumptive and continuous eligibility provisions had done S0.22 Centers 

also explained increased demand as a result of the downturn in the economy. A 

growing number of unemployed women have neither the income nor the health 

insurance to afford private medical care, and therefore seek subsidized care at the 

centers. Reflecting the perceptions of several administrators we interviewed, one 

reported that “demand has increased due to the drug epidemic, an increase in teen 

pregnancy, and an increase in the number of older women having children.” 

Also contributing to the increase in demand is the diminishing number of community 

providers who are willing to treat low-income and Medicaid patients. one center we 

visited was the sole provider of obstetric care in its service area. Many centers 

reported that, although there were private obstetricians in their service areas, none 

would care for Medicaid or uninsured women. One administrator summarized 

comments made by many we visited when he noted: “Our center is experiencing the 

effects of the withdrawal of private physicians from the Medicaid program, with a 

tremendous overflow of patients.” 

w Fifiy-six percent of urban centezs reported that they do not coordinate as pati of their 

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

by the Fublk Health Service. l%k may, in paq rqilect variations in the di$iition of 

“case management” among centem 

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

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

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

requires centers to coordinate care through case management.z4 

Most centers provide some of the services recommended by the PHS, but 56 percent 

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

case-management system. Forty-five percent reported that they do not coordinate 

discharge planning and 24 percent reported that they do not coordinate delivery 

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

8

1, 

I 

Pigure 4 

I Percentage of Centers that DO NOT Case Manage Each Perinatal Service 

-w * ~45% 

o% 10% m% 30% 40% 50% 60% 

Percentage of Centers that DO NOT Case Mansge Each Service 

l~-”’’s””’u’=-””’-’”’” 

There is no common definition of what case management entails. One center director


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


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


services and not refer to such coordination as case management.


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


on average, 29 percent of each center’s prenatal clients and 26 percent of their infants


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


1990,Z 

9


II 
Athough the CPCP was intended, in part, to support centers’ case-management


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


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


�	 On averag< 51 pe~ent of each center’s prenatal clierm entered care in the fmt 

tri.rnater of pregnancy in 1990. Nationally, 76 pement of all womq 62 pexent of 

rnirwr@ wome~ and 58 pexent of wornen in Healthy Stati project areas entered care 

during the fit trimester.% 

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

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

average, 39 percent of each center’s 1990 prenatal clients did not enter care until the 

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

1989 national rates of 18 percent of women entering in the second trimester and 4 

percent in the third.27 Although the CPCP was intended, in part, to encourage 

earlier entry into care, responses to our survey indicate that there was no significant 

difference between CPCP-funded centers and other centers with regard to the 

percentage of perinatal clients who entered care in the first trimester. Our study does 

not allow a comparison of CPCP grant recipients and other centers with regard to 

trends over time in first-trimester entry into care. 

Several centers reported that motivating women to seek early prenatal care is among 

their biggest problems. Women with inadequate health insurance sometimes delay 

entry into care in an attempt to minimize the costs associated with care. Staff at 

several centers we visited agreed with one administrator who explained that some 

women who have had children before “believe that they are experts in perinatal care, 

and do not consult with physicians.” Teenagers, who sometimes try to conceal their 

pregnancies, are apprehensive about prenatal appointments. Cultural biases against 

medical intervention lead some immigrant women to avoid care. 

Additional barriers to care were suggested: staff at one center explained late entry 

into care as a factor of language barriers and the “fear of deportation of women who 

are not legal residents.” The staff at another center explained that many of their 

clients are “so overwhelmed by life crises, including drugs, poverty, mental illness, and 

hopelessness, that perinatal care is not a priority.” 

Although sumey responses indicate that most centers conduct outreach, several centers 

indicated that their efforts are minimal. One administrator explained what was 

apparent at many centers we visited when he reported that, because his center was 

already ovemhelmed by demand, outreach efforts had been temporarily suspended. 

10


— 
�	 On averagg 26 pement of each centds fiht-trirnester erudkx received fewer than 9 

prenatal viri.m. Ow study did not examine the extent W which these patienk3 may have 

received care ekwhere. 

The American College of Obstetricians and Gynecologists recommends that women 

entering care in the first trimester receive a minimum of 9 prenatal visits.m on 

average, however, 26 percent of each 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, there was no significant difference between CPCPfunded centers and other centers with regard to the percentage of first-trimester 

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

Women with limited financial resources and inadequate insurance coverage often 

minimize the number of their prenatal visits, especially when care is billed per visit 

instead of as a package for the full course of the pregnancy. one center administrator 

reported a problem common to many centers when he explained that long waits, both 

between scheduled appointments and in the crowded waiting room, discourage women 

from seeking care. 

Difficulties with child care and transportation were cited as resulting in a reduced 

number of perinatal visits by many with whom we spoke. At one center, the staff 

noted that an inability to arrange child care discourages women from making and 

keeping appointments. One administrator said that public transportation to the center 

was very time-consuming. Another administrator reflected a common perception 

when she reported that “these women must constantly address basic living needs, and 

so lack interest in prenatal care.” Drug abuse was cited at several centers as another 

factor that diminishes women’s interest in prenatal care. 

~ 17@-six percent of the centers did not ofier prenatal appointments at times convenient 

for wotig women. 

Availability of Prenatal Appointments: In 1990, 36 percent of the centers provided no


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


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


and prenatal care.


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


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


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


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


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


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


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


11

i~ 

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


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


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


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


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


we inter-viewed.


sEVm/u MAJOR CON~ SERIOUSLY LIMIT THE CAPAC~ OF 

WAN CENTERS TO PROVIDE PERINATM C-. 

�	 Mdcai stiff shortagq in pan as a result of cti in the National HeaLth Service Coqx 

in the 1980’4 preseru seriou problems at 59 pexent of centem 

Although demand for perinatal services increased 23 percent at urban centers, the 

number of full-time equivalent obstetricians, family physicians, and certified nurse 

midwives rose only 12 percent (see append~ C for survey responses). Forty-seven 

percent of the centers reported that at least 1 of these clinical positions was currently 

vacant (see table 1); and 24 percent reported that at least 1 of these positions had 

been vacant for over 1 year. In addition, 37 percent of the centers reported that 

medical staff shortages have become more severe since 1988, and 28 percent cited 

high medical staff turnover as a serious problem. 

Table 1
 Percentage of Centers Reporting at Least One Clinical Provider Position Vacant?g


!, Nurse Midwife c: t“:? “::z11% 6% 

Source: OTG Survey of Urban Community Health Centers, June 1991 

N=167 

Recruitment and Retention Problems: Centers have historically faced serious


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


and benefits are generally not comparable to those in the private sector. One survey


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


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


burn-out and bankruptcy.”


12�
A shortage of staff means more frequent on-call rotations, which in turn makes a 

center less attractive to prospective employees. Insufficient support from the wider 

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

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

or adequate backup from local providers. Unattractive facilities and locations in highcrime areas also hinder recruitment efforts. 

National Health Service (2xps: Centers have historically relied upon the National 

Health Service Corps for a large percentage of their providers, but this program 

experienced major funding cuts during the 1980’s. Several center administrators with 

whom we spoke reported that they have often been unable to retain corps providers 

beyond their obligated terms of service and have found it difficult to replace them. 

(See appendix A for more information.) 

Staffing Models: Obstetricians are in short supply, and many are unwilling to work in 

community health center settings. They are also the most expensive providers to 

support: Their salaries and medical malpractice insurance premiums are substantially 

higher than those of other providers. The medical director of one site we visited 

expressed a view common among experts when he remarked that nurse midwives, 

physician assistants, and nurse practitioners are “the future of inner city care” because 

of their lower cost. Family-physician and certified-nurse-midwife models of care also 

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

obstetricians do not believe that family physicians or certified nurse midwives should 

perform deliveries and are reluctant to provide backup services for them; and many 

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

staffing models are impractical for many centers. 

� % cost of medical malpractice insurance has been a serious &ain on r~oumes at 56 

percent of the centem 

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


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


commercial medical liability insurance rates and cutbacks in the National Health


Service Corps have resulted in dramatically increased expenditures on medical liability


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


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


revenues.w


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


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


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


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


cost.


13

Concerns about restricted staff productivity and increasing costs were echoed by many 

of the survey respondents and center administrators with whom we spoke. One 

center’s insurance carrier placed a cap on the number of deliveries its family 

physicians could perform each year. A recent change in insurance coverage for 

midwives led to a substantial increase in another center’s insurance rates.3~ 

Escalating malpractice costs led another center to ask, “what can be done to control 

malpractice costs for providers willing to volunteer time at the center?” 

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

that extends medical malpractice liability protection under the Federal Tort Claims 

Act (fTCA) to health care providers at the centers.32 

w	 Seventy-six perceru of the centers reprt sericm problems stemming fmm Mdcaid 

policies and procedurm--such as a burdensome application process, bw reimbursement 

mtes, a limiled range of covered services, or limited eligibil@ 

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

1990.33 Despite recent changes in the Medicaid system intended to increase access 

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

to provide comprehensive, timely care (see table 2). 

I Table 2 1 

~ Percentage of Centers Citing Each of the Following I 

Medicaid Factors as a Serious Limitation 

~~ Burdensome application procedures ! 56% II 

# Inadequate reimbursement rates I 47% II 

~ Slow reimbursement process 43% I 

Restrictive eligibility criteria 41% 

I, Limited range of covered services / 38T0 ~ 

Source: C)IG Survey of Urban Community Health Centers, June 1991 

N=167 

Application Process: The process of applying for Medicaid benefits is burdensome 

and confusing to both centers and their clients. As one center administrator noted, 

the complexity of the process frequently leads to patients’ “failure to follow through 

with procedures for obtaining benefits.” “The process is so time-consuming,” another 

reported, that the experience of “women receiving Medicaid cards in their third 

trimester is very common.” Several centers reported similar problems. A number of 

State Medicaid agencies had not begun to place eligibility workers at centers, even 

though recent Federal law had required them to begin doing so.~ 

14


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


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


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


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


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


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


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


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


presumptive eligibility process was so frustrating that many women miss medical


appointments. Some centers have encountered difficulty finding other providers who


accept presumptive eligibility clients on referral.


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


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


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


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


we would not have them without grants.”


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


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


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


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


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


additional States may have begun to implement these provisions.


EligiiiMy Many centers reported that Medicaid eligibility requirements are still too


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


centers are expected “to charge clients who can’t pay.” Further, according to OIG


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


~ On average, 21 percent of cenler perinulal clients were uninsured in 1990. 

At 33 percent of the centers more than 25 percent of the perinatal clients were 

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

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

scale. 

w Seventy-nine perceru of the centen reprt serious problems stemming @m 

unsati$actoiy coordinalwn of perinatal services in the commun ity, a tick of other ikal 

pmvidm willing to treat uninsured and publicly insured wornq dificu.i@ an-anging 

obstetric backup for center stafl and for consultation for high-tik ctints, or dim 

obtaining hospital pn”vikges for center stafi 

15

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.% 

Twenty-six percent of the centers, however, do not participate in perinatal care 

consortia. Ten percent of the centers cited limited relationships with local community 

and government organizations as a factor that seriously hinders the provision of 

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

Table 3 

Percentage of Centers Reporting the Participation of Each of the 

Following in a Cmnxnunity Perinatal Care Consortium 

~ Teaching hospitals 1 54% I Government social services 349Z0 

Local health departments	 i 53% ~ Private-practice physicians ~ ,~ \ ~ Other health clinics ~ 4396 ~ Nonteaching hospitals 25% 

I 

II Private nonprofit groups ‘ 42% II Local schools I 20% II ! I State health departments I 35% ~~Other 1 10% i 

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

N=167 

Many centers indicated that, although they participate in perinatal care consortia, 

these involve minimal activity and have limited results. Several centers noted that they 

participate in consortia addressing only specific problems--most commonly, substance 

abuse. Eighty percent reported that their consortium activities do not include local 

schools; 74 percent that they do not include private-practice physicians; and 65 percent 

that they do not include State health departments.39 

The Imczd Medical Establishment: Sixty-one percent of the centers reported that a 

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

seriously limits the comprehensiveness of center care; 35 percent reported that this 

shortage has become a more severe problem since 1988. 

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

integration of the clinical staff into the larger medical community . . . to assure followup of referred care and the availability of timely and quality consultations.”4° 

Centers indicated, however, that they Fdce serious difficulties arranging both backup 

and referrals. Thirty-one percent of the centers reported serious difficulty arranging 

obstetric backup for certified nurse midwives and 22 percent reported such problems 

for family physicians. Twenty-one percent cited difficulty arranging consultation for 

high-risk clients as a serious limitation. 

16

Many of thecenter administrators weintetiewed reported that they are constrained


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


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


noted that his center’s biggest problem is the “provision or identification of referral/


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


noted that, “even when Medicaid rates went up, private doctors didn’t come back” to


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


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


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


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


did not do their part in facilitating the center’s provision of care.


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


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


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


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


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


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


nurse midwives is a serious limitation to care.


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


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


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


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


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


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


by its inability to retain such backup.


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


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


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


another noted that no local hospital takes uninsured patients.


w� L&z&d space seriourly hinders the provirwn of services at 64 pexent of the centers. 

In additiq limited coilocalwn of services on site seriously restricts the 

comprehensiveness of care at 23 pe~ent of the centers. 

Thirty-eight percent of the centers reported that inadequate space has become a more 

serious problem since 1988. Illustrating the ways in which inadequate space can 

hinder service delivery, one administrator indicated that the small number of 

examination rooms at that center limits its providers’ productivity. The center had 

temporarily stopped accepting new prenatal clients because of the lack of space. 

Another center had struggled for years to increase its clinical staff capacity; having 

recently done so, it must still limit the number of clients served because of space 

constraints. Still another noted that, in a recent survey of patient satisfaction, the 

17

most common complaints were long waiting times and congestion in the waiting room. 

State PrimaV Care officials who had recently visited this center remarked that it was 

“so crowded that we had to go in through the employees’ entrance.” 

Fifty-nine percent of the centers reported that no other public organizations, aside 

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

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

likely than other centers to cite limited collocation of semices on site as a serious 

constraint. 

18

CONCLUSION


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

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

three themes concerning their performance of this role. 

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

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

and budgetary resources, the centers have demonstrated considerable growth. 

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

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

Service. Limitations are particularly apparent in the scope of case-managed services 

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

first trimester of pregnancy. 

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

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

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

Medicaid policies and procedures, medical malpractice insurance, relationships with 

other medical providers, and clinic space. 

19

APPENDIX A


FEDEIUL SUPPORT FOR PERINATAL CARE 

AT COMMUNITY HEALTH CENTERS 

The Federal Government supports the perinatal services provided by community 

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

mechanisms, including Medicare and Medicaid reimbursements, Maternal and Child 

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

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

access of women to those semices, including the following: 

Medicaid Expansions: Congress has mandated several changes in the Medicaid 

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

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

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

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

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

(3) pr=mptiw eligiiihty eligibility for temporary coverage, limited to a maximum of 

61 days for ambulato~ sewices only, is based solely on self-reported income; 

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

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

enrollment sites, including CHCS. 

Federal& Qualified Heal[/l Cen[en (FQHC): The Omnibus Budget Reconciliation Acts 

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

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

cost of covered services. 

7he Comprehensive Perina[al Care Program (CPCP): In 1988, the PHS launched this 

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

perinatal visits. The CPCP provides supplemental funding for enhanced services, 

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

1989. In FY 1991, 290 of the urban, rural, and migrant health centers received a total 

of $33 million in CPCP supplemental funding;43 80 percent of the urban respondents 

to our survey that offered perinatal services received CPCP funding for at least 1 year 

between 1988 and 1991. In fiscal years 1992 and 1993, $44.7 million was appropriated 

for CPCP.44 

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

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

improve maternal and infant health care. 

A-1

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

perinatal care, including: 

National Health Setvice Corps (NHSC): The PHSoffers both scholarships and 

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

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

providers have traditionally worked incommuni~ health centers. After substantial 

cuts in program size in the early 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


METHODOU3GY


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


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


and data.


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


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


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


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


A review of geographic and demographic information suggests no significant


differences between respondents and nonrespondents.


Of the 178 urban respondents, 11 (6 percent) provided no perinatal services on site


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


unless otherwise noted, reflect the responses of those 167 centers (79 percent of all


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


period.


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


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


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


year in which the initial grant was awarded.


Not all respondents provided complete information. We calculated trends presented


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


relevant information for all years.


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


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


significance at the .05 level. In reporting responses to survey questions that solicited


information on a scale, we combined responses of “moderately” and “substantially” and


reported them as “seriously” or “serious.”


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


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


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


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


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


seven had received CPCP funding.


B-1

Intemiews: ~estudy team held discussions with (l)officials in PHS's Bureau of 

Primary Health Care (BPHC) (then called the Bureau of Health Care Delivery and 

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

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

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

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

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

Association of Community Health Centers. 

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

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

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

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

applicants through the Perinatal User Profile reports. 

B-2

APPENDIX C


URBAN SURVEY RESPONSES 

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


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


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


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


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


parentheses as appropriate.


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


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


appendix C for a discussion of statistical methodology.


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


1988: Yes=152 No=15 

1989: Yes=159 NO=8 

1990: Yes=165 No=2 

1991: Yes=164 No=3 

A CASELOAD 1988 1989 1990 

1. Please indicate: 

MEAN (N) 

a.	 the number of women who received prena[al 

care at your center: 481 (126) 530 ( 149) 558 (157) 

b.	 the percentage of these clients who were 

high-rislq as defined by your center: 37% (92) 39% (115) 39% (128) 

c.	 the percentage of these clients who were 

low-risk as defined by your center: 49% (88) 48% (109) 49% (125) 

d.	 the number of births to your center’s 

clients: 321 (120) 354 (135) 362 (143) 

2.	 Of the women who gave birth in your service 

area, what percentage received prenatal care 

at your center? 25% (71) 29% (81) 32% (79) 

c-1 
B. COMMUNITY COORDINATION 

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

Yes = 123 No =44 If YES, please continue. 

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

a. state health department: 58 f. nonteaching hospitals: 41 

b. local health department: 88 g. private-practice physicians: 44 

c. health clinics: 72 h. gov. social setvice agencies: 56 

d. schools: 34 i. non-profit organizations: 69 

e. teaching hospitals: 90 j. other: 16 

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

your center’s involvement. 

C. CLINIC SITES AND HOURS 1988 1989 1990 

1. Please indicate the number of MEAN(N) 

a. clinic sites operated by your center: 1.95 (159) 2.01 (161) 2.06 (164) 

b.	 clinic sites at which prenatal care 

was provided: 1.50 (158) 1.57 (161) 1.59 (165) 

2.	 On how many days a week did your center


provide scheduled prenatal appointments


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


3. On how many Saturdays a month did


your center provide scheduled


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


D. Funding 

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

was: 

Larger= 109 Smaller=21 Unchanged=30 

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

a. Private insurance: 6.95% (148) c. Medicaid: 67.30% (152) 

b. No insurance: 20.70% ( 149) d. Other: 4.00%0 (155) 

c-2 
3.	 To what extent have the fo]]owing factors 

at your center over the past three years? 

a. Medicaid eligibility expansions: 

b.	 Medicaid presumptive and 

continuous eligibility provisions: 

E. PERINATAL OUTREACH 

resulted in increased demand for perinatal semices 

Not at alU Moderately/ 

Somewhat Substantially 

62 87 

68 81 

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

efforts? (Please check all that apply) 

a. Teenagers: 140 c. Non-English speakers: 92 

b. Substance abusers: 78 d. Other: 51 

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

(Please check all that apply) 

a.	 Community d. Schools: 109 

centers: 98 e. Welfare offices: 52 

b. Shops: 27 f. Churches: 59 

c.	 Door-to-door in the g. Other: 66 

neighborhood: 43 

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

(Please check all that apply) 

a. Television: 34 d. Radio: 45 

b. Newspapers: 69 e. Other: 49 

c. Pamphlets: 132 

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

Greater= 114 Smaller=11 l%e same=32 

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

More clients= 124 Fewer clients=7 lhe same numberof clients=20 

c-3 
F. PERINATAL SERVICES 

1. Please indicate which of the following 

offered on site, please circle On. If these 

or paid referral--please circle O& 

a. Ultrasound: 

b. Amniocentesis: 

c. Genetic counseling: 

d. Non-stress testing: 

e. Dental care: 

f. Nutritional services: 

h. Health education: 

i. Birthing classes: 

j. Parentinghfant care classes: 

k. Family planning: 

1. Smoking cessation programs: 

m. Substance abuse treatment: 

n. HIV counselinghesting: 

semices were provided by your center. If these were 

were offered off site--either through contract, affiliation, 

1988 1989 1990 

0n=42 on=51 on=57 

Off=lol Off’loo OH= 103 

On=6 on=5 00=7 

0E=136 Off= 143 m= 147 

on=14 on=17 on=22 

off=l19 Off= 124 Off= 126 

on=35 00=48 on=50 

OE=98 0ff=90 off=95 

On=lll on=l14 on=l15 

01T=32 0Ef=36 off=43 

on=135 on=139 on=154 

off=14 off=17 0H=9 

on=139 on=147 0n=158 

Off=lo 0H=8 0H=6 

0n=84 on=95 on=lo6 

0E=54 OE=54 (M=52 

0n=87 On=98 On=lzl 

otT=45 Off-=43 0iT=32 

on=lso 0n=154 on=160 

0H=2 0ff=3 off=3 

0n=52 0n=58 on=75 

0tT=65 0ff=66 0E=65 

0n=25 0n=28 on=44 

off= 102 off= 104 OtT= 103 

0n=81 011=117 on=143 

off=47 0E=29 Off= 18 

2. Compared with 1988, the range of perinatal 

semices offered by your center in 1990 was: 

Greater= 127 Smaller=6 Unchanged=30 

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

in the following programs? 

a.	 Medicaid: Yes=38 Yes=63 Yes=108 

No=117 No=94 No=56 

b.	 WIC: Yes=l13 Yes= 123 Yes=134 

No=43 NO=36 No=31 

c-4 
1988 1%9 1990 

4. Did other government or private social setice 

organizations provide services on-site at your 

center? 

5. Did your center facilitate access to perinatal 

care by providing the following semices? 

a. Transportation to and from appointments: 

b. Translation for non-English speaking clients: 

c. Child care during center appointments: 

d. Home visits: 

G. STAFFING 

1. How many full-time equivalents of each 

of the following provided perinatal services 

on-site at the center? (N= 167) 

a. Obstetricians: 

b. Family physicians: 

c. Certified nurse midwives: 

d. Nurse practitioners: 

e. Physician assistants: 

Yes=42 Yes=49 Yes=66 

No=113 No=11O No=99 

Yes=74 Yes=89 Yes=97 

No=80 No=71 No=67 

Yes=120 Yes=127 Yes=133 

No=32 No=30 No=28 

Yes=ll Yes=14 Yes=19 

No=145 No=147 No=146 

Yes=76 Yes=lo3 Yes=l15 

No=78 No=58 No=50 

1988 1989 1990 

0.89 0.99 0.93 

0.64 0.72 0.75 

0.28 0.33 0.35 

0.57 0.65 0.67 

0.17 0.19 0.21 

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

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

which have been vacant for more than one year. (N= 167) 

a. Obstetrician: 

b. Family physician: 

c. Certified nurse midwife: 

3.	 Compared with 1988, the 

local hospitals in 1990 was: 

(i) (ii) (iii) 

Numberof More than More than 

Vacanaes six months one year 

0.41 0.34 0.20 

0.25 0.20 0.13 

0.14 0.11 0.07 

percentage of your perinatal providers with admitting privileges at 

Larger =44 SmaUer=24 Unchanged =91 
H. TIMING OF CARE 

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

a. Fh_st trimester: 50.8% (N= 156) 

b. Second trimester: 39.1% (N=154) 

c. Third trimester: 10.3% (N=139) 

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? 

I. APPOINTMENTS FOR CARE 

1988 

69.3% (67) 

66% (84) 

69.5% (79) 

1989 1990 

7190 (94) 74% (108) 

66.4% (121) 71% (142) 

69.7% (1 10) 73.9% (128) 

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

appointment? 

Pregnancy tests are offered Less than one week: 47 

on a walk-in basis: 105 One-two weeks: 12 

More than 

two weeks: 3 

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

Yes=150 NO=16 

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

The first perinatal visit is Less than two weeks: 75 

provided in conjunction Two-four weeks: 58 

with the pregnancy test: 26 One-two months: 7 

More than 

two months: 1 

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

generally: 

Shorter= 56 Longer=33 The sarne=68 

C-6 
J. CASE MANAGEMENT 

1. Does your center currently provide case management to promote the coordination of services 

for perinatal clients? 

Yes=161 NO=6 If YES, please continue. 

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

The client’s primary care doctor: 4 

The client’s primary care nurse: 23 

The appointments secretary: o 

A multidisciplinary team: 69 

A center employee whose main 

responsibility is case management 

for perinatal clients: 59 

Other: 6 

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

Ail perinatal clients: 129 

All high-risk perinatal clients: 22 

Only certain groups of 

perinatal clients: 16 

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

a. Risk assessment: 155 

b. Planning of care: 152 

c.	 Assessment of adequacy and 

appropriateness of services: 134 

d. Client advocacy: 146 

e.	 Contact with other organizations 

to arrange for services / 

schedule appointments: 159 

f.	 Assistance with papemork related to 

WIC, Medicaid, and other programs: 154 

g. Discharge planning: 92 

Coordination of 

h.	 Medical sewices provided 

on-site at the center: 153 

i.	 Medical services provided 

off-site: 129 

c-7 
Continued: 

j. Delivery setices: 

k.	 Social services provided 

on-site at the center: 

1.	 Social services provided 

off-site: 

m. Nutritional setices: 

n. Health education: 

0. Other: 

5.	 Compared with 1988, the percentage 

in 1990 was: 

Larger= 140 Smaller=3 

6.	 Does your center often encounter 

and from facilities to which perinatal 

For delivecy: Yes=41 

For other care: Yea=52 

127 

143 

117 

155 

153 

26 

of all center perinatal clients case managed by your staff 

Unchanged= 11 

problems assuring the timely transfer of medical records to 

clients are referred? 

No=120 

No=1O3 

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

reschedule missed appointments: 

71% (N=151) 

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

(please check all that apply): 

Mail= 156 Phone= 161 Home visit=112 Other= 15 

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

provider or the same provider team at each perinatal visit? 

Yes=153 NO=6 

C-8

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

limits yourcenter’s ability to provide perinatal services: 

Moderately/ 

1. Shortage of medical staff 

2. Shortage of nonmedical staff. 

3. High medical staff turnover: 

4. High nonmedical staff turnover: 

Difficulty obtaining admitting privileges 

at local hospitals for: 

5. obstetricians: 

6. family physicians: 

7. certified nurse midwives: 

8. High cost of malpractice insurance: 

Difficulty obtaining malpractice insurance for: 

9. obstetric providers: 

10. all providers: 

Difficulty arranging medical backup for: 

11. OB supervision of certified nurse midwives/ 

nurse practitioners: 

12. OB 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 setvices: 

28. Limited space: 

29. Other 

Not at W


Somewhat sub6tantiauy


67 95 

112 47 

113 44 

135 22 

132 13 

118 21 

81 40 

68 88 

120 27 

124 22 

97 43 

99 28 

97 59 

123 32 

146 16 

63 98 

101 46 

133 6 

59 101 

83 71 

93 69 

86 75 

99 60 

95 65 

72 91 

119 36 

111 33 

58 102 

10 9 

c-9 
Which of these factors have become LESS SERIOUS or MORE SERIOUS limitations since 

1988? 

1. Shortage of medical staffi 

2. Shortage of nonmedical staff 

3. High medical staff turnover: 

4. High nonmedical staff turnover: 

Difficulty obtaining admitting privileges 

at local hospitals for: 

5. obstetricians: 

6. family physicians: 

7. certified nurse midwives: 

8. High cost of malpractice insurance: 

Difficulty obtaining malpractice insurance for: 

9. obstetric providers: 

10. all providers: 

Difficulty arranging medical backup for: 

11. OB supervision of certified nurse midwives/ 

nurse practitioners: 

12. OB 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 cz?rtified nurse midwivtxl 

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 

More


Serious serious


60 23 

19 21 

17 14 

5 21 

5 20 

11 12 

14 10 

43 11 

16 12 

9 11 

27 13 

14 13 

31 13 

20 18 

6 28


56 9 

11 24 

3 20 

40 22 

36 12 

30 30


31 44


23 34


30 52


37 37


16 41 

12 19 

61 21 

6 1 

c-lo 
L CONCLUSION 

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

Increased= 149 Decre&A=7 Not changed=8 

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

your service area has: 

Ineread=lo6 Decreased=36 Not changed=22 

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

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

faced in the past three years? 

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

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

C-II

APPENDIX D


1. 

2. 

3. 

4. 

NOTES


National Center for Health Statistics (NCHS), 1992. The 1989 U.S. infant 

mortality rate was 9.8 deaths per 1,000 live births. The provisional rate for 

1990 is 9.1 deaths per 1,000; and the provisional rate for 1991 is 8.9 per 1,000. 

These rates represent considerable improvement over the 1950 rate of 29.2, but 

the pace of improvement has slowed in recent years and has not been 

experienced equally by all segments of the population. According to the most 

recent international data, the 1988 U.S. infant mortality rate for whites alone 

places the nation 17th lowest in the world, while the rate for blacks alone 

places it 36th. Native Americans and Puerto Ricans also have infant mortality 

rates considerably higher than the national average. 

NCHS, 1988. These are the most recent data available. 

U.S. Public Health Semite (PHS), Healthy People 2000: National Health


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


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


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


Sarah S. Brown, editor: Institute of Medicine, Prenatal Care: Reaching Mothens 

Reaching Infants, National Academy Press, Washington, D. C., 1988, p. 4. 

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

Association, Washington, D. C., 1988, pp. 20-23. An increasing number of 

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

Medicaid-insured patients because of high malpractice premiums and low 

Medicaid reimbursement rates. 

In September 1990, the American College of Obstetricians and Gynecologists 

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

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

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

number of deliveries they performed. Average obstetric premiums rose 248 

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

Corporation, “Professional Liability and Its Effects: Report of a 1990 Survey of 

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

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

differences from the prior survey. 

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

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

D-1

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

1987.) 

5. NCHS, “Advance Report on Final Natality Statistics, 1989,” MonthZy VW 

Statistics	 Report, vol. 80, no. 8, Supplement, December 12, 1991, p. 43. These 

1989 data are the most current available. 

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

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

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

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

received less than adequate care. 

6.	 “Cohesion Sought in Medical Aids: Antipoverty Funds Used for Centralized 

Services,” 771e New York Times, May 22, 1966. 

7.	 Alice Sardell, The U.S. 13rpenrnent in Social Medicine: Z4e Community Heahh 

Center Program, 1965-1986, University of Pittsburgh Press, Pittsburgh, PA 1988, 

p. 66. 

8.	 Bonnie Lefkowitz, Bureau of Primary Health Care (BPHC), PHS, “The 

Institutionalization of Community Health Centers,” speech to the American 

Public Health Association, November 13, 1983, p. 4. This number represents 

consolidation as well as elimination of grantees. 

9.	 As of June 1991, PHS also funded 302 rural community health centers. The 

capacity of these centers to provide perinatal services is addressed in the OIG 

inspection report The Perinatal Service Capacity of The Federally Funded 

Community Health Centers: Rural Centem (OEI-01-90-02331). Some 

community health centers received both Section-330 funds and Section-329 

funds for care provided to migrant workers; an additional 71 centers received 

only Section 329 funding. 

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

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

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

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

$559 million. (BPHC and the Assistant Secretary for Management and Budget 

[ASMB].) 

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

from the centers through the Bureau’s Common Reporting Requirements 

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

applicants through the Perinatal User Profile reports, 

D-2

1’3 

lL.	 Unless otherwise noted, all of the differences between groups (such as CPCPfunded centers and other centers) cited in this report a~e statistically significant 

at the .05 level. 

13.	 Centers that served fewer than 200 prenatal clients in 1988 served an average 

of 110 in 1988 and 215 in 1990. Centers that sewed between 200 and 999 

clients in 1988 served an average of 465 in 1988 and 581 in 1990. Centers that 

seined 1,000 or more clients in 1988 sened an average of 1,886 in 1988 and 

1,971 in 1990. 

14.	 In 1988--before CPCP funds were awarded--those centers that eventually 

received funding sened an average of 526 clients; the other centers seined an 

average of 231. In 1990, the CPCP-funded centers sewed an average of 641 

clients; other centers seined an average of 311. 

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


Moving Ahead,” CPCP-funded centers served 33,938 pregnant teens in 1990,


which they report is more than triple the number served in 1988. Also


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


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


BPHC’S CPCP data, however, does not permit a comparison of CPCP-funded


centers and other centers.


15.	 These centers served an average of 372 prenatal clients in 1988 and 504 in 

1990. Centers with perinatal populations that were less than half Medicaidenrolled served an average of 811 clients in 1988 and 845 in 1990. 

16.	 Our survey inquired about the provision of a representative range of perinatal 

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

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

childbirth classes, parenting/infant-care classes, family planning, smokingcessation programs, substance-abuse treatment, and HIV counseling/testing. 

17.	 Our survey inquired about the provision of four services that facilitate access to 

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

appointments. 

18.	 Some centers are able to complete enrollment on site. Other centers only 

distribute forms or provide assistance in completing them. In such cases, 

applicants must complete the enrollment process at the appropriate State 

offices. Some centers reported that staff sometimes accompany clients to the 

State offices to facilitate the process. Some centers complete all nutritional 

assessment and paperwork for WIC on site, but clients must obtain vouchers at 

a different location. 

D-3

19. There wasa 163percent increase inthenumber of CPCP-funded centers that 

20. 

21. 

22. 

23. 

24. 

25. 

provided Medica~d enrollment assistance on site. There wasa433 percent 

increase in the number of centers without CPCP funding that provided this 

service. In 1988, 35 CPCP-funded centers and 3 other centers provided on-site 

assistance with Medicaid enrollment. By 1990, 92 CPCP-funded centers and 25 

other centers offered this service. 

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 change in center revenues from data for 

those 146 urban centers (82 percent of urban survey respondents, or 72 percent 

of all urban grantees) that both responded to our sumey and provided financial 

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

Total reported revenues for these 146 centers increased from $415 million in 

1988 to $544 million in 1990. PHS Section-330 grants to these centers 

increased from $163 million in 1988 to $193 million in 1990. Medicaid 

reimbursements to these centers increased from $84 million in 1988 to $134 

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

grants, Section-329 and -340 grants, WIC grants, Title X grants, Title XVIII 

Medicare payments, Title XX payments, other third party payments, patient 

collections, State and local revenues, and donations. 

We excluded these 11 centers from the calculation of the statistics presented in 

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

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.” 

PHS, Caring for Our Future, p. 2. 

PHS, Healthy People 2000, p. 366. 

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

“social sewices” for “psychosocial services.” 

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 to the center. In addition, in some 

D-4

immigrant communities, women are discouraged from leaving their homes for 

at least one month after delivery. Some women may receive follow-up care 

from other providers, but it is unclear to what extent the centers track these 

women after delivery. 

26.	 NCHS, 1992. The 1989 data for national rates of entry into care are the most 

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

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

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

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

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

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

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

Aberdeen, South Dakota (rates are for the Northern Plains Native American 

populations in North Dakota, South Dakota, and Nebraska); Baltimore, 

Maryland; Birmingham, Alabama; Boston, Massachusetts; Chicago, Illinois; 

Cleveland, Ohio; Detroit, Michigan; Lake County, Indiana; New Orleans, 

Louisiana; New York, New York; Oakland, California; the Pee Dee region, 

South Carolina; Philadelphia, Pennsylvania; Pittsburgh, Pennsylvania; and 

Washington, D.C. 

27.	 NCHS, Montidy VI[al Stattitics Repoti, 1991, p. 43. These 1989 data are the 

most recent available. 

28.	 ACOG, S[andard-sfor Obstetric-Gynecological Services, 7th cd., Washington, 

D. C., 1989, p. 16. 

The PHS has required that “all centers, regardless of size, must assure that the 

semices that they deliver conform to the Standards for Obstetn”c-Gynecolo@”c 

Services” (“Perinatal Care: How to Establish Perinatal Services in Community 

Health Centers,” PHS, 1985, p. 96.) 

A 1989 PHS report, Caring for Our Future: The Content of Prenatal Care, 

suggests slightly different guidelines. This report recommends that healthy 

women receive nine prenatal visits during a first pregnancy and seven prenatal 

visits during subsequent pregnancies (p. 50). The report suggests that women 

at risk, because of either psychosocial or physical factors, might require more 

prenatal visits (p. 71). Psychosocial and physical risk factors include inadequate 

personal support systems, single marital status, adolescence, advanced age, high 

stress and anxiety, less than high school education, low income, inadequate 

housing, inadequate nutritional resources, communication barriers, smoking, 

alcohol abuse, and illicit drug use (p. 79). 

29.	 Nonresponses may have resulted in an underestimate of the percentage of 

centers with such vacancies. 

D-5

30. 

31. 

32. 

33. 

34. 

35. 

36. 

37. 

38. 

39. 

U.S. General Accounting Office, Medical Malpractice: Data on Claims Needed 

to Evaluate Health Centers’ Insurance Alternatives @IRD-91-98), Washington, 

D. C., May 1991, p. 1. These data are for all Section-330 grant recipients. 

The clinic’s midwives had originally been covered under its general liability 

policy, but must now be insured individually. 

P.L. 102-501. Under the Ff’C~ 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, seven percent of each center’s perinatal clients were privately 

insured and four percent were covered by other mechanisms in 1990. 

The Omnibus Budget Reconciliation Act of 1990 required States to locate 

eligibility workers at sites other than AFDC enrollment sites, including CHCS, 

as of July 1991. 

Several administrators speculated that States lacked the funds needed to 

implement outstationing of eligibility workers. At one center, a State eligibility 

worker was stationed on site, but her effectiveness was limited because she was 

unable to access the regional Medicaid database and was not allowed to make 

long-distance telephone calls to the agency office. 

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. 

OIG, Draft report Medicaid Expansions for Prenatal Care: State Update 

(OEI-06-90-00161), May 1992. 

At one site we visited, where only 5 percent of the perinatal clients were 

covered by Medicaid and 70 percent were uninsured (most clients were working 

poor and failed the asset test), the director noted that grant funds are necessary 

to subsidize sliding scale fees. 

P. E., pp. 4-5. 

Centers report a range of coalition activities, including formulation of 

recruitment and retention strategies; sharing of services; use of a common 

medical record; on-line appointment, registration, and data transfer with local 

hospitals; coordination of referrals; improved communication; telephone 

D-6

hotlines; public forums forperinatal issues; media relations; contact with 

legislators; consultation with governmental agencies; and community education. 

40. P. E., p. 18. 

41.	 Our survey only addressed admitting privileges. During interviews, center staff 

reported hospital restrictions on the delivery privileges of certified nurse 

midwives and family physicians. 

42. P. E., p. 19. 

43. HRS~ FY 1993 Justification of Appropriations, vol. 1, p. 61. 

44. BPHC and ASMB data. 

D-7