Community Health Centers and Second-Class Health Care

Federally-funded community health centers (CHCs) are a significant part of the safety net. They provide care to low-income Americans, most of whom either have no health insurance or rely on Medicaid. The G.W. Bush Administration expanded CHCs dramatically, and the Affordable Care Act signed by President Obama does so even further, to the point they may serve as many as 30 million Americans a year in the near future. While seeing CHCs as laudable, many progressive health care policy analysts have fretted that the care provided in these centers is not at the same level of quality as that received by privately insured patients in other settings. A new study published in the American Journal of Preventive Medicine shows that this is indeed the case.

The research team examined over 30,000 ambulatory care visits to assess quality measures such as providing adequate medications for chronic illnesses, screening for high blood pressure, counselling patients about the need for exercise and the like. The quality of care provided in CHCs was compared to that provided by primary care doctors in private practice.

The difference in health care quality across the two settings was profound: CHCs provide much better primary care than do private practice doctors. Of the 18 quality measures examined, CHCs were superior on 11, equal on 6 and inferior on 1. When the researchers adjusted the findings for difference in patient characteristics, private sector care was not superior in any respect, and was on most indexes significantly worse.

Some people will find the prevalence of second-class health care in the private sector astounding, just as they are surprised to find out that VA medical centers frequently outperform their private sector counterparts in communities around the country. But there is simply nothing in the profit motive that guarantees quality health care. Indeed, it can just as easily drive needless and risky diagnostic procedures, overuse of specialists and a neglect of the fiscally low stakes but clinically important practices that are the bread and butter of high-quality primary care.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

14 thoughts on “Community Health Centers and Second-Class Health Care”

  1. One of the many mistakes made by reunited Germany after the collapse of the DDR was the simple imposition of the West German health care system, in an area where East German practice was as good and sometimes better: as, I understand, the provision of primary care in polyclinics.

    The abstract of the paywalled article doesn´t say whether the private practices were analysed by size of practice. You´d expect group practices – encouraged in the British NHS since the 1965 Family Doctors´ Charter – to have better medical records, nursing/midwifery/health visitor services, a rota for home visits, antenatal clinics, and other things. So is the differentiator the profit motive, or just size?

    1. Even if you control for size — and thus exclude the overworked, behind-the-times or revenue-focused single practitioners and small groups — community health centers are on average going to be better organized than group practices, because they’re designed to be group organizations from the start. In addition, CHCs are probably more likely to see entire families, whereas (in the US at least) many group practices tend to be segregated by age and often by specialty.

      It reminds me a little about the old days of computer chess, when machines first started beating grandmasters. Retrospective analysis of games apparently showed that the programs played unspectacular but very consistent chess, without unforced errors, while even the best humans typically could not go 40 moves without making at least one significant unforced error. If you just cut off the bottom of the distribution you’ve done a great thing.

    2. If you are interested in medical topics and want articles, your best routes are:
      1. For academics, use your college or university library. Ask if they are Docline members in addition to OCLC. PS- If you are accustomed to OCLC turn around, the 24-48 hours typical of Docline will be an eye opener.
      2. Sign up for Lonesome Doc with a local Docline library. Then order through PubMed.

  2. Before our last move, we went to a CHC (even though we had good insurance). (Blue Ridge Medical Center)

    They were really good at the basics, partly because they were clear that being really good at the basics was why they existed. Managing diabetes, COPD, and routine childhood checkups and immunizations was most of what they did–and they had staffed to that.

  3. It would seem that these centers of primary care could be strengthened if they had an additional income stream from insured patients. How can one find a local CHC? Just as many women who can afford a private gynacologist continue to get their care from Planned Parenthood, perhaps many insured families would choose to get their primary care here.

  4. Overtreatment/overdiagnosis is measured in only a few of the criteria in the study: no benzodiazepines for depression, no screening EKG in low-risk patients, and no screening urinalysis in low-risk patients. The highest odds ratio in the table in favor of the federally qualified clinics was for not using a screening EKG in the low risk patients (9.5). Next time this study is done, they need to look for other variables related to overtreatment and overdiagnosis. Low back pain, surprisingly, was not one of the study variables; the use of imaging for acute onset back pain is generally appropriate only for certain defined red flag signs, and the overuse of MRI and other imaging is common. Overdiagnosis can lead to overtreatment.

    The recent outbreak of fungal meningitis in patients treated with epidural steroid spinal injections (ESI) has put one possible overtreatment variable in the public eye; ESI is discouraged in the UK National Health Service for many conditions for which its use is common in the USA. It is sad that so many people were made sick and died; it would be tragic if it turned out that many of the infections arose from conditions for which ESI is unlikely to be beneficial. Since the current outbreak was related to the use of methylprednisolone from the New England Compounding Center, it seems very likely that the patients who received the injections were treated in private practice settings. Publically funded clinics are unlikely to be able to pay routinely for luxuries like compounding pharmacies.

  5. Well, shiver me timbers. This is good news.

    I wonder though, how would they match up against Kaiser? Or maybe that’s not a fair question to ask. Anyway, this is good news.

    1. I miss Kaiser. My new employer uses Blue Shield and I feel completely left out in the cold. I can’t even get anyone who I can talk to directly because the medical group and Blue Shield insist on deferring to one another. With Kaiser it was a consistent, known entity that took care of everything pretty damn-well, doctors-pharmacy-insurance being one chain. Ironically, even though it is now easier to shop for doctors, I’ve been forced to because the care is so inconsistent and disconnected.

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