For the underserved, primary care landscape is changing
Photo/Edd Cote
Noreen Johnson Smith, the vice president of development and advancement at Family Health Center in Worcester, where the number of patients served last year was up 29 percent over 2009.
This spring, when UMass Memorial Health Care announced plans to close its two-physician Plumley Village Heath Services clinic at 116 Belmont St. in Worcester, many in the city were outraged. The clinic serves nearly 2,000 patients, many of them low-income people from surrounding neighborhoods who find it convenient and attentive to their specific needs. For example, its bilingual staff is particularly valuable to Spanish-speakers in the area.
“UMass is supposed to be nonprofit,” said Joyce McNickles, the secretary of the Massachusetts Women of Color Coalition, who has been advocating for the clinic’s patients. “Unless they’re really bleeding money from community health centers, they really shouldn’t be pulling out just because they’re not making money.”
UMass CEO Eric Dickson said the reasons for the clinic closing are complicated—involving the sale of the building where it was located and the lack of appropriate space nearby—but he said it does also involve belt-tightening by the large health care system.
“The market has changed,” Dickson said. “If we don’t change with it, we will go the way of the dodo bird. Sometimes it’s incredibly painful.”
For low-income people, there are many barriers to receiving consistent, effective primary care, from transportation and language barriers to doctors who don’t accept MassHealth, the Massachusetts Medicaid program. UMass and other big players in Central Massachusetts health care have different ideas about where blame lies for this problem.
But one thing that’s clear is that an increasing amount of primary care in the region is being provided by organizations set up specifically with low-income and marginalized people in mind: federally qualified community health centers.
Dickson argues that the overall market in Central Massachusetts has shifted as for-profit institutions have become a greater presence in the region.
Saint Vincent Hospital and its associated physician practices, originally organized as a Catholic non-profit, has been part of for-profit organizations for more than a decade, and is currently owned by Tenet Healthcare Corp. Reliant Medical Group, which has primary care and specialist offices around the region, went from nonprofit to for-profit status last year when it was acquired by for-profit OptumHealth. The Central Massachusetts Independent Physician Association became part of private equity-owned Steward Healthcare last year.
To Dickson, given that MassHealth reimburses providers at a lower rate than commercial insurers do, it appears that for-profit players will make fewer investments in areas where many people rely on the public insurer.
“It’s not bad people doing bad things, but the math doesn’t lie,” Dickson said. “If you’re trying to enhance shareholder equity, you’re not doing everything you can to grab market share in the Medicaid space.”
Challenges from reimbursement rates
Dickson argues that UMass is taking on more than its fair share of publicly insured patients. When it comes to hospital visits, he said, UMass and its affiliates have 57 percent of the market share in its service area, but they have a 65-percent share of Medicaid services and only a 49-percent share of commercial ones.
Some of the region’s for-profit health care providers push back against Dickson’s arguments. Tarek Elsawy, president and CEO of Reliant, said Reliant provides care to 29,000 Medicaid patients.
“Reliant’s commitment to caring for low-income and underserved populations is as strong as it has ever been,” he said in a statement.
Elsawy said his organization is expanding to accommodate more primary care patients from all payer categories. He noted that the group is also participating in the MassHealth Accountable Care Organization, an initiative designed to improve the coordination of care for MassHealth patients. UMass participated in a pilot of the ACO program but decided last August not to continue in it.
After UMass announced the Plumley clinic closing, Family Health Center, located on Queen Street in Worcester, hired one of the clinic’s two doctors and agreed to accommodate any of the Plumley patients who want to get care there.
“We are working very hard to make sure that’s a smooth transition for any patient who wants to come,” said Noreen Johnson Smith, vice president of development and advancement at Family Health.
Family Health, which has locations serving much of Worcester County, is one of three federally qualified health centers in Central Massachusetts. The others are Worcester-based Edward M. Kennedy Community Health Center and Community Health Connections, which covers the Fitchburg-Gardner-Leominster area.
These community health centers are the product of the 1960s War on Poverty. They provide a range of medical services, from primary care to behavioral health and dental care. Because health is closely tied to other basic needs like housing and jobs, they coordinate their work closely with other local service providers. By federal statute, the majority of their board members must be patients who get care at the clinic.
“That remains a really important message in today’s world, that we need to hear the voices of consumers of programs,” Johnson Smith said. “They play a very important role on the board."
Busier community heatlh centers
The community health centers are open to everyone, including commercially insured people and people without insurance. But in 2017, by far the most common form of insurance for Family Health Center’s patients was Medicaid, at 71 percent, followed by Medicare at 12 percent.
Johnson Smith said one in six Worcester residents receive care at either Family Health or Edward M. Kennedy, and the number of primary care patients served by Family Health Center alone has grown from 16,822 in 2009 to 21,723 last year, a jump of 29 percent.
Community health centers may be becoming increasingly popular as some other health care providers choose not to accept MassHealth. Karen Culkeen, program director for the Gardner Visiting Nurses Association’s Healthy Families program, said it can be hard to help the parents and children the program serves find primary care doctors.
“Our greatest challenge is with physicians not accepting new patients and/or not accepting insurances, particularly MassHealth,” Culkeen said in an email.
Johnson Smith said the community health centers face some of the same pressures as any other doctor’s office, including an aging population with more complex needs and difficulty recruiting primary care physicians in a system where specialists often get higher pay and greater prestige. But she said the centers can at least partially offset the inadequacy of Medicaid reimbursement rates with public and private grants and donations, which are more crtical amid shaky federal funding.
Community Health Connections, which serves 28 communities in North Central Massachusetts, has been growing by 4 to 7 percent a year. Jackie Buckley, the center’s chief operating officer, said one area of growth has been retirees who find their previous doctor’s offices won’t take Medicare. The center also opened a site on Water Street in Fitchburg early this year, offering specialized service for homeless city residents and other care.
“We have to keep looking for additional providers and expanding our services,” Buckley said.
As for Dickson, he said UMass is increasingly focused on supporting the community health centers—providing funding and space for their work, and placing medical residents from UMass Medical School at the centers—rather than trying to duplicate their services at UMass-run doctors’ offices.
“We’ve tried to partner more with the federally qualified health centers,” he said. “They have a lower cost base, they have a higher reimbursement rate, and they have more comprehensive services.”
Correction: An earlier version of this story incorrectly said that Reliant Medical Group provides care to 29,000 Medicare patients. They are Medicaid patients.
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