Community Clinics as An Alternative to the ER?

I may be more optimistic than Harold Pollack that the Affordable Care Act (ACA) will reduce ER use (see Pollack's guest post). After all, the ACA provides an additional $11 billion in funding for Federally Qualified Health Centers (a.k.a. “community clinics.”) Many are open after hours, and as existing community clinics are expanded and new ones are built, they could serve as medical homes for patients who now get their care at their local emergency room. This year alone, the ACA will provide a 50 percent increase in federal support for these clinics where patients can receive less expensive, preventive and primary care. (It’s worth noting that the government has already begun to distribute this money; this is just one example of many programs that cannot be “de-funded.”) The legislation also permanently authorizes the community health center program, which once had to be reauthorized every five years.

Who will staff these clinics? The National Health Service Corps provides many of the physicians who work in community clinics, and under the ACA, it’s slated for a $1.5 billion increase in funding over the next five years, essentially tripling its resources for attracting primary care doctors to work in medically underserved areas. When the new legislation’s insurance exchanges come on line in 2014, private insurers will be required to contract with “essential community providers” and to pay them no less than their current Medicaid rate per patient visit. (Today, reimbursements are sometimes lower than Medicaid reimbursements; insurers are not competing for the low-income customers who go to community clinics. )

Nurses and nurse practitioners both staff and help manage neighborhood clinics, and the ACA aims to boost the supply of nurses in the system by hiking the amount of loan money available to nursing school candidates with limited financial means by 25%. Another reason that we don’t have enough nurses today is that we don’t have enough nursing school teachers. Often, they are paid less than a nurse practicing in the field. Recognizing the problem, the ACA also authorizes canceling up to 85 percent of medical school loans if students commit to teaching in nursing programs.

Finally, the Affordable Care Act provides $159.1 million to support health care workforce training. This includes "$106 million in grants to support all levels of nursing education," $29.5 million for geriatric education and training programs, and $23.6 million "to support Centers of Excellence programs that are designed to improve the recruitment and performance of underrepresented minority students preparing for health professions careers." 

After reading Pollack’s post, I wondered what he thought about community clinics as an alternative to the ER. In a phone conversation this afternoon, he sounded enthusiastic: “I think this is an uncovered issue. It’s not that I’m pessimistic; hopefully community clinics will improve the quality of patient care.

“But,” he added, “the picture is complicated. There is a notion of inappropriate ER use–but patients don’t think of it the same way that health experts and policy-makers do. Many patients believe they’ll get better care at the ER of a brand-name hospital rather than at a community clinic, whether or not this is true.

“There is also this idea that your right to care is the same as your right to free care at an ER. We are not going to be able to teach our way out of the problem, because lack of knowledge is only one of the issues in play, and not necessarily the central one. We should be more open to the idea that people will use ERS for some things that would appall people who study health service delivery.

“If you expand insurance coverage, you are going to create a lot of good alternative sources of care, but,” Pollack points out, “you also will make ER care more affordable.” (In fact, under the ACA, insurers are required to cover ER use even if a patient is outside his “network.”)   

In the end, the “goal is not necessarily to reduce ER use,” says Pollack. “You can have more cost-effective care within the ER at an urgent visit center.” In other words, not everyone who walks into an ER has to undergo a battery of expensive tests.

Clearly, Pollack is right. Reality is always going to be messier than our best-laid plans. Under health care reform, we should be prepared to adapt to what patients need and expect. The goal is to provide the best care possible, as efficiently as possible. This many mean re-thinking how we finance and structure ERs. No doubt, different solutions will work better in different communities. Most importantly, as Pollack suggests, we must get past the notion that an ER is a “dumping ground” for “free care.”

4 thoughts on “Community Clinics as An Alternative to the ER?

  1. This is an interesting and somewhat complicated subject. For a fascinating perspective and a sense of the difficulties we face, people should read Dr. Atul Gawande’s most recent New Yorker Magazine article titled “The Hot Spotters” “Can we lower medical costs by giving the neediest patients better care?” Among lower income patients, a tiny fraction of them account for a hugely disproportionate share of healthcare costs.
    Dr Gawande’s article can be found here:

  2. The Community Health Center (CHC) movement deserves more discussion in light of the ACA act because I see it as a hopeful sign that salary systems can attract and retain good providers who are in medicine/healthcare for the right reasons. Many years ago I work in a CHCs as a PHS dental director. Back then (1978-1990), all providers seemed to be on scholarship or loan repayment, and as soon as their “commitment” was up, they left. Now I sit on the Board of a CHC in my community, and all providers and dentists are on salary with almost all having no loan repayment commitment to stay any longer, yet they do. These are first rate providers, BTW! Many were loan repayment when they started, but now the salaries they get are better, and they seem to understand that this salaried method of practicing medicine in a large group has real mental and lifestyle advantages. I find that interesting, and wonder what effect the ACA will have on providers’ views of decent lifestyles and payment incentives! I am at least encouraged by what I see at “my” CHC, but maybe there is some location advantage of this RURAL CHC over others that I am missing.

  3. Barry & NG
    Barry–Thanks for the link to Gawande’s article.
    I had read it quickly, but just sat down and read it carefully.
    The idea of identifying high-cost patients and giving them better care seems to me excellent.
    And it makes sense that with this group it is particuarly important that health care workers be people from their community, who speak their language–and who the patients trust.
    Also no copays and no deductibles seem essential as well as the idea that healthcare is a service profession.
    When someone asks “can I get an appt. today” the answer should be “yes.”
    Fewer obstacles to care. When there are obstacles low income people are less likely to persevere; they are accustomed to thinks not working out, and are more likely to give up.
    Better-educated, higher-income people are likely to be more aggressive (“demanding even, in a good way) in seeking and getting the care they need.
    And paying doctors a lump sum per patient so that their income depends on keeping the paitents coming back (good service) and keeping them well makes sense.
    Finally, what the article calls “rogue” docotrs are a problem –these are doctors who are totally self-interested, and are in business simplly to accumulate fee-for-service payments, encouraging patients to come back for visits and undergo tests they don’t need.
    NG– I think everything you say is true.
    I see CHC’s as one of the brightest spots in the
    health reform bill. We’re putting real money into expanding them.
    As to whether they work as well in citities, all I can say is that in NYC we have quite a few excellent community clinics. I plan to be writing about them in the not-too-distant future.
    One thing I’ve noticed in NYC is that they don’t just provide service to low income people. Young twenty-somethings who live in less expensive neighborhoods like them for the convenience— they can go in very early in the morning before work, to have their throat checked to make sure its not stripe, to renew birth control pills, whatever.
    (When my daughter lived in the Times Square area she frequently used the community clinic.)
    These young people tend to like the doctors working in community clinics– they tend to be patient-centered, friendly, helpful.
    And 20-somethings don’t care at all that the funniture in the waiting room is far from immpressive . . .
    By improving “systems” some of these clinics have also greatly reduced waiting times.
    I know a group that has been working with them –with great success.
    Will write more about this.

  4. Dr. Pamela Wimble has been instrumental in the community-based clinic. She and her colleagues have collaborated on a number of hospital and clinic models that stress the needs of the community. She will be speaking at the One Path Summit, in Atlanta, GA in March. For more info go to