Community Health Centers: A Pharmacist's Perspective

I am delighted to write this commentary immediately after the historic 1-year anniversary of President Obama signing the Affordable Care Act (ACA) into law. I have the distinct privilege to work in a community health center in Hartford, Connecticut, where care is given to the most underserved population. Many in the healthcare profession are unaware of what a community health center is and are unfamiliar with the mission of these facilities. So I will try to explain in this brief column what community health centers are, who they serve, and the tremendous opportunity they present for pharmacists and pharmaceutical care management.

Currently in the United States 1250 community health centers operate in more than 8000 locations and serve 23 million patients in all 50 states and all US territories. This health center setting comprises a substantial share of the nation’s primary care infrastructure. One-fourth of all primary care visits for the nation’s low-income population are provided by these health centers. Congressional investments, including most recently ACA, have become the means by which to double health center capacity to serve 40 million people by 2015.

Because of the direct investment in community health centers, health consumers will have more primary care options, which is critical because 60 million US residents lack a source of primary care due to provider shortages. As health centers expand to reach more communities in need, they will serve large numbers of patients with complex health problems. Of course, with the current shift in Washington, it is unknown whether the promised funds for expansion will materialize.

Although community health centers provide services not typically provided in other care settings, their costs still are lower. Their costs run at least a dollar less per patient per day compared with costs in all physician settings ($1.67 vs $2.64), and far below the cost of a hospital stay. Despite their lower costs of care, these centers generate significant returns on investment by reducing the need for costly care at hospitals.¹

By focusing on primary healthcare, health centers keep down healthcare costs for all consumers, taxpayers, and governments.1 For example, Medicaid beneficiaries who rely on health centers for usual care are 19% less likely to use the emergency department for unnecessary visits and 11% less likely to be hospitalized compared with beneficiaries relying on other providers. Greater health center capacity reduces hospital emergency department use among low-income populations.

Health centers already save the healthcare system $24 billion annually. As they expand to reach new, unserved communities, health centers will save an additional $122 billion in total healthcare costs between 2010 and 2015, including $55 billion for Medicaid over the 5-year period. Of that amount, the federal government will save $32 billion, while states will benefit from the rest.¹

The official definition of a federally qualified health center (FQHC) is a type of provider defined by the Medicare and Medicaid statutes. FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act.

There are many benefits to being an FQHC. For FQHCs that are Public Health Service Section 330 grant recipients, the biggest benefit is the grant funding. Other benefits include:

• Enhanced Medicare and Medicaid reimbursement.

• Medical malpractice coverage through the Federal Tort Claims Act.

• Eligibility to purchase prescription and nonprescription medications for outpatients at reduced cost through the 340B Drug Pricing Program.

• Access to National Health Service Corps.

• Access to the Vaccine for Children program.

• Eligibility for various other federal grants and programs.

Health centers focus on meeting the basic healthcare needs of their individual communities. They are directed by boards with a consumer membership as the majority and maintain an open-door policy, providing treatment regardless of an individual’s income or insurance coverage. Health centers serve the homeless, residents of public housing, migrant farm workers, and others who have emergent and chronic healthcare needs, but who have limited resources to secure treatment through traditional channels. A majority of health center patients (70%) live in poverty. The National Association of Community Health Centers states that health centers, which serve 20% of low-income, uninsured people, provide substantial benefits to their communities:

• They provide comprehensive care, including physical, mental, and dental care.

• They save the national healthcare system between $9.9 billion and $17.6 billion a year by helping patients avoid emergency departments and make better use of preventive services.

Pharmacy services provided in these health centers have a notably important role to play in improving the efficiency of care and the health outcomes of the patients served. These pharmacies are allowed to participate in the federal 340B Drug Pricing Program, which results in significant savings estimated to be 20% to 50% of the cost of pharmaceuticals. The purpose of the 340B program is to enable these entities to stretch scarce federal dollars, reaching more eligible patients and providing more comprehensive services. However, it is of paramount importance that health centers be able to provide the same high-quality pharmaceutical care and medication therapy management (MTM) that is enjoyed in other practice settings.

The operational configuration of the health center offers patients a variety of providers and services at 1 location. For populations who have numerous challenges in housing and transportation, having pharmacy services and primary care providers in the same location is of great benefit.

Health center pharmacists also offer MTM. These core medical safety net providers need to provide MTM services because medication-related problems and medication mismanagement contribute to public health challenges and additional healthcare costs in this country, circumstances that are well documented in the literature. Medication therapy management services offered at community health centers include medication therapy reviews, pharmacotherapy consults, anticoagulation management, immunizations, health and wellness programs, and many other clinical services. Pharmacists provide MTM to actively manage drug therapy, encourage adherence, and identify, prevent, and resolve medication-related problems. In these ways they help patients get the most benefit from their medications.

The culturally diverse population, coupled with diverse languages and literacy issues typically found in community health centers, makes this at-risk population in dire need of pharmacist and pharmacy services. Pharmacists participate on the pharmacy and therapeutics committees of the health center and assist with formulary development and maintenance, provider education about formulary issues, and the 340B program. It is my observation that patients would go without their necessary drug therapy if the community health center pharmacists did not assist in financial management of the medication regimes as well as facilitating patients’ participation in pharmaceutical manufacturers’ safety net programs.

We all have a responsibility to support those caregivers working with the most underserved populations and to provide education about the various practice settings that can benefit from the expertise of a pharmacist. Through maximizing the pharmaceutical care delivered, sound recommendations made by pharmacy and therapeutics committees, and enhancement of primary care, we can strive to keep patients out of the emergency departments and hospitals, take care of this poorest of the poor population, and reduce the healthcare costs for everyone.