The mini-hospital

As a young girl growing up in Boston's Bromley Heath public housing development, Paula McNichols never dreamed she'd one day manage something as important to her community as a neighborhood health center. But, "luckily for me," McNichols says, "times have changed." This year marks her twelfth as executive director of the Brigham and Women's Brookside Community Health Center in Jamaica Plain.

McNichols' good fortune came out of an idea sprouted nearly 40 years ago in Massachusetts by people like Jim Hunt, now president and CEO of the Massachusetts League of Community Health Centers. Hunt and others saw an urgent need for healthcare based in poor urban and rural communities. Their dream was to establish health centers that the state's underserved and uninsured could easily access. Such centers would offer comprehensive healthcare to everyone, regardless of ability to pay.

They would employ neighborhood residents. They would be open during odd hours to increase their accessibility. And they would do an excellent job.

Healthcare pioneers
That dream came true, starting in 1965, when the nation's first community health center opened at Columbia Point in Dorchester. Nearly 40 years later, 50 Massachusetts community health centers at 101 sites-from Boston to Framingham, Great Barrington to Worthington-provide a broad range of medical services to their neighbors.

These centers buzz with activity. Last year, more than three million patients were cared for in the Commonwealth's community health centers, according to the league. And they care for approximately 43 percent of the state's medically underserved, one out of every ten residents.

Brookside alone sees 10,000 of the area's poorest residents each year. The children, adults, and elders who walk through the center's doors would in many cases be forced to seek care in already overcrowded emergency rooms or forego doctors altogether if the center were not there.

People come to be treated for everything from sore throats to AIDS, teeth cleanings to prenatal care. They receive mental healthcare, social services, substance abuse care, HIV education and counseling, and a host of other critical services. "They also rely on the center to provide them with all kinds of information and advice," says McNichols. "For example, we help them apply for MassHealth and food stamps."

To be sure, caring for those who can least afford it presents a constant challenge for health centers to stay afloat when, in many cases, fees barely cover costs. As Hunt notes, "There is always that mission-and-margin dilemma. But in the frontlines of the community health centers, all financial issues are put aside so that quality access can be achieved."

Only the beginning
Such efforts are apparently paying off. A report issued in late 2002 by the National Academy of Sciences' Institute of Medicine praised health centers for their strong track record in chroniccare management and other services. The health centers, says the academy, provide care "that is at least as good as, and in many cases superior to, the overall health system in terms of better quality and lower costs."

In addition to being more cost effective than the system as a whole, community health centers are also credited with saving hospitals money by alleviating the crunch in overcrowded emergency rooms. Hunt points to the Greater Lawrence Health Center as an example. By collaborating with Lawrence General Hospital, engaging in "mutual referrals"-sending patients to the health center for primary care, to the hospital for emergency or specialized treatment-the hospital saw "an 11 percent reduction in emergency room use. And that's happening in other places, too," Hunt says.

This is occurring because people who would otherwise go to an emergency room for non-emergency care-usually because they are uninsured and can't afford a private doctor-can turn to their community health centers instead. But while emergency room savings "have, in fact, been a result" of community health centers, says Hunt, the centers "were not created for this purpose."

According to Kerin O'Toole, the league's public affairs manager, community health centers also don't turn a profit for the hospitals that operate them. "Usually, the hospitals take a loss," O'Toole says. She is referring to the small number of the state's community health centers that are run by hospitals, such as Bowdoin Street Health Center, funded by Beth Israel Deaconess Medical Center, and the Martha Eliot Health Center, run by Children's Hospital.

So why do the hospitals bother? The relief on congested emergency rooms is one reason. Another, says O'Toole, is that "hospitals have an interest in building up the primary care infrastructure in their immediate communities." Perhaps the hospitals also know that by taking the initiative through community health centers, they can avoid onerous legislation.

Indeed, O'Toole points out that some states, for example California, New York, and Idaho, are mandated by state regulatory agencies to provide free care or other community services. In Massachusetts, there is no such mandate. The state's attorney general encourages hospitals to provide community benefits such as free care and AIDS education, but law does not require such services. This helps avoid, for one thing, keeping up with mountains of paperwork to prove compliance.

More work to do
Despite the obvious successes of community health centers, Hunt sees huge tasks left undone. Though he's proud of the quality of care and the number of people reached, "many more could be served," he says.

The Kaiser study also notes the gap: "Even as health centers [nationwide] have expanded to respond to the problem of medical underservice, their penetration remains well below national estimates of need. The 12.5 million persons reached by centers in 2002 represented only 25 percent of the estimated 50 million low income persons without a regular source of healthcare that year." And while Massachusetts remains a community health centers pioneer-the state has the most health centers per capita in the nation-Hunt sees the gaps all too clearly. "We can provide more chronic-disease management," he says. "We can open more pharmacies in the health centers, open our doors to more frail, elderly people, serve more people with disabilities."

To reach these goals, he adds, "we need more government investment."