| Program Category | 1990 | 1995 | 2000 |
|---|---|---|---|
| Health centers | 530 | 694 | 722 |
| Patients | 6 million | 7.7 million | 9.6 million |
| Funding | $500 million | $756 million | $1 billion |
Becoming the Bureau of Primary Health Care
A new director and a new name
Dr. Marilyn Gaston became the director of HRSA’s Bureau of Health Care Delivery and Assistance (BHCDA) in 1990. Soon after her arrival, Dr. Gaston decided the bureau needed a new name. She held a contest for employees to propose new names. Many were suggested. In the end, employees settled on the name Dr. Gaston had in mind all along: the Bureau of Primary Health Care (BPHC).
A focus on health centers
BHCDA had managed maternal and child health activities since 1982. In 1990, HRSA moved all of these into its new Maternal and Child Health Bureau.
BPHC oversaw the National Health Service Corps until 2002, when it moved to HRSA’s Bureau of Health Professions. The Bureau of Health Professions would later form part of today’s Bureau of Health Workforce.
There were other programs and initiatives managed at BHCDA and BPHC in the 1980s and 1990s. For instance, BPHC oversaw HRSA’s Black Lung Clinics Program (to treat coal miners), National Hansen’s Disease Program, and Lower Extremity Amputation Prevention (LEAP) Program. Over time HRSA moved all of these to different bureaus, leaving BPHC to focus on health centers.
The 340B Drug Pricing Program
In 1992, Congress created a new program under Section 340B of the Public Health Service Act. To be covered by Medicaid and Medicare Part B, drug companies had to provide discounts on drugs purchased by health centers and other safety net providers. Health centers could pass the savings on to patients. Or they could reinvest the money to increase access or improve patient services.
“When you look at the cost of pharmaceuticals, being able to buy those through the 340B Program has been a lifesaver,” according to Roland Gardner, former director of Beaufort-Jasper-Hampton Comprehensive Health Services. “You can use those dollars to expand your services.”
The Federal Tort Claims Act
The Federal Tort Claims Act (FTCA) allows citizens to sue the federal government for the actions of federal employees in the course of doing their jobs. Health centers and their staff became eligible for FTCA coverage in the early 1990s. Staff, leadership, and some contractors at an FTCA-covered health center (as well as volunteers, as of 2016) could be treated as Public Health Service employees for the purpose of medical malpractice liability coverage.
This means health centers that receive FTCA coverage don’t need to pay for medical malpractice insurance.
Benefits of FTCA coverage
“FTCA was huge for health centers,” recalls Rachel Gonzales-Hanson, CEO of Community Health Development, Inc. and later an executive at the National Association of Community Health Centers. “It allowed us to save so much money. We were able to use the savings to provide more services, pay staff better wages, and cover other important expenses.”
BPHC’s FTCA Program ensures that health centers protect patient safety and reduce risks. BPHC provides training and technical assistance to help health centers avoid medical mistakes.
The Health Centers Consolidation Act of 1996
Previous statutory authorities
Congress authorized funding for community health centers in 1975 under Section 330 of the Public Health Service Act. They authorized funding for migrant health centers in 1962 through the Migrant Health Act. They authorized funding for health centers serving people experiencing homelessness in the McKinney-Vento Homeless Assistance Act of 1987. Finally, they authorized funding for health centers serving public housing residents in the Disadvantaged Minority Health Improvement Act of 1990.
Within BPHC, these four types of health centers were managed by different people in different offices, which led to inconsistencies in their handling.
Combined authority
In 1996, Congress combined all four types of health centers under Section 330 of the Public Health Service Act:
- Section 330: Community health centers serving a general underserved population
- Section 330(g): Health centers serving migratory and seasonal agricultural workers
- Section 330(h): Health centers serving people experiencing homelessness
- Section 330(i): Health centers serving residents of public housing
After that, all four types of health centers were funded and managed together. They all followed the same program requirements and oversight activities. All were eligible for FQHC reimbursement rates, 340B drug pricing, FTCA coverage, and the other benefits of the program.
Health centers that received funding under multiple categories could apply for all of them using a common application. This led to efficiencies, both for the bureau and for the health centers.
The Loan Guarantee Program
The Health Centers Consolidation Act of 1996 also authorized a new federal program. This program guaranteed up to 80% of the principal and interest on loans taken out by health centers for capital projects.
Due to a lack of credit or collateral, many health centers have trouble getting affordable loans for construction or renovation. A loan guarantee can enhance their credit profile. This reduces the lender’s risk and allows them to provide a loan with more favorable terms.
Developing the Uniform Data System
Since the Bureau Common Reporting Requirements (BCRR) in the 1970s, a key feature of the program has been the collection of grantee data. In 1996, the bureau replaced BCRR with the Uniform Data System (UDS). The UDS is a standardized reporting system used by all HRSA-funded health centers (and all look-alikes since 2011). Health centers report each year on a core set of information. This lets BPHC make sure they are meeting program requirements. It also lets BPHC assess the impact of the program.
Electronic submission
Like BCRR, UDS data were first submitted on paper. In 2000, BPHC created an “electronic submission” option—which was an email address to send the file. Beginning in 2005, health centers received “custom software” that let them send their report via File Transfer Protocol (FTP). Or they could still use the email address. Finally, in 2008, health centers could use an online system connected to HRSA’s Electronic Handbooks to submit their data.
Clinical quality measures
In its early years, UDS collected data on services provided, types of providers, the number of visits, costs and revenues, patient demographics, patient income, insurance coverage, and “selected diagnoses and services rendered.” This gave raw totals for certain diseases or conditions, but it didn’t show clinical outcomes.
BPHC began to collect data on quality of care and health outcomes for the first time in 2008. The first quality measures were early entry into prenatal care, childhood immunizations, and pap tests. Health centers reported outcome data on low birthweight infants, hypertension, and diabetes control.
Over time, BPHC has added more clinical measures. The bureau uses this data to provide targeted technical assistance. It also has used the data to assess the progress of initiatives focused on diabetes, cardiovascular health, HIV, and others.
Publication of data
At first, BPHC published UDS data only at the national level. The bureau gave state and regional summary reports to grantees and their Primary Care Associations (PCAs), but these were not shared publicly. Since 2011, BPHC has published data at the health center level. Sharing this data has led to quality improvements as health centers can see how they compare with peers and find ways to improve.
Health Center Controlled Networks
Health information technology was an exciting new tool in the 1990s. It could be used to manage patient data, track diseases and prescriptions, coordinate care among providers, and streamline administrative and financial management. It could improve efficiencies and quality of care and make data reporting much easier. But the new electronic systems were expensive, and health centers were not always ready to meet their technical demands.
In 1994, a group of health centers joined together into a network. This gave them some of the advantages of a large health system. It became easier to implement new electronic systems and to make other financial and organizational improvements. Health Choice Network in Florida was the first example of what would eventually be called a Health Center Controlled Network (HCCN).
Today, HRSA provides funding for 49 HCCNs. They use this funding to provide training and technical assistance on health information technology for their participating health centers. More than 80% of all HRSA-supported health centers and look-alikes are part of an HCCN.
Models That Work
In 1995, BPHC launched the Models That Work campaign. The goal was to highlight health centers that had shown particular success in reducing barriers to care. Then, BPHC would share their methods so that other health centers could create similar programs.
Models That Work selected winners through national competitions in 1995, 1996, 1998, and 2000.
Health Disparities Collaboratives
In 1998, the bureau launched a new effort to eliminate health disparities in populations served by health centers. BPHC worked with PCAs, National Clinical Networks, the Institute for Healthcare Improvement, HHS components, and many others to create the Health Disparities Collaboratives.
Health centers chose a multi-disciplinary team that would spend time each week in training and discussion. This included time away from the health center to attend learning sessions and a national forum on the subject of the collaborative. Health center staff could learn from each other and from experts in the field.
The first collaborative focused on improving diabetes outcomes. Later collaboratives focused on cardiovascular disease, asthma, cancer, depression, perinatal safety, and oral health. About 800 health centers participated in the program, before it shifted into other knowledge-sharing and quality improvement initiatives after 2008.
An ambitious goal: 100% Access/0 Health Disparities
In 1998, BPHC announced a new vision: 100% of the people in America should have access to high-quality health care. There should be no gaps between the wealthy and the low-income, between those who had insurance and those who did not.
The goal seemed impossible. But those involved were passionately committed. “When people would complain that eliminate is too bold, too unrealistic,” Dr. Gaston later recalled, “I would ask, ‘What is the level of disparity you are willing to live with?’”
BPHC hoped to enroll 500 communities within three years. Each would receive financial and technical assistance to increase access to care. The leaders of successful communities would be identified as models, teachers, and advocates.
By the end of 2001, BPHC had identified dozens of benchmark communities. Successful projects were being replicated in scores of other places. More than 600 communities had enrolled as participants and were tracking their progress.
The 100% Access/0 Health Disparities initiative set down a marker that the program is still working towards today. “It generated a lot of interest and enthusiasm,” Dr. Gaston said. “And I think we have to keep insisting. I think our goal still has to be to get 100% of our people access to care.”