Health centers at 40: implications for future public policy

Mission, margin, and the role of consumer governance in decision-making at community health centers

OBJECTIVE

We explore the role of consumer trustees in decision-making as community health centers (CHCs) work to navigate the tension between pursuing their mission to provide primary care to all regardless of ability to pay and maintaining their limited finances.

METHODS

We interviewed 30 trustees from 16 CHCs in 14 different states, asking extensively about decision-making processes at their CHC related to services and finances, as well as perceived advantages and disadvantages of consumer governance.

RESULTS

Respondents described mission-dominant, margin-dominant, and balanced decision-making philosophies, and different decision-making pathways for service provision and finances. Consumer trustees were lauded for their role in informing the board of service quality and community needs, but criticized for being professionally unskilled and exhibiting a lack of objective decision-making.

CONCLUSIONS

While CHC boards do play a role in navigating the tension between mission and margin, executive directors and staff appear to be more influential.

When patients govern: federal grant funding and uncompensated care at federally qualified health centers

OBJECTIVE

To determine if the proportion of consumers on federally qualified health center (FQHC) governing boards is associated with their use of federal grant funds to provide uncompensated care.

METHODS

Using FQHC data from the Uniform Data System, county-level data from the Area Resource File and governing board data from FQHC grant applications, the uncompensated care an FQHC provides relative to the amount of its federal funding is modeled as a function of board and executive committee composition using fixed-effects regression with FQHC and county-level controls.

RESULTS

Consumer governance does not predict how much uncompensated care an FQHC provides relative to the size of its federal grant. Rather, the proportion of an FQHC's patient-mix that is uninsured drives uncompensated care provision.

CONCLUSIONS

Aside from a small executive committee effect, consumer governance does not influence FQHCs' provision of uncompensated care. More work is needed to understand the role of consumer governance.

Do patients have a voice? The social stratification of health center governing boards

CONTEXT

To ensure community responsiveness, federally qualified health centres (FQHCs) in the United States are required to be governed by a patient majority. However, to the extent that these patient trustees resemble the typical low-income patients served by FQHCs, status generalization theory suggests that they will be passed over for leadership positions within the board in favour of more prestigious individuals.

METHODS

Using 4 years of data on health centre governing boards obtained from the Health Resources and Services Administration via a Freedom of Information Act Request, the likelihood of holding executive committee office is modelled as a function of trustee characteristics using Chamberlain's conditional logistic regressions.

RESULTS

The results indicate that representative patient trustees are significantly less likely than other trustees to hold a position on the executive committee or serve as board chair.

CONCLUSIONS

Given the power of the board leadership to set the agenda, the reduced likelihood of representative patient trustees serving in leadership positions may ultimately limit the representative voice given to patients, making FQHCs potentially less responsive to their communities. These findings also have important implications for other settings where engaging and empowering patients is sought.

Consumer governance may harm health center financial performance

INTRODUCTION

Federally qualified health centers (FQHCs), which must be governed by a patient majority, have historically struggled to remain financially viable while caring for a disproportionately low-income and uninsured population. Consumer governance is credited with making FQHCs responsive to community needs, but to the extent that patient trustees resemble the typical low-income FQHC patient, patient trustees might lack the capacity to govern, harming financial performance as a result. Thus, this study sought to empirically evaluate the relationship between FQHC board composition and financial performance.

METHODS

Using data from years 2002-2007 of the Uniform Data System and the Area Resource File, and years 2003-2006 of FQHC grant applications, FQHC operating margin was modeled as a function of board and executive committee composition, the interaction between them, general time trends, other FQHC and county-level factors, and FQHC-level fixed effects. Trustees were classified as representative (ie, low-income) consumers, nonrepresentative (ie, high-income) consumers, and nonconsumers on the basis of their self-reported patient status and occupation.

RESULTS

Each 10 percentage point increase in the proportion of representative consumers on the board is associated with a 1.7 percentage point decrease in operating margin. This effect becomes insignificant if any consumers serve on the executive committee. There is no significant relationship between the proportion of nonrepresentative consumers and operating margin.

CONCLUSIONS

If consumers are given leadership roles on the board, consumer governance does not harm financial performance and may be beneficial enough in other respects to justify its being required as a condition of federal FQHC funding. Without such strengthening of the provision, consumer governance appears to harm financial performance and it is unclear from this study whether it offers other benefits that are significant enough to justify this financial risk.

Consumer governance and the provision of enabling services that facilitate access to care at community health centers

BACKGROUND

Federally qualified health centers (FQHCs) are primary care clinics, governed by a consumer majority, which accept patients regardless of ability to pay and provide nonclinical enabling services that facilitate patients' access to care. Understanding how FQHCs decide which services to provide is important, because enabling services are not typically reimbursed.

OBJECTIVE

To model enabling service provision as a function of FQHC board composition.

METHODS

FQHC-level data were drawn from multiple years of the Uniform Data System (UDS) (2002-2007), and merged with county-level data from the Area Resource File (ARF) (2002-2007) and board data from FQHC grant applications (2003-2006). The scope and volume of enabling services an FQHC provides are modeled as a function of board composition, executive committee composition, the interaction between them, general time trends, and other FQHC and county-level controls.

RESULTS

The proportion of consumers on the board does not affect the scope of enabling services, but the proportion of descriptive consumers (who resemble typical FQHC patients) on the executive committee is associated with a significant increase in the scope of enabling services a health center provides. Neither the proportion of consumers on the board nor the proportion of consumers on the executive committee affected the volume of enabling services provided.

CONCLUSIONS

Consumer governance, specifically on the executive committee, plays a small role in determining which enabling services an FQHC provides, but more work is needed to identify factors associated with variation in the scope and volume of enabling services across FQHCs.