Volume 9 Number 2
Fishing Lake Harriet in Minneapolis.
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Summer 2007
The mission of the Office of Rural Health & Primary Care is to promote access to
quality health care for rural and underserved urban Minnesotans. From our unique position
within state government, we work as partners with communities, providers, policymakers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
Many Communities, One Health Care Safety Net
Travel season is here, and many of us make summer trips to the Twin Cities for ball games,
shopping trips and the State Fair. Some of us head north to the lake. I’ve been traveling too, and
as I think about how mobile many of us are, I’m reminded that we share basic health care
needs wherever we live and wherever we travel. Particularly when we look through the lens of
health care access, it’s reassuring to find that those working to maintain our health care safety
net have much in common, whether they’re in rural Minnesota or in the Twin Cities. Though
every community faces different barriers, the goal of improving access to care is a shared one for
those working in rural and undeserved areas.
DIRECTOR’S CORNER
Mark Schoenbaum
Assuring access involves many components. There’s the need for facilities, medical equipment
and workforce. Whether in St. James or the Cedar Riverside neighborhood in Minneapolis,
safety net providers are finding creative ways to invest in the facilities and equipment needed for
high quality care. Workforce shortages affect our whole health system, and safety net providers
often struggle to compete; however, they’re also great at tapping volunteer and donated
services. Twin Cities’ community clinics have a long tradition of finding donated specialist
services, for example. Volunteering is also woven throughout our rural health system, where
over 75 percent of ambulance personnel are volunteers.
Affordability is of course key to one’s ability to access care, and this issue of our Quarterly
focuses on the health care safety net in the Twin Cities and the state resources that support it.
Minnesota’s Federally Qualified Health Centers, both urban and rural, serve Minnesota’s
uninsured and low income population, offering sliding fees to the 40 percent of their patients
who are uninsured. And in addition to the uncompensated care they provide in rural
Minnesota, our Rural Health Clinics and Critical Access Hospitals have helped their patients sort
through the maze of the new Medicare programs so they can continue to receive affordable care
at their local clinic and hospital.
In communities like Canby, Madelia and North Minneapolis, hospitals and community clinics
have figured out how to provide access on site to essential dental care. On Bloomington
Avenue in Minneapolis and in the southeastern Minnesota city of Wabasha, mental health
services, a crucial but scarce commodity, are available to the community. By offering this range
of care, Minnesota’s health care safety net is responding not only to the whole patient but to
the whole community.
Effective access also requires that services be located close enough to the population that needs
care, and there has to be a good enough means of transportation to get there. Minnesota’s
community clinics and rural hospitals from Deer River to St. Paul’s West Side work to provide
transportation so their patients can connect with needed services.
An imperative for access is cultural and linguistic acceptability to the communities we hope to
serve. Non-English speaking populations have grown in both Minnesota’s urban and rural areas,
and safety net providers are responding throughout the state to address the challenges of
providing interpreter services and helping new arrivals navigate the health care system.
Whether urban or rural, community clinics and hospitals throughout the state are committed to
assuring access. With this shared common mission, Minnesota is fortunate to have a health care
safety net serving our citizens across the state.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care. He can be
reached at [email protected] or (651) 201-3859.
2
By David L. Quincy, Bemidji Area Office of Indian Health Service
Indian Health Service is an agency in the U.S. Department
of Health and Human Services that operates a
comprehensive health service delivery system for
approximately 1.9 million of the nation’s estimated 3.3
million American Indians and Alaskan Natives. Services
are provided through a system of Indian Health Service
(IHS) and tribally owned and operated health facilities as
well as urban clinics. The Urban Indian Health Programs
consists of 34 nonprofit 501(3) (c) programs nationwide.
The programs operate under contracts and grants awarded
pursuant to IHS Title V, Urban Indian Contracts.
The Bemidji Area of the Indian Health Service includes
Minnesota, Wisconsin and Michigan, in which there are 34
tribes with services provided to approximately 128,000
American Indians. In Minnesota, 12 tribal health programs
with three tribes (Red Lake, Leech Lake and White Earth)
provide services in conjunction with federally operated
service units. In Minnesota’s largest urban metropolitan
area, Minneapolis, there are approximately 26,000
American Indians (Census 2000). The Bemidji Area IHS
contracts with the Indian Health Board (IHB) of
Minneapolis, which was the first IHS-funded urban program.
Indian Health Board
IHB’s target population is the urban American Indian
community and other underserved populations,
particularly those in the Minneapolis/St. Paul
Metropolitan area. In FY 2006, the program reported
serving 3,359 American Indian and Alaskan Natives. A
critical aspect to all of the services is the strong emphasis
upon holistic treatment and cultural sensitivity. Many
American Indians and Alaskan Natives living in the urban
areas receive a portion of their care at IHS or tribal
facilities on the reservations—a primary reason is the lack
of health care coverage closer to home.
IHB services include primary medical care, dental care,
prevention and management of chronic diseases,
outpatient psychotherapy, psychological assessments,
interdisciplinary Fetal Alcohol Spectrum Disorders
evaluations, psychiatric evaluations and medication
management, social work, chemical dependency
assessments and follow up, doctoral level psychology
internship training, and culturally appropriate Alateen and
Alcoholics Anonymous meetings. Women, Infants and
Children Supplemental Food Program includes nutrition
education for children under 5 years of age and for
pregnant and breastfeeding women through one-on-one
nutrition counseling, vouchers to buy healthy foods,
support and help with breastfeeding.
IHB is a Joint Commission on Accreditation of Healthcare
Organization and a Federally Qualified Health Center
(FQHC). The program is also a Community 330 Clinic
under the Bureau of Primary Health Care. For uninsured
patients who are ineligible for Minnesota health care
programs and Medicare, IHB offers a sliding fee scale from
25 to 100 percent.
Issues and concerns
• Because of changes in eligibility requirements for
Medicaid, programs see more patients who may not
have any insurance coverage. This reduces the third
party revenue generation and therefore the ability to
provide additional services.
• Reduced numbers of American Indians and Alaskan
Natives are living in the Phillips neighborhood, where
the Indian Health Board is located.
• Medication is an ongoing issue as the clinic does not
have a pharmacy and many patients do not have
means to purchase pharmaceuticals.
PARTNER FOCUS
Indian Health Services:
Reaching out to underserved populations
For more information regarding the Indian Health Board of
Minneapolis, contact:
Dr. Patrick Rock, Executive Director
Indian Health Board of Minneapolis
1315 E. 24th St.
Minneapolis, MN 55404
(612) 721-9800
Native American Community Clinic
The Native American Community Clinic (NACC) is
another option for Native health care in the Twin Cities
area. Although NACC does not receive funding from the
Indian Health Service, the clinic’s patient population is 80
percent Native American and its mission is focused on
decreasing health disparities of Indian people. NACC, an
FQHC, provides full service family practice health care.
NACC has comprehensive services for diabetes, prenatal
care, and programming for Fetal Alcohol Spectrum
Disorder (screening, assessment, treatment and follow-up).
NACC provides case management services, insurance
eligibility counseling and health education as well as
community outreach programs including teaching the
“Living in Balance” course offered to all Indian
organizations in the metropolitan area. NACC accepts
private and public insurance and offers a sliding fee scale
to uninsured patients.
See “Indian Health Services”
(back page)
3
COMMUNITY FOCUS
Minnesota’s Urban Health Care
By Debra L. Jahnke, Office of Rural Health and Primary Care, Primary Care Programs Coordinator
What is the health care safety net?
Minnesota communities vary greatly based on geography and socioeconomic factors, but the basic health care need is
essentially the same: access to and availability of quality health care. The health care “safety net” of community health
centers, local health departments and public hospitals are organizations that provide health care access to medically
underserved urban populations.
Who uses safety net services?
Two common indicators of health care access, as well as health status, are poverty status and uninsurance rate.
Populations in poverty are often underinsured and, like the uninsured, lack a medical home. According to the 2000
Census, over 21.5 percent (1,035,000 people) of Minnesotans are under 200 percent of the federal poverty level. By
county, the population under 200
percent of poverty varies from 9.8
Map A
percent to 44.8 percent with
nearly half of Minnesota counties
at 30 percent or higher.
Minnesota’s largest metropolitan
area is a seven-county area,
referred to as the Metro area,
which includes the twin cities of
St. Paul and Minneapolis. Over 53
percent of the state’s total
population lives in the Metro area,
as well as over 76 percent of the
total populations of color.
In the urban area, populations in
poverty are heavily concentrated
within the cities of St. Paul and
Minneapolis with many census
tracts reporting 30 to 88 percent
of the population under 200
percent federal poverty level. Map
A shows percentages of the
population at 200 percent federal
poverty level by census tract for
the seven county metro area.
According to the 2000 Census, approximately 10.4 percent of Minnesota’s population includes African/African Americans,
Asian Americans and Pacific Islanders, Hispanics/Latinos, American Indians and other racial/ethnic groups. While
Minnesota is generally considered one of the healthiest states in the United States, this healthy status is not shared by its
populations of color. The Minnesota Department of Health, Office of Minority and Multicultural Health (OMMH) focuses
on the disparities in health status among Minnesota’s populations of color. According to OMMH, Minnesota’s populations of
color face health disparities related to infant mortality, lack of prenatal care, diabetes, cardiovascular disease,
immunizations, teen pregnancy, HIV/AIDS and sexually transmitted diseases. Some of the most serious disparities
experienced by these populations are preventable and could be decreased with access to basic primary care services.
4
Safety Net
In addition to the health disparities, these populations also experience a high rate of poverty and uninsurance. According to
the 2004 Minnesota Health Access Survey (a collaborative survey by the Minnesota Department of Health and the
University of Minnesota School of Public Health), the overall rate of uninsurance in Minnesota was 7.4 percent. However,
uninsurance rates for racial and ethnic minorities were dramatically higher than for white populations. The uninsurance rate
for white populations was at
5.9 percent, 12.8 percent for
Map B
black populations, 9.8 percent
for Asian populations, 21
percent for American Indians.
Hispanic/Latinos had the
greatest uninsurance disparity
at 34.2 percent.
Similar to populations of
poverty, a large percentage of
Minnesota populations of color
are concentrated in St. Paul
and Minneapolis and are
primarily served by Federally
Qualified Health Centers
(FQHCs). Map B shows
percentages of total minorities
by census tract for the seven
county metro area, according
to Census 2000.
What is a Federally
Qualified Health Center?
For these heavily concentrated
poverty and minority urban
populations, Federally Qualified
Health Centers (FQHCs) are critical safety net access points. FQHCs, often referred to as community health centers, are
private nonprofit or public organizations that provide primary and preventative health care services to medically
underserved populations. Medically underserved populations include those with no health insurance, no money to pay for
health care out of pocket and dependent upon Medicaid and other public programs.
Under Section 330 of the federal Public Health Service Act, clinics may qualify as FQHCs under several programs
including the Community Health Center Program, the Migrant Health Center Program, the Health Care for the Homeless
Program, and the Public Housing Primary Care Program. All of these programs provide grant funding to qualifying
organizations to subsidize health services to the uninsured. An additional Section 330 provision, the FQHC Look Alike,
provides reimbursement incentives for clinics that meet the requirements under the Community Health Center but does
not provide the grant funding. More information on these programs is available at
http://www.health.state.mn.us/divs/cfh/orhpc/rhpc/fqhcsection330.htm
According to the Minnesota Association of Community Health Centers (MNACHC), FQHCs provided care to over
68,000 (41 percent of their total patients) uninsured Minnesotans in 2005. Additionally, 81 percent had household
5
COMMUNITY FOCUS
incomes under 200 percent of the federal poverty level and 35 percent of patients were enrolled in a public health care
program (MinnesotaCare, GAMC, Medicaid or Medicare).
There are 11 FQHCs in the seven county metro area with multiple satellite sites. All 11 primary facilities and most of
their satellite clinics are
located in St. Paul and
Map C
Minneapolis. Despite the
locations, FQHCs serve
patients from across the
entire seven county metro
area. Map C identifies
FQHC patients by zip code
represented as a percentage
of total FQHC patients.
In addition to a broad
distribution of patients
across the metro area,
urban FQHCs are serving
patients from many rural
areas. Map D is a state map
that indicates all the zip
codes in which urban
FQHC patients reside.
What are the Challenges
of the FQHCs?
Federally Qualified Health
Centers face difficult
challenges in providing care
to their target population.
The number of uninsured
patients at FQHCs has
increased, on average, 7.6 percent each year since 1999. Services to these patients are uncompensated except for
whatever patients can pay. Under federal guidelines, FQHCs are required to accept all patients regardless of ability to pay
by offering a sliding fee scale to those at or below 200 percent federal poverty guidelines. Fees are sometimes discounted
down to zero for those patients at the lowest level of poverty.
The number of underinsured patients, those dependent upon Medicaid, General Assistance Medical Care (GAMC) and
MinnesotaCare, has increased an average of 15.4 percent per year since 1999 with Medicare increasing an average of 8.1
percent per year. While reimbursements for care under these programs are more beneficial than no payment at all, they
are still less than the cost of care provided. The rising percentage of uninsured and underinsured has increased
uncompensated care costs that have been compounded by smaller percentages of insured patients.
The MNACHC reports that the cost of serving the uninsured for member clinics has increased drastically in recent years.
From 2002-2004, the costs of serving the uninsured at MNACHC clinics increased 24 percent from $14.8 million to
$18.4 million. In 2006, one urban and one rural FQHC satellite closed due to financial hardships related to
uncompensated care costs and rising numbers of uninsured patients.
Cultural and linguistic isolation of patients are also challenges that make it difficult and costly for FQHCs to provide care.
About 24 percent of 2005 patients were best served in a language other than English. With the increasing immigration
from a variety of African and Asian countries, this can mean a very broad range of languages. For example, the
Minneapolis School District reports that 56 languages are spoken in their schools. Many FQHCs are recruiting multilingual
and multicultural providers but still need to use extensive and costly translation services. Also, over 63 percent of patients
belonged to communities of color. As discussed earlier, these populations experience a high percentage of health
disparities. These health conditions often result in complex medical needs, increasing the expense of providing care.
6
Map D
What assistance is available for FQHCs?
The Office of Rural Health and Primary Care operates a variety of financial and technical assistance programs that help
FQHCs provide services to the medically underserved.
• Technical Assistance: On-site technical assistance is available to primary care practices on reimbursement, accounts
receivable management, administrative processes, revenue and business planning, information systems and
contracting.
• Community Clinic Grants: Grants support the capacity of eligible organizations to plan, establish or operate clinical
services for populations with low incomes.
• Indian Health Grants: Grants help applicants establish, operate or subsidize clinic facilities and services to offer health
services to American Indians who live off reservations.
• Loan Repayment: A variety of loan repayment programs are available to primary care providers (including medical,
dental and mental health) who agree to complete a service obligation at an eligible facility or location.
• E-health Grants and Revolving Loan Fund: Per the 2007 Legislature, one-time funding is available for investments in
health information technology to improve patient safety, interconnect clinicians and communities and strengthen and
improve public health in Minnesota.
• Federally Qualified Health Center (FQHC) Subsidies: The 2007 Legislature recently made subsidies available to
FQHCs operating in Minnesota to continue, expand, and improve federally qualified health center services to
populations with low incomes.
More information on these programs and other Office of Rural Health and Primary Care programs that support that health
care safety net in Minnesota is available online at ttp://www.health.state.mn.us/divs/cfh/orhpc/rhpc/office/home.htm
7
Indian Health Services (continued from page 3)
To learn more about the
Office of Rural Health & Primary
Care programs, visit our Web site:
http://www.health.state.mn.us/divs
/cfh/orhpc/rhpc/office/home.htm
This information will be made
available in alternative format –
large print, Braille, or audio
tape – upon request.
Printed on recycled paper with a
minimum of 20% post-consumer waste.
The ORHPC Quarterly is using
electronic distribution instead
of the mail. Subscribe at
http://www.health.state.mn.us/su
bscribe.html
or request other arrangements by
contacting Cirrie Byrnes at
[email protected]
or (651) 201-3844.
Pharmacy Services
Fond-du-Lac Tribal Health and Human Services will be providing pharmacy services to eligible
American Indians beginning in July 2007. Located in the East Franklin Business Center, Mash ki
i ki waa kaa igan (Medicine House) will accept prescriptions from physicians and other qualified
medical staff from the Native American Community Clinic and the Indian Health Board of
Minneapolis. Other provider prescriptions will not be accepted. Medicare, Medicaid and other
third party insurance will be billed; however, patients will not be charged. For more
information, contact:
Joni Buffalohead, Pharmacy Administrator
Mash ki i ki waa kaa igan
1433 E. Franklin Ave.
Minneapolis, MN 55404
(612) 874-1989.
85 E. 7th Place, Suite 220
P.O. Box 64882
Saint Paul, Minnesota 55164-0882
Mark Schoenbaum, Director
Cirrie Byrnes,
Editorial Assistant
For more information on the Native American Community Center, contact:
Dr. Lydia Caros, Executive Director
Native American Community Clinic
1213 E. Franklin Ave.
Minneapolis, MN 55404
(612) 872-8086
http://www.nacc-healthcare.org