JEFFERSON CITY — Marketta Hayes sat at her dining table in her Columbia home looking at an empty Lipton Iced Tea bottle.
“Oh,” she said, sliding the bottle away from her. “I didn’t know there was that many calories in here. That’s a lot.”
Hayes is a retired Kansas City school teacher who moved to Columbia 14 years ago when her daughters were attending college at MU. She raised three daughters and a son by herself, after her husband was killed in a boating accident in Michigan in 1974.
Hayes said she has become far more health conscious since she started going to the Family Health Center in 1996.
“Could be because I’m getting older,” she said with a laugh. “But no, I’m just really more conscious about my health and stuff and wanting to live longer and be a productive member of society.”
The Family Health Center is Columbia’s federally qualified health center. Under a supplemental appropriations measure passed by Missouri’s House, federally qualified health centers statewide would receive $60 million for buildings and equipment. And under the General Assembly’s plan to restructure Medicaid, federally qualified health centers would play a major role in providing health care coverage for lower-income Missourians.
Federally qualified health centers receive federal funding to provide medical care to the uninsured. The centers also get cost-based reimbursement from the state for Medicaid patients, and serve Medicare patients.
Gloria Crull, the center’s executive director, said that the center is in line for $1.3 million. Because the bill has yet to pass the state Senate and the money isn’t in hand, she’s counting her chickens carefully. But she has general ideas about the best way to spend it.
She said $500,000 would go toward new dental equipment and a new building or an expansion of a dental satellite office in the Chariton County town of Salisbury.
“Because there’s not a dentist in Chariton County, what we’re trying to do is solve the geographic barrier to access to care,” she said. “So if we can build the building and the equipment, we’ll hire the staff on our own and we can then provide the services within that county.”
Another $500,000 would go to the dental office in Columbia for expansion of its building as well as additional dental equipment.
The remaining $300,000 would go to renovate the Family Health Center in Columbia at Worley Street and West Boulevard and purchase additional equipment. She said the health center needs more space and more equipment to serve more patients.
“There’s a capacity limitation to how many people we can see,” Crull said. “I mean, it’s the reality, and so there are people that are unserved. There is no doubt about that.”
Statewide, 19 federally qualified health centers provide care to nearly 300,000 low-income, uninsured Missourians annually. Combined with satellite offices, they provide 90 service sites.
In 2006, the Family Health Center and its three satellite offices served 10,003 patients in 37,047 visits. Boone County and its nine neighboring counties share the health center.
Crull said the health center opened in 1992 as a result of citizen concern for the medically underserved.
“It was sort of shocking because, you know, there are so many health services in Columbia that you would not think there was a gap in service,” she said. “The problem was that they couldn’t pay full-charge, out-of-pocket.”
Crull said low-income, uninsured people avoid medical services because they can’t afford to pay for them. Then they do exactly what a federally qualified health center is designed to prevent: They go to the emergency room to receive much more expensive care.
“Your goal is to make it affordable so that they will manage their care at the primary-care level and not end up in the emergency room utilizing high-dollar services,” she said.
In addition to being a patient, Hayes is secretary of the center’s governing board. Hayes said she became a “consumer member” because she wanted to have an impact.
She started going to the health center because her private physician was too expensive.
“And back then, I was on my high horse. I could pay everything,” she said. “And I told (my daughter), ‘Oh, I don’t want to go to that place (the health center). It’s just like charity.”
Later Hayes added, “I think I was talking to my daughter and I was saying to her, ‘Karen, I just can’t keep paying this money to this doctor,’ and she said, ‘Well, you knock them but give them a try. Give Family Health a try, and if you don’t like it, then you don’t have to stay.’ And I stayed.”
Rep. Robert Schaaf, a St. Joseph Republican and family physician, was one of only four House members to vote against the funding bill, which passed 153-4. He said that because of the cost-based reimbursement, federally qualified health centers get four times the reimbursement that physicians receive.
He said that if a Medicaid patient “walks into my office, I get $23. They walk into a federally qualified health center — depending on the reimbursement — they get $85 to $100.”
Schaaf said the $60 million would create an unfair competitive advantage for federally qualified health centers and that the money would be better spent raising the Medicaid reimbursement rate for physicians than building new buildings.
“Putting $60 million into building more FQHCs that are highly paid when we won’t pay our own physicians as much as it costs them to provide care — it’s immoral,” he said. “It’s an immoral use of our money.”
Federally qualified health centers place a heavy emphasis on primary care. Each patient that walks through their doors is assigned a provider and placed on a treatment plan, whether they are a senior with diabetes or heart disease, or in their 20s with no known health problems.
“But a lot of people — the urgent care system, if you will, is the way they think,” said Kay Strom, chief operating officer of the health center. “If something’s hurt, if something’s broken they take that piece of them to the doc and get it treated, where the primary care concept is looking at the whole patient and a planned approach.”
Hayes said she goes to the center about once every three months for periodic checkups and believes the primary care she’s receiving is “excellent.”
Strom said treatment plans differ based on the needs of the patient. But essentially, it is a plan used to inform patients of their primary care needs. A relationship is established with the assigned provider, and the patient is able to participate in achieving the goals set out in the plan.
“But the thing that is different is that there is some responsibility and a plan for ongoing care in contrast to an emergency room that looks at the patient at this moment in time and says what they need to be treated for this day, this hour and then beyond that is not their job,” Strom said. “It’s somebody else’s job.”
Included in the treatment plan, Strom said, are goals for increasing exercise and quitting smoking.
“It may be something as simple as they need to increase their exercise,” she said. In that case, she said, the advice to exercise more might involve instructions to walk around the couch three times during every commercial. “That’s a start,” she said.
Strom said the goals are meant to be attainable so patients can achieve them and then set new goals.
Hayes, who is uninsured, said the sliding-fee scale the center offers makes quality health care affordable. “I couldn’t afford a real doctor,” she said. “It’s just that simple ... When you don’t have any insurance, it’s hard.”
To further make health care affordable, Strom said, the center has three programs to make prescriptions less expensive to ensure that people are getting the medication they need.
The center provides patients with sample prescriptions. It also participates in indigent drug programs with pharmaceutical companies, which offer discounted or free medications on a voluntary basis.
The federally qualified health center is also able to purchase medications at the lowest federal pricing through a contract with Kilgore Medical Pharmacy.
Schaaf said the legislation that would provide state funds to the federally qualified health centers is a “systematic movement” to place Medicaid patients in a substandard tier of health care.
“When you want to encourage people to be seen by a certain provider, you jack up the reimbursement for that provider and that’s what’s happening here,” he said.
Schaaf said the level of care that patients receive at the federally qualified health center is not as good as what they receive at a physician’s office because they get “shuffled off” to a nurse practitioner.
“You have to ask yourself the question: What is the quality of care delivered from a nurse practitioner as opposed to delivered by a doctor?” he said. “Well, the nurse practitioner will tell you that they’re better, but they’re obviously less well-trained.”
Hayes said she has had a nurse practitioner since she started going to the Family Health Center and that she likes it better because the nurse practitioner is female and she found it difficult to find a female doctor when she moved to Columbia.
It is not a requirement that health center patients see a nurse practitioner, she said. Despite the fact that nurse practitioners don’t have the same training as doctors, she said, “they are good.”
Strom said that many Medicaid patients have to come to the federally qualified health centers because there are too many doctors who won’t see Medicaid patients.
“If the doc has got his practice full and he needs to cut somewhere because he can’t take care of everything that’s there, they may often cut the Medicaid because their reimbursement rate is lower on that,” she said. “And if you can only see ‘x’ number of patients a day, you want to maximize what you’re going to get out of those patients.”
Strom also said that some doctors don’t think that Medicaid patients will mix well with their other patients in the waiting room. “They don’t want to lose their private-pay-insurance paying patients because of having the waiting room filled with people that may not have the same dress standards and behavior standards,” she said. “That’s a delicate one to walk around, but it’s real.”
All in all, Crull said her work at the health center is meaningful and that the patients are appreciative of having access to decent health care at a reasonable price.
She said that she thinks there is a general public opinion that people take advantage of the Medicaid system.
“I think it’s very few people,” she said. “By and large, people want to just take care of their families, make a living, be healthy, and pay their bills just like everybody else.”