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Will a new health agency expand access to affordable care or out-compete established community health centers in Western North Carolina, possibly undoing decades of work?
That’s one of several questions raised by Asheville-based Appalachian Mountain Community Health Centers, which in August won federal approval and $704,167 in startup money.
The organization will open a new, central facility near downtown Asheville later this year and offer a half-dozen satellite clinics at existing sites across the region.
But some observers are questioning the new organization’s ties to Mission Health, saying Appalachian Mountain wasn’t created collaboratively with other federally qualified community health centers (FQHCs).
Mission’s management partner, the Mountain Area Health Education Center, incorporated the new organization in 2013, temporarily dubbing it “Mountain Area Health Center.”
The subsequent federal application lacked letters of support from neighboring FQHCs, their state association or the N.C. Department of Health, according to documents obtained by Carolina Public Press.
However, Mission CEO Ron Paulus did submit a letter of support.
Community health centers in America were “set up to not have the hospitals involved, (and) to cushion against profit-driven health care models,” said Chuck Shelton, director of Bakersville Community Health Center in Mitchell County.
In mostly rural WNC, where a high percentage of residents are uninsured and/or low-income, there’s a great need for affordable, accessible health care, Shelton said. “The new FQHC can help, (but) we’re quite concerned about the implications of a hospital system becoming involved.”
“When we first heard that Mission and MAHEC were going to collaborate in creating a new FQHC, we reached out right away,” said Jennifer Henderson, director of Hendersonville-based Blue Ridge Community Health Services.
“We were very disappointed we were never asked for a letter of support. It was a waste of taxpayer money to duplicate what was already there, (and) counterproductive to (create) a new startup.”
Appalachian Mountain director Nic Apostoleris said he’s had “straight talk” with Henderson and other FQHC leaders. The former interim chief operating officer of a community health center in Massachusetts, as well recently serving as board president for the National Health Care for the Homeless Council, he wasn’t involved in the creation of Appalachian Mountain.
“All I can say is, I’m going to do whatever I can to collaborate … so this is a net gain for the community,” he said. “We’re all in it for the same thing — improving public health.”
Meeting the need
Including Appalachian Mountain, nearly 40 federally qualified community health centers serve North Carolina, with more than 1,000 nationwide.
These nonprofit entities that provide care to the country’s most vulnerable — “medically underserved populations/areas or special medically underserved populations comprised of migrant and seasonal farmworkers, the homeless or residents of public housing,” according to the Health Resources and Services Administration, the federal agency that oversees the program.
The nonprofit, community-based model came out of President Johnson’s War on Poverty in the 1960s, said Ben Money, director of the North Carolina Community Health Center Association. From the start, FQHCs served a high percentage of uninsured and low-income patients in both rural and urban areas.
Community health centers fill a niche and are “always going to be there,” he said.
Along with grants, insurance payments and other revenue, FQHCs receive cost-based or “enhanced” federal reimbursement for Medicaid patients, Money said.
To qualify for that support, the organizations have to meet several requirements, such as demonstrating community need, providing a suite of care, maintaining a core staff, offering a sliding scale for fees and making an “effort to establish and maintain collaborative relationships with other health-care providers,” according to HRSA.
Applications for new FQHCs are scored on how well these requirements are addressed. Most of them don’t win approval, Apostoleris said.
Money said the federal government boosted the program with an $11 billion allocation spread over five years starting in 2010 as part of the Patient Protection and Affordable Care Act. The infusion has helped create 22 new access sites and seven new FQHCs in North Carolina.
But community health centers often have long histories in their service areas, including WNC: Blue Ridge, initially called the Migrant Council of Henderson County, was founded in 1963 as one of the nation’s first community health centers.
Asheville-based WNC Community Health Services was created in 1993 to serve HIV/AIDs patients in the region but now also serves as a primary-care provider for Buncombe County’s low-income residents.
Hot Springs Health Program started in 1971 when two nurses, Linda Ocker Mashburn and Rae Ann Gaserowski, opened a primary-care clinic for Madison County’s remote mountain communities.
Bakersville launched with a $13,000 community-fundraising drive in 1974 and received FQHC status about four years ago.
Each of these organizations is community-driven — born out of local need and organized by local leaders and residents, Shelton said. “We’re able to make more human-based decisions than business decisions, so we can serve our patients better,” he said.
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“They’re all local (and) social-mission oriented,” said Apostoleris, whose background includes work as a clinical psychologist in a rural community health center.
Typically, FQHCs are focused on primary and preventative care that addresses medical, social, dental, behavioral and other health needs, he said. The nonprofits help keep people out of emergency departments and, instead, work with a team of providers for inexpensive, comprehensive care that can include treatment for chronic conditions like diabetes or heart disease.
“What we’re all trying to do is expand access to health care,” Henderson said. “Our main purpose is to care those who are most vulnerable.”
FQHCs qualify to receive a higher federal reimbursement rates than hospitals, doctors or private practices, in part because the nonprofits “are a vital source of primary care for millions … seeking a quality source of care in every state, territory and in the District of Columbia,” according to the HRSA.
Talk of forming a new community health center started more than two years ago. MAHEC director Jeff Heck filed incorporation papers in 2013 and later submitted an application to the HRSA. MAHEC also took over management of Mission Health’s primary-care network in 2014.
Established in 1974, MAHEC is part of a statewide program for training and retaining physicians and other health-care professionals. It covers 16 WNC counties, making it geographically the largest of the state’s area health education centers.
Its doctors deliver more than 2,000 babies yearly. Its clinics see more than 22,000 Medicaid patients, Heck said.
“Our OB-GYN providers see women from all over (the region),” he said, “especially those with high-risk pregnancies, regardless of their ability to pay.”
Less than a quarter of MAHEC patients have insurance or government coverage like Medicaid. “Many providers limit the number of these patients because the (federal) payment is so much lower than commercial insurance,” Heck said.
WNC, like much of America, faces a shortage of primary-care doctors, but for every doctor, at least four additional employees are needed, such as nurses, physician assistants and front desk personnel, Heck said.
Add interpreters, social works, counselors and others who can help provide a full range of services, and “the economics don’t work,” he said.
But the region’s need remains high. The decision to form Appalachian Mountain was based on answering this question, Heck said: “Could we work to establish another FQHC in the community that could change how we’re compensated, so that we could provide more services to more people? We (Mission and MAHEC) decided to help get it off the ground.”
Getting FQHC status means MAHEC’s partners can “receive a higher reimbursement from government payers, (which) enables us to provide all the services needed,” Heck said.
Asked to what extent MAHEC sought support or agreement from other FQHCs about forming the new entity, Heck emphasizes his organization’s “extensive collaborative efforts with WNC FQHCs, rural health centers and other safety net providers.”
More than 300 MAHEC-trained doctors work across the region currently, according to Heck. “Through the years, all of the safety-net institutions have benefitted from recruiting our doctors when they graduate,” he said.
Heck also said the region’s established FQHCs “are terrific health-care centers, but we have so much more need. … I don’t see how this (new entity) can be anything but good for WNC.”
The Mission connection
Mission Health operates six hospitals in the region, from Angel Medical in Macon County to Blue Ridge Hospital in Mitchell County. As of mid-September, its primary-care network numbers nearly 1,000.
Asked about its connection to Appalachian Mountain and the perception that it’s building a health-care monopoly, CEO Ron Paulus said, “Mission Health can be a facilitator of many entities.
“We don’t need to control everything. We don’t want to. But we can help.”
Appalachian Mountain is “a separate entity,” said Sonya Greck, Mission’s senior vice president of behavioral health and safety-net services.
A recent community assessment identified two key needs for Buncombe County and the region — behavioral health and primary care, she said.
“That’s what drives our strategy,” Greck said. “The demand is there. So the opportunity to provide a resource for access to care is what it’s about.”
In the last five years, Mission has been reorganizing and expanding, “shifting our emphasis away from a hospital lens and into a community-based, wellness lens,” Paulus said.
“We’re here to help improve the health of the citizens of WNC and the surrounding region.”
Mission does have its own “business-model needs,” he said.
Paulus laid out a mix of strategies in 2012 for meeting financial and health care goals, including a “highly collaborative relationship” with MAHEC. That included a bullet point about establishing a “safety-net coalition, with (the) goal of giving FQHC status to MAHEC, (which would) improve financial operations by millions.”
Asked about this point, Paulus said the health-education center was exploring an FQHC “look-alike” model at the time “that would have enabled additional resources … to be applied to the most needy in our community.”
Paulus took the helm at Mission five years ago and recalled being “dumbfounded (by) the degree of unmet need and the lack of access that people had to care.”
That’s not a criticism of established providers, he said, but a recognition of regional needs. Lack of affordable, accessible health care is “not exclusively a Mission (Health) problem. It’s a Southern Appalachian problem,” Paulus said.
“As I said in my support letter with (for Appalachian Mountain’s) grant application, access to primary care is the top health disparity that our community members face here.
“We began to think about what we could do to support (community needs) in ways that aren’t necessarily the traditional model. The FQHC is a tiny part of that.”
Mission started collaborating with MAHEC about two years ago to provide clinical services to the area’s homeless, Greck noted. “MAHEC and the Asheville Buncombe Community Christian Ministry worked with us to provide a space, then the site at 7 McDowell St. came up,” she said.
That location is set to be the new access point, or NAP, for Appalachian Mountain.
“It made sense for us to partner with MAHEC to help connect patients with primary care. The new FQHC is part of that,” she said.
Mission also helps create a comprehensive crisis center as an alternative for patients who need behavioral health support but would, typically, end up in the hospital’s emergency department. Such initiatives came out of community conversations and creative approaches, Greck said, countering the allegation that Mission has not been a collaborator.
She said Mission’s motto — “Be well. Get well. Stay well.” — is about “looking to the full spectrum of care — that’s going to make for a healthier community.”
“We could be looked at as more formidable than we actually are,” Apostoleris said of Appalachian Mountain.
Opening of the McDowell Street location, not far from Mission’s central campus, had been scheduled for late September but has been delayed. The satellite clinics haven’t yet been finalized but will be sited at existing centers, he said, such as public-housing locations around Asheville and as far west as Robbinsville, where there are no FQHCs and the nearest hospital is a county away.
Meanwhile, the McDowell Street waiting room remains empty, but a large painting, done by a patient, offers a colorful, hopeful mountain scene.
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Consumers make up more than half of Appalachian Mountain’s 11-member board, as federal guidelines require is, as federal guidelines require. “My board is my boss,” Apostoleris said.
Reflecting on the concerns he has heard so far, Apostoleris said area FQHC leaders want to know if he’s faithful to the community health movement and mission. “They want to know if I’ll be worthy,” he said.
“We have to work together,” Henderson said. “In the best scenario, the (new FQHC) increases access to health care, and these are not just hospital sites.”
Money asks whether the new FQHC, because of its ties with Mission, will have an unfair advantage in how patients are assigned to providers. If so, one of the mountain FQHCs might not have sufficient revenue to survive.
The goal is to direct patients “to FQHCs that are best equipped clinically to care for [their] particular … needs,” Apostoleris responded to those concerns. “Collaboration is the only answer to addressing serious public health problems.”
Still, Shelton says he’s looking to protect Bakersville’s patient base while continuing to provide good care. He’d also like to expand to areas like Yancey County, where there’s no hospital or community health center. Bakersville, which operates two Mitchell County locations and serves patients from neighboring Unicoi County, Tennessee, as well as McDowell in North Carolina, has gained two new physicians but lost one. “That limits us,” Shelton said.
“Collaboration has always been an important part of the health center program because it avoids unnecessary duplication of services and makes the best use of taxpayer dollars,” Henderson said. “The current health centers in the region take pride in our ability to work together.”
Apostoleris asks for patience as his new organization gets going. He said leaders like Henderson and Shelton are “strong advocates of public health.”
“I see this (new) center as a hub for Appalachian Mountain, as a showcase for what we’re trying to do,” he said. “If this works out the way it’s supposed to, it will be good for everybody.”