Original Article

Primary Care Quality: Community Health Center and Health Maintenance Organization

Authors: Leiyu Shi, DRPH, MBA, Barbara Starfield, MD, MPH, Jiahong Xu, MPH, MS, Robert Politzer, Jerrilyn Regan


Objective This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO. Methods Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics. Results After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance. Conclusion Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

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1. U.S. General Accounting Office. Community Health Centers: Challenges in Transitioning to Prepaid Managed Care(GAO/HHS 95-138). Washington, DC, U.S. General Accounting Office, April 1995.
2. Freeman HE, Kiecolt KJ, Allen HM II. Community health centers: An initiative of enduring utility. Milbank Mem Fund Q Health Soc 1982; 60: 245–267.
3. Gardner RJ. National health care reform and community and migrant health centers. J Health Care Poor Underserved 1993; 4: 268–271.
4. Dievler A, Giovannini T. Community health centers: Promise and performance. Med Care Res Rev 1998; 55: 405–431.
5. Shi L, Politzer RM, Regan J, et al. The impact of managed care on the mix of vulnerable populations served by community health centers. J Ambul Care Manage 2001; 24: 51–66.
6. Zwick DI. Some accomplishments and findings of neighborhood health centers. Milbank Mem Fund Q 1972; 50: 387–420.
7. Reynolds RA. Improving access to health care among the poor: The neighborhood health center experience. Milbank Mem Fund Q Health Soc 1976; 54: 47–82.
8. Seacat MS. Neighborhood health centers: A decade of experience. J Community Health 1977; 3: 156–170.
9. Rosenbaum S. Community and Migrant Health Centers: Two Decades of Achievement. Washington, DC, National Association of Community Health Centers, 1987.
10. Sardell A. The United States Experiment in Social Medicine: The Community Health Center Program, 1965–1986. Pittsburgh, University of Pittsburgh Press, 1988.
11. Patton LT. Community health centers at 25: A retrospective look at the first 10 years. J Ambul Care Manage 1990; 13: 13–21.
12. Zuvekas A. Community and migrant health centers: An overview. J Ambul Care Manage 1990; 13: 1–12.
13. Shi L, Frick KD, Lefkowitz B, et al. Managed care and community health centers. J Ambul Care Manage 2000; 23: 1–22.
14. Politzer RM, Yoon J, Shi L, et al. Inequality in America: The contribution of health centers in reducing and eliminating disparities in access to care. Med Care Res Rev 2001; 58: 234–248.
15. Regan J, Lefkowitz B, Gaston MH. Cancer screening among community health center women: Eliminating the gaps. J Ambul Care Manage 1999; 22: 45–52.
16. Frick KD, Regan J. Whether and where community health center users obtain screening services. J Health Care Poor Underserved 2001; 12: 429–445.
17. Falik M, Needleman J, Korb J, et al. ACSC Experience by Usual Source of Health Care: Comparing Medicaid Beneficiaries Who Rely on CHCs with Medicaid and Beneficiaries Who Rely on Other Primary Care Providers. Washington, DC, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, July 1998.
18. Ulmer C, Lewis-Idema D, Von Worley A, et al. Assessing primary care content: Four conditions common in community health center practice. J Ambul Care Manage 2000; 23: 23–38.
19. Division of Health Manpower and Resources Development, Institute of Medicine. A Manpower Policy for Primary Health Care: Report of a Study(IOM Pub. 78-02). Washington, DC, National Academy of Sciences, 1978.
20. Institute of Medicine. Defining Primary Care: An Interim Report. Washington, DC, National Academy Press, 1994.
21. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, Oxford University Press, 1998, rev ed.
22. Bindman AB, Grumbach K, Osmond D, et al. Primary care and receipt of preventive services. J Gen Intern Med 1996; 11: 269–276.
23. Roos NP. Who should do the surgery? Tonsillectomy-adenoidectomy in one Canadian province. Inquiry 1979; 16: 73–83.
24. Shi L. The relationship between primary care and life chances. J Health Care Poor Underserved 1992; 3: 321–335.
25. Starfield B. Is primary care essential? Lancet 1994; 344: 1129–1133.
26. Shi L. Primary care, specialty care, and life chances. Int J Health Serv 1994; 24: 431–458.
27. Greenfield S, Rogers W, Mangotich M, et al. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties: Results from the medical outcomes study. JAMA 1995; 274: 1436–1444.
28. Lohr KN, Brook RH, Kamberg CJ, et al. Use of medical care in the Rand Health Insurance Experiment: Diagnosis- and service-specific analyses in a randomized controlled trial. Med Care 1986; 24( 9 Suppl): S1–S87.
29. Keeler EB, Sloss EM, Brook RH, et al. Effects of cost sharing on physiological health, health practices, and worry. Health Serv Res 1987; 22: 279–306.
30. Newhouse JP; The Insurance Experiment Group. Free for All? Lessons from the Rand Health Insurance Experiment. Cambridge, MA, Harvard University Press, 1993.
31. Starfield B. Effectiveness of Medical Care: Validating Clinical Wisdom. Baltimore, The Johns Hopkins University Press, 1985.
32. Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, Oxford University Press, 1992.
33. Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with the delivery of clinical preventive services. Med Care 1998; 36( 8 Suppl): AS21–AS30.
34. Starfield B, Cassady C, Nanda J, et al. Consumer experiences and provider perceptions of the quality of primary care: Implications for managed care. J Fam Pract 1998; 46: 216–226.
35. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: Tests of data quality and measurement performance. Med Care 1998; 36: 728–739.
36. Green LA. Science and the future of primary care. J Fam Pract 1996; 42: 119–122.
37. Grumbach K. Separating fad from fact: Family medicine, primary care, and the role of health services research. J Fam Pract 1996; 43: 30–33.
38. Donaldson MS, Vanselow NA. The nature of primary care. J Fam Pract 1996; 42: 113–116.
39. Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Pract 2001; 50(2): E1.
40. Shi L, Huang Y, Kelly K, et al. Gastrointestinal symptoms and use of medical care associated with child day care and health care plan among preschool children. Pediatr Infect Dis J 1999; 18: 596–603.
41. Shi L, Lu N, Zhao M, et al. Respiratory symptoms and use of medical care associated with child day care and health care plan among preschool children. J S C Med Assoc 2000; 96: 335–340.
42. Cassady CE, Starfield B, Hurtado MP, et al. Measuring consumer experiences with primary care. Pediatrics 2000; 105: 998–1003.
43. Davis K, Collins KS, Schoen C, et al. Choice matters: Enrollees’ views of their health plans. Health Aff (Millwood) 1995; 14: 99–112.
44. National Committee for Quality Assurance. Technical Report: Report Card Pilot Project. Washington, DC, National Committee for Quality Assurance, 1995.
45. Hellinger FJ. The effect of managed care on quality: A review of recent evidence. Arch Intern Med 1998; 158: 833–841.