Assessing the Effectiveness of
Policies to Improve Access to

Primary Care for Underserved
Populations

 

Funding for this report was provided by
the National Institute for Health Care
IS colaaee

AUGUST 2022

By Maanasa Kona, Megan Houston,
Jalisa Cark, and Emma Walsh-Alker

GEORGETOWN, CENTER ON
UNIVERSITY _ HEALTH INSURANCE
McCourt School of Public Policy REFORMS

 

AV GDL oysh avis »

Memorial Fund

 
TABLE OF CONTENTS

ADSUraCt 0000... eesceetcecsnssnrcecencsecccesssncceecesssncceeseescsueesenseaccesensescesseaceeuecsessesceceescncuateesoncoacoees 4
INTPOCUCTION.............cccecssccscecesecsesssccsscsseseseossessnesescacsessossscceessscasoesseesscacessssessacseessccessasseeoncoees 4
BackGLround ........ssscsccscccscsssssessenssrsecceesessessssnenseanaeseosessesssessenenseosasseessessessssssseassassesessosseesnsnnes 5
Geography and Demographics ..............scsccccsscoressersesssssessonenssessnscserersesoncssesseasnsesosensnsees 5
Key Stakeholders..............sccsssrccsssscessssscnsssessnsscssessonseecessssensensonseescasensonseesesoessonsensosseesoes 7
Governmental AGe@ncies ..........ccsccsssccesessseesssscesecsncesensoessessceesesnssesessoesensaeeesneosssenaee 7
The Total Cost of Care Model...........cccccccecseceeceseessseeeeseesescceceeseeseenseeeseesssecoesesseseaeeessensenensees 8
Primary Care Provide'. .............:scccccsssssscsscetssscnteceeesssscnseesesessensseccessonensenscesessenseneees 9
Nongovernmental Organizations .................:ccccesscceceseosesecnecessenesesseneensseeereeseceesseneees 10
Methodology.........sccccscccsccrecscstcenscecenssecnectsenscesenscseencceceassesenccssesscescassesensceeesscesensessescoesens 10
Descriptive Analysis and FindingS...............ssscsssssssssssesssscessssscssessssscessetsseanssssssssesessessecseesens 10
1. Availability of Primary Care Climicians.............ccccsccsssescesetessersssseescessesessecsesssecceserseeseesees 10
There Is a Shortage of Primary Care Providers Who Serve Underserved Populations.....10
State Programs to Improve Recruitment and Retention Have Been Successful,
But the Scale of Programs Is Insufficient .................cscccssecessoeccessceenesssceeescceenesseceessseeens 11
Potential Long-Term Impact of MDPCP on Improving Primary Care Access for
Medicaid and Low-Income Populations. ...............c:esscscccessesseseeserssennessesersenenenteesronsenentens 12
Worry about Broader Trends for Careers in Primary Care.............::ccccsssssscsceserssesseetetensees 13
Even When NPs and PAs Face No State-Level Restrictions on Scope of Practice,
Federal Barriers Create ISSUGS ..............::ccssssceresssccessececeesseceessocecessaeenensseeeescceeneeseceessaesens 13
The Urban Health Residency Program's Successes in Recruitment and Retention.......... 14
2. Improving Access to Outpatient Clinics for Underserved Communities ................0.000000 4
FQHCs Are a Vital Safety Net Provider and Rely on State and Federal Support................ 14
Successes and Challenges of a University Hospital-Affiliated Clinic
Converting to am FQHC.......cccccecssnssseeenessessessonenseceesscaceaseeasenenconsnsssesensenesesesseeaseasens 15
The Role of Hospitals in the Delivery of Primary Care in Baltimore City.................sccessee 16
The SBHC Model Is Stalled Because of Lack of Funding and Regulatory Barriers............ 16
The Success and Scalability of the Rales Center Model.................csssssssssssscsscecenneceeseceeeee 18
3. Removing Structural Barriers to Primary Care .............cscccsssssssccsssssssessessscsesssssssessssnsesees 18
State and Local Efforts Improve Access to Telehealth, But It Is a
Work in Progress. ........cscscsssscssscsecsessseeseseeesssnssesscsensesonecesaenesseseceesesasassasseseasenesesaeeesensanes 18
Transportation ls a Major Barrier, But Several Providers Have
MobiliZed to Overcome It..........ccccscsecsssssscessecesscssecensccececsseccessescesseeessssoesessccesesessesessasens 19
Difficulties in Finding Primary Care Outside of 9 to 5 ou... ccssssssescessesesscescnsseteoseesens 20

Milbank Memorial Fund » www.milbank.org 2
4. Making Primary Care More Affordable................ssscssssesssssssssssecsesscssccsessesscssesssssosesessencens
State Decisions Have Helped People Get and Use Health Insurance Coverage................
Some Gaps in Affordability Remaim....................:csccsssececeeesssesscoeeesenessssoeensesseccaesenseseneees

5. Improving Comfort and Communication between Providers and Patients.................00+.

The State Is Making an Effort to Support CHWs through Certification,

But Barriers Persist .............csssccccsssssssceccesessaneenscenensenseeesasensaeascessesenseessecenssnseesensenseeesaatas
Providers Can Foster Cultural Competency in Their Practices and Connect

With Their COMMUNITIES..............cccsssescssseceesssssessesscsesesssnesessonsesenssessenessesenscssseoneseseones
Balancing Clinical Efficiency and Spending Time with Patients, and Where

Traditional Access Measures Might Fall Short ...............cscssssccessesssseescesessessceeesssssessecesesnes

6. ALot of Independent Activity, But Not Enough Local Coordination...............ssscssssesercees
COMCIUSION..............2eceesscccenscenenseesenscerensconenseecenscerenseenenscesenscerensessenscenenseneenseesenssetenseeenessenense

About the Authors. ............cccssssccconsssescessccrecesccsonccnecsseccccscessseessosacesessesencecesesccocscessesssonecssseees

Milbank Memorial Fund -« www.milbank.org
ABSTRACT

This case study of Baltimore City, Maryland," is the second ina series of case studies
designed to assess the effectiveness of various policy initiatives to expand access to primary
care in a region, particularly for underserved populations. Several parts of the city are
classified as primary care health professional shortage areas, and many policy initiatives
have been implemented to make primary care more accessible, but barriers persist.

For example, Baltimore has a significant number of physicians, but not enough of them
provide primary care to low-income and Medicaid-eligible populations in the city. State
programs to attract more providers to serve underserved areas and populations have been
helpful, but the scale of the programs has been too small to move the needle. Federally
qualified health centers(FQHCs) are a critical safety net provider in the city and have
benefited from many state-level policy decisions, but school-based health centers (SBHCs)
in the city have struggled to expand because of a lack of funding and significant regulatory
burdens.

While efforts to improve access to primary care through telehealth are underway, barriers
like lack of broadband access or lack of smartphones persist for some subpopulations.
Despite several efforts by providers to connect patients with transportation options for
primary care, transportation remains one of the biggest barriers to primary care access.
The state has made significant strides in making primary care affordable by supporting
policies that expand health insurance coverage and affordability. However, the inability of
undocumented immigrants to enroll in subsidized health insurance remains a major gap.

The state's innovative Total Cost of Care model and the Maryland Primary Care Program have
the long-term potential to improve primary care access in Baltimore, but local stakeholders
expressed a need for more local input in designing incentives for further investment in
primary care. Local stakeholders also expressed frustration at not having the funding to
establish a local forum for planning and implementation of a broad primary care strategy for
the city.

INTRODUCTION

It is difficult to overstate the importance of primary care to ensure robust population health
outcomes. Evidence shows that not only can primary care prevent illness and death,' but it

is also associated with reduction in health disparities.? Countries with strong primary care
systems experience better health outcomes than those with weak primary care systems,
including reduced unnecessary hospitalization and less socioeconomic inequality,' as well as
improved management of chronic diseases.' Unfortunately, the United States falls short on
many indicators that demonstrate the strength of a nation's primary care system.®

* Baltimore City is separate from Baltimore County; wherever Baltimore is mentioned in
this case study, the authors are referring to Baltimore City and not Baltimore County.

Milbank Memorial Fund - www. milbank.org 4
To strengthen a primary care system, a threshold issue to consider is how to improve access.
The primary care access problem can be divided into five composite and interconnected
dimensions, known as the five As: (1) availability of primary care clinicians, (2) accessibility

of primary care services geographically, (3) accommodation, such as through appointment
availability and hours, (4) affordability, and(5) acceptability, such as by ensuring comfort and
communication between patient and clinician.®

In a Milbank Memorial Fund issue brief' and five accompanying fact sheets, we assessed

the evidence to determine whether policy initiatives that target primary care access have
reduced health care disparities. Now, in this series of five case studies, we assess the impact
of these policy initiatives at a local level to better understand implementation challenges and
successes. The first case study focused on Grant County, New Mexico.°

This second case study focuses on efforts to improve access to primary care in Baltimore
City, Maryland. Future case studies will focus on one urban and two rural primary care
health professional shortage areas with relatively large numbers of minority or low-income
populations.

BACKGROUND

Geography and Demographics

Baltimore, the most populous city in Maryland, is located alongside the Chesapeake Bay
and has long served as an important port for the east coast of the United States. Baltimore
City is a separate legal and political entity from Baltimore County despite their geographic
proximity," and Baltimore City has been treated as equivalent to a county since 1851." This
case study focuses on Baltimore City (see map).

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The city of Baltimore has a population of about 585,700" that is roughly 58% Black, 28%
white, and 7.8% Hispanic/Latino." The Black population in Baltimore has decreased by
15% since 2010 but remains the largest racial group in the city."* While constituting a much

 

HPSA scores provide a basis for
determining eligibility and resources for
several federal and state programs targeting
primary care access across the country.

The federal government designates areas

as primary care HPSAs when they have (1)
a low ratio of population to primary care
providers (PCPs), (2) a high percentage

of population below the federal poverty
line, (3) poor infant health quality, and (4)
longer travel times to the nearest source of
care. The federal government scores HPSAs
from zero for the areas with the lowest
need to 25 for those with the highest need.
HPSA designations can be geographic
HPSAs (where the entire population living
in that area is experiencing a provider
shortage), population HPSAs (where
specific populations like low-income
populations or Medicaid enrollees in an
area are experiencing a provider shortage),
or facility HPSAs (facilities like FQHCs are
automatically designated as HPSAs, making
them eligible for the federal and state
programs mentioned earlier).

MUA designations are the basis of eligibility
for the FQHC and FQHC Look-Alike
programs. MUA designations depend on an
Index of Medical Underservice (IMU) score,
which is calculated from the (1) number

of PCPs per 1,000 people, (2) percentage

of population at the federal poverty level,

(3) percentage of population over 65, and
(4) infant mortality rate. IMU scores fall
between 0 and 100, and a score of 62 or
below results ina MUA/P designation.
Baltimore City has 14 MUA designations
with IMU scores ranging from 38.6 to 61.6."

Milbank Memorial Fund - www. milbank.org

smaller share of the total population,
Baltimore's Hispanic/Latino population
has grown by 77% since 2010."
Neighborhood level-data from 2020
show that many residents of color,
particularly Black and Hispanic/Latino
residents, live in the eastern and
western areas of the city.

The average per capita income across
the city is $32,699, and the poverty
rate is 20% (compared with the
national average rate of 11.4%)."A
significant wealth gap exists between
the white residents and the racial

and ethnic minority residents of
Baltimore City: the median household
income for Black residents in 2017
was $33,801, while the median income
for white households was almost
double at $62,751." Stark income
disparities also exist geographically
throughout the city. City maps show
that pockets of affluence, such as

the Fells Point neighborhood (with a
median household income of almost
$99,000 between 2015 and 2019) lie
next to high-poverty areas, such as the
Oldtown/ Middle East neighborhood
(with a median household income of
roughly $21,500 between 2015 and
2019)."

A 2021 community needs assessment
conducted by the Maryland Primary
Care Office found that Baltimore City
ranked lowest among all 24 Maryland
county-level jurisdictions in terms

of certain key population health
metrics.2° Twelve areas in the city
are currently designated as primary
care geographic or population Health Professional Shortage Areas (HPSAs); two of these are
designated high needs geographic HPSAs, six are low-income population HPSAs, and four
are Medicaid-eligible population HPSAs. About 48% of city residents live in a primary care
HPSA. Furthermore, about 75% of Baltimore residents live in a federally designated Medically
Underserved Area(MUA), which serves as the basis of eligibility for the federally qualified
health center (FQHC) and FQHC Look-Alike programs. (See box.)

While Baltimore residents experience many significant barriers to accessing primary care,
lack of health insurance coverage is not necessarily one of these barriers. As of 2020,
6.8% of Baltimore residents under age 65 did not have health insurance, a lower rate than
the national uninsured rate of 8.6%.?'2 This can likely be attributed to multiple factors,
including Maryland's decision to expand Medicaid under the Affordable Care Act (ACA) as
well as its support for policies to boost health insurance enrollment." In 2020, 32.3% of
noninstitutionalized Baltimore residents were enrolled in Medicaid or the Children's Health
Insurance Program (CHIP), while 59.1% had private insurance."4

Key Stakeholders

A significant number of state and local entities play a role in the provision of primary care
services to Baltimore residents.

Governmental Agencies

The Maryland Department of Health js divided into multiple offices, some of which are
tasked with managing primary care-related initiatives throughout the state. The Office of
Population Health Improvement (OPHI), within the Department of Health, uses data, fed-
eral and state funds, and partnerships with other stakeholders to oversee and implement a
number of primary care-related programs." The offices under the OPHI umbrella include the
Primary Care Office, the Office of Workforce Development, the Office of School Health, and
the state Community Health Worker (CHW) program.

¢ The Primary Care Office consists of two staff members and is funded solely by the
Bureau of Health Workforce within the Health Resources and Services Administration
(HRSA) to produce a primary care needs assessment (most recently published in 2021),2"
designate primary care HPSAs in Maryland, administer federal HRSA programs such as
the National Health Service Corps(NHSC) in Maryland, and provide technical assistance
to FQHCs and other primary care organizations serving underserved communities."

¢ The Office of Workforce Development receives federal and state workforce development
funds to bolster the health care workforce in high-need areas, including Baltimore City,
through programs such as the State Loan Repayment Program (which is funded by both
the federal and state governments), the Maryland Loan Assistance Repayment Program
(fully funded by the state), the Conrad 30(U-1 Visa Waiver) Program, and the Preceptor
Tax Credit Program (which provides tax credits for certain health care providers who
oversee and mentor trainees)."°

Milbank Memorial Fund « www.milbank.org 7
e The Office of School Health works with the Maryland Department of Education to devel-
op standards for and to evaluate health services provided by school nurses.*" The school
nursing program is separate from the school-based health center program, which is
currently run through the Maryland Department of Education*'but will be transferred to
the Bureau of Maternal and Child Health at the Maryland Department of Health.*2

¢ Beginning in 2019, OPHI also oversees the certification of individual CHWs and the
accreditation of CHW training programs, receiving guidance from the State Community
Health Worker Advisory Committee.

The Total Cost of Care Model

In 1971, the Maryland legislature enacted a law regulating commercial hospital re-
imbursement rates; in 1977 the state's authority was expanded to include Medicare
and Medicaid rates, resulting in an all-payer rate setting system. The state's Health
Services Cost Review Commission was established as an independent agency to
establish hospital rates with the goal of containing costs while improving access to
care, health equity, financial stability, and hospital accountability. The commis-
sion's authority applies to inpatient services and outpatient services provided at a
hospital or on the campus of a hospital.

In 2014, the Centers for Medicare & Medicaid Services entered into a new agree-
ment with Maryland called the All Payer Model (APM) with the goal of moving
Maryland hospitals to a global budgeting system while monitoring key quality

and utilization measures. Although the APM succeeded in improving quality and
decreasing the growth in hospital costs, its effects were limited to hospitals, and it
did not provide for coordination across the entire health care system. In 2019, the
APM transitioned to the Total Cost of Care (TCOC) model encompassing all the
health care that patients receive, whether in a hospital or in the community.® The
TCOC model emphasizes care coordination, team-based care, primary care, and
population health improvement. Under its agreement with the federal government,
Maryland is required to save $300 million in annual Medicare spending by the end
of 2023.

Housed under the Maryland Department of Health, the Maryland Primary Care
Program (MDPCP) is a key component of the TCOC model. MDPCP is a volun-
tary program open to all primary care practices and FQHCs in the state.* It pro-
vides funding and support for practices to transform to a team-based, coordinated
primary care model and allows PCPs to play an enhanced role in the prevention
and management of chronic diseases. One of the five MDPCP transformation areas
is focused on lowering barriers to care, specifically by expanding office hours. Four
million Marylanders (two-thirds of the state) receive primary care from the 476
practices participating in MDPCP, which pays them about $150 million in fees to
fund these practice transformation activities. Fifty primary care practices and three
FQHCs in Baltimore City are part of this program.

Milbank Memorial Fund « www.milbank.org 8
The Community Health Resources Commission (CHRC) is a quasi-independent commission
established in 2005 under the Maryland Department of Health that provides grant funding
to help community-based groups expand access to health care resources and foster health
equity in underserved areas of the state." Since its inception, the CHRC has provided about
$119 million in funding to about 665 organizations. In 2022, it awarded $13.5 million to nine
grantees under the "Pathways to Health Equity" established as part of the Maryland Health
Equity Resource Act. Three of the nine grants work directly to reduce health disparities in
Baltimore City.

In Baltimore, the Baltimore City Health Department (BCHD) serves as a central hub for many
public health initiatives, including expanding access to primary care. While BCHD does not
directly provide primary care, it operates two clinics that provide basic reproductive health,
dental, and immunization services. Further, BCHD oversees programs that help improve ac-
cess to primary care, such as the provision of nonemergency medical transportation services
for Medicaid beneficiaries, school nursing services, and maternal and child health services."
BCHD also runs the city's Local Health Improvement Coalition (LHIC), a state-mandated
coalition that brings together stakeholders including hospitals, community-based organi-
zations, and FQHCs to develop a population health framework across the city. The Baltimore
LHIC is currently focusing on three issue areas: diabetes management, social determinants
of health, and care coordination."

Primary Care Providers

e Fourteen private and two Veterans Affairs hospitals operate within Baltimore City, and
multiple hospital systems have affiliated outpatient clinics that provide primary care."
For example, Johns Hopkins University operates clinics both on its Baltimore City
hospital campuses and through its affiliated Johns Hopkins Community Physicians, a
physician group providing primary care across the state including three clinics in
Baltimore City (a fourth clinic transitioned into an FQHC in 2020).** MedStar Health runs
seven primary care clinics,"* and University of Maryland Medical Center operates one
family medicine clinic in Baltimore.*®

e There are six FOHC systems in Baltimore,"* running 24 service delivery sites in the city
and a mobile van.*' Baltimore Medical System is the largest FOHC in Maryland, serving
over 50,000 patients in the Baltimore area each year."®

¢ There are 17 school-based health centers (SBHCs) currently operating in Baltimore City
schools. Eight of them are operated by Baltimore Medical System, seven by the Baltimore
City Health Department, and one by the Rales Center, which is a part of Johns Hopkins
School of Medicine.*®

e Free clinies including the Esperanza Center and Shepherd's Clinic provide primary care
for low-income or uninsured Baltimore residents.

Milbank Memorial Fund « www.milbank.org 9
Nongovernmental Organizations

e Health Care Access Maryland (HCAM) is a nonprofit organization that helps uninsured
and underinsured residents enroll in both public and ACA marketplace health insurance
plans. HCAM also provides care coordination services to help insured residents better
understand and use their Medicaid benefits.

¢ Central Maryland Area Health Education Center (CMAHEC) is part of the federal
Area Health Education Center program established in 1972 to improve recruitment and
retention of PCPs in medically underserved areas. Located within the University of
Maryland School of Medicine, CMAHEC is one of three Area Health Education Centers
in the state, and its operations extend to six counties and Baltimore City.°' CMAHEC
organizes rotations in underserved areas for health professions students, trains CHWs,
conducts continuing education programs, and engages in some community health inter-
vention programs.®

Methodology

To better understand how the efforts of the various stakeholders to improve primary

care access for underserved Baltimore residents have fared, we conducted 16 qualitative
interviews with local PCPs, local and state officials, advocates, and experts with close ties
to Baltimore and knowledge of the primary care landscape in the city. Interviews occurred
between March 14 and May 18, 2022.

DESCRIPTIVE ANALYSIS AND FINDINGS
1. Availability of Primary Care Clinicians

There Is a Shortage of Primary Care Providers Who Serve Underserved
Populations

One public health official observed that although the many renowned and large medical
institutions in the city generate a multitude of providers, there is a significant shortage of
PCPs who accept Medicaid and treat low-income patients in Baltimore. The PCPs that do
practice in the city are not equally distributed: certain neighborhoods have no full-time PCPs,
some neighborhoods have one PCP for tens of thousands of people, and other neighborhoods
have one PCP for every 20 or so people.** While one PCP for every 2,500 patients is seen

as an ideal ratio by some, there is evidence that this might still be too many patients per
practitioner.™

Furthermore, according to a public health official, all of the areas in the city designated as
experiencing a provider shortage have shown a further decrease in the number of PCPs in
recent years. As a result, existing shortage designations have been expanded to apply to
broader swathes of underserved populations.

One stakeholder who coordinates a program that connects emergency room patients with

a PCP stated that "it is a struggle every day [to find a PCP ]." Another stakeholder who helps
low-income patients connect with health care found that Medicaid enrollees experienced
wait times of at least four weeks for initial primary care appointments, which they consider to
be excessive for this patient population.

Milbank Memorial Fund « www.milbank.org 10
Some stakeholders blamed burnout from the COVID-19 pandemic for the loss of providers.
At the same time, as one state-level policy advocate put it, "Maryland is a huge exporter of
medical professionals." Many medical students and residents who come to train in renowned
medical schools and hospitals have no ties to the region and do not stay there. Stakeholders
found that recruitment can be a particular challenge for FOHCs given their lower levels of
compensation, but once physicians are recruited, turnover is relatively low because these
physicians are generally more mission driven. FQHCs that have ties with medical residency
programs have also had some success recruiting from them.

Multiple stakeholders also expressed concern about the turnover and vacancies among
support staff such as "medical assistants and front desk staff" because of the pandemic and
the stress it has placed on them. Many have chosen to leave the health care field altogether.
The lack of support staff can be disruptive and diminish the patient experience, and it can
add to provider burnout and negatively affect the retention of PCPs in the long run. One FOHC,
where a decision was made a few years ago to pay support staff a higher wage than other
FOHCs paid, has been able to weather these shortages somewhat better as a result.

State Programs to Improve Recruitment and Retention Have Been Successful,
But the Scale of Programs Is Insufficient

Between the Primary Care Office and the Office of force Development, the Maryland Office of
Population Health Improvement manages a number of programs to develop the primary care
force practicing in underserved areas:

¢ Federally funded National Health Service Corps(NHSC) scholarship and loan assistance
programs place primary care, dental, and mental health clinicians in sites with workforce
needs. As of 2021, 83 service sites in Baltimore were eligible to receive NHSC providers,
and the city had 45 active NHSC primary care providers (12 physicians, 29 nurse practi-
tioners, and four certified nurse midwives).

¢ The Maryland Loan Assistance Repayment Program (MLARP) is fully funded by the state
and is available for both physicians and PAs. The State Loan Repayment Program (SLRP)
is funded by federal government and requires the state to match federal funds. SLRP is
applicable to both physicians and physician assistants (PAs) working in primary care or
mental health.

In FY2022, there are 6 MLARP-only recipients in Baltimore, and one of them practices
primary care. In FY2022, there are four recipients of both SLRP and MLARP funding in
Baltimore, and all of them practice primary care.

e« The J-1visa waiver program is a federal-state collaboration that eases certain immigra-
tion restrictions on foreign-trained physicians in return for a three-year commitment to
practice in an approved underserved area. Each state can request up to 30 waivers per
year, and since 2016, Maryland has annually obtained waivers for at least 29 physicians in
both primary care and specialty services. This program has become more competitive
every year. In FY2022, there are 46 J-1 physicians practicing in Baltimore.

Milbank Memorial Fund « www.milbank.org Nl
e The preceptor tax credit program is a state-funded program that gives state income tax
credits to physicians, nurse practitioners, and physician assistants who mentor students
and trainees at in certain programs in underserved areas of the state. In FY2022, the
state approved a total of 123 credits (32 for physicians, 77 for nurse practitioners, and 14
for physician assistants across the state).

These programs are better at filling a few key workforce gaps and are limited in their ability
to broadly expand the primary care workforce. One public health official characterized these
programs as "very successful' at recruiting and retaining providers but found that the city's
needs far exceed the supply of clinicians generated through these programs. The scale of
these programs is small, and the providers enrolled in these programs make up less than
10% of all primary care providers in the state. One FOHC stakeholder found that while these
programs used to give safety net providers like FOHCs "an edge" in recruitment a few years
ago, now the effect is diluted because there are so many sites and few program recipients.
Further, the majority of J-1 visa waiver recipients are specialists or focus on inpatient care
instead of primary care. Practice sites are often hospitals, which tend to have the necessary
resources to hire immigration attorneys to help these physicians and their families gain
citizenship, and they choose to expend these resources on specialists over primary care
physicians.

Another problem is the lack of a recent assessment of how many clinicians who enrolled in
these state-level programs are continuing to serve underserved populations in Maryland.
According to a public health official, a 15-year-old assessment found that about 70% of them
stayed in Maryland, but the assessment did not look into whether the clinicians were still
seeing Medicare and Medicaid populations in underserved areas. Efforts to track providers
in 2012 could not be kept up because of the lack of staff and money. Recently, in an effort to
improve these data gathering efforts, Maryland became one of the 30 states® participating
in a national collaborative to better gather and manage this kind of provider retention data
(3RNET's Provider Retention & Information System Management, or PRISM).®

Potential Long-Term Impact of MOPCP on Improving Primary Care Access for
Medicaid and Low-Income Populations

While it is not a traditional workforce development program, in the long run, the MPCP could
potentially increase the number of PCPs, particularly those serving Medicaid enrollees and
other underserved populations. First, the program provides significant funding and other
operational support to primary care practices as they transition to team-based, coordinated
care. This can increase earnings for PCPs(practices in the program can make up to twice
what they would if they were serving on a fee-for-service basis). The program also has the
potential to reduce administrative burdens,*' making the field more attractive to medical
trainees. However, at least one stakeholder involved in primary care delivery found that
participation in MDPCP had not yet resulted in the reduction of any administrative burdens.
Second, MDPCP provides enhanced payments for PCPs who practice in high-need areas,

in the hope that this will create incentives for more PCPs to serve these areas. Third, a
condition for participation in MDPCP is that practices have to be open to accepting new

Milbank Memorial Fund « www.milbank.org 12
patients. While MDPCP does not have much enforcement authority to ensure practices are
accepting new patients, one official found that making it a condition of participation can
still help increase access. However, it is important to note that it might be difficult to fully
understand how much MDPCP ends up impacting access, because the program does not
directly evaluate participants on access measures that can capture the above gains.

Worry about Broader Trends for Careers in Primary Care

While not specific to Maryland or Baltimore City, several stakeholders brought up broader
concerns with how the medical field trains, values, and treats PCPs. One provider found that
primary care is not given the same importance as other specialized fields. For example, it

is "very hard to get promoted and get tenure in primary care," and only about 1% of federal
research funding goes to primary care.®® PCPs also often make significantly less money than
their specialist counterparts.®® One primary care clinician and professor worried that this

pay gap prevents those without the privilege of accumulated wealth, as may be the case for
students from communities underrepresented in medicine, from pursuing primary care.
They also found that this lower level of reimbursement signals "lower relative value of primary
care work," and that talented medical students are frequently told that they are "too smart
for primary care" in both direct and indirect ways. Ina city like Baltimore, with its renowned
medical institutions and high-stakes medical research, the draw of specialty medicine can be
even more pronounced.

Finally, several stakeholders raised an alarm about the "workforce crisis in primary care"
because of provider burnout. One primary care clinician and residency program director said
that while doctors who deliver hospital-based services rarely have to handle calls to insurers
about medical management issues themselves, PCPs frequently have to place these calls
themselves. Several stakeholders pointed to the significant amount of after-hours work

like responding to messages and handling medical notes that receives no reimbursement
and adds to the burnout. Many PCPs who work with high-need populations in Baltimore
experience additional stress from working with diminished resources and not always being
able to connect their patients to help with respect to social determinants of health like food
and housing.

Even When NPs and PAs Face No State-Level Restrictions on Scope of Practice,
Federal Barriers Create Issues

Maryland does not limit NPs and PAs in terms of their ability to treat patients independently,
but one NP we spoke to expressed frustrations about gaps in federal laws that impact their
ability to fully do their job. They offered two examples. First, under federal law, NPs can only
prescribe medication-assisted treatment for substance use disorders to a 100 patients

at atime compared to physicians, who can potentially go up to 275 patients at a time.

In one Baltimore practice where only NPs hold the necessary permission to write these
prescriptions, the NPs are quickly reaching their limit. Second, NPs expressed frustration
that Medicare rules require a physician to sign off on certain supplies for patients with
diabetes. This rule requires extra patient visits at a clinic where appointments are already
hard to come by. While the federal government has made some attempts to fix this issue,
the NP reports that there are still access problems.

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Local Program Highlights: The Urban
Health Residency Program's Successes
in Recruitment and Retention

Johns Hopkins University runs two Urban
Health Residency Program-a combined
internal medicine-pediatrics program and
a primary care track internal medicine
program-that are based out of a local
FQHC. Over 90% of the graduates of these
program have stayed in primary care, and

about 75% of them have stayed in Baltimore.

Program officials attribute success in
retaining students in primary care to (1)
their rigorous interview process to ensure
they are picking people who are committed
to primary care, (2) building a community
around these residents that fosters their
interest in primary care, (3) focusing on the
wellness of their residents, and (4) giving
them an enjoyable primary care experience.
Being a part of an FQHC has served as a
draw in terms of recruiting residents who
are interested in the mission of urban health
for underserved populations. The residency
programs were also able to make strides in
recruiting residents underrepresented in
medicine by creating an associate program
director position dedicated to diversity,
equity, and inclusion to help recruit these
residents and support them once they are
in the program. As a result, in recent years,
about half the class of residents has been
made up of those who are underrepresented
in medicine.

2. Improving Access to
Outpatient Clinics for Un-
derserved Communities

FQHCs Are a Vital Safety Net

Provider and Rely on State and

Federal Support

FQHCs are community health clinics
that primarily serve underserved
communities with high rates of
uninsured and Medicaid-, CHIP-, and
Medicare-eligible individuals.®? They
receive federal grants to provide no-
or low-cost primary care services,

and they are also eligible to receive
enhanced payments for services
provided to patients covered under
Medicare, Medicaid, and CHIP.
Baltimore City is home to six FOHC
systems running 33 safety net sites
(eight of these are SBHCs, and one is

a mobile van) serving about 140,000
patients. On average, close to 90% of
the patients receiving FOHC services
are either uninsured or covered under
Medicare, Medicaid, or CHIP, and
almost all are at or below 200% of the
federal poverty level. Combined, these
FQHCs see about 65% of the estimated
213,000 people in the city who are at
or below 200% of the federal poverty
level, which makes these clinics the
predominant source of health care

for the low-income population in
Baltimore.

According to FOHC stakeholders, both federal and state government funding have been
essential in allowing FOHCs to serve as safety net providers for high-need populations.
Maryland's decision in 2014 to expand Medicaid also served as a financial boon to FOHCs.

As one FQHC clinician observed, the increase in Medicaid-covered patients led to a "very
large expansion of staff and services, both in depth and breadth." One FQHC stakeholder
said that today a full third of the center's revenue comes from billing Medicaid and Medicare,
while a stakeholder at another FOHC said that "the bulk of its revenue" comes from billing

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these public insurers. However, gaps remain in the services eligible for Medicaid and CHIP
reimbursement. For example, FOQHC officials noted that CHW services and other services to
assist this complex patient population with social determinants of health are generally not
covered.

The state also provides capital grants to FOHCs for purchasing or expanding buildings and
equipment.® Further, MDPCP started allowing FQHCs to join the program in 2022, and so far
three of the six FOHC systems in the city have joined. These FQHCs are eligible for targeted
care management payments and access to organizations that provide technical assistance
while they transition toward more team-based and population health-centric primary care.

Successes and Challenges of a University Hospital-Affiliated Clinic Converting
to an FOHC

One large university hospital that ran a primary care clinic in Baltimore found that, despite
heavy investments, they were unable to sustainably provide the necessary resources to
meet the high needs of the communities they served. The university hospital consequently
partnered with an existing FOHC system and converted its primary care clinic into an FQHC.
While the clinic is now officially a part of the FQHC system, the university hospital continues
to supply physicians to the clinic, run a primary care residency program at the site, and
provide additional funding to the clinic. While this conversion is recent, some early indicators
suggest that it is helping expand access to underserved communities. The clinic now sees
a higher proportion of uninsured patients and now sees patients enrolled in all the Medicaid
managed care organizations (MCOs), whereas it used to contract with only one Medicaid
MCO. The clinic used some of the additional revenue it received from converting to an FQHC
to hire additional staff, including case managers, two CHWs, and an additional primary care
physician.

In addition, a natural symbiosis can occur when FOQHCs house primary care residency
programs. One residency program director found that having their residents practice at
an FQHC was a huge recruitment incentive, and the residents really valued the experience.
In return, one FOHC was able to recruit from the pool of residents in training at its clinics.
Partnerships like these can create a sustainable pipeline of providers, with positive
downstream effects on access to primary care.

However, some residency program faculty members expressed concerns about whether

the goals of teaching and research, particularly of a university hospital-affiliated residency
program, can work harmoniously with the clinical goals of an FOHC. One stakeholder familiar
with the conversion of the university hospital-based clinic to an FQHC said that it took a lot
of work on the part of both the university hospital and the FQHC system to ensure that the
residency program at the converted clinic continued to achieve its sometimes disparate
goals.

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The Role of Hospitals in the Delivery of Primary Care in Baltimore

Every hospital in Baltimore runs or is affiliated with at least one primary care clinic. Some
clinics operate directly on the hospital campus while others are located in the community.
Maryland's unique TCOC model is expected to create incentives for hospitals to invest more
in outpatient primary care in order to improve population health and reduce utilization of
inpatient services and the total cost of health care. Hospitals retain any cost savings they are
able to generate. One hospital stakeholder mentioned that the hospital used funds received
under the TCOC model to "expand home-based primary care and to better serve high-needs
pockets." While some hospitals might have already started down this path, the TCOC model
does not currently require hospitals to invest any savings they generate under the model
into primary care for underserved areas. One stakeholder familiar with the primary care
landscape in the city said they have seen hospitals invest in community-based organizations
targeting social determinants of health, but there has been no notable investment in
improving access to primary care.

The agency that oversees the implementation of the TCOC model is developing requirements
for hospitals to reinvest saved revenue in (1) community initiatives and/or (2) primary care,
mental health care, and dental care in a designated underserved area. One local stakeholder
said that it willbe important for these upcoming requirements to be more prescriptive

and include the input of those familiar with local population health needs. The stakeholder
worried that without more direction, every hospital would independently decide how to
reinvest its savings, which could make it difficult to coordinate and achieve population health
goals. Likewise, one stakeholder worried that without local community, provider, and health
department input on requirements for hospital investment, this effort to improve population
health outcomes would end up being piecemeal and ineffective.

As part of the TCOC model, the State of Maryland has a contract with the federal government
committing to save the Medicare program about $300 million by 2023. The state will then
get to keep these savings for reinvestment into its health care system. Those familiar with
the state's efforts on this front worried about the lack of centralized planning in developing a
strategy for deploying this money.

The SBHC Model Is Stalled Because of Lack of Funding and Regulatory Barriers

School-based health centers (SBHCs) help children from underserved areas and their families
overcome barriers to primary care such as lack of transportation, inability of parents to

get time off from work, and unaffordability.°*SBHCs are separate from school nurses, who
generally provide acute care for injuries and illnesses, help with chronic health conditions,
and screen for health problems, but do not diagnose and treat illness."° SBHCs, on the other
hand, have at least one PCP, such as a pediatrician, nurse practitioner, or physician assistant,
who can diagnose and treat children." According to one policy expert, "SBHCs are considered
an enhancement to school health services," and ideally an SBHC would be well integrated with
a robust school nursing program, but both programs are underfunded in Baltimore.

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Only 17 of the 167 schools in the city have an SBHC,"" and all but two of these are run by the
largest FOHC system in the city, Baltimore Medical System. About 70% of SBHCs in the state
are run by FQHCs, and according to one local school health expert, the partnership between
the two entities can have many advantages. SBHCs tied to FOHCs can bill Medicaid and CHIP
for services provided to the children, and FOHCs that want to establish or expand SBHCs can
take advantage of federal grants to do so."

Despite the benefits of being sponsored by an FQHC, direct funding for SBHCs in Baltimore
City is limited. First, until recently, the state allocated only $2.4 million (recently increased
to $9 million)" to fund the 90 SBHCs throughout the state," and on average, these funds
covered only about a third of the total costs of SBHCs." A 2018 report found that Maryland has
significantly less state-level funding for SBHCs than other states with similarly sized SBHC
programs." The recent increase to $9 million is a step in the right direction, but according to
an SBHC policy expert, this amount is still not sufficient when split between the 90 SBHCs.
While Baltimore City does have a $22 million line item for school health, it is unclear how
much of this funding is specifically for SBHCs because this line item also includes the school
nursing program and several other non-SBHC-related school health funding needs.® One
SBHC provider said SBHCs tend to run at a loss because they provide services to uninsured
children as well as services they cannot bill for (attending school meetings, providing care
coordination, and taking care of nonmedical wellness needs of the children they serve).

Aside from worries about funding, regulatory and administrative barriers have made it
difficult to establish new SBHCs. SBHCs have to comply with state rules for SBHCs (even if
they are not seeking state funding), follow any relevant state loan repayment program rules
(if hiring someone through the program), and coordinate with the local health department.
While one public health official found that these steps were necessary to balance the
interests of safety with that of increasing access to primary care, a local SBHC policy expert
found that the documentation required to start an SBHC can rival or even surpass the
documentation required for other types of health centers and clinics. While recent legislation
expanded the types of SBHC sponsors that can bill Medicaid, historically only SBHCs
sponsored by FQHCs, local health departments, and nonhospital outpatient clinics could bill
Medicaid;®' this barrier prevented the hospital systems in the city from establishing SBHCs.

Finally, one SBHC policy expert pointed out that the lack of data about the cost of running an
SBHC, particularly when the funding for school nursing and SBHCs bleeds together, makes

it difficult to advocate for more funding. They found that a lack of city-level strategy for the
deployment of SBHCs might be why Baltimore has not seen a significant expansion in the
number of SBHCs in many years.

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Local Program Highlights: The Success
and Scalability of the Rales Center
Model

The Rales Center, a part of the Johns
Hopkins Children's Center, was established
in 2014 to establish, operate, and evaluate a
comprehensive model of school health. The
resulting SBHC was launched in 2015, and
today some stakeholders refer to it as the
"Cadillac of the SBHC model." This SBHC
serves almost 1,600 students in the largest
elementary/middle school in city, and 99%
of its students identify as US-born African
American. More than 80% of the students
are eligible for reduced-price or free meals
and are insured by Medicaid. The students
of this school had high rates of several
health conditions. For example, about 36%
have asthma, which is about twice the state
level. In a 2021 evaluation, the Rales Center
reported that its SBHC was able to avert

an estimated 263 ambulance transports
and emergency room visits due to asthma
exacerbations. After four years, the center
was able to reduce SBHC utilization by
23% "due to a substantial decrease in acute
asthma visits.®

While one SBHC policy expert said that
they did not necessarily believe that every
school needs a model as comprehensive as
the Rales model, they thought that many
schools serving similar student bodies
could benefit from such a model. According
to the Rales Center, SBHCs like the one

it established are unlikely to be sustained
by billing revenue alone, and will require
additional public and private funding, such
as state and local public funds, and support
from hospitals and payors."

5. Removing Structural
Barriers to Primary Care
State and Local Efforts Improve
Access to Telehealth, But It Is a

Work in Progress

The pandemic has changed the way
providers and patients think about
telehealth. One patient advocate found
that during the pandemic, the increase
in telehealth reimbursement and
loosening of regulatory barriers helped
patients overcome barriers related to
transportation, work hours, and child
care.

In 2019, the first year that MDPCP

was implemented, only about 30%

of enrolled practices regularly used
telehealth, but during the pandemic,
MDPCP collaborated with external
funders and the state medical society
to provide free telehealth platforms

to every practice in the program.
Within a month, 99% of practices had
fully implemented telehealth. MDPCP
also provided technical assistance to
practices on working with patients who
found the technology to be challenging.
One FQHC stakeholder said that they
were able to ramp up to 50% telehealth
within three to four weeks of the start
of the pandemic.

At the city level, the Baltimore City
Health Department partners with
MedStar to run a telehealth program
focused on senior centers. When
patients come to the senior center,
program staff help them navigate
the telehealth technology. One public
health official found that the program

worked well particularly because it was set in a location that residents were already visiting
to get their blood pressure and other vital signs checked. This helped them feel more
comfortable than if they attempted to log in by themselves.

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During the pandemic, Baltimore City Public Schools (BCPS) partnered with a health care
technology company, K Health, to provide access to telehealth services through a mobile
application (app) for students and their families for a full calendar year. The program
generated about 900 visits (about 80,000 students are enrolled in BCPS) and was mostly
used by Medicaid recipients and undocumented immigrants. About a third of those who used
the app decided to purchase a primary care membership once the free year was up because
they found the app to be alot easier, more accessible, and more affordable' than traditional
primary care. The fact that some Medicaid enrollees were willing to pay for an app to access
primary care that should have already been available to them under their Medicaid plan raises
concerns about the lack of access to primary care under Medicaid. However, because this
program was a very small-scale intervention in terms of the proportion of BCPS students
enrolled and the free services lasted only a year, it is unclear how much impact programs like
these can have on a larger scale.

Despite state and local efforts, one state official described making telehealth accessible

to underserved communities as a "work in progress." While broadband access is often seen
as more of a challenge in rural places than in urban areas, broadband access is limited in
Baltimore. The mayor has hired a digital equity coordinator to help provide better broadband
access across the city. BCHD will be part of this effort by extending broadband to senior
centers that did not have access before, enabling the many low-income seniors in the city
who lack a smartphone or Wi-Fi to access telehealth services.

Transportation Is a Major Barrier, But Several Providers Have Mobilized to
Overcome It

Multiple stakeholders cited a lack of affordable, accessible transportation as one of the most
significant barriers that underserved Baltimore City residents face in accessing primary care
services. Though FOHCs and similar providers in a large city like Baltimore are often located
near bus routes, one stakeholder noted that a patient may have to take two or three different
buses to reach aclinic. Both cost and travel time were highlighted as barriers to the use of
public transportation to the use of public transportation.

BCHD and some providers deploy a variety of strategies to alleviate transportation barriers.
BCHD operates a nonemergency medical transportation service for Medicaid beneficiaries
that is fully paid for by Medicaid, but the service has several limitations. First, to qualify,
patients often need a doctor's note showing medical need. Patients cannot access this
service just because they are unable to afford other transportation. Second, parents who
have medical appointments cannot bring their children with them. Third, the service needs
to be scheduled a day in advance, and according to a patient advocate, it is not a door-to-
door experience. Finally, the service is limited to Medicaid enrollees and is not available to
uninsured people or those with other types of insurance.

Some local providers offer their own subsidies for public transportation and access to
ride-sharing platforms. For example, one provider contracts with Uber Health to transport
patients to their primary care appointments. Some PCPs use the additional payments they

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receive from MDPCP for serving populations with higher needs to provide ride-sharing
vouchers. Further, multiple providers mentioned helping patients fill out any necessary forms
to get access to public transportation subsidies.

Mobile clinics can also help improve access. During the COVID-19 pandemic, mobile
clinics provided COVID-19 tests and vaccinations, and one provider expressed hope that
their organization would continue to use its mobile vaccination clinic after the pandemic
to provide a broader set of services. However, a provider stakeholder with a long-standing
mobile clinic explained that mobile clinics have their own challenges. For example, they
generally must partner with a brick-and-mortar location, such as a soup kitchen or shelter,
where they can ensure their staff has access to bathroom facilities.

Difficulties in Finding Primary Care Outside of 9 to 5

Multiple stakeholders referenced the importance of offering after-hours care for the
Baltimore residents they serve, the majority of whom may not "have the leisure of...paid time
off requests' to go to a primary care appointment. In response, safety net providers have
tried to orient their clinical schedules around patients' needs. While federal rules require
FQHCs to offer emergency care after hours, some FQHCs in Baltimore offer regular primary
care appointments outside of the traditional 9-to-5 window. Primary care practices enrolled
in MDPCP are also encouraged to expand access to care by expanding their hours. However,
according to providers and patient advocates, these efforts come nowhere close to meeting
the demand for after-hours appointments given the general shortage of PCPs and staff. One
provider finds that they cannot ask their staff to work extended hours, because many of them
are single parents.

4. Making Primary Care More Affordable
State Decisions Have Helped People Get and Use Health Insurance Coverage

One patient advocate identified lack of insurance coverage as the number one obstacle to
primary care they have seen over the years. They found that the ACA was instrumental in
reducing Maryland's uninsured rate from 13%* to 7%.* They also credited other state policy
decisions in achieving these coverage gains. In 2019, the state legislature passed legislation
establishing the Maryland Easy Enrollment Health Insurance Program,® which allows people
to opt into insurance enrollment while filing their tax return. While enrollment increases

in the program's first year were modest, it produced important gains among low-income
working adults, who make up a disproportionate share of the uninsured.® In 2021, the state
enacted a law to provide insurance subsidies for low-income young adults age 18 to 34 and
budgeted $20 million for these subsidies.®° Because this age group is the most likely to be
uninsured, this policy serves the dual purpose of increasing the number of people enrolled

in insurance plans and drawing young people into the risk pool, which ends up lowering
health insurance costs for everyone." While it is too soon to fully assess the success of this
initiative, enrollment by young adults increased 6% during the 2022 open enrollment period.
These programs suggest that reducing enrollment barriers and lowering premiums can drive
up enrollment in health insurance, which in turn helps make primary care more affordable.

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Stakeholders familiar with insurance issues said that before the ACA was enacted, confusion
about how to use health insurance prevented people from accessing necessary care. Today,
they find that the state has "one of the best [ACA marketplace] staffs in the country" and

that the health insurance marketplace (Maryland Health Connection) staff help enrollees

get the most out of their coverage. In Medicaid, the Maryland Department of Health funds
organizations to help Medicaid beneficiaries better understand and use their coverage.

One of these organizations relies on CHWs to handle routine education and navigation. One
patient advocate found that while these organizations "make Medicaid MCOs look good," they
are exclusively government supported. They argue that requiring MCOs to contribute some of
their funding could help these organizations increase the scope and scale of their services.

Some Gaps in Affordability Remain

Despite all these coverage gains, undocumented immigrants are barred from Medicaid or
subsidized marketplace insurance. Undocumented immigrants can use FQHCs and other
safety net providers and take advantage of sliding-scale fees based on their income, but
patient advocates have found that worry over documentation and immigration enforcement
can be barriers to seeking critical primary care services. One patient advocate mentioned
that one insurer has a program that provides very low-cost health coverage specifically

to people who are otherwise ineligible for coverage. While they found this program to be
immensely helpful, this year only approximately 100 slots were available to them, which is far
less than what is needed.

5. Improving Comfort and Communication between Providers
and Patients

The State Is Making an Effort to Support CHWs through Certification, But

Barriers Persist

A CHW is a "frontline public health worker who is a trusted member of, or has an unusually
close understanding of the community served. This trusting relationship enables a CHW

to serve as a liaison to, link to, or intermediary between health and social services and the
community to facilitate access to services and improve the quality and cultural competence
of service delivery." In 2018, the state legislature enabled the certification of CHWs and
accreditation of CHW training programs. Since then, the state has certified over a thousand
CHWs, about a third of whom work in Baltimore. Stakeholders find that there is a growing
interest in CHW certification based on the enthusiasm for renewals as well as the fact that
every week more people apply for their initial certifications.

To understand where certified CHWs are employed and how they are paid, the state
partnered with the University of Maryland to conduct a survey of CHWs and CHW employers.
The results are expected to be published soon. The survey could help identify what kinds

of metrics employers are using to evaluate CHWs' impact on their patients. MDPCP also
encourages its participating practices to use CHWs and finds that most of them do.
Practices apply the additional payments they receive from MDPCP for seeing patients in
high-need areas toward hiring CHWs. To fully integrate CHWs into care teams, one residency

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program director found that helping residents understand how to best leverage the skills
of CHWs can encourage them to better integrate their services into their practices in the
future.

One of the biggest barriers to more primary care practices incorporating CHWs is the lack of
funding. CHW services cannot be billed to Medicaid in Maryland, and one provider said that
they have to rely on grants to maintain CHW funding.

Providers Can Foster Cultural Competency in Their Practices and Connect with
Their Communities

Baltimore has been ranked the tenth most segregated city in America." This majority-
Black city scores the lowest in Maryland county-level rankings on critical population health
outcomes, such as prevalence of diabetes, heart failure, and asthma in young adults.®
Multiple stakeholders spoke about the need to hire and train providers who can provide
culturally sensitive primary care to the city's low-income Black and Latino communities.
One FOHC provider spoke about their meticulous hiring process, which includes a
behavioral interview, and said that interviewees "have to demonstrate a level of compassion
and sensitivity expected for a population that has so many challenges related to social
determinants of health." Another FOHC provider spoke about the importance of training
providers to speak with patients, not at patients, and to move from "this is my plan for you" to
"what's our plan together." Both stakeholders agreed that the implementation of anti-racist
tenets and practices needs to be intentional and built into the organization's culture.

Several providers argued that training for cultural competency must start early. One
residency program director reported that their program trains residents to look beyond
their patients' specific health concerns to other challenges they might be experiencing,
like food insecurity, eviction, bill collections, violence, and addiction. The residents of this
program are able to take advantage of support staff like CHWs, case managers, and other
community organizations to better help patients overcome these challenges. Residents and
other providers are also encouraged to participate in the local neighborhood association
and conduct community site visits to perform basic services like blood pressure checks
and health education. These efforts have gone a long way in establishing comfort and trust
between the residents and the patients they serve. The program director also noted that
diversifying the residency class can help gain the trust of the communities they serve.

Balancing Clinical Efficiency and Spending Time with Patients, and Where
Traditional Access Measures Might Fall Short

Appointment wait times are frequently seen as a handy measure for access, but the safety
net providers we spoke to expressed unease with the idea of weighting clinical efficiency
so highly over the need to take time to fully address the needs of their complex patient
population. Providers said that private practices are driven to see a high volume of patients
per day because they are paid on a fee-for-service basis, and FQHCs are driven to do the
same because of clinical efficiency goals. University- or hospital-affiliated clinics, on the
other hand, have less pressure to see as many patients because they receive financial

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support from the university or hospital. At least one FOHC that serves a particularly high-
need population expanded appointments from 15 to 30 minutes to better support the
complex needs of patients. They found that their providers are happier because they now
have more time to devote to each patient's specific needs, and this change has helped with
provider retention in the long term. One provider urged for the development of more nuanced
access measures that take these concerns into account.

6. A Lot of Independent Activity, But Not Enough Local Coordination

Primary care in Baltimore City involves a large number of FQHCs, many hospitals and their
affiliated clinics, a handful of free clinics, several state agencies, a couple of local agencies,
an assortment of insurers, and a number of community organizations. However, no forum
exists to bring together all these entities to plan for primary care delivery across the city. One
public health official said that the many hospitals and private practices in Baltimore are not
really obligated to communicate with the local health department or each other as they would
have to if they were one of only a few hospitals or clinics in a rural area. Another official said
that while most stakeholders in the city recognize the need for better access to public health,
they have differing ideas on how to achieve this. Some support the expansion of FQHCs, and
some want to focus on workforce development measures, while others think hospitals need
to provide better support for primary care. The official worried about the lack of a "greater
population health strategy."

Unfortunately, as one official put it, "public health has been underfunded for so long' that
there is no bandwidth or capacity to do the kind of convening and organizing work necessary
to develop and implement a cohesive primary care strategy. One provider pointed to the
Baltimore LHIC as an example of centralized coordination. The LHIC has developed a
diabetes regional partnership in the region, bringing together various providers, community
partners, state officials, and academic centers to "ramp up high-yield programs related to
reducing the incidence of diabetes." The role of the LHIC has waxed and waned with different
administrations in the city, but in the latest iteration, it has successfully convened "all of

the major players in one spot." However, the scape of the LHIC's work is narrowly drawn and
limited to specific projects for which it can obtain funding. The LHIC itself is not a funded
entity, which prevents it fram engaging in broader activities like population health planning.
Yet, one provider thinks that with the necessary funding, the LHIC could be a forum for
broadly discussing primary care and other population health needs.

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CONCLUSION

Baltimore is bustling with physicians, but unfortunately, residents in underserved areas of
the city continue to experience a significant lack of access to primary care providers. This
disconnect has many causes. First, while the city's many medical schools and residency
programs attract a significant number of trainees, they frequently tend to either leave the
area or specialize in something other than primary care. Second, the physicians who do
practice primary care in the city are concentrated in primarily white, higher-income areas,
leaving gaps in access for those living in primarily Black and low-income neighborhoods and
for those enrolled in Medicaid. Third, state-run workforce development programs have been
successful in recruitment and retention, but the scale of the programs is so small that they
have barely been able to move the needle in terms of improving access to primary care.

FOQHCs play an essential role in the delivery of primary care to the city's underserved
population, and they have been well supported by various state-level decisions like Medicaid
expansion and the capital grants program. However, this same level of support is lacking

for another type of safety net provider, SBHCs. SBHCs in the city have struggled to expand
and have stalled under lack of funding and significant regulatory burdens. Hospital- and
university-affiliated clinics sit in an interesting space within the city. Though they often see
low-income or Medicaid-eligible patients, teaching hospitals and universities have found it
challenging to sustainably run clinics that specifically cater to these patients, because they
tend to take on fewer patients than FQHCs and private practices to focus on other goals like
teaching and research.

Various providers and local stakeholders have embarked upon efforts to find ways to reduce
structural barriers to primary care through interventions like telehealth, but stakeholders
found that barriers like lack of broadband access or lack of smartphones still leave some
subpopulations without the ability to use it. Despite this dense urban city's better-than-
average public transportation system, almost all stakeholders found that a lack of affordable,
efficient transportation remains a barrier for underserved populations.

Maryland has, however, been very successful in terms of tackling at least one type of barrier
to access: coverage affordability. Maryland's decisions to expand Medicaid, establish an easy
enrollment process, provide subsidies for low-income young adults, and invest in community
organizations and partners who can help people enroll and use their coverage have all played
a role in keeping the uninsured rate low. That said, the inability of undocumented immigrants
to enroll in subsidized health insurance remains a major gap.

In terms of fostering communication and comfort between the provider and patient
communities, Maryland has taken the first steps to deploy CHWs by establishing formal
certification of CHWs as well as accreditation of CHW training programs. However, it still
needs to develop a sustainable financing model for their services. In addition to leveraging
CHWs, a number of providers also emphasized the need for training culturally sensitive
clinicians who can look beyond the immediate health needs of their patients and help
connect them with social services.

Milbank Memorial Fund « www.milbank.org 24
The innovative TCOC model and MDPCP both hold great promise in terms of improving the
landscape of primary care access in the state and in Baltimore. The TCOC model could
successfully create incentives for hospitals to invest more in upstream efforts to improve
population health, but they might be more likely to succeed in improving access to primary
care if they collaborate with local stakeholders to find an incentive structure that makes
sense for the community. The relatively new MDPCP has already recruited many primary care
practices in the state and supports their transformation into team-based and coordinated
care. While participation in this program does not directly require practices to expand the
population they serve, recently implemented incentives might help nudge practices toward
serving underserved populations.

Finally, a lot of independent activity occurring at the state and city levels affects access
to primary care in Baltimore, but there is insufficient funding to establish and sustain a
local forum where stakeholders can come together. Creating a space for local providers,
public health officials, and patient advocates to coordinate and plan for population health
and primary care goals on a citywide basis could help improve access to primary care for
underserved populations.

Milbank Memorial Fund « www.milbank.org 25
NOTES

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7Kona M, Houston M, Gooding N. The Effectiveness of Policies to Improve Primary Care
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Georgetown_6.pdf. Accessed February 18, 2022.

®Kona M, Houston M, Walsh-Alker E. Evaluating the Effectiveness of Policies to Improve
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3Kona M, Houston M, Clark J, Walsh-Alker E. Assessing the Effectiveness of Policies to
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June 13, 2022.

Milbank Memorial Fund »« www.milbank.org 26
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Milbank Memorial Fund »« www.milbank.org 27
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Milbank Memorial Fund »« www.milbank.org 28
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Milbank Memorial Fund »« www.milbank.org 29
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Milbank Memorial Fund « www.milbank.org 30
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Milbank Memorial Fund » www.milbank.org 31
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Milbank Memorial Fund »« www.milbank.org 32
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Milbank Memorial Fund »« www.milbank.org 33
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Milbank Memorial Fund « www.milbank.org 34
ABOUT THE ATHORS

Maanasa Kona, UD, is an assistant research professor and faculty member at the Georgetown
University McCourt School of Public Policy's Center on Health Insurance Reforms in
Washington D.C. Her current research addresses state-level regulation of private health
insurance and implementation of the Affordable Care Act.

Megan Houston, MPH, is a research fellow at the Georgetown University McCourt School of
Public Policy's Center on Health Insurance Reforms. Her research focuses on state efforts at
health care cost containment, and monitoring insurance reforms at the state and federal
level.

Jalisa Clark, MPH, is a research fellow at the Georgetown University McCourt School of
Public Policy's Center on Health Insurance Reforms in Washington D.C. Her research topics
include state measures to improve health equity and federal requirements for private health
insurance.

Emma Walsh-Alker is a research associate at the Georgetown University McCourt School of
Public Policy's Center on Health Insurance Reforms in Washington D.C. Her research
investigates policy developments that impact consumer access to affordable and
comprehensive private health insurance.

Milbank Memorial Fund »« www.milbank.org 35
About the Milbank Memorial Fund

The Milbank Memorial Fund is an endowed operating foundation that works to improve

the health of populations and health equity by collaborating with leaders and decision
makers and connecting them with experience and sound evidence. Founded in 1905, the
Fund engages in nonpartisan analysis, collaboration, and communication on significant
issues in health policy. It does this work by publishing high-quality, evidence-based reports,
books, and The Milbank Quarterly, a peer-reviewed journal of population health and health
policy; convening state health policy decision makers on issues they identify as important
to population health; and building communities of health policymakers to enhance their
effectiveness.

 

The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan
analysis, study, research, and communication on significant issues in health policy. In the Fund's
own publications, in reports, films, or books it publishes with other organizations, and in articles it
commissions for publication by other organizations, the Fund endeavors to maintain the highest
standards for accuracy and fairness. Statements by individual authors, however, do not necessarily
reflect opinions or factual determinations of the Fund.

© 2022 Milbank Memorial Fund. All rights reserved. This publication may be redistributed digitally for
noncommercial purposes only as long as it remains wholly intact, including this copyright notice and
disclaimer.

 

 

 

Milbank Memorial Fund
645 Madison Avenue
New York, NY 10022
www.milbank.org

Milbank Memorial Fund » www.milbank.org 36