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Ability of Community Health Centers to Obtain Mental Health Services for Uninsured Patients
To the Editor: Federally funded community health centers (CHCs) in 8 southeastern states provided comprehensive primary care services to 2.3 million patients in 2003. Forty-six percent of these patients are uninsured, 66% have family incomes below the federal poverty level, and 60.5% are ethnically African American, Hispanic, or Latino.1 Based on anecdotal reports of access problems, we conducted a survey to assess the ability of CHC clinicians to obtain specific mental health services for their uninsured patients.
Methods
The Southeast Regional Clinicians’ Network represents clinicians from all 146 federally funded CHCs in the southeastern United States. The National Center for Primary Care at Morehouse School of Medicine, Atlanta, Ga, is their academic partner for practice-based research. We faxed a 1-page survey to the medical director of each CHC; questions required a response of "yes," "no," or "I don’t know," and there was an opportunity for open-ended comments.
Results
Surveys were returned by 89 (61.0%) of the 146 CHCs. All 8 states in the region were represented (range, 6-19 responses per state). Settings and patient populations were similar between respondent and nonrespondent CHCs (67% vs 67% rural counties; 46.9% vs 46.6% uninsured, 29.9% vs 29.8% African American, and 12.2% vs 11.1% Hispanic/Latino patients in respondent vs nonrespondent CHCs, respectively).
Every respondent reported inability to obtain at least 1 mental health service for uninsured patients. Medications were generally perceived to be obtained more easily than behavioral therapies (Table), with selective serotonin reuptake inhibitor antidepressants more accessible (86.5%) than antipsychotics (52.8% for risperidone and 58.4% for phenothiazines). Most widely available among nonpharmacologic therapies by report were depression counseling (86.5%) and mental health counseling (83.1%); less common were psychotherapy (56.2%) and psychologist referral (64.8%). About 1 in 3 clinicians reported being able to refer uninsured patients for stress management, anger management, or grief counseling or to a domestic violence shelter. About 40% reported being able to obtain family therapy or group therapy.
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Table. Perception of Ability to Obtain Specific Mental Health Services for an Uninsured Patient by Medical Directors of Community Health Centers*
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Substance abuse treatment was reported to be more available, but only 64.0% of clinicians said that they could help an uninsured patient enroll in a detoxification program, and 66.3% believed they could obtain outpatient substance abuse rehabilitation services. About 40% felt that they could obtain relevant diagnostic tests such as formal psychological testing (38.2%), computed tomography (39.3%), or brain magnetic resonance imaging (37.1%). Access to a community mental health center for their patients was reported by 70.8%.
Comment
In these southern states, a significant proportion of safety-net primary care professionals report that mental health services are unavailable to their low-income, uninsured patients. The surgeon general’s report on mental health2-3 and the Institute of Medicine4-5 both state that low-income and/or ethnic minority patients face significant access barriers to mental health services and are often underdiagnosed and undertreated for mental health conditions.
There are some limitations of this study. Since these data were derived from a sample of medical directors of federally funded community health centers in 1 region of the United States, they may not represent the experience of all clinicians in these settings, in other safety-net organizations, or in other regions of the country. Perceived inability to find resources does not always mean that they are unavailable in the community; however, the perception of unavailability or inaccessibility may make it unlikely that appropriate referrals will be generated. Conversely, even if a clinician perceives that such services are available, he or she may not be consistently providing the appropriate mental health treatment, referrals, or follow-up. Nevertheless, we believe that our findings support the need for evaluating methods for linking safety-net primary care with community mental health and substance abuse programs, whether through referral linkages or mental health care professionals embedded within the primary care team.
George Rust, MD, MPH
RustG{at}msm.edu
Elvan Daniels, MD;
David Satcher, MD, PhD
National Center for Primary Care
Morehouse School of Medicine
Atlanta, Ga
Janice Bacon, MD
G. A. Carmichael Health Center
Canton, Miss
Harry Strothers, MD, MMM
Department of Family Medicine
Morehouse School of Medicine
Thomas Bornemann, EdD
Carter Center
Atlanta, Ga
1. Bureau of Primary Health Care. Section 330 Grantees Uniform Data System (UDS) Calendar Year 2003 Data, Region IV Roll-up Report. Available at: http://bphc.hrsa.gov/uds/data.htm. Accessed December 14, 2004.
2. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. 1999. Available at: http://www.surgeongeneral.gov/library/reports.htm. Accessed August 24, 2004.
3. Department of Health and Human Services. Mental Health, Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. 2001. Available at: http://www.surgeongeneral.gov/library/reports.htm. Accessed August 24, 2004.
4. Institute of Medicine. Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press; May 2002:5.
5. Institute of Medicine. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: National Academy Press; 2003:74-75. The Quality Chasm Series.
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2005;293:554-556.
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