How to Pay Your East Boston Neighborhood Health Center Medical Bills Online

THE PRIMARY CARE PRACTICE

East Boston is a large health center providing comprehensive primary care services to the population of East Boston. The relatively new three story building is open 24 hours a day, 7 days a week, for emergency care and provides an array of other services from 8:30 a.m. to 9:00 p.m. The health center services include adult medicine, pediatrics, adolescent medicine, obstetrics and gynecology, home care, dental care, social services, nutrition services, public health nursing, optometry and opthalmologoy, and laboratory and X-ray services. These services have been expanded over the 14 years of operation in response to identified community needs.

Anyone is welcome to register as a patient at East Boston and, except for walk-ins and emergencies, appointments are necessary. The number of visits to East Boston has almost doubled in six years, from 63,026 visits in FY 1977 to 121,747 in FY 1983, with the biggest increase being in adult medicine (8,690 to 29,112), home care ((2,427 to 8,062), and lab and radiology (1,332 to 6,481).

Both the East Boston staff and board of directors are concerned with providing high quality medical care efficiently. Patients are encouraged to contact anyone on the executive staff or on the board of directors if they feel their needs are not being met.

Organizationally, the community board is in the top administrative position. Immediately under the board are the medical director and the administrative director. (See .) They are coequal and split their work between programmatic medical issues/ medical affairs and financial and management, respectively. Immediately below the medical and administrative directors are the members of the executive committee, i.e., the chief financial officer, the general operations manager, and the operations manager for research. The medical staff relates to the medical director and the general operations manager supervises the nursing staff and all other care givers.

Organization Chart of East Boston Neighborhood Health Center.

There are 17 departments at East Boston. The medical staff is divided into teams. Internal medicine, for example, has 8 to 10 teams consisting of an internist, a mid-level nurse practitioner or physician assistant, and a medical assistant. The patient is either assigned to or choses a particular team and receives all of his/her primary health care from that team. The medical assistant is reported to be a key person in dealing with the community. The medical assistant makes appointments, takes calls, and is essentially the medical staff liaison with the teams patients. When the health center moved into the new building there was a sense among the practitioners and among the community people that there was a breakdown of personal contact. In the old building, there were one or two people who sat at the “front desk” and and knew everyone who came and went. The new building was designed with many work stations and the capacity to see more people and offer more services but direct personal contact with the same receptionist became more difficult. It was at this time the medical staff looked into another way of organizing the medical care and it was then they went to the team approach.

In general, the medical record system at East Boston is organized by family; each nuclear family is given a number that is assigned to the medical records for that family. However, beyond physically storing the records together there doesnt seem to be much by way of linking family information to patient records. When a patient is seen, only the medical record for that patient is pulled. The medical data on the entire family is not automatically available at the time of contact with any given individual. The medical record itself contains a standard problem list for the individual. The problem list is displayed prominently at the top right side of the chart. However, the problems for the family group or other family members relevant to this individual are not displayed systematically. Similarly, data on the patients environment, occupation, and the patients family and economic condition, although noted in an initial work-up or subsequent progress note, is not as readily available as the individuals problem list. And, except for cases in which tests, such as tympanograms, have been made, there is no mechanism for routinely linking patient information obtained as part of the epidemiologic studies being done in the community with patients clinical records.

Currently, East Boston is working with two data systems. It has a time-sharing arrangement with a local company that is used for billing, accounts payable, and general ledger. This system contains little or no clinical information that could be useful for anything but billing.

The other data system exists to support the volume of data collected and analyzed for epidemiologic research. This research data system is part of Channing Labs, which is linked to the Harvard Computer Systems. Although much of this patient data is collected on an individual basis (e.g., patient specific data collected in door-to-door surveys, clinical data collected on subsets of patients fitting criteria for certain studies, etc.), little of this information is routinely added to the patients medical records or the financial management data system. At present it appears that there are very few ways to link patient specific data from the medical record, from the management data system, and from the various data bases involved in research.

Recognizing the need for more than general accounting type data, East Boston has contracted, as of July 1, 1983, with a firm to develop an in-house data system and management information system. According to the financial officer, this development and implementation is expected to take about two to three years. Currently, personnel from the health center are working with the consulting firm in a needs assessment for the new data system. The emphasis for this new management information system will be on billing and will not include or attempt the computerization of the medical records. The new management information system will, however, result in the development of a new encounter form. It is unclear whether or not this new management information system will have the capacity to engage in community research projects.

East Boston does have several other sources of data. The medical director noted that in Massachusetts there is what is called “the police list”, which is a census done by the police annually for purposes of voter registration. It is not very accurate, but gives some measure of the entire population. There are also U.S. census data specific to and available for East Boston. Furthermore, the state of Massachusetts collects a good deal of information around certain vital statistics. Dr. Taylor mentioned that aggregate data from birth certificates, for example, since 1975 represents a very rich source of information about marital status, risk of the mother, etc., and because East Boston is a geographically identifiable area of the city with distinct zip codes, the information that the state feeds back to East Boston is very useful information.

East Boston has several academic ties. It is linked as a subcontractor to Channing Laboratories now of Brigham Womens Hospital (BWH). East Boston subcontracts with BWA to do commmunity research in East Boston. It was through this link that the center first became a site in the federal Hypertension Detection and Follow-up Program and the various other studies that were piggybacked on to that. East Boston also participates in several primary care residency programs and provides a placement for interns from the local schools of public health.

The financing for East Boston comes basically from two major sources. One is service related revenues and the other is community research ( ). Generally speaking, the service-related revenues represent approximately 90 percent of the total revenues, and the community research component represents the balance. The service-related revenues include income from patients directly and from third party payers as well as income from service contracts, usually with public sources (city, state, and local). In the last few years approximately 75 to 78 percent of total revenues was from patients directly and third party payers while about 14 to 17 percent was generated from service contracts and grants.

Total Annual Revenues for East Boston Neighborhood Health Center by Source and by Year.

Revenues from community research, which in FY 1983 were approximately $650,000, include a portion for direct cost (59 percent) and another portion for indirect cost (41 percent). What seems noteworthy in East Bostons financing is the large percentage of revenues (approximately 60 percent in 1982) that came as fees for services from private insurance and Medicare. It should also be noted here that East Boston because of its ties to Boston City Hospital (BCH) is treated, for reimbursement purposes as an outpatient clinic of BCH. This level of reimbursement is somewhat higher than if East Boston were a free-standing clinic or group practice.

Over the years, there have been some changes in the organization of financing at East Boston that have influenced the practice of COPC. Generally, the changes had to do with the movement from a health center that had no billing (1972 to 1975) to a health center today that generates almost $5 million from patient revenues as result of billing third-party payers. The administrative director reported that there was no billing at the health center prior to 1975. From 1975 to 1978, there was an inefficient and ineffective system of billing third-party payers. In 1978, the Health Center earned $365,000 in third-party reimbursement. One year later, in 1979, the center earned $750,000 in third-party revenues–almost double the previous year. This revenue increase was as a result, in large part, of more efficient billing. The revised billing system combined with eventual increases in the number of visits and the actual utilization of the health center has generated the bigger total revenues. This kind of financing allows some flexibility and probably contributes to some cross-subsidization of the nonreimbursable community-oriented services.

Another change in the financing that influenced the East Bostons financial status was negotiation of indirect cost rate for their community research project. Acting as a subcontractor for Peter Bent Brigham Hospital, East Boston was able to secure an indirect cost rate of 41 percent. This has helped absorb some of the administrative costs of running East Boston as a COPC.

East Boston seems to have been relatively unaffected by the various fluctuations in public funding over the last 10 years. Its financial situation seems to be marked by steady and rapid growth due primarily to the innovation of some sound financial management techniques in 1978 that marked a significant increase in revenues for the health center. When asked, the financial officer noted that the current emphasis on fiscal management at East Boston (i.e., hiring a full-time financial manager) is more a function of organizational development and increased size than it is of concern over recent cut-backs.

East Boston defines its community as all of the residents in the geographic area, which, according to the 1980 census, numbered 32,000. This figure is about the same as that determined by the house-to-house survey done by the health center for its community research project.

East Boston is predominantly an Italian-American working class community located on the east side of Boston, isolated from the rest of the city by the Boston Harbor, and sharing their geography with Logan Airport. The 1980 U.S. Census reported that the median income for East Boston was $14,496, whereas for the city of Boston it was $16,253 and it was $21,258 for the Commonwealth of Massachusetts. According to the last census, the percent of people falling below the poverty level is 16.7 percent compared with 20.2 percent for the city of Boston and 9.6 percent for the Commonwealth. In East Boston, the percent of adults over 25 with a college degree is 11.6 (the lowest in all Boston neighborhoods). For the city, the figure is 33.4 percent and it is 35.8 for the Commonwealth. The percent of the work force categorized as managers and professionals is 12.3, the lowest in Boston, while 33.1 percent of East Bostons work force are categorized as blue collar. This represents the highest percent of blue collar workers in Boston. East Boston then appears to be comprised of working poor.

The infant death rate for children under one year in East Boston is considerably lower than for the city as a whole. According to information from the Maternal and Infant Program of the Massachusetts Department of Family Health Services, in 1980 there were 644.3 infant deaths per 100,000 live births in East Boston as compared to 1,601.8/100,000 for the city of Boston.

Other ethnic groups are in evidence in East Boston. After Italian American, the second largest group is made up of a mix of Spanish-speaking people from Central and South America. Another group that arrived fairly recently in East Boston is Southeast Asians, mostly refugees and poor. There were no ratios, however, or actual figures given for the proportion of people in each ethnic group.

From discussions with the director of social services, it appears that East Boston has good relations with a number of other community agencies in the area. She reported that East Boston has community-wide respect and visibility and is often called upon by other social agencies to intervene or to counsel and/or to assume some responsibility for the social welfare of people living in East Boston. She also suggested that this might occur in part because people seem more willing to go to a health center for counseling or assistance than to another social agency.

The practice generally relates to community groups and other community health resources through the staff. The board has attempted to maintain an arms-length distance from the many organizations with both overt and covert political aims within the community.

There are several projects or programs where East Boston is working closely with other local agencies. Specifically, there is something called the Parent Advocacy Consortium, 10 to 12 agencies all concerned with problems of children and of rearing them. This group meets monthly and is coordinated by the social service department at East Boston. Another example of cooperation is something called the Elderly Services Network, wherein the social service department at the health center works closely with the community mental health center to coordinate services for the elderly. There has also been considerable contact between the medical director and various community groups in relation to the community surveys and epidemiologic research that has been part of East Boston activities.

East Boston is a community governed and community run program. The East Boston Health Commitee, Inc., owns the building, is responsible for hiring staff, and is the grantee and/or contracting agent in awards of this kind. Health committee meetings are held monthly. Any resident of East Boston is allowed to attend. In general, the attendance at the health committee meetings is on the order of 30 to 40 individuals per meeting. The board of directors of East Boston is elected from members of the health committee and serve staggered terms of two years.

Elections to the board occur in September at the monthly meeting of the health committee. An individual is eligible for election to the board if he/she has attended four out of six of the previous meetings (or can present a written excuse for not attending). Election to the board is then based on a majority vote of those members of the health committee present for the vote.

Since its inception, the board has guarded against the possibility of a board member profiting in any way from being on the board. For example, the board made a decision that no relative of a board member is eligible for employment at the health center. The board members are not paid for their activities nor do they receive per diem or travel for attending board meetings.

The board clearly governs the practice, and sets all relevant policy. They are responsible for the staffing of all positions within East Boston. Although they rely heavily on the medical director and the administrative director, the board members have the final say on all policy matters related to the program. Instances were cited in which apparently competent physicians were not hired as a result of poor performance at their interview with the community board.

The members of the community board of directors bring a great deal of insight about the communitys desires for medical care into the policy arena of the program. Although the board is primarily concerned with issues such as acceptability and accessibility of East Bostons services, they nonetheless are involved in identifying subsets of the community whose health needs are not being met. There are fewer examples in which the board was able to specifically identify a health need to which health center services should be directed. During the interviews, it was repeatedly stressed by the staff that the board has direct involvement in the identification of the survey research activities as well as the specific proceedures to be followed. However, because of the close interaction between the board, the medical director and administrative director, it is difficult, for example, to determine the extent to which the board was involved in identifying the elderly population within the community as the focus for the recent senior health project.

Theoretically, the community board can and does address all aspects of the operation of the practice. However, there appears to be little board concern for financial matters. They apparently rely a great deal on the staff executive committee for dealing with financial matters. Often the board will approve projects such as starting a cable television program, developing a congregate housing project, implementing a new management information system, etc., without a great deal of concern over the cost implications of these decisions. They trust that the staff will explore the financial implications of proposed projects.

There are a number of advantages in having the community involved in administration of a health center like East Boston, not the least of which is the continual reminder of the patient perspective. However, community involvement does not occur without some costs. There are direct costs that include the personnel time for preparing for the meetings as well as attending the meetings. Preparations for the East Boston board meeting is fairly extensive in that this board reviews all personnel to be hired and requires that in most of the cases, at least two candidates be presented for their consideration. This occupies a great deal of administrative staff time. There is also the actual meeting time. The community board meets weekly for 10 months of the year for approximately three hours per meeting. The entire executive committee need to be available for each of those meetings. This represents considerable administrative personnel costs.

There are also indirect costs associated with having a community board. Indirect costs in this case are the costs incurred by dealing with issues raised by the board, the costs related to “putting out the fires” it discovers. Given that the board tends not to concern itself with the financial ramifications or implications of their decisions some of their decisions about dealing with community matters can be very expensive for the center.

COPC ACTIVITIES AT EAST BOSTON

Care and treatment of the elderly of East Boston has been a concern of the center since its establishment. Community leaders have recognized for some time the need for appropriate services for the increasing number of elderly in the community. More recently, East Boston is involved in a systematic effort to identify and document the health needs of the elderly. They are collaborating with the University of Iowa and Yale in a study of health status of the elderly, funded by National Institute on Aging. This is intended to be a five-year study, with annual surveys of the senior citizens in the community.

In 1982, the first Senior Health Survey was done of all individuals within the community over the age of 65 years. This door-to-door survey examined the individuals functional status, cognitive functioning, blood pressure, and functioning in activities of daily living, and measured the peak expiratory flow rates in all individuals. The survey was nearing completion at the time of the site visit, and it was believed to have captured 80 percent of the community over 65. In addition, in 1983, a random 10 percent of the subset of the community over the age of 65 years was brought into the health center for a detailed neurologic evaluation as part of a study examining the prevalence of Alzheimers disease in a noninstitutional population. Questions designed specifically for feedback into the service mix of the practice were also included in this senior survey. For example, one of the questions asked was, “What services would you like to have added to East Boston?” East Boston has used the results of the Senior Health Survey to identify several specific health needs of East Bostons elderly and measures have been taken to address these needs.

According to the survey results, a substantial number of elderly people perceived difficulty in obtaining foot, eye, and dental care. Although East Boston was already providing these services, the staffing and the number of clinic sessions held per week was increased to meet the expressed needs of the community. Foot care clinics were increased from two to nine sessions per week, in the morning, afternoon, and evening. Dental staff were increased by 1 dentist and two additional dental chairs were added. And, eye clinics went from 10 to 12 sessions per week and evening hours were added. The increase in personnel and number of clinic sessions was decided by the board in conjunction with the executive committee of East Boston. Announcements of the expanded services were placed in the two local newspapers in order to inform the entire community.

The impact of the modifications made on the perceived accessibility to these services will be assessed by repeating the same question(s) on the next Senior Health Survey in July 1985 and from preliminary evidence from telephone interviews scheduled for 1984. Since the foot and eye clinics services have been expanded the sessions have been booked. The eye clinic experienced a dramatic increase in visits from 239 in July to 407 in August of 1983.

Results of the 1982-1983 Senior Health Survey also revealed that many of the elderly people in the community have difficulty in traveling from their home to the clinic. East Boston is currently seeking funding for a local transport system for the elderly seeking care at the center. In addition, the survey confirmed that there are a large number of dependent elderly in East Boston, a community that has strong extended family ties and that resists institutionalization of elderly.

In response to the identified needs of these dependent elderly and sensitive to the cultural resistance to institutionalization, the community board tried to obtain funding to convert an old school near the health center to congregate housing for the dependent elderly in the community. An application was submitted to the Department of Housing and Urban Development to finance the renovation. Monies were awarded in September, 1983. Plans are now being made for a 44 unit structure tentatively scheduled to begin in 1986. Some staff from East Boston will be on the board of directors, as will be the Steering Committee and will help set criteria for admission but will not manage the building. East Boston will provide the medical care for the residents. Determining the impact of this change will be a longer range endeavor, however, results of the annual Senior Health Surveys over the next four years may provide some indication of the impact of this congregate housing arrangement in the health of East Bostons elderly.

East Boston has a death rate due to homicide that exceeds the national urban rate. In 1981, one of the pediatricians at East Boston reviewed death certificates and tabulated causes of death for East Boston residents under the age of 40 years. The results suggested a higher proportion of deaths due to homicide and violence in East Boston than in other urban areas of the United States. The protocol for counseling parents in child rearing and discipline practices was modified to reflect a de-emphasis on practices that condone or may predispose to violence. Programs are also being developed for the community health block of cable television that will highlight and discuss selected dilemmas in child rearing. At the time of the site visit, there were no plans for monitoring the effect of these changes on the homicide rate. The effects were considered to be so long-range that they would be difficult to link to program modifications.

Concern over the adequacy of prenatal care of pregnant women in East Boston can be traced to several sources. The clinicians noted that they were seeing many children in Well Child Clinic whose mothers had either received little/no prenatal care or, more commonly, received prenatal care from a source outside the community. The staff at East Boston then reviewed birth certificate data from the State Department of Public Health, Division of Family Health Services. These data revealed that many East Boston mothers were not receiving prenatal care or, if they were receiving care, it was not at East Boston. In talking to women with positive pregnancy tests done at East Boston, practitioners discovered that they didnt want to deliver at Boston City Hospital, the hospital for which East Boston physicians had admitting privileges. Since they wanted the same physician for both prenatal care and delivery they chose often to go elsewhere for their prenatal care. In response to this identified need, the community board lobbied the Health Commissioner (City of Boston) to open Beth Israel Hospital for deliveries by East Boston physicians. The case load of prenatal patients at the East Boston doubled in the year following the change in admitting privileges. The birth certificate data were reviewed following the change to Beth Israel and they confirmed that more East Boston women were getting prenatal care at the health center. It is not known, however, how many of the women now using East Boston for prenatal care were among the portion of the population receiving inadequate prenatal care and how many were receiving adequate care, but from sources other than the health center.

East Boston Neighborhood Health Center and South End Community Health Center

FAQ

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