C A S E
C. W. Williams
The Metrolina Health Center was started by Dr. Charles Warren “C. W.” Williams and several medical colleagues with a $25,000 grant from the Department of Health and Human Services. Concerned about the health needs of the poor and wanting to make the world a better place for those less fortunate, Dr. Williams, Charlotte’s first African American to serve on the surgical staff of Charlotte Memorial Hospital (Charlotte’s largest hospital), enlisted the aid of Dr. John Murphy, a local dentist; Peggy Beckwith, director of the Sickle Cell Association; and health planner Bob Ellis to create a health facility for the unserved and underserved population of Mecklenburg County, North Carolina. The health facility received its corporate status in 1980. Dr. Williams died in 1982 when the health facility was still in its infancy. Thereafter, the Metrolina Comprehensive Health Center was renamed the C. W. Williams Health Center.
“We’re celebrating our fifteenth year of operation at C. W. Williams, and I’m celebrating my first full year as CEO,” commented Michelle Marrs. “I’m feeling really good about a lot
This case was written by Linda E. Swayne, The University of North Carolina at Charlotte, and Peter M. Ginter, University of Alabama at Birmingham. It is intended as a basis for classroom discussion rather than to illustrate either effective or ineffective handling of an administrative situation. Used with permission from Linda Swayne.
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of things – we are fully staffed for the first time in two years, and we are a significant player in a pilot program by North Carolina to manage the health care of Medicaid patients in Mecklenburg County (Charlotte area) through private HMOs. We’re the only organization that’s approved to serve Medicaid recipients that’s not an HMO. We have a contract for primary care case management. We’re used to providing care for the Medicaid population and we’re used to providing health education. It’s part of our original mission (see Exhibit 16 /1) and has been since the beginning of C. W. Williams.”
Exhibit 16 /1: C. W. Williams Health Center Mission, Vision, and Values Statements
To promote a healthier future for our community by consistently providing excellent, accessible health care with pride, compassion, and respect.
Respect each individual, patient, and staff member as well as our community as a valued entity that must be treasured.
Consistently provide the highest quality patient care with pride and compassion. Partner with other organizations to respond to the social, health, and economic development needs of our community.
Operate in an efficient, well-staffed, comfortable environment as an autonomous and financially sound organization.
Committed to the pioneering vision of Dr. Charles Warren Williams, Charlotte’s first Black surgeon, we will move into the twenty-first century promoting a healthier and brighter future for our com- munity. This means:
C. W. Williams Health Center will offer personal, high-quality, affordable, comprehensive health services that improve the quality of life for all.
C. W. Williams Health Center, while partnering with other health care organizations, will expand its high-quality health services into areas of need. No longer will patients be required to travel long distances to receive the medical care they deserve. C. W. Williams Health Center will come to them!
C. W. Williams Health Center will be well managed using state-of-the-art technology, accelerating into the twenty-first century as a leading provider of comprehensive community-based health services.
C. W. Williams Health Center will be viewed as Mecklenburg County’s premier community health agency, providing care with RESPECT: R eliable health care E fficient operations S upportive staff P ersonal care E ffective systems C lean environments T imely services
C . W . W I L L I A M S H E A LT H C E N T E R : A C O M M U N I T Y A S S E T
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Michelle continued, “I’ve been in health care for quite a while but things are really changing rapidly now. The center might be forced to align with one of the two hospitals because of managed care changes. Although we don’t want to take away the patient’s choice, it might happen. In order for me to do all that I should be doing externally, I need more help internally. I believe we should have a director of finance. We have a great opportunity to buy another location so that we can serve more patients, but this is a relatively unstable time in health care. Buying another facility would be a stretch financially, but the location would be perfect. The asking price does seem high, though. . . .” (Exhibit 16 /2 contains a biographical sketch of Ms. Marrs.)
Community Health Centers1
When the nation’s resources were mobilized during the early 1960s to fight the War on Poverty, it was discovered that poor health and lack of basic medical care were major obstacles to the educational and job training progress of the poor. A system of preventive and comprehensive medical care was necessary to battle poverty. A new health care model for poor communities was started in 1963 through the vision and efforts of two New England physicians – Count Geiger and Jack Gibson of the Tufts Medical School – to open the first two neighborhood health centers in Mound Bayou, in rural Mississippi, and in a Boston housing project.
In 1966, an amendment to the Economic Opportunity Act formally established the Comprehensive Health Center Program. By 1971, a total of 150 health cent- ers had been established. By 1990, more than 540 community and migrant health centers at 1,400 service sites had received federal grants totaling $547 million to supplement their budgets of $1.3 billion. By 1996, the numbers had increased to 700 centers at 2,400 delivery sites providing service to over 9 million people.
Community health centers had a public health perspective; however, they were similar to private practices staffed by physicians, nurses, and allied health pro- fessionals. They differed from the typical medical office in that they offered a broader range of services, such as social services and health education. Health
Exhibit 16 /2: Michelle Marrs, Chief Executive Officer of C. W. Williams Health Center
Michelle Marrs had over 20 years’ experience working in a variety of health care settings and delivery systems. On earning her BS degree, she began her career as a community health educator working in the prevention of alcoholism and substance abuse among youth and women. In 1976 she pursued graduate education at the Harvard School of Public Health and the Graduate School of Education, earning a masters of education with a concentration in administration, planning, and social policy. She worked for the US Public Health Service, Division of Health Services Delivery; the University of Massachusetts Medical Center as director of the Patient Care Studies Department and administrator of the Radiation Oncology Department; the Mattapan Community Health Center (a comprehensive community-based primary care health facility in Boston) as director; and as medical office administrator for Kaiser Permanente. Marrs was appointed chief executive officer of the C. W. Williams Health Center in November 1994.
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centers removed the financial and nonfinancial barriers to health care. In addi- tion, health centers were owned by the community and operated by a local volunteer governing board. Federally funded health centers were required to have patients as a majority of the governing board. The use of patients to govern was a major factor in keeping the centers responsive to patients and generating acceptance by them. Because of the increasing complexity of health care delivery, many board members were taking advantage of training opportunities through their state and national associations to better manage the facility.
Community Health Centers Provide Care for the Medically Underserved
Federally subsidized health centers must, by law, serve populations that are identified by the Public Health Service as medically underserved. Half of the medically underserved population lived in rural areas where there were few medical resources. The other half were located in economically depressed inner- city communities where individuals lived in poverty, lacked health insurance, or had special needs such as homelessness, AIDS, or substance abuse. Approximately 60 percent of health center patients were minorities in urban areas whereas 50 percent were white/non-Hispanics in rural areas (see Exhibit 16 /3).
Typically, 50 percent of health center patients did not have private health insur- ance; nor did they qualify for public health insurance (Medicaid or Medicare). That compared to 13.4 percent of the US population that was uninsured (see Exhibit 16/4).
Exhibit 16 /3: Ethnicity of Urban and Rural Health Center Patients
Urban Health Center Patients Rural Health Center Patients
African American/Black 37.0% African American/Black 19.6% White/Non-Hispanic 29.9% White/Non-Hispanic 49.3% Native American 0.8% Native American 1.1% Asian/Pacific Islander 3.2% Asian/Pacific Islander 2.9% Hispanic/Latino 27.2% Hispanic/Latino 26.5% Other 1.9% Other 0.6%
Exhibit 16 /4: Insurance Status of US Health Center Patients, C. W. Williams Health Center Patients, the US Population, and North Carolina Population
Health Center US Population North Carolina C. W. Williams Patients Population Health Center Patients
Uninsured 42.7% 13.4% 14% 21% Private Insurance 13.9% 63.2% 64% 10% Public Insurance 42.9% 23.4% 22% 69%
C O M M U N I T Y H E A LT H C E N T E R S
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Over 80 percent of health center patients had incomes below the federal poverty level ($28,700 for a family of four in 1994). Most of the remaining 20 percent were between 100 percent and 200 percent of the federal poverty level.
Community Health Centers Are Cost Effective
Numerous national studies have indicated that the kind of ongoing primary care management provided by community health centers resulted in significantly low- ered costs for inpatient hospital care and specialty care. Because illnesses were diagnosed and treated at an earlier stage, more expensive care interventions were often not needed. Hospital admission rates were 22 to 67 percent lower for health center patients than for community residents. A study of six New York city and state health centers found that Medicaid beneficiaries were 22 to 30 percent less costly to treat than those not served by health centers.2 A Washington state study found that the average cost to Medicaid per hospital bill was $49 for health center patients versus $74 for commercial sector patients.3 Health center indigent patients were less likely to make emergency room visits – a reduction of 13 per- cent overall and 38 percent for pediatric care. In addition, defensive medicine (the practice of ordering every and all diagnostic tests to avoid malpractice claims) was less frequently used. Community health center physicians had some of the lowest medical malpractice loss ratios in the nation.
Not only were community health centers cost efficient, patients were highly satisfied with the care received. A total of 96 percent were satisfied or very satisfied with the care they received, and 97 percent indicated they would recommend the health center to their friends and families.4 Only 4 percent were not so satisfied, and only 3 percent would not recommend their health center to others.
Movement to Managed Care
In 1990, a little over 2 million Medicaid beneficiaries were enrolled in man- aged care plans; in 1993 the number had increased to 8 million; and in 1995 over 11 million Medicaid beneficiaries were enrolled. Medicaid beneficiaries and other low-income Americans had higher rates of illness and disability than others, and thus accumulated significantly higher costs of medical care.5
C. W. Williams Health Center
C. W. Williams was beginning to recognize the impact of managed care. Like much of the South, the Carolinas had been slow to accept managed care. The major reasons seemed to be the rural nature of many Southern states, markets that were not as attractive to major managed care organizations, dominant insur- ers that continued to provide fee-for-service ensuring choice of physicians and hospitals, and medical inflation that accelerated more slowly than in other areas.
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Major changes began to occur, however, beginning in 1993; by 1996 managed care was being implemented in many areas at an accelerated pace.
Challenges for C. W. Williams
Michelle reported, “One of my greatest challenges has been how to handle the changes imposed by the shift from a primarily fee-for-service to a managed care environment. Local physicians who in the past had the flexibility, loyalty, and availability to assist C. W. Williams by providing part-time assistance or volunteer efforts during the physician shortage are now employed by managed care organizations or involved in contractual relationships that prohibit them from working with us. The few remaining primary care solo or small group practices are struggling for survival themselves and seldom are available to provide patient sessions or assist with our hospital call-rotation schedule. The rigorous call-rotation schedule of a small primary care facility like C. W. Williams is frequently unattractive to available physicians seeking opportunities, even when a market competitive compensation package is offered. Many of these physician recruitment and retention issues are being driven by the rapid changes brought on by the impact of managed care in the local community. It is a real challenge to recruit physicians to provide the necessary access to medical care for our patients.”
She continued, “My next greatest challenge is investment in technology to facili- tate this transition to managed care. Technology is expensive, yet I know it is crucial to our survival and success. We also need more space, but I don’t know if this is a good time for expansion.”
She concluded, “One of the pressing and perhaps most difficult efforts has been the careful and strategic consideration of the need to affiliate to some degree with one of the two area hospitals in order to more fully integrate and broaden the range of services to patients of our center. Although a decision has not been made at this juncture, the organization has made significant strides to comprehend the needs of this community, consider the pros and cons of either choice, and continue providing the best care possible under some very difficult circumstances.”
Traditionally, the patients of C. W. Williams Health Center that needed hospital- ization were admitted to Charlotte Memorial Hospital, a large regional hospital that was designated at the Trauma 1 level – one of five designated by the state of North Carolina to handle major trauma cases 24 hours a day, 7 days per week (full staffing) as well as perform research in the area of trauma. Uncompensated inpatient care was financed by the county. Charlotte Memorial became Carolinas Medical Center (CMC) in 1984 when it began a program to develop a totally inte- grated system. In 1995, C. W. Williams provided Carolinas Medical Center with more than 3,000 patient bed days; however, the patients were usually seen by their
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regular C. W. Williams physicians. As Carolinas Medical Center purchased physi- cian practices (over 300 doctors were employed by the system) and purchased or managed many of the surrounding community hospitals, some C. W. Williams patients became concerned that CMC would take over C. W. Williams and that their community health center would no longer exist.
“My preference is that our patients have a choice of where they would prefer to go for hospitalization. Our older patients expect to go to Carolinas Medical, but many of our middle-aged patients have expressed a preference for Presbyterian. Both hospitals have indicated an interest in our patients,” according to Michelle. She continued, “We may not really have a choice, however. We recently received information that reported the 12 largest hospitals in the state, including the teach- ing hospitals – Duke, University of North Carolina at Chapel Hill, Carolinas Medical Center, and East Carolina – have formed a consortium and will contract with the state to pay for Medicaid patients. At the same time all 20 of the health centers in the state – including us at C. W. Williams – are cooperating to develop a health maintenance organization. We expect to gain approval for the HMO by July 1997. Since 60 percent of our patients are Medicaid, if the state contracts with the new consortium, then we will be required to send our patients to Carolinas Medical Center.”
C. W. Williams Health Center provides primary and preventive health services including: medical, radiology, laboratory, pharmacy, subspecialty, and inpatient managed care; health education/promotion; community outreach; and transporta- tion to care (Exhibit 16/5 lists all services). The center was strongly linked to the Charlotte community, and it worked with other public and private health services to coordinate resources for effective patient care. No one was denied care because of an inability to pay. A little over 20 percent of the patients at C. W. Williams were uninsured.
The full-time staff included five physicians, two physician assistants (PAs), two nurses, one X-ray technician, one pharmacist, and a staff of 28. Of the five physicians, one was an internist, two were in family practice, and two were pediatricians. The PAs “floated” to work wherever help was most needed. With the help of one assistant, the pharmacist filled more than 20,000 prescriptions annually.
Patients at C. W. Williams
All first-time patients at C. W. Williams were asked what type of insurance they had. If they had some type of insurance – private, Medicare, Medicaid – an appointment was immediately scheduled. If the new patient had no insurance, he or she was asked if they would be interested in applying for the C. W. Williams discount program (the discount could amount to as much as 100 percent, but
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every person was asked to pay something). The discount was based on income and the number of people in the household. If the response was “no,” the caller was informed that payment was expected at the time services were rendered. Visa, Mastercard, cash, and personal check (with two forms of identification) were accepted. At C. W. Williams, all health care was made affordable.
C. W. Williams made reminder calls to the patient’s home (or neighbor’s or relative’s telephone) several days prior to the appointment. When patients arrived at the center, they provided their name to the nurse at the front reception desk and then took a seat in a large waiting room. The pharmacy window was near the front door for the convenience of patients who were simply picking up a prescription. The reception desk, pharmacy, and waiting room occupied the first floor.
When the patient’s name was called, he or she was taken by elevator to the second floor where there were ten examination rooms. After seeing the physician, physician assistant, or nurse, the patient was escorted back down the elevator to the pharmacy if a prescription was needed and then to the reception desk to pay. Pharmaceuticals were discounted and a special program by Pfizer Pharmaceuticals provided over $60,000 worth of drugs in 1995 for medically indigent patients.
The center’s patient population was 64 percent female between the ages of 15 and 44 (see Exhibit 16/6). Nearly 80 percent of patients were African Americans, 18 percent were white, and 2 percent were other minorities. Patients
Exhibit 16/5: C. W. Williams Health Center Services
Primary Care and Preventive Services Diagnostic Laboratory Diagnostic X-ray (basic) Pharmacy EMS (crash cart and CPR-trained staff) Family Planning Immunizations (MD-directed as well as open clinic – no relationship required) Prenatal Care and Gynecology Health Education Parenting Education Translation Services Substance Abuse and Counseling Nutrition Counseling Diagnostic Testing: HIV Mammogram Pap Smears TB Testing Vision/Hearing Testing Lead Testing Pregnancy Test Drug Screening
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were quite satisfied with the services provided as indicated in patient sur- veys conducted by the center. Paralleling national studies, 97 percent of C. W. Williams patients would recommend the center to family or friends. Selected service indicators by rank from the patient satisfaction study are included as Exhibit 16/7.
Exhibit 16/6: C. W. Williams Health Center Patients by Age and Sex
Females 1991 1992 1993 1994 1995
<1 343 408 263 198 101 1– 4 434 552 692 647 417 5 –11 322 572 494 641 658 12–14 376 197 150 148 124 15 –17 361 168 146 121 92 18 –19 264 152 85 82 67 20 –34 749 1,250 967 964 712 35 – 44 869 617 479 532 467 45 – 64 583 567 617 658 658 65+ 400 488 531 527 524 4,701 4,971 4,424 4,518 3,820
<1 367 471 328 199 119 1–4 439 516 707 625 410 5 –11 440 644 598 846 738 12–14 171 175 128 120 104 15 –17 180 133 79 76 155 18 –19 126 67 28 23 69 20 –34 296 389 219 187 126 35 – 44 313 296 182 205 132 45 – 64 229 316 273 294 235 65+ 151 248 190 190 181 2,712 3,255 2,732 2,765 2,269
Total 7,413 8,226 7,156 7,283 6,089
Exhibit 16 /7: Patient Satisfaction Study
Rank Selected Service Indicators Mean Score
1 Helpfulness/attitudes of medical staff 3.82 2 Clean/comfortable/convenient facility 3.65 3 Relationship with physician/nurse 3.58 4 Quality of health services 3.28 5 Ability to satisfy all medical needs 3.20 6 Helpfulness/attitudes of nonmedical staff 2.72
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C. W. Williams Organization
The center was managed by a board of directors, responsible for developing policy and hiring the CEO.
BOARD OF DIRECTORS The federal government required that all community health centers have a board of directors that was made up of at least 51 percent patients or citizens who lived in the community. The board chairman of C. W. Williams, Mr. Daniel Dooley, was a center patient. C. W. Williams had a board of 15, all of whom were African Americans and four of whom were patients and out of the workforce. Two mem- bers of the board were managers/directors from the Public Health Department (which was under the management of CMC). There were two other health professionals – a nurse and a physician. Other board members included a CPA, a financial planner, an insurance agent, a vice president for human resources, an executive in a search firm, and a former professor of economics. A majority of the board had not had a great deal of exposure to the changes occurring in the health care industry (aside from their own personal situations); nor were they trained in strategic management.
THE STAFF The center was operated by Michelle Marrs as CEO, who had an operations officer and medical director reporting to her (see Exhibit 16/8 for an organiza- tion chart).
Eventually the director of finance, who had worked at the center for over ten years, resigned. “She was offered another position within C. W. Williams,” said Michelle, “but she declined to take it. Frankly, I have to have someone with greater expertise in finance. With capitation on the horizon, we need to do some very critical planning to better manage our finances and make sure we are receiving as much reimbursement from Washington as we are entitled.”
There were some disagreements between the board and Ms. Marrs over responsi- bilities. Employees frequently appealed to the chairman and other members of the board when they felt that they had not been treated fairly. Ms. Marrs would prefer the board to be more involved in setting strategic direction for C. W. Williams. “A two-year strategic plan was developed late in 1995 that has not been moved along, embraced, and further developed. Committees have not met on a regular basis to actualize stated objectives.”
C. W. Williams Was Financially Strong
The center received an increasing amount of federal grant money for the first ten years of its operation as the number of patients grew, but leveled off as most government allocations were reduced (see Exhibit 16/9). Although the amount
C . W . W I L L I A M S H E A LT H C E N T E R
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collected from Medicare was increasing, the amount collected compared with the full charge was decreasing (see Exhibit 16/10). Exhibits 16/11 to 16/14 provide details of the financial situation.
Carolina ACCESS – A Pilot Program
In fiscal year 1994 ( July 1, 1994 to June 30, 1995), North Carolina served more than 950,000 Medicaid recipients at a cost of over $3.5 billion. The aged, blind, and disabled accounted for 26 percent of the eligibles and 65 percent of the expenditures. Families and children accounted for 74 percent of the eligibles and 35 percent of the expenditures. Services were heavily concentrated in two areas: inpatient hospital – accounting for 20 percent of expenses – and nursing- facility/intermediate care/mentally retarded services – accounting for 34 percent of expenses. Mecklenburg County had the highest number of eligibles within the state at 50,849 people, representing 7 percent of the Medicaid population.
What started out in 1986 as a contract with Kaiser Permanente to provide medi- cal services for recipients of Aid to Families with Dependent Children in four counties became a complex mixture of three models of managed care. Carolina ACCESS was North Carolina Medicaid’s primary care case management model of managed care. It began a pilot program named “Health Care Connections” in Mecklenburg County on June 1, 1996.
Exhibit 16 /9: C. W. Williams Funding Sources
Funding Source 1991 1992 1993 1994 1995
Grant (Federal) 740,000 666,524 689,361 720,584 720,584 Medicare 152,042 157,891 258,104 260,389 301,444 Medicaid 381,109 453,712 641,069 562,380 456,043 Third-Party Pay 25,673 14,128 84,347 90,253 51,799 Uninsured Self-Pay 300,748 441,508 174,992 262,817 338,272 Grant (Miscellaneous) 0 0 0 11,500 48,000 Total 1,599,572 1,733,763 1,847,873 1,907,923 1,916,142
Exhibit 16 /10: Funding Accounts Receivable
Amount Amount Full Charge Collected Full Charge Collected
Medicare 436,853 260,389 369,306 301,444 Medicaid 914,212 562,380 725,175 456,043 Insured 99,202 90,253 61,021 51,799 Patient Fees 899,055 …