In summary, evidence exists to support the value proposition for CHCs, but no evidence comes from formal cost-effectiveness studies. This surprising result holds although CHCs have been part of the safety net in the U.S. health care system over a period of time when economic considerations have been important. The best established components of a value proposition are access and utilization. Favorable findings for public health (e.g., reduced avoidable hospitalizations) and community development also are reported in the literature. The literature is weaker on health, health-related quality of life, and long-term changes in expenditures. Also, none of the prior studies carefully evaluate the costs of provide care in CHCs versus alternative settings. To move from a value proposition that allows us to think of CHCs as being conceptually “cost-effective” to a formal analysis of the cost-effectiveness of CHCs, costs must be assessed and the linkages must be made between process and other utilization measures and health outcomes.
Returning to the questions posed at the end of the section outlining the conceptual model, the care at CHCs has been shown to be at least as effective as care provided elsewhere. This finding is largely in terms of short-term process measures that have not been translated into long-term health-related quality of life outcomes necessary for state-of-the-art formal cost-effectiveness analyses. Limited aspects of public health and community development have been investigated. Costs have not been reported in most studies. Substantial modeling would be required to link the short-term process changes to long-term health-related quality of life and expenditure changes to use in formal economic analyses. The perspective of an analysis generally only applies to cost-effectiveness analyses, so this was not analyzed.
Given the importance of economic evaluation in today’s policy environment, researchers, policy makers, advocates, and those given the job of implementing CHC programs are left with two questions: (1) Why has so little been done to assess the cost-effectiveness of CHCs formally? and (2) Is this type of research is necessary for CHC policy making and implementation?
The dearth of research may be explained in part by the difficulty of assessing organizations’ cost effectiveness. Although some cost-effectiveness research has been done on organizations such as long-term care organizations,16
most cost-effectiveness research has been done on specific treatments. As an example, in contrast to the limited literature on CHCs, a search of “chronic obstructive pulmonary disease” and “cost effectiveness” yields 66 articles from 2005 alone.
The standards that have been set for cost-effectiveness evaluations of medical interventions may not be appropriate for evaluating CHCs. Standards for economic evaluation studies were set sufficiently high so that several years after the recommendations were released, even some general cost-effectiveness studies failed to follow basic recommendations.17
There would be many challenges to meeting the standards when evaluating CHCs. Making long-term epidemiological projections to link to cost and quality of life is difficult for care provided by CHCs because the CHC represents a piece of a system of care for multiple diseases experienced by multiple population subgroups. Earlier, the prevalence of literature on CHC cost effectiveness was compared with clinical cost-effectiveness literature. For most clinical conditions, there are many interventions or pharmaceutical products that can be analyzed individually or in combination. Each alternative often is dealing with only a specific condition. More complexity is found in an analysis of testing blood products prior to transfusion in which analysts had to model the incidence of hepatitis B, hepatitis C, and HIV.18
Modeling the effects of CHCs or the care provided at them would be even more complex because of the need for a diverse set of disease models. Further, users of CHCs face many other environmental factors that can affect their lives so that standard epidemiological models may not be valid for this population. Long-term epidemiological models specific to this population may need to be developed. Further, cost data can be difficult to summarize at any level more specific than that reported in standard administrative databases. Because CHCs obtain funds from multiple sources, trying to track their costs using the funds received from a single source would be meaningless. Determining which perspective to use is also difficult as the CHC population may be its users or may be the entire local population.
To facilitate formal cost-effectiveness analyses that can add structure to policy debates, future analyses of care at CHCs should extend beyond process measures. A formal cost-effectiveness analyses could provide transparent information about the economic value of care at CHCs. If such analyses prove to be impossible to conduct, the degree to which all components of the value proposition are understood can be described for all concerned. Even this will facilitate rational decision making. Although having an understanding of all components of the value proposition is not equivalent to adding formal cost-effectiveness analysis to the policy and implementation process, any additional structure is useful.
In conclusion, more formal cost-effectiveness studies could enhance the discussion of policy options for improved access to primary care in underserved areas. Policy makers have several options to achieve this goal: (1) establishing and supporting a CHC; (2) subsidizing private providers through bonus payments, debt relief, or exchanging service for educational funding; or (3) expanding health insurance coverage. Cost-effectiveness analyses, although continuing to be difficult to perform and needing to be supplemented by noneconomic considerations, will help in understanding whether the first option is most valuable.