The Current and Future State of the Largest Primary Care System in the US - Dr. Kyu Rhee, CEO of the National Association of Community Health Centers

Michael Carrese: Hi, everybody. I'm Michael Carrese, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. And we're going to do that today by learning more about a vital player in meeting America's healthcare needs: Community Health Centers. CHCs, as they're known, provide primary care services to more than 31.5 million people, regardless of ability to pay, at over 15,000 sites in every state, U.S. territory, and the District of Columbia. 

With us to provide details on the role of CHCs and how they're adjusting to changes in health care and technology is Dr. Kyu Rhee, the president and CEO of the National Association of Community Health Centers -- a role he assumed earlier this year. 

Dr. Rhee has had a long career as a physician executive, scientist, teacher, and entrepreneur, working to advance primary care, public health, and health equity for underserved populations through leadership roles at CVS, IBM, and also federal agencies focused on quality and innovation. 

Thanks so much for being with us today. 

Dr. Kyu Rhee: Thank you, Michael. Thank you for having me.

Michael: I'd like to start with learning more about you and what first got you interested in medicine, and then the specialties of internal medicine and pediatrics.

Dr. Rhee: Yeah, so I started thinking about my career by just seeing my parents, my mom and my dad. My mom served as a nurse at Suburban Hospital, which is now part of the Hopkins system and my dad worked at the World Bank. He was an economist, focused on understanding broad system issues in developing economies.

So with the two of them, I got interested in healthcare and I also got interested in understanding the broader system of healthcare. Med-Peds, as is often known -- internal medicine and pediatrics, the care of adults and the care of children -- was kind of my approach to being a family doctor, and that's what got me interested.

I love pediatrics because when you focus on children, you have to think about the broader system, and when you think about adults, internal medicine, you often are challenged with issues of trying to understand a diagnosis and a treatment approach. So, while diagnosis and treatment is relevant for both, when you think of families, you have to think about the system they're in and how you advance the health of that family in that community. 

Michael: It kind of makes sense, given your interest in the system perspective, that you worked at these high-level major organizations in the private and public sectors over the decades. I'm wondering what drew you to this particular space of Community Health Centers and what your goals are as the new president and CEO. 

Dr. Rhee: So I started my career as a healthcare worker. I did a combined degree: a medical degree and a master's degree in public policy. At that time, my focus in healthcare policy at the Kennedy School of Government at Harvard was on care delivery for underserved populations. That's where I learned about Federally Qualified Health Centers (FQHC) or Community Health Centers and that's where my master's thesis was focused on: what it would take to become an FQHC. The title was actually very Shakespearean, it's To Be or Not to Be, FQHC. 

So, through that process, I went through medical school and healthcare policy training. I was fortunate enough to get a National Health Service Corps scholarship, which is basically like the Peace Corps in the U.S. They pay for your tuition and your lodging and expenses, as long as you make a commitment to serve primary care and underserved communities. I was fortunate to be able to have that program support me through my med school training and then out of medical school, my first job out of residency was in a Community Health Center. 

I knew what it was like to work as a primary care physician. In that setting, I knew what it was like to be a physician leader and executive as a medical director and chief medical officer in that setting. And then as you shared, you know, I became a bit more like my dad wanting to understand the bigger system issues after understanding the clinical issues, like what my mom did as a nurse. I was interested in trying to solve the broader system problems. So, my roles in the public sector were very much focused on health disparity populations, the populations I served as a primary care doc, as a med-peds physician. 

Then I did spend the last thirteen years in the private sector looking at the big data issues at a big company like IBM, with global health, and then looking at US health and healthcare issues with CVS Health. So, it was a natural progression of my career to go back to my roots and look at the role of the largest primary care system in our country, Community Health Centers, and the role it can have in not only advancing primary care, public health, but of course, health equity. 

Michael: So, you're obviously bringing a tremendous amount to the table. You've had some years to kind of look at the system from the outside. Now you're at the inside, you're at the helm. What are you seeing in a big picture sense where you need to focus your time and energy?

Dr. Rhee: So I believe right now, Community Health Centers are the largest primary care system in the U.S. We serve one in eleven Americans. That's over 31.5 million Americans at over 15,000 sites. The populations we serve are predominantly underserved and poor. 90% of the population we serve are below 200% of the poverty level and 70% are below 100% of the poverty level. So, if you think of the poverty level -- which is one person having $9,000 to $10,000 annually, it's an incredibly underserved population. Forty-one percent of the people we serve are rural and 63% are minorities. So, in many ways, I believe strongly that we're already the provider of choice, the employer of choice, and the partner of choice when it comes to addressing primary care and health equity for our nation. 

There are so many things that distinguish us as the provider, employer, and partner of choice. I believe we're very innovative in that we have an innovation that no other part of the health care system has: we have boards of Community Health Centers that are governed by the patients. It is a provision that is part of the DNA of Community Health Centers that you have to have a 51% user board that represents the people you serve. So, health being local, and when you're in a community health center, who runs that community health center, the patients in that exam room are people who represent that. Those patients are on the board. 

Another key principle is regardless of ability to pay -- you referenced that -- as opposed to other parts of the health system, where they're often asking you your insurance status and whether or not you have to pay before you're being seen. Regardless of your ability to pay, we have to see you and take care of you and provide comprehensive, affordable primary care. We go also beyond the exam room. While I served as a med peds physician -- and I understood the clinical issues and problems of diabetes, hypertension, asthma, cancer, depression, mental health issues, substance abuse issues -- CHCs go beyond the exam room and think about the broader determinants of health and we look at solutions that help address housing insecurity, food insecurity, transportation challenges, translation challenges. So, we definitely go beyond just clinical and healthcare and go to the broader determinants of health.

We also look to represent the people we serve. So, while the US population is 40% minority and health disparities are a higher burden for those minority groups -- and also we have a large percentage of the population that suffer from rural island frontier disparities as well -- we have people in those communities delivering comprehensive, high quality primary care. Our workforce is representative of the people we serve as well in terms of our diversity and we also have people in those communities that are in those communities that are in those areas.

So, these are just some areas that demonstrate we're not only what I would believe to be the best part of our health system, we're also the most innovative, the most diverse, and the most

resilient, because so much of health goes beyond an exam room and our ability to be resilient for those communities and support their resiliency is an extraordinary strength in our health system. 

Michael: Well, that's a terrific overview. I do want to dive in on the health equity issue in a second, but first, I was just so curious about your point about the local boards being governed by patients. Can you give us an example or two of how you think that's made an impact...what those local boards have brought in terms of innovation or anything else that comes to mind? 

Dr. Rhee: I think there’s power in having boards that represent the diversity of populations that suffer from health disparities. I was fortunate when I did my master's thesis at The Kennedy School -- To Be or Not to Be FQHC -- one of the health centers that I supported in its transition from a free clinic to a Federally Qualified Health Center was Clinica Monsignor Oscar A. Romero which is in downtown Los Angeles. I actually served on that board and also was a chair of that board. I saw that the benefits of having patients on that board were that you were ultimately, hearing from their perspectives -- the needs that they had for their families, for their community -- and they challenged the paradigm of not only assuring we had the right clinical resources to serve their needs and the patients that they represent. So, whether it was adding and integrating oral health or behavioral health or social health or pharmacy services with comprehensive primary care, but also thinking more broadly about integration with community-based organizations and thinking about health more holistically in terms of employment, in terms of housing, in terms of education, in terms of access to healthy choices like food. 

So, they helped you see it from the perspective of the people that ultimately you serve. It also challenged us as a board to think in terms of making sure we communicated in a way that was culturally sensitive and linguistically concordant, because sometimes -- if you're predominantly serving limited English proficient populations -- you often had to be very thoughtful about even including translator services in board meetings and such. So, it does so many things that I think changes the dynamics of healthcare and how it's delivered, and we often say that we have to be patient-centered, but how can you be any more patient-centered than having a board that represents the patients you serve and making sure that that board is 51% patients? 

Michael: Absolutely. So, on the health equity front, as you know, it's long-standing problem that got a lot of attention because COVID really shined a light on just how bad the disparities were. There's been a lot of talk about it and a lot of initiatives and I'm just wondering -- because your folks are on the ground and you have such a large system -- if you see actually any signs of progress toward that end? And if so, can you give us some examples of the role CHCs are playing in meeting those goals? 

Dr. Rhee: Look, the core component of what Community Health Centers do is deliver primary care and health equity for the people they serve. And the populations we serve are health disparity populations predominantly. If you look at the fact that 20% of the people we serve are uninsured, 50% have Medicaid, 40% are from rural communities, and 63% are minority populations, these are all groups that suffer those health disparities and we have an extraordinary workforce of over 300,000 plus and over 15,000 sites of clinicians who address primary care, oral health, behavioral health, social health, and pharmacy services. 

The way I like to simplify it is, if you thought about our nation and you were thinking like it was a family of four, in general, one to two members of that family are suffering from health disparities. So, while we serve one in eleven Americans today, I believe strongly in the next twenty years, just like we did in the last twenty years, we tripled in size of people we served to focus on those health disparity populations. I believe we can and should serve one in three Americans and move from the one in eleven we serve today to one in three. 

Michael: Wow. 

Dr. Rhee: And so addressing that requires a lot of what I just highlighted: being local; having boards that represent the patients you serve so that you meet those local needs and their needs going beyond healthcare to the broader determinants of health; making sure you have a workforce that represents the people you serve, because so much of that is about trust in terms of healthcare; and really reducing those disparities that, as you suggested, during the pandemic, we witnessed tragically in terms of COVID deaths and cases. These are the populations that suffered the most, the ones that Community Health Centers serve. 

I have a family member, one of my two daughters, who has asthma. So what do we do? We focus on her health and often allocate resources to support her health so she could be as healthy as my other daughter or me and my wife. Similarly, in our nation we have one in four, one in three people who suffer from health disparities, and we have a responsibility to address that. In my mind, Community Health Centers are core to our ability to achieve health equity, primary care prevention, and public health for our nation. 

Michael: You know, I'm listening to this, and you have so much on your plate and you just mentioned the goal of growing to serving one in three from one in eleven Americans. I'm just wondering, you know, do you have the resources you need to do all this? And if not, talk about that a little bit. 

Dr. Rhee: Yeah, so just so you know, the Community Health Center movement started in 1965, with the war on poverty, the Civil Rights movement. It started as a demonstration project and from that first patient we served in the Mississippi Delta in rural Mississippi in 1965, to now serving over thirty-one and a half million Americans nearly sixty years later, there's no question you can't deliver on a mission without margins and resources. The current cost is about $100 per person per month, of the thirty-one and a half million Americans.

So, if you think about the current cost of serving one in eleven Americans, it’s maybe $40 to $45 billion to provide comprehensive primary care for populations that need it the most. You're correct, to triple that, you're going to need more resources and you're going to need a lot of these partnerships that currently exist between health centers and their local communities to grow and to get deeper. 

What I've admired about health centers -- having served in them as a physician, as a physician leader, and as now seeing them at a system level -- is they're incredibly innovative. They deliver real impact, they save lives and save money. If you invest in primary care, you save and prevent hospitalizations and ER visits. So, in many ways, as I speak on Capitol Hill or in state capitals and to policy makers and partners across the health system -- including health plans, and hospitals -- they all recognize that an investment in Community Health Centers actually saves lives and saves money. 

I want to highlight this: we do need more resources, but ultimately, we're going to deliver health equity, primary care prevention, and save money down the line.

Michael: As you know, were in the middle of a lot of simultaneous crises that seem awful big and difficult to solve and seem to be growing. I would tick off just two of them: the opioid substance use crisis and folks who are unhoused. Given everything you've described, the CHCs are obviously in the middle of that. I'm just wondering if you feel like the system is overwhelmed...if you feel like it's a slog and we're not making progress, it's getting worse, or do you feel hopeful about your ability and the ability of the rest of the healthcare system to get on top of these things and make some progress? 

Dr. Rhee: I'm hopeful. I believe strongly that the movement of Community Health Centers, nearly sixty years old, has found ways to improve primary care and health equity for people who need it the most. So far, I visited twenty-three health centers. I've met the frontline staff. I met their leaders. I've heard about their strategies, whether it's in rural Mississippi or downtown Los Angeles. I've been amazed at our ability to be creative for serving urban, rural frontier and island populations across our country. So, I am very hopeful that our movement has grown and that the nature of our nation is about doing what's right, and finding solutions and investing those solutions to save lives and save overall healthcare dollars. 

I went to neighborhood health centers in Nashville, Tennessee. You were talking about like homelessness or housing insecurity...I saw a homeless shelter and clinic right next to where the Ritz-Carlton was being built in downtown Nashville and I was amazed at the work we're doing there, along with a lot of public housing facilities. I saw some sites right next to, you know, challenging public housing situations and we find solutions locally that are patient-governed and that meet the local needs. 

In other places I've seen us be very protective about food insecurity and create food pharmacies and local partnerships with soup kitchens or food banks. At the same time you might get a drug prescription, you get a food pharmacy prescription and you're getting access to healthy, nutritious foods. 

So, I'm not going to suggest that we've solved these problems. We still suffer horrible disparities, but the nature of what I believe the experience is in our country is that we find ways to do the right thing. And while I'd like a lot of that to happen much quicker, you know, the nature of our country is that justice evolves. I think health justice is continuing to evolve and I think health centers are a big reason why I'm very hopeful. 

Michael: Well, it's very encouraging to hear somebody in your shoes speak that way. We're almost out of time and we wanted to give you a chance, as we do all of our guests, to provide a little advice to the med students and early health care professionals in our audience, partly about, you know, this is a vast healthcare system, very complicated and they're listening, trying to figure out where do I fit into all of this? So what's your advice? Maybe I wouldn't be surprised if you put in a little plug for working in CHCs, but what would you say to them? 

Dr. Rhee: So my advice is, the process of going to medical school and training and residency is all about learning a skill that will help improve a person's health. But think broader about the broader system in which you're delivering that care. And people do have to make that decision, like I did, to consider whether or not you want to invest 100% into that clinical care delivery, or do you want to think broader about the system? 

My advice to folks is that we need clinical leaders who understand how care is delivered, but also challenged to improve the broader system, and so whether that opportunity is working in the nonprofit sector, as I did, or the public sector or the private sector, be open, to all different sectors of your career; be open to saying that your experience on the front lines of care delivery is relevant for leaders to know and understand; and be open to taking on leadership roles because I believe strongly, the more clinical leaders we have who are actually helping make the big decisions in boardrooms, in the C-suite, the better off we'll be for the care that needs to get delivered and delivering that quintuple aim of improved health outcomes, lower costs, improved patient experience, improved provider experience, and health equity. 

Michael: Well, that is a lot of great food for thought. I'm afraid to say we're out of time, but I want to thank you so much, Dr. Rhee, for being with us today and more importantly, for the incredibly important work that you and CHCs are doing all cross the country.  

Dr. Rhee: Yes, and you might not know that Community Health Centers are all around you, and they're doing extraordinary work and they're a great place to not only learn, contribute, but also lead and be part of the movement. So, I'm grateful for you giving me a chance to share some of that and share this with your audience. Thank you, Michael.

Michael: Happy to do so. I’m Michael Carrese, thanks for checking out today's show. And remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.