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© 2005 American Public Health Association
DOI: 10.2105/AJPH.2004.040311
FIELD ACTION REPORT |
The authors are with the Refugee and Immigrant Health Program, Bureau of Communicable Disease Control, Massachusetts Department of Public Health, Jamaica Plain, Mass. Paul L. Geltman is also with the Department of Pediatrics, Boston University School of Medicine, Boston, Mass.
Correspondence: Requests for reprints should be sent to Paul L. Geltman, MD, MPH, Refugee and Immigrant Health Program, Massachusetts Department of Public Health, 305 South St, Jamaica Plain, MA 02130 (e-mail: paul.geltman{at}state.ma.us).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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US law and regulations stipulate a process for the health screening of refugees. The responsibility of caring for refugees resettled in the United States rests, in part, with public health or welfare departments. Massachusetts has met its screening responsibilities through the innovative creation of a network of private preferred providers.
We explore the Massachusetts model of public–private collaboration within the context of federal refugee health priorities and current state fiscal restraints affecting public health programs, and demonstrate the model’s accomplishments.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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Over the past decade, approximately 70000 refugees have resettled in the United States each year. US federal regulations stipulate a process for the health screening of refugees shortly after they arrive in the country. Responsibility for this screening rests in part with public health or welfare departments. This screening is usually the first contact of newly arrived refugees with the US health care system and provides an important opportunity for promptly addressing the unmet health needs of refugees, educating refugees about the US health care system, and facilitating a transition into primary care.
In most states, refugee health screening is performed at state or county public health clinics. By contrast, Massachusetts has met its screening responsibilities by creating a network of private preferred providers. We discuss the Massachusetts model for refugee health screening within the context of federal refugee health priorities and current state fiscal restraints affecting public health programs, and we demonstrate the model’s accomplishments.
A refugee is a person who has crossed an international border owing to a well-founded fear of persecution.1 In this report, "refugees" will be defined as those eligible for federally funded refugee health screening, including refugees, recipients of political asylum, and Cuban and Haitian entrants. During state fiscal years 1999 through 2001, over 7000 refugees resettled in Massachusetts from over 40 different countries (Table 1
).
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OVERVIEW OF CURRENT REFUGEE HEALTH SCREENING PRACTICES |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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Refugees are required to undergo an overseas health screening. Because refugees often have unmet health needs and come from situations of poor hygienic conditions with endemic infectious diseases, US regulations permit and fund a second, domestic screening to eliminate health-related barriers to successful resettlement while protecting the health of the public. Departments of health or public health usually run these screenings; however, the breadth of clinical services and laboratory testing that are provided varies considerably among states.
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FUNDING OF REFUGEE HEALTH SCREENING SERVICES |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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The organization of and payment for refugee health screening services may influence their content and delivery. Funding may come from several sources: Refugee Medical Assistance (RMA, via the US Office of Refugee Resettlement [ORR]), Medicaid, preventive health grants from ORR, and state or local government funds. RMA is normally used as a funding stream to provide Medicaid coverage for refugees who are not eligible for Medicaid under typical criteria used by states. ORR regulations allow states with an approved screening plan to use RMA funds to pay for refugee health screening for all refugees provided that the screening is initiated within 90 days after arrival. Otherwise, states must rely on Medicaid reimbursement (with funding streams from either Medicaid or RMA) directly to medical providers who perform refugee health screening services. In such cases, the scope of refugee health screening services depends on the state’s Medicaid plan, and entry to care depends on the refugee’s receipt of Medicaid coverage.
KEY FINDINGS
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Most states use county and local public health clinics to provide refugee health screening services. Others fund private health clinics in areas where refugees are concentrated, or they rely on private physicians who accept Medicaid to perform screenings without guidance or standard requirements. Reflecting the economic recession, state and federal budget cuts in recent years have had a negative impact on states’ ability to maintain public health program infrastructures for clinical programs such as refugee health screening.
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THE MASSACHUSETTS EXPERIENCE |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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The Massachusetts experience demonstrates how a state can creatively combine various health priorities and funding streams into a coordinated program tailored to the state’s infrastructure. In 1987, the Refugee and Immigrant Health Program of the Massachusetts Department of Public Health developed formal recommendations for refugee screenings. Unlike most other states, Massachusetts does not have county or local public health clinics. Therefore, screening depended on the cooperation of private practitioners, health centers, and other clinics and their willingness to screen refugees with Medicaid coverage still pending. As a result, public health authorities could not control timeliness, consistency, physician knowledge of refugees, or the quality of the screening. Lag times between the refugee’s arrival and receipt of Medicaid coverage often resulted in delays of several weeks or months before screening was implemented, if it was at all.
In 1995, with approval by ORR, the Massachusetts Department of Public Health established a unique competitive procurement process to develop a network of private clinics, mostly federally qualified community health centers, specially qualified for screening refugees—a "preferred provider network" called the Refugee Health Assessment Program (RHAP). No other state with significant resettlement has relied exclusively on such a contract-based network. RMA-funded payment to RHAP providers is determined by state Medicaid rates for each Current Procedural Terminology code for the various components of the clinical encounters (billing codes for the evaluation and management complexity level of the office visit, visual acuity testing, laboratory tests, etc.). Because it is bundled per capita, the reimbursement rate paid to the clinics conveys the requirement of complete implementation of RHAP protocols.
Recent refugees come from an increasingly diverse array of countries (Table 1
). The RHAP network has ensured delivery of culturally and linguistically appropriate care and facilitated the development of specialized programs to meet changing refugee health needs. Examples include a refugee oral health project and coordinated services for HIV-positive refugees. An example of multilingual/multicultural patient information in Bosnian is shown in Figure 1.
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DISCUSSION AND EVALUATION |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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The Massachusetts model facilitates prompt screening with standardization and improved quality of care. In addition to basic screening, the program allows rapid implementation of specialized protocols to meet specific refugee health needs. By concentrating refugee health screening in contracted clinics, providers and staff develop clinical expertise in refugee health issues and adapt more easily to increasingly diverse refugee populations and their language needs. The RHAP has also promoted the dissemination of this knowledge to other medical practitioners and the public through the publication of clinical research and program screening data (box page198
). | ENHANCING KNOWLEDGE OF REFUGEE HEALTH The following published research by RHAP clinicians has increased knowledge of the health status of more recently arrived refugee populations:
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The contractual preferred provider system has improved completion of screening and, most importantly, facilitated transition to primary care. In Massachusetts fiscal year 1995, 31% of eligible refugees completed screening; the rate increased to 83% in fiscal year 1997. Since fiscal year 1998, 90% overall have completed screening. In fiscal year 2003, 91% of eligible refugees had screening, including 94% of those identified overseas as needing medical follow-up after arrival in the United States. On average, the screening for all eligible refugees was initiated within 19 days after arrival. In addition, over 99% of those completing the screening did so within the federally mandated 90 days after arrival in the United States. These rates compare favorably with those of other states during the same period.8–10
Initiating primary care is a critical component of RHAP; however, comparative data are limited. It is likely that few refugees promptly initiated primary care before the implementation of RHAP. While a number of factors influence the transition to primary care and other medical follow-up health screening,11,12 RHAP’s efforts to train their contracted clinicians as primary care providers for refugees have played a significant role. Continuing medical education activities for RHAP clinicians, and contract monitoring with clinical feedback by RHAP, have helped heighten awareness of refugee health issues among contracted primary care providers. Similarly, the combined clinical experiences of specific providers performing refugee health screenings have increased their ability to diagnose and manage refugees’ health problems. The result is that most refugees have opted to continue with RHAP providers. By using likely primary care clinics for refuge health screening, RHAP provides a seamless transition into primary care for most refugees.
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NEXT STEPS |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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As refugee backgrounds and needs change, health screening programs must adapt and adopt positive elements of managed care such as provider networks. Since September 11, 2001, after which the numbers of overseas refugees declined, refugee health programs have been screening larger numbers of political asylum recipients and other special visa holders who have very different origins from refugee populations that have been well-studied. Programs must actively assess the health needs of newer or emerging populations that previously were not represented sizably among refugees entering the United States. In doing so, programs must compare these needs to those of past refugee populations on which refugee health screening guidelines often were based. The use of a limited provider network facilitates program evaluation and monitoring for changing needs.
In the context of the increasingly complex structure of health care delivery combined with government budgetary restraints imposed by the poor economy in recent years, use of public–private models can help streamline and standardize health screening services. Preferred provider networks would allow rapid implementation of health screening with smooth transition into primary care. Lastly, use of RMA funding through a stable and well-developed reimbursement mechanism reduces delays in implementing screening due to reimbursement uncertainty, thus facilitating a healthier start to refugees’ new lives in the United States.
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Footnotes |
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Peer Reviewed
Contributors
Both authors jointly conceived of, drafted, and edited this report.
Accepted for publication June 26, 2004.
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References |
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TOPABSTRACTINTRODUCTIONOVERVIEW OF CURRENT REFUGEE...FUNDING OF REFUGEE HEALTH...THE MASSACHUSETTS EXPERIENCEDISCUSSION AND EVALUATIONNEXT STEPSReferences |
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1. Convention Relating to the Status of Refugees. New York, NY: United Nations; 1951.
2. Nelson KR, Bui H, Samet JH. Screening in special populations: a "case study" of recent Vietnamese immigrants. Am J Med. 1997;102:435–440.[CrossRef][Web of Science][Medline]
3. Geltman PL, Augustyn M, Barnett ED, Klass PE, Groves BM. War trauma experience and behavioral screening of Bosnian refugee children resettled in Massachusetts. J Dev Behav Pediatr. 2000; 21:257–263.
4. Barnett ED, Christiansen D, Figueira M. Seroprevalence of measles, rubella, and varicella in refugees. Clin Infect Dis. 2002;35:403–408.[CrossRef][Web of Science][Medline]
5. Geltman PL, Radin M, Zhang Z, Cochran J, Meyers AF. Growth status and related medical conditions among refugee children in Massachusetts, 1995–1998. Am J Public Health. 2001; 91:1800–1805.
6. Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995–1999. Pediatrics. 2001;108:158–162.
7. Geltman PL, Hedgecock C, Cochran J. Intestinal parasites among African refugees resettled in Massachusetts and the impact of an overseas pre-departure treatment program. Am J Trop Med Hyg. 2003;69:657–662.
8. Lifson AR, Thai D, O’Fallon A, Mills WA, Hang K. Prevalence of tuberculosis, hepatitis B virus, and intestinal parasitic infections among refugees to Minnesota. Public Health Rep. 2002; 117:69–77.[CrossRef][Web of Science][Medline]
9. Kennedy J, Seymour DJ, Hummel BJ. A comprehensive refugee health screening program. Public Health Rep. 1999;114:469–477.[CrossRef][Web of Science][Medline]
10. Vergara AE, Miller JM, Martin DR, Cookson ST. A survey of refugee health assessment in the United States. J Immigr Health. 2003;5:67–73.[Medline]
11. Kang D, Kahler LR, Tesar CM. Cultural aspects of caring for refugees. Am Fam Physician. 1998;57:1245–1256.[Medline]
12. Forrest CB, Starfield B. Entry into primary care and continuity: the effects of access. Am J Public Health. 1998;88: 1330–1336.
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