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A PSYCHOLOGIST’S RURAL HEALTH RESOURCE GUIDE: WORKING IN A MEDICAL HOME PRACTICE SEEING MEDICAID CLIENTS AND/OR IN A PRIMARY CARE HEALTH SETTING IN RURAL AREAS OF NEW MEXICO.
 
Ricardo Gonzales, Ph.D., Diversity Delegate
 
These materials describe the intent and the provision of behavioral health services in a Core Service Agency and in a Primary Care medical clinic that is either a Federally Qualified Health Center or a Rural Health Center (FQHC/RHC) here in New Mexico.   These materials also offer suggestions and resources for working in these clinical environments.  There presently are 34 Core Service Agencies located in 32 counties here in New Mexico. Another term that is used to describe a Core Service Agency is Medical Home/Clinical Home. The state has parceled out our 32 counties into 13 collaboratives made up of two to three counties per collaborative (click on map -colab.map.pdf….).   There also are approximately 117 Primary Care Clinics (FQHC/RHC) located throughout the state in these 32 counties - (click on link www.nmpca.org/index.php?option=com_content&view=article&id=56&ITemid=58).
The State’s intention about Medicaid behavioral health care has evolved over the years moving towards a greater integration and coordination of services (both behavioral and medical) for those who are Seriously Emotionally Disturbed (and children), and those with substance abuse problems (and children).   Because injury and violence mortality death rates in many counties of New Mexico continue to exceed national rates (click on –2010 New Mexico Substance Abuse Epidemiology Profile.pdf;  2009 disparities report.pdf  it has been difficult for the State to maintain the status quo in their delivery of behavioral health services, particularly given the federal dollars the State gets to address these problems.   
New Mexico is actually one of six states in the nation selected by SAMHSA (the Substance Abuse and Mental Health Services Administration) to create a model state that others can learn from to address the issues of poverty and the lack of access to quality based behavioral health services.   The development of Core Service Agencies and the focus on behavioral health care in Primary Care setting is also in response to the Federal Government’s Health Care Reform Plans and the expansion of Medicaid services. It is estimated that the Medicaid population will grow from over 100,000 individualsto over 300,000 seeking behavioral health services (based on recent estimates from discussion with OptumHealthNM, Administration involving Medicaid expansion from 133% to 400% of poverty).  Consequently, the above efforts are timely.
Medicaid Service Limitations: Over the years the New Mexico Psychological Association (NMPA) has pushed for greater numbers of psychologists to workwith the Medicaid population. While there are approximately 550 practicing psychologists in New Mexico, there are only 134 psychologists in independent practice whosee Medicaid clients, and their caseloads are limited (click on http://www.nmpsychology.org/displaycommon.cfm?an=1&subarticlenbr=88).  These provider numbers become more descriptive of the need when viewed as they are distributed among the thirteen collaboratives (click on map–colab.map.pdf and below tables of Psychologist Medicaid Providers).
Directories of Psychologist Providers..………….ValueOptions (2009)………OptumHealth (2011)
LC1 (Los Alamos, RioArriba, SantaFe)...............................    26                                        29
LC2 (Bernalillo)……………………………………………………   52                                         46
LC3 (Dona Ana)……………………………………………………  24                                         32
LC4 (Guadalupe, Mora, SanMiguel)………………………….....   3                                           3
LC5 (Chaves, Eddy, Lea)…………………………………………   4                                           3
LC6 (Grant, Hidalgo, Luna)…………………………………………1                                            0
LC7 (Catron, Sierra, Socorro, Torrance)……………………….... 1                                            0
LC8 (Colfax, Taos, Union)…………………………………………..5                                            4
LC9 (Curry, Roosevelt)………………………………………………1                                            0
LC10 (DeBaca, Harding, Quay)…………………………………... 0                                            0
LC11 (McKinley, SanJuan)………………………………………    2                                            2
LC12 (Lincoln, Otero)………………………………………………. 4                                            5
LC13 (Cibola, Sandoval, Valencia)……………………………....  8                                            8
                                                                       Total………  ____                                      ____
                                                                                           134                                       134    
 
Our NMPA Provider Survey indicated that few Psychologists see Medicaid clients because of inadequate pay, and because of experiences with administrative and clinical barriers and encumbrances to providing these services.    However, the survey and other subsequent reviews have investigated Medicaid payment rates and have found them comparable/no worse than other insurance companies (see below fees). The lack of Medicaid participation by Psychologists seems best described as due to the “sum total” of problems of working within this system (e.g., changing systems with billing glitches/delays, concerns over not getting paid for services managing complicated patients, on top of paperwork requirements that change with system changes, etc.). 
Allowable Costs:
CPT…………..….90801…….90806……90846…….90847……96101……96118
Medicaid...……..106.67…….72.75…….67.90……..82.45.…….87.30……97.00
Medicare...….....154.61……93.54…….87.64……..109.03……84.21……101.30
(Note: the Percentage differences on allowable costs for above CPT codes for major companies are more comparable to Medicaid rates).
 
If as a provider you do not participate in the Medicaid System because of the above noted encumbrances, Core Service Agencies (CSAs) and Federally Qualified Health Centers/Rural Health Centers described below might be considered alternative venues to working with Medicaid clients.  
                                                                   
A Core Service Agency:   The State of New Mexico Interagency Behavioral Health Purchasing Collaborative (i.e., the PC…the Purchasing Collaborative) approved the development of Core Service Agencies in June of 2009 (click on – csa.pln.pdf).   Since this time, the PC has been qualifying these programs, making use of the Federal dollars that are attached to the development of Medical Home models on which the Core Service Agency is based. The goal of these programs is to provide a quality based service that addresses the entire spectrum of behavioral health and medical needs that a patient with serious mental illness might have. Psychologists are included in the mix of providers, as assessment teams are to be multidisciplinary.   Participants on these teams must have advanced degrees as part of the core service provision. These services include “enhanced assessments” (based on a case formulation plan), and “comprehensive service planning” based on the comprehensive assessment, further requiring that case formulation plans be developed within specific time frames, and that these services beprovided not only for adults but for children and theelderly as well. This is clearly a task that requires advanced education and training not easily accomplished by someone with less than a doctoral degree.  And yet, a review done by the Behavioral Health Research Center of the Southwest (BHRCS) on “safety-net institutions” (community mental health centers) in rural areas currently providing these services indicates that staff in these environments are minimally educated and trained (click on -Willging et al. 2009(2).pdf), and that they have difficulties keeping up with clinical work demands.
It is yet unclear about the hiring practices of Core Service Agencies. Some psychologists, however, are already employed by these agencies. Click on the following (csa.1.pdf, p.2) which enumerates the CSAs that presently have been approved by the State’s PC.   Phone numbers to call individual agencies to inquire about these services are included.  Finally, click on (csa.nonphysician.pdf) that describes the specifics about the enhanced assessment and coordination plans, and the payment mechanism for these services.  
Federally Qualified Health Center/Rural Health Center:  Primary Care settings (e.g., Federally Qualified Health Centers - FQHC/Rural Health Centers –RHC) are different from Core Service Agencies in that both medical and behavioral health services are provided “under one roof”.   Providers can bill for both Medicaid and Medicare services.   These medical settings are part of the Federal Government’s Health Care Reform Plans for Medicaid expansion to include those between the 133% - 400% poverty range.      
An RHC must operate in a non-urbanized area as defined bythe state, while an FQHC can operate in either an urbanized or rural area (a rural area is outside a metropolitan statistical area). Payment caps are different for an urban vs. a rural FQHC. In either environment – FQHC or RHC - the programs require a provider shortage (underserved) designation.  Most counties in New Mexico receive this designation.
FQHC/RHC Medicare payments are based on an “all Inclusive reimbursement” rate in which provider productivity is particularly important (click on - fqhc rhc.comparison.pdf– Comparison of the Rural Health Clinic and Federally Qualified Health Center), as contrasted with Medicaid rates (which are based on a more complicated cost based reimbursement that may differ from state to state because of state and managed care priorities and regulations (click on files – medicaid’s new payment system.gao.rpt.pdf, medicaid rural health.pdf and Medicaid.Balanced Budget Act of 1997.htm).   As well - the following attachment (click on  fqhc rhc.reimbursement.pdf-  Reimbursement of Mental Health Services in Primary Care Setting, Chapter IV) details Medicaid regulations that allow states to be flexible in their reimbursement priorities/plans, those of which include the payment for behavioral health services by specialty providers. This manual also offers recommendations as to how one might seek to change state regulations that that may prohibit the Medicaid payment of specialty providers in these Primary Care settings (see Chapter VI).    
Most important - in an FQHC/RHC Medicare/Medicaid pay providers only with advanced degree designations (e.g., clinical psychologist, clinical social worker, psychiatrist, nurse practitioner, clinical nurse specialist, physician’s assistance). Other counselor groups are not included in this non-physician practitioner group.  The Scope of Services in these environments allows for specialty (behavioral health services) to as well be designated as “core” services. To be eligible for certification as an RHC that facility must meet requirements regarding location, staffing and provisions of services established by PL 95-210. The literature on the provision of specialty behavioral health services in rural/underserved areas supports the integration of specialty behavioral health services with medical services, and sees these types of behavioral health services as an effective strategy for maximizing the use of scarce rural health care resources. This integration of services has also been shown to improve access to quality of mental health services for rural residents as well astoreduce the social stigma associated with seeking mental health services (click on -Provision MH Svcs by Rural Health cl.s.pdf).
Rural Health Care Practitioner Tax Credit:   Psychologists who provide care in rural/underserved areas of the state (be they in private practice, or working in a CSA or FQHC/RHC) are eligible for an income tax credit of $5000. The provision of health care includes (but is not limited to) time providing services to patients, time traveling to eligible practice locations, time managing/administering health care provision, time participating in continuing professional education, and time on routine annual or sick leave. This tax credit is not related to any insurance plan. It was created as an incentive for health care providers to practice in these designated rural areas at least half time. Click on link (http://nmhealth.org/pdf/Clinical Psychologist Eligibility Matrix.htm) for specific counties, cities and towns designating underserved areas.   Also click on link http://nmhealth.org/PHD/OPRH.shtml for this tax credit program application and rules.
Selling Ourselves/Selling Our Wares:  When seeking employment a Psychologist should be prepared to talk about psychological training and expertise. Because of psychologists’ unique training they are best suited for working in FQHC/RHC environments, and are better skilled than less educated behavioral health providers particularly for working in these “medical” environments. Our Provider Survey indicated that Psychologists are likely to encounter the least number of clinical and administrative encumbrances working with Medicaid clients in a Primary Care setting. Psychologists are trained in a full range of evidence based practices, as well as in areas involving the therapeutic alliance, and cultural competence. Because of Psychologists’ advanced training and expertise they are best suited to interface with medical provider teams and physicians in Primary Care settings to evaluate/formulate comprehensive treatment plans for a full range of disorders to include chronic disease/illness (e.g., diabetes, heart disease, obesity, and cancer), acute behavioral health care emergencies and to coordinate comprehensive services. 
A Psychologist is also able to develop prevention and intervention strategies to reduce the risk of the above noted illnesses, and to supervise sub-specialty providers in these Primary Care settings. Unfortunately, in many of these primary care environments physicians carry the burden of addressing the above noted problems. For example, a large percentage of patients who present themselves to primary care physicians with physical symptoms suffer from a well-defined mental disorder (e.g., in rural areas of New Mexico this rate is approximately 50%-70%). And yet many of their mental health needs remain undetected. Other Primary Care studies of individuals who die by suicide indicate that approximately 90% have a mental disorder, and 40% had visited their primary care doctor the month before their suicide (APA Practice Organization, February 2009).
When talking about our expertise, it would be helpful to know about State behavioral health Medicaid service limitations and how our expertise can fill the gap in these service limitations, and improve upon the competence and quality of these services.  These studies describe limitations related to the quality of services offered in these environments. When one discusses quality services one, for example, can also discuss issues involving cultural competence (and) evidence based care in these rural environments. The following (click on - Willging et. al.2009(2).pdf) details for you information about administrative and clinical practices in New Mexico’s Public Behavioral Health System (e.g., rural Safety-net Institutions such as a community mental health centers).  At our NMPA website an article entitled “Psychologist Involvement with Medicaid - Working with the Poor and Disenfranchised in New Mexico” also details the history of behavioral health care reform the State has undertaken over the last 10 years. Each of these reports indicates that in rural environments clinical expertise and cultural competence is limited. Providers are minimally educated, there are problems keeping up with paper-work demands, and concerns about the appropriate delivery of behavioral health services. In these environments the use of evidence based treatment is as much a foreign term as is the practice of cultural competence. 
Evidence Based Treatment/Cultural Competence: Evidenced Based Treatments (EBT) with culturally and ethnically different populations is evolving. The use of the term Practice Based Evidence (PBE) makes reference to the use of evidence based treatment strategies with ethnically/culturally different populations and the evolving nature of this body of research. Regarding this research, others have coined the phrase – “starting from the ground up” to describe the study of effective behaviorally based strategies currently being used in culturally sensitive ways(click on – ebp.cc.childrens.mh.pdf). This article finds that appropriate adjustments to evidence based treatments can be made for specific cultural groups, but further research is required to understand what adaptations and modifications are needed to improve implementation of evidenced based practices. The focus is on adaptations of existing evidence based practices to accommodate cultural variations, thus assuring that cultural competence is taken into account in the implementation of these practices.
 A caveat with respect toevidence based treatment research (EBT) is that “this research” does not give adequate attention to non-specific factors such as the therapeutic alliance and actual processes mediating therapeutic change (click on – MENTAL HEALTH SERVICES RESEARCH JENSEN.pdf). However, APA best clarifies these issues for the practice of psychology in an American Psychologist article – (click on ebp.apa sum.pdf- Evidence Base Practice in Psychology, 2006).   This article also highlights the importance of applying empirically supported principals to psychological assessment, case formulation, and the therapeutic relationship with interventions that include the integration of research, clinical expertise, and patient characteristics. 
Cultural competence most importantly requires that a provider be accurately aware of culturally-  learned assumptions about themselves and their clients, that providers comprehend the culturally relevant facts about a client’s culture, and that providers are able to skillfully and sensitively intervene to bring about positive change through their interventions. As part of the discussion about cultural competence it is important to convey to others that state licensing and re-licensing requiresthat a Psychologist must keep these skills updated as part of the State’s licensing requirements. The Psychology Licensing Board is the only professional board in the state having these requirements.  The New Mexico Psychological Association facilitates this process by providing a large venue of on-line cultural competence courses for educating providers to work directly with cultural groups here in NM (click on - www.nmpsychology.org).  
 Attached is a link to a video-streamed (2-day, approximately 6 hours) workshop at the University of Wisconsin (March, 2008 – click on  http://www.wiphl.com/events/index.php?category_id=3704&subcategory_id=5095) presented by Emeritus Distinguished Professor of Psychology and Psychiatry from the University of New Mexico, Dr. William R. Miller. The title of the workshop is - Bridging the Science Practice Gap/The Promise and Perils of Evidence-based Treatment. I have included this section because of the wealth of ideas and information this presentation offers to one when discussing expertise in a Primary Care environment and “selling our wares” to administrators. The workshop poses  several important questions as backdrop to a review of addictions treatment literature – 1)Why use EBTs?, 2)Which are EBTs and who decides?, 3) Where can EBTs be used in services?, 4) When should EBTs be used?,  5)How do clinicians learn EBTs?, and 6) What are the potential pitfalls?.  These questions and their answers become critical in light of the State’s plan (noted above) to integrate behaviorally based treatment with primary/medical care, and the expectation that behavioral services be quality based and effective strategies/techniques (e.g., the State is moving more and more towards requiring the use of evidence based practices/treatments).  
This two-day presentation by Dr. Miller also looks at primary care settings as the venue for implementing evidence based treatments. Day one of the workshop (see March 5 and click on http://www.uwex.edu/ics/stream/event.cfm?eid=15311) goes into some detail describing the process of Motivational Interviewing. The presentation is clearly an important one when looking at how psychology might interface with medicine in the treatment of substance abuse disorders (given the high rates that appear in these environments – at least 10% with a Dependence diagnosis). This section also discusses how payer systems have been set up in Wisconsin and how Brief Intervention trainings have been expanded from Primary Care environments into rural areas.  On day two of the workshop “Going Beyond the Basics” (see March 6, AM and PM presentations - click on  http://www.uwex.edu/ics/stream/event.cfm?eid=15311), the presentations (answer the above previously noted questions) as well offers ideas to administrators to address behavioral  treatment retention rates, payment for services, quality improvement with evidence based care, the importance of accurate empathy as a skill to consider when hiring staff, and the integration of evidence based behavioral treatment with medical services in a primary care setting.
Working in a Primary Care Environment/My Thoughts:   I have attached a Position Description that goes into some detail describing the duties of a clinical psychologist employed in a rural hospital serving Native Americans here in New Mexico (click on -psych.pd.doc). The duties require a well rounded clinical psychologist  who is not so much expert in one specific clinical area (e.g., neuropsychology, psychopharmacology, addictions treatment), but rather one who is able to flexibly assess and provide behavioral and mental health care in a variety of areas to adults, children and or elderly,  and who also is able to consult with medical staff to address the psychological and the physical impact of chronic disease and illnesses (while appropriately using outside experts to address advanced stages of illness/injury and to help prevent a worsening of illness/injury, or death).  Having prior training and/or experience in a medical setting is key to developing this well rounded background.   
 
I received my Ph.D. in Clinical Psychology at the University of New Mexico. I have worked at the Santa Fe Indian Hospital approximately 27 years. Before coming to Santa Fe I worked as a clinical psychologist (on Active Duty in the Army for three years). I trained in an APA Approved Clinical Psychology Internship (while on Active Duty in the Army) at William Beaumont Army Medical Center (in El Paso, Texas) for 15 months. I then took the helm as the Psychology Services Chief at the Blanchfield Army Community Hospital at Ft. Campbell, Kentucky. I worked as Chief Psychologist for approximately 15 months before leaving the military and beginning my employment at the Santa Fe Indian Hospital. During my work as Psychology Chief in Kentucky I received training in neuropsychological testing at the VA Medical Center in Nashville, Tennessee. Upon returning to Santa Fe I picked up additional education at the University of New Mexico to obtain my LADAC (Licensed Alcohol and Drug Abuse Counseling) through the NM Counseling Board.
I have always worked in primary care settings either under the supervision of a psychiatrist or a psychologist, although my current supervisor is the Medical Director at the Santa Fe Indian Hospital. The Santa Fe Indian Hospital is an acute care medical facility that provides a range of inpatient and outpatient medical and behavioral health services to Native Americans. I interface and have established collegial relationships with Pediatricians, Internists and Family Practice physicians, Psychiatrists (adult/child psychiatry), in which we co-manage complicated medical and psychiatric cases on a variety of medications. Many of the cases I see include patients with psychological trauma, panic attacks, depression, polysubstance abuse and dependence, the individual and family sequela/adjustment to these problems, and a large elderly population with dementias and advanced problems with diabetes. There are numerous cultural and traditional issues one must consider in providing care to this population, and both understanding and sensitivity around these issues is clearly important when providing the above noted behavioral and mental health care.  At our cultural competence website (click on - www.nmpa.com) I have attempted to expose providers to a large body of research (and continuing education) pertaining to work with cultural groups here in New Mexico.
Tying It All Together: The Primary Care Association (PCA) is located in Albuquerque and its website is at (click on - http://www.nmpca.org). The goals/mission of PCA are to provide: 1) professional education and technical assistance for the development of staff, boards and advocates, 2) legislative and other types of advocacy, 3) avenues for networking and information sharing among and between member organizations, clinics and staff, 4) assistance to communities to build infrastructure and secure resources for new primary care clinics, and 5) liaison between members and State and Federal agencies, and other care related groups and organizations. 
The PCA identifies 117 Primary Care/medical settings around the state – click on (http://www.nmpca.org/index.php?option=com_wrapper&view=wrapper&Itemid=34), some of which include school based medical and behavioral health clinics.   Of these 117 medical settings approximately 65 are without behavioral health services. This is noteworthy in light of Federal and State Regulations, and Medicare and Medicaid services that consider Psychologists a “Core” service and which pay for these services in FQHC/RHC settings. 
Part of your preparation for selling yourself to find work in a Primary Care setting would be to first study the clinic listing provided to you above (see above NMPCA link). Next – it may be helpful to get a visual perspective on things, and maps always come in handy in this process. Therefore, review the following maps and city locations by clicking on each of these maps (placing one on top of another) for study of city/town locations and collaborative, particularly where you are located (click on - nmcitandtowns.pdf,and colab.map.pdf). It is important to consider the “Psychologist Medicaid Provider” tables (p.2 of this report) to know where psychology practice in the state is limited and or without providers. Next, place on top of these maps the map locating the various FQHCs/RHCs in the state and by clicking on the following link – www.nmpca.org/index.php?option=com_content&view=article&id=56&ITemid=58.  56% of these Primary Care clinics (65 clinics as noted above) are without behavioral health services.  Also keep in mind the “Practitioner Tax Credit” underserved designated areas of the State where you choose to practice (click on http://nmhealth.org/pdf/Clinical Psychologist Eligibility Matrix.htm). Study the Primary Care Agency locations along with the above maps/materials to know where the various FQHCs/RHCs are located.   Consider offering your services in Primary Care service areas where you are located (or where there are psychologist service limitations). 
The following points should be considered in this process:
1) Study as much of the above attachments and materials//Dr. Miller video stream (see p.6 of this report) as you can to fully prepare yourself for seeking out employment in a Primary Care setting and for considering ways to sell yourself. It is best if you read and know about the attachments/materials identified both under the topic of Core Service Agencies and materials identified for Primary Care settings.  
2) Take a chance. Get a feel for psychology work in a Primary Care setting by discussing these issues with staff at the Primary Care Association. Remember that they are a liaison to service providers in these Primary Care areas. Consider making phone calls and request interviews with specific Primary Care Clinics to discuss employment possibilities.
3)  If after several phone calls where you seem to be running into roadblocks, let us (NMPA) know about your progress so that we might advocate for you at a higher level…..the Purchasing Collaborative, your State Legislator, the PC Ombudsman, OptumHealthNM).
4) Know as much as you can about the issue of Medicaid and Medicare payment in rural areas. There are three major articles I have attached for your reading to help prepare yourself (see above p.3, p.4). These materials explain how a Primary Care setting will generate revenue by hiring a Psychologist, and also address how to get around State/managed care roadblocks to payment in these settings.
5) Core Service Agencies (and the PC’s plan to implement Enhanced Assessments and Comprehensive Service Planning) ideally require the skills of a doctoral trained clinician. Some Core Service Agencies have already hired Psychologists. This venue (like the above recommendations for Primary Care settings) would be to study CSAs locations. Know about the Psychologist service limitations in your area, and where you are located on the map. Next, make phone calls to these CSAs and request interviews.  Click on csa.1.pdf, see page 2 which lists State collaboratives and the CSAs that are located in these collaboratives.
REFERENCES:
APA Practice Organization. 2009. Health Care Reform: Congress Should Ensure That Psychologists’ Services Are Key In Primary Care Initiatives. (Practice Central at http://www.apapracticecentral.org/advocacy/medical/health-care-reform.aspx).
APA Presidential Task Force on Evidence-Based Practice. 2006. “Evidence-Based Practice in Psychology.” American Psychologist. 61 (4): 271-285.
Comparison of the Rural Health Clinic and the Federally Qualified Health Center Programs. Sterling, VA: Health Resources Services Administration (HRSA), 2006.
Gale, J., Shaw, B., Hartley, D., 2010. “The Provision of Mental Health Services by Rural Health Clinics. “Maine Rural Health Research Center” (#43): 1-48.
Isaacs, M., Haung, L., Hernandez, M., Echo-Hawk, H. 2005. “The Road to Evidence: The Intersection of Evidence-Based Practices and Cultural Competence in Children’s Mental Health.” National Alliances of Multiethnic Behavioral Health Associates. Annie E. Csdry Foundation (Contract #280-03-0101).
Jensen, P., Weersing, R., Hoagwood, K., Goldman, E. 2005. “What is the Evidence for Evidence-Based Treatments? A Hard Look at Our Soft Underbelly.” Mental Health Services Research, 7 (No.1): 53-74.
New Mexico Substance Abuse Epidemiology Profile. Santa Fe, NM: Substance Abuse Epidemology Program, Injury and Behavior Epidemology Bureau, 2010.
Racial and Ethnic Health Disparities Report Card, Santa Fe, NM: New Mexico Department of Health, Division of Policy and
 Performance, 2009.
 
Reimbursement of Mental Health Services in Primary Care Settings. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2008.
Willging, C., Waitzkin, H., Lamphere, L. 2009. “Transforming Administrative and Clinical Practice in a Public Behavioral Health System: An Ethnographic Assessment of the Concept of Change.” Journal of Health Carefor the Poor and Underserved. 20:866-883.

 

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