McConnel has astutely homed in on a topic of active debate among free clinic practitioners. Unfortunately, McConnel's own cost-per-patient calculations disguise the issue's complexity. Consequently, his conclusion that free clinics are 6 times more costly than CHCs is unsound.
Free clinics and CHCs differ in what costs are counted. Community health centers use Table 8A in the Uniform Data System1 to report staffing, medical care, other clinical services, enabling services, and overhead costs. Unlike the example free clinic—Harrisonburg-Rockingham Free Clinic—CHCs are not allowed to report costs that they do not incur and pay. Community health centers do not report costs associated with specialty care referrals or diagnostic services beyond routine laboratory and radiographic examinations because these generally fall outside their “scope of project.”2 Recognizing the difficulties of uninsured patients receiving these services elsewhere,3- 4 the Harrisonburg-Rockingham Free Clinic, like many free clinics, makes formal arrangements with other health care providers for its patients to receive free or reduced cost specialty care and diagnostic services and has reported these downstream costs as part of its enterprise. Excluding the costs for nonroutine diagnostic services and specialty care referrals would substantially reduce the Harrisonburg-Rockingham Free Clinic's costs.