An Interview with Charles Alfero

by Beth Blevins

Charles AlferoCharles Alfero has served as the Chief Executive Officer of Hidalgo Medical Services (HMS), a Community Health Center providing comprehensive primary medical, dental, mental health, family support and community development services in southwestern New Mexico. Alfero has been working with Hidalgo since its development in1993, prior to its inception in 1995. He will soon be moving to the role of Director of the HMS Center for Health Innovations (CHI). In addition, Alfero was recently named the Director of the National Center for Frontier Communities.

Formerly, Alfero was Director of Rural Outreach for the University of New Mexico Health Sciences Center and Director of the Community Health Service Division in the NM Department of Health. He has developed and/or assured the continuation of hospital, primary care and related service delivery systems in numerous communities in New Mexico for more than 30 years. He also serves on the Boards of Directors of the National REACH Coalition and the National Rural Health Association, among others.

Alfero lives with his wife and their blended family of four “unique and cool” kids and “too many” pets in downtown Silver City, NM. He plays mandolin and tenor guitar in an Americana band, which sometimes goes by the name of “Greg and Charlie.” The band has played at the Tucson Folk Festival and local venues and benefit shows in and around Silver City and New Mexico.

You recently assumed the directorship of the National Center for Frontier Communities (NCFC), which is now housed at HMS-CHI. What does the Center do? And how will it integrate with other activities and functions at HMS?

The Frontier Center is an independent non-profit organization with an incredible history of identifying frontier health as a priority and equity issues in access and financing. Its mission is to be a clearinghouse, conduct research, provide education, and offer leadership on issues of importance to frontier communities. Five different sections of the health care reform act of 2010 include frontier considerations due largely to this organization. The National Rural Health Association honored the 25th anniversary of the frontier “movement” at its annual meeting this May in Austin.

When Carol (Miller) decided to retire, she approached me and asked if we would consider managing NCFC. HMS is doing this as part of its new Center for Health Innovation, which is also working on health workforce programs and racial and ethnic approaches to community health and related issues. CHI is doing this in partnership with the National REACH Coalition and other community development programs. CHI staff works with the Frontier Center under a professional services contract.

Do you envision any changes for the Frontier Center now that it has moved to HMS?

The Center will continue its rich legacy of supporting the most remote places in the country. We are attempting to vigorously expand and diversify our resource base to allow us to focus on broader community issues in the frontier beyond health. And we will continue to work on health services with NRHA, FORHP and others as a key part of the frontier economy and population health.

What is a “frontier” community—how do you define it?

There are multiple definitions of frontier. Most are density and distance based formulae. A standard is <6 people per square mile, or more, depending on the program, and 30 minutes or an hour or more to the next level of service delivery, depending on the program. There is a consensus definition on the NCFC website. There is another definition being developed by FORHP under a contract as we speak. There will probably be others as time goes on simply because one size, or in this case definition, does not fit all.

Why does New Mexico have so much frontier?

You have to realize it’s mostly high desert and mountains, and national forests comprise five million acres just around a two-county area here. The closest cities are 60 miles apart—that’s how far a stagecoach can go in a day, which is one condition that determined the distance between communities originally. In between there’s hundreds of acres of ranch land—no churches, no gas stations, no towns. Hidalgo County has 1.7 people per square mile.

What do you think is the biggest struggle for frontier communities in New Mexico? Are the challenges in the NM frontier different than Alaska frontier, or even Arizona frontier, or do they share some/many commonalities?

I think every place is unique. Certainly the Pacific Islands are as remote as the Alaskan frontier, yet their issues of health care access may be different in terms of the infrastructure available to respond to needs. It’s a matter of perspective and relativity. Does an uninsured farm worker in Arizona have more or less access to care than an isolated Native American in a remote village in Alaska? Geographically, maybe not; practically, maybe. It really depends on local, state and national policy, or the lack thereof, and how they impact those individuals in their communities.

In the absence of a standardization of care, there will always be inequities or, even in some cases, the ability to attempt to have equity. It is either up to public or private organizations or self-determined community interventions to improve upon current conditions regardless of where they are. Public policy either promotes or discourages improvement. We have these things in common as well as the need for a voice.

What common goals do frontier and rural share—and how are they different?

A key economic (health included) concept is that rural is not small urban. That is, the conditions that make certain things possible in urban areas don’t exist in the same way in rural places. A city of one million has different economic, infrastructure and social issues than a city of 49,000. The same can be said of the difference between communities of 49,000 and 3,000. Health care possibilities are different, infrastructure, etc.

One of my concerns is that we try to apply the same economic and financing models in frontier health delivery that we do in urban hospitals or clinics. That is, urban hospitals thrive in a financing environment that encourages high volume, high tech and expensive care. Frontier health services are particularly impacted by payment systems that favor high volume, high cost/high price health care. We should be looking at other models. Those are partially the conditions that The Hidalgo Plan (see below) was developed in response to: a stable population and increasing health costs that can only be mitigated by providing more services. This is very difficult in a small population where you are already seeing 75 percent of the population. Ultimately it is unsustainable without direct subsidies or targeted payment strategies that may not really serve to improve health or reduce costs if they are just intended to keep you open doing what you’ve always done.

The distribution of health professionals is also a common problem in rural and frontier communities, as is certain other government policies like Payments in Lieu of Taxes (PILT) which is supposed to be an offset for places that cannot generate local taxes due to the existence of public lands.

Tell me more about the HMS Center for Health Innovations (CHI) and how it will integrate with the Frontier Center.

Charles Alfero, Americana Band

In his spare time, Alfero plays mandolin and tenor guitar in an Americana band with his friend, Greg Renfro (right).

CHI is a planning, resource, program and policy development institute within HMS. It will serve as the strategic planning, evaluation and grant writing function for HMS. It also seeks ways to integrate various aspects of community and health systems in order to improve the health of the population locally but also with a focus on state and national health policy and modeling. I have always felt that it is critical for organizations serving the underserved to play an active role in assuring its success through good and supportive policy. The HMS Board of Directors has always understood that healthy communities and health care delivery are not two separate things but part of a continuum of necessary services. Remote, poor and otherwise disenfranchised people or communities are not often well served by market models.

To that end HMS is also proposing “The Hidalgo Plan” which is, in short a frontier model Accountable Care Organization (ACO) that looks to include Medicare, Medicaid and the Uninsured into an integrated financing system in order to improve health, reduce health care costs and improve the delivery of health services. It is a model that has been passed by the NM legislature in 2011 but was unfortunately vetoed by the NM Governor. We are trying also to work on the Hidalgo Plan administratively and through federal programs.

We put so much focus on volume and intensity when thinking about policy in general instead of trying to understand national infrastructure needs in terms of farm, ranch and related industries that are the backbone of national security (in terms of food and other natural resource supply, and a place where people recreate or escape to when they need to). These places tend to be poorer, older, and higher in minority representation and other factors that make it difficult for them to succeed. CHI is working on those issues with a broad range of local, state and national partners and stakeholders. It is a non-government-located approach to identifying and working on these perspectives, and really quite unique.

HMS began in a trailer in the early 1980s. In 2003, when the Rural Monitor did a short article (no longer available online) on HMS’ Family Support Centers program, HMS had four centers. How has HMS changed over the years?

In 1995 we started two days per week with $35K in state funds and support from Hidalgo County government. We currently have in excess of 160 staff and a budget of more than $13 million and full or part time family support staff at all of our 11 clinical locations. But a key point to mention is that HMS was dormant between 1985 and 1995 and there were no medical services at all in the county during that period. People traveled great distances for even basic care.

The Family Support Program has grown into a broader range of services with more technical knowledge and expertise as part of the program. In addition to significant and formal FS worker training, we now have trained care coordinators, a dietitian, and nursing staff as part of the Family Support program. The core or heart of the program is still the Promotores or Community Health Workers. It now goes beyond diabetes care and works in a variety of ways to help people in need.

How many clients and how broad a geographic range does HMS serve now?

HMS’ primary service area includes Grant and Hidalgo counties, the two southwestern-most counties in New Mexico. This covers an area of 7,414 square miles—about the size of Connecticut and Rhode Island combined—with a population of 34,408. We serve over 50 percent of the total population. Patient visits are currently between 65,000 and 70,000 per year for medical, dental and/or mental health. This does not include all of the family support clients we see that might use other providers for those services.

Generally we serve everyone with the need for our services. The majority or our patient population is Hispanic, like the community. As we serve more and more of the community, our patients are more like the community as a whole. The majority of our patients are poor and the most frequent reason people visit our clinics is for chronic disease management, which Family Support focuses on. The most rapidly growing service in terms of demand is dental—this year it is growing at more than 27 percent.

What is the biggest challenge in providing services in your two NM counties?

Getting health care service to remote, small communities or frontier areas is difficult in terms of financial viability and health professional recruitment and retention. Retention is the more difficult of the two health professional considerations, almost as difficult as good community fit. For the most part, we have been fortunate in these regards, but still need to work better at them.

In many ways we have been blessed over the last decade and a half to have an incredibly forward-thinking board and staff and also very supportive partners such as Arthur Kaufman, MD VP for Community Health at UNM’s Health Sciences Center and Gila Regional Medical Center, the hospital in Silver City, local elected officials. We are in a place where what we do is sustainable for the most part although it takes constant dedication from our staff and consistent public policy to ensure health care access to the underserved. And these days the latter is somewhat problematic given perceived public budget problems and the seeming lack of importance of strong social policy.

Why did you come to New Mexico in the first place?

I grew up in a poor neighborhood, in White Plains, NY, where there was violence and drugs and felt that I had to get away. New Mexico was warm, small and cheap. I came here 40 years ago to attend Western New Mexico University, a small frontier university, which was cheaper than going in-state. It took me four minutes to get over New York. It felt like I was meant to be here.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Spring 2011 Issue