Nakela Cook, MD, MPH


Chief of Staff, National Health, Lung and Blood Institute/ National Institutes of Health, Bethesda, MD

Dr. Cook is interested in working to eliminate health and health care disparities, particularly in cardiovascular outcomes through her clinical work, research, and health care policy. While at Massachusetts General Hospital (MGH), she was an active member of the Health Disparities Committee. She has conducted a project related to the ability of patients at community health centers to access secondary and tertiary levels of care and a study investigating referral patterns for cardiovascular care. Dr. Cook was named as the Administrative Fellow for the Cardiology Division 2004-2005; she has received the William A. Schreyer Award for her promise as a young investigator in cardiology at MGH, the MGH Fellows Award for Excellence in Clinical Teaching, the UAB Outstanding Young Alumni Award, and the American Heart Association Young Investigator Award.

Dr. Cook received her bachelor’s degree from the University of Alabama at Birmingham and her medical degree from Harvard Medical School. She completed her internal medicine residency at the Massachusetts General Hospital and continued on to a cardiology fellowship there. She received her M.P.H. with a concentration in Health Care Policy as part of the CFHU Fellowship in 2004. She is also an alumnus of the Boston Fellows leadership program of the Partnership, Inc.






Access to Specialty Care and Medical Services in the Community Health Center Population


Despite improvements in the overall health of the U.S. population, medically underserved populations and areas still exist. These populations experience higher rates of morbidity and mortality and are often uninsured, ethnic or racial minorities, lower income or geographically isolated.  Community health centers were first funded by the federal government in the mid-1960’s with a mission to provide primary and preventive health care for individuals in rural and urban medically underserved communities. Community health centers equalize access to primary care regardless of insurance status, but do not address the disparities in accessing secondary level care. The existence of barriers to access of specialty care and services for minority and uninsured populations may contribute significantly to disparities in health and health outcomes overall for the medically underserved. In the current US health system, disparate health outcomes between the medically underserved and the mainstream result in part from tiered levels of care based upon insurance status and accessibility to needed specialized services

More recently the safety net of community health centers has been explored. Research has identified that capacity for the uninsured is inadequate outside of health centers with strained specialty services, pharmaceutical services, dental care, and behavioral health care.1 Directors in ten sampled states reported that when patients at community health centers need care not provided on site, including specialty services and diagnostic procedures, cost is a main barrier to access specialty referrals.2 Even surveyed providers at academic health centers report access to specialty care very difficult for uninsured patients relative to those privately insured.3 This project evaluates access to specialty care and medical services with the following aims:

  •     Assess whether access to specialty medical care and laboratory/diagnostic procedures differs according to patients’ insurance status, and if so, identify potential barriers.
  •     Assess whether specialty medical care and laboratory/diagnostic procedures differ according to the proportion of minority patients served by community health centers.


Sample Executive Directors and Medical Directors at Community Health Centers across the nation were surveyed regarding access to specialty services. The data collection protocol consisted of an initial mailing to 1802 potential respondents followed by the mailing of reminder cards two weeks after initial mailing. A second mailing was sent to non-respondents.

Survey Development The survey instrument is a compilation of original and adapted items based upon discussions with key informants and literature review. Survey domains include health center characteristics, referral access, barriers to referral, and strategies to improve referral success by insurance status.

Statistical Analysis Preliminary analysis of 179 Executive Director surveys was performed. Descriptive statistics were used to describe the extent to which community health centers are experiencing problems with access to specialty referrals and laboratory and diagnostic procedures and to evaluate the ability to obtain needed referrals and specialty care according to insurance status. Bivariate tests were used to compare whether access to such services varies by insurance type.


Preliminary analysis of reports from Executive Directors at 179 community health centers revealed that the need for medically necessary referral does not differ by insurance status. However, obtaining referral to specialty services differs by insurance with uninsured patients attaining referral a lower percentage of the time. Executive Directors reported that barriers limit access to specialty care and medical services a greater extent of the time for uninsured patients compared to private patients. Executive Directors revealed that the creation or improvement of locally integrated referral networks as well as mandates for specialists to expand charity provision were strategies they thought would improve access to specialty services. Lastly Executive Directors’ perceptions of the quality of specialty services varies by insurance with uninsured patients having a lower perceived degree of quality.


Access to specialty care and medical services is a problem with greater perceived barriers for uninsured patients, and patients with Medicaid, relative to privately insured patients, despite equivalent need for medically necessary referrals.

Faculty Preceptors:

Magda Peck, ScD, Executive Director, CityMatCH
Paul Wise, MD, MPH, Co-Chief, Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital


    Felt-Lisk S, McHugh M, Howell E. Monitoring local safety-net providers: Do they have adequate capacity? Health Affairs 2002; 21(5):277-283.
    Gusmano MK, Fairbrother G, Park H. Exploring the limits of the safety net: Community health   centers and care for the uninsured. Health Affairs 2002; 21(6): 188-194.
    Weissman J, Moy E, Campbell E, et al. Limits to the safety net: Teaching hospital faculty report on their patients’ access to care. Health Affairs 2003; 22(6): 156-166.