Swimming Upstream: Improving Access to Indigent Health Care in the Midst of Major Economic Challenges

© 2010, The Urban Institute Health Policy Center • www.healthpolicycenter.org page 1 Introduction In early 2008, San Mateo County embarked on a comprehensive health system redesign initiative. This initiative is designed to improve access to high-quality care for uninsured and underinsured adults, while supporting the financial sustainability of the San Mateo Medical Center delivery system. The launch of this effort, however, coincided with mounting fiscal challenges associated with the economic recession and state budget crisis that threatened the county’s ability to support these efforts. Despite these challenges, the county has made significant progress in improving access and patient care. The purpose of this brief is to present initial findings from a comprehensive evaluation conducted by the Urban Institute1 and the University of California San Francisco and to offer lessons for local and national policymakers, county leaders, program administrators, and providers about how progress is possible despite severe financial obstacles. The Context San Mateo County’s Health System includes the San Mateo Medical Center (SMMC), an integrated delivery system with a public hospital,2 six adult primary care clinics, four pediatric clinics, two teen/youth clinics, four dental clinics, obstetrics, and a handful of additional specialty clinics. All of the county clinics are federally qualified health centers. Fees for uninsured patients are charged on a sliding scale relative to income. For its lowest income ―medically indigent‖ patients who fall within the county’s legal responsibilities, the county has a locally created coverage program, ACE (Access and Care for Everyone), that has been in place for two decades.3 Despite being one of the wealthiest counties in the United States, San Mateo County has felt the strain of the recent recession. Residents of the county have experienced an erosion of employer-sponsored insurance, and patient cost-sharing (premiums and co-pays) responsibilities have risen. This has led to an increased reliance on the public health care system, which has created additional strain on the county’s resources. Without resources for capacity expansion, providing timely access to publicly funded primary care appointments has been a significant challenge. Swimming Upstream Improving Access to Indigent Health Care in the Midst of Major Economic Challenges Sarah Benatar, Dana Hughes, Embry M. Howell, Genevieve Kenney December 2010 © 2010, The Urban Institute Health Policy Center • www.healthpolicycenter.org page 2 Commitment to Improving Health Care Quality and Access San Mateo County has exceptionally committed leaders and staff who have a history of working co-operatively and creatively to address the health care needs of the underserved. With this latest initia-tive, the county leadership set out to achieve the following goals for expanding coverage and improv-ing access to health care:4 Increase access to care for low-income adults; Improve the financial viability of the SMMC system; Leverage all partners (public and private) in providing care to the uninsured and underinsured; Implement seamless coordination of care across providers; Improve the ease of use of the safety net; and Expand coverage to all adults (with an ultimate goal of covering 36,000 to 44,000 uninsured adults). The county has taken several steps toward achieving these goals. For example, it won a three-year grant of $7.5 million annually from California’s Medicaid Hospital Financing Waiver. With this sup-port, the county was able to secure federal matching funds to cover uninsured, documented adults whose income is less than 200 percent of the federal poverty level. This has helped to finance costs to the county in caring for uninsured adults and improving access to primary care. The county contin-ues to cover adults with incomes less than 200 percent of federal poverty who do not qualify for the federally funded coverage initiative (primarily due to documentation status) through county-funded coverage known as the ―ACE County‖ program. Benefits, co-payments, and care co-ordination are identical for ACE and ACE County enrollees and are very similar to those of the Medi-Cal program. The provider network for ACE and ACE County enrollees is comprised of the SMMC clinics, emer-gency room, and hospital; the Ravenswood Family Health Center (a private, federally qualified com-munity health center); and physician practices and other hospitals that provide care unavailable at the SMMC. The county and Ravenswood Family Health Center (RFHC) have launched ambitious efforts to rede-sign the care delivery model in their safety net clinics. These efforts include four components: Team-based care, to increase efficiency and leverage physician time through the use of other health professionals, such as nurses. Patients are seen by the same physician, nurse and cleri-cal staff team each time they visit a clinic. Disease