California Program on Access to Care Findings

C P A C February California Program on Access to Care Findings 2008 Increasing Health Care Access for the Medically Underserved in Four California Counties Annette Gardner, PhD, MPH Some of the most active and creative experimentation with expanding health care coverage today is taking place at the local level. This study examines four California counties that are adopting policies and programs to strengthen their county-level health care systems. The four counties are: Fresno, Humboldt, Santa Cruz, and Solano. All of these counties have populations under one million and limited resources. Yet, all have mobilized stakeholders and created infrastructures to address health care barriers. We begin with a brief overview of county health care systems in general, followed by a synopsis of the systems currently in place in the four California counties, as well as the access issues these counties face. Next, we will examine the numerous and diverse approaches these four counties are using to expand health care coverage for vulnerable populations. Overview California counties bear significant responsibility for the health of their residents. Under California law, counties are the providers of last resort for lowincome, uninsured people with no other source of care. There is significant diversity in how counties meet the health care needs of vulnerable populations, including the medically indigent and Medi-Cal populations. Some counties have county-run health care delivery systems while other counties contract out for these services. Some counties have a public Medi-Cal managed care plan, such as a Local Initiative or a County Organized Health System, and are well positioned to offer insurance coverage to new target populations. There are also commonalities in how counties can leverage their resources and mobilize their communities to expand health care access for the medically underserved. For example, 34 rural counties participate in the County Medical Services Program (CMSP) for the medically indigent, while the remaining 24 counties participate in the Medically Indigent Services Program (MISP). County Synopsis Fresno County is located in the Central Valley. Fresno is primarily a rural and agricultural county with a large Latino community. It has a population of 874,000 people; approximately 18 percent of the population is uninsured. It is a Medically Indigent Services Program (MISP) county, and it contracts out services for the medically indigent to an entity called Community Medical Centers. Medi-Cal managed care services are provided through two commercial plans, Blue Cross and Health Net. Humboldt County is located on the Northern California coast. Humboldt is a rural county with a population of 128,000 people; approximately 16 percent of the population is uninsured. It is a County Medical Services Program (CMSP) county, and services are provided through non-county clinics and private hospital emergency rooms. Medi-Cal services are delivered through a Fee-For-Service (FFS) model. Santa Cruz County is located on the Central Coast. Santa Cruz is a partially rural county in close proximity to the Bay Area. It has a population of 251,000 people; approximately 12 percent of the population is uninsured. It is a MISP county, and provides services through county-operated health clinics and private hospitals. Medi-Cal services are provided through a County Organized Health System (COHS) model, the Central Coast Alliance for Health. Solano County is located between San Francisco and Sacramento. Solano is mostly a suburban county with a population of 404,000 people; approximately 7 percent of the population is uninsured. It is a CMSP county, and services for the medically indigent are provided by county and non-county clinics. Medi-Cal services are provided through a COHS model, the Partnership Health Plan of California. Although the four counties include rural and small city areas and vary in size and population, they share some

of the same access issues, notably lack of insurance for low-income adults and lack of specialty services, including dental care and mental health care. Three of the four counties have significant geographic barriers and transportation issues. Lack of primary care services are more pronounced in Fresno and Humboldt counties than in the other two counties. There are also some differences in the underserved populations. Fresno has an underserved farm worker population whereas Santa Cruz has an underserved Medicare population. Addressing the barriers to health care in these counties poses major challenges. A central issue is the lack of flexibility in existing programs targeting low-income populations, such as MISP/CMSP, Medi-Cal, and Medicare. The four counties also have minimal discretion in leveraging limited public resources. However, some leveraging opportunities recently arose in the areas of outreach and enrollment funding for children in new and existing health insurance programs. Methods The UCSF investigator conducted one-hour phone interviews in December of 2006 with three or four informants in each of the four counties. The goal was to identify important factors facilitating increased access to care in counties with limited resources. Selection was based on the counties involvement in countywide access activities, such as a Children s Health Initiative (CHI), and the presence of an access coalition to plan and/or implement the activities. The study asked informants to describe various features of their county health care system, both current and evolving. The informants interviewed included members of the county health agency, private sector providers and/or health insurance plans, the leadership of the local access coalitions, and the leadership of Medi-Cal managed care plans. Findings The interviews revealed four primary factors that contribute to expanding access to health care: 1) planning and implementing access initiatives, 2) establishing an access coalition, 3) identifying funding sources, and 4) expanding information technology. When examining county access initiatives in the four counties, the study found similarity in the types of initiatives selected, but great diversity within each type. Specifically, the study found that: All four counties recently launched health insurance programs for children who are not eligible for existing public programs; three counties (Fresno, Santa Cruz, and Solano) have comprehensive Healthy Kids programs, and one county (Humboldt) launched CalKids, a limited insurance program. These programs tend to be part of a Children s Health Initiative or CHI, which also includes outreach and enrollment activities targeted to children and their families. Three of the counties are developing insurance programs targeting different adult populations. Fresno is seeking to insure farm workers. Santa Cruz is seeking to cover indigent adults using State SB 1448 funding. In Humboldt County, a task force is exploring the feasibility of a community health plan, which would expand coverage to uninsured adults. Humboldt is also exploring coverage of In Home Service Support (IHSS) workers. Solano already has insurance coverage for IHSS workers. Three of the counties have activities proposed or underway to reform programs for medically indigent populations. Some of these proposed changes are more modest than others. Santa Cruz hopes to expand its Medi-Cruz program, which currently provides coverage for an isolated medical event, and make it more like an insurance program with a six-month enrollment period. Solano is working with Kaiser Permanente to increase access to specialty care. Humboldt is looking to add behavioral services to its existing program. All four counties have outreach, enrollment, and insurance retention programs underway, which are in tandem with launching their child insurance programs. All four counties have activities underway to educate people about insurance options and/or use of services. Usually these education activities are combined with outreach and enrollment activities. All four counties have initiatives underway to expand county and/or non-county clinics, such as adding new sites and hours of services.

Two counties (Fresno and Solano) have initiatives underway to train and/or attract more providers. The other two counties (Humboldt and Santa Cruz) are considering ways to attract providers, particularly specialists. For example, the Medical Society in Humboldt County is leading an effort to form a multi-specialty group practice to help recruit and retain physicians. There are diverse options here, such as partnering with academic institutions to train more doctors, applying for designations to attract providers (designations such as Health Professional Shortage Areas), and working with health care organizations to attract specialists. Significant public and private support are being leveraged to develop information systems to house, track, and share data among providers. Two counties (Fresno and Santa Cruz) implemented One-e-App, a web-based system to enroll people in a range of social service programs. Humboldt is in the process of implementing One-e-App. Solano implemented CalWin, a system to determine eligibility for CalWORKS social services. All four counties have efforts underway to coordinate some aspect of their health care delivery system, particularly the integration of behavioral health services in a primary care setting. This may continue to be an area of emphasis as counties allocate their Proposition 63 funds under the Mental Health Services Act. When examining access coalitions, the study found these groups are an important vehicle for planning and implementing access initiatives. Coalitions provide the infrastructure and staffing that other health care agencies often lack. The study showed that: Three of the four county coalitions (Humboldt, Fresno, and Santa Cruz) received funding under the federal Healthy Communities Access Program, a grant program that has played a major role in coalescing or evolving coalitions throughout the U.S. Except for Fresno s coalition, which is comprised primarily of safety net providers, these coalitions tend to represent all of the health care stakeholders, including health care providers, the county health or public health agency, community-based organizations, foundations, and insurers. Coalitions are able to address the unique issues in their respective communities. For example, Humboldt s coalition launched an Employee Assistance Program (EAP). Santa Cruz s coalition is focusing on the Locality 99 issue (low Medicare reimbursement for rural counties). Fresno s coalition is focusing on information technology and the implementation of One-e- App. Lastly, Solano s coalition is increasingly involved in health care disparities. The Solano Coalition for Better Health, the oldest of the four coalitions, is the primary agency for the county s access initiatives. It is responsible for directing county Tobacco Settlement dollars to access initiatives. It has a three-year strategic plan and submits its recommendations to the county s Board of Supervisors for approval. Additionally, it partners with the county on securing funding for diverse initiatives and provides input on the county s program for the medically indigent. Fresno Health Community Access Partners, the newest of the four coalitions, may be evolving into the lead agency. It includes members from the safety net provider community, and has a well-developed infrastructure to plan and implement access programs, such as Healthy Kids. Humboldt and Santa Cruz are between the other two counties in age and development. Both coalitions are recognized as lead agencies that work in partnership with their respective counties, represent all the health care stakeholders, and have a track record of achievements. However, these coalitions rely on grant funding and are still developing some of their infrastructure, such as a strategic planning process. While all four coalitions must address ongoing resource constraints and episodic issues like competition among stakeholders, there are many factors that facilitate the success of these organizations, including: 1) high stakeholder commitment and involvement, particularly among the CEOs from participating organizations; 2) a good track record of accomplishments; 3) agreement on coalition goals; 4) established relationships among participants; and 5)

staff support to convene meetings, facilitate communications, and assist with planning processes. Although broad-based participation may be important, coalition representatives emphasized the need to have sustained participation by the leadership of coalition organizations. Funding for access initiatives comes from many different sources and tends to be project-driven. The UCSF study found that: Except for Solano, which has dedicated Tobacco Settlement funds to improve access to health care, funding in the remaining three counties is piecemeal. Public funding includes State support for outreach and enrollment in existing public insurance programs, federal support via the Healthy Communities Access Program, and local First 5 (Prop 10) funding for CHI activities. Funding for the medically indigent comes from a combination of county general fund support (GFS) and Realignment (State) funding. Private foundation support continues to be strong and includes premium assistance for children s coverage programs, safety net provider support, and technical assistance for coverage expansions. While grant funding affords coalitions the opportunity to expand in new directions, such as quality improvement and workforce development, it isn t sustainable. Representatives from the four counties described the diverse information technology (IT) initiatives underway, as well as access coalition involvement in these initiatives. The study found that: All four counties are in different stages of implementing IT systems at the county and/or provider level. Most counties are evolving toward a centralized data system. However, these counties are approaching data system development from different directions and building on different IT applications. Telemedicine capacity appears to be provider driven, and is used in rural areas where there is limited access to providers, particularly specialists. Similarly, electronic information systems used to exchange information are limited to individual providers. Santa Cruz and Solano have cross-provider applications. Policy Recommendations Policies providing local flexibility in changing state and federal programs such as MISP/ CMSP, Healthy Families, and Medi-Cal would help counties increase access to care for lowincome populations. County diversity requires sensitivity to local conditions and needs, and precludes a one size fits all approach. Local flexibility to experiment with existing programs has the potential to create new models that meet the needs of each county s uniquely diverse population. County stakeholders would benefit greatly from a stable and coordinated funding environment. Currently, counties grapple with chronic resource constraints and rely on piece-meal and project-driven funding from a combination of public and private support. A stable funding environment would allow counties more flexibility to target the unmet health care needs of their residents, and to explore new areas for health care expansion. Support of multi-stakeholder coalitions will greatly assist counties with few resources. The presence of a coalition dedicated to planning and implementing countywide access initiatives may be a key factor in overcoming health care access barriers. Coalitions will allow counties with limited resources to pursue strategies they might not otherwise undertake and catch up with counties that have more resources. A coalition approach affords counties the ability to secure resources, coordinate among stakeholders, and implement programmatic expansions to provide health care for vulnerable populations. Three counties (Fresno, Humboldt, and Santa Cruz) are implementing One-e-App, due to support from the California Health Care Foundation.

Annette Gardner, PhD, is an academic specialist at the Philip R. Lee Institute for Health Policy Studies and an assistant professor in the Department of Social and Behavioral Sciences at the University of California, San Francisco. For more information, contact: Annette Gardner, PhD, MPH Assistant Professor Department of Social and Behavioral Sciences UCSF School of Nursing Academic Specialist Philip R. Lee Institute for Health Policy Studies University of California, San Francisco 3333 California Street, Suite 265 San Francisco, CA 94118 tel: (415) 514-1543 fax: (415) 476-0705 email: annette.gardner@ucsf.edu Funding for this study was provided by the California Program on Access to Care, an applied policy research program administered through UC Berkeley s School of Public Health in cooperation with the University of California Office of the President. The author s views do not necessarily represent those of CPAC, U.C. Berkeley s School of Public Health, or the Regents of the University of California. California Program on Access to Care California Policy Research Center University of California Office of the President 1950 Addison Street #203, Berkeley, CA 94704-2647 Tel: 510-643-3140 Fax: 510-642-7861 Email: cpac@ucop.edu http://www.ucop.edu/cprc/cpac.html