DELIVERY SYSTEM GAP ANALYSIS MERCED COUNTY Prepared by Pacific Health Consulting Group November 21, 2013
What is the purpose of the gap analysis? Estimate how many uninsured residents will be eligible for Medi-Cal, Covered CA and the remaining ineligible following coverage expansion Describe the characteristics of the uninsured in Merced County, the safetynet delivery system that cares for them and current/future coverage programs Identify current and projected access/capacity challenges for low-income residents Highlight steps that County stakeholders can take to monitor and act on outcomes and challenges following the 2014 coverage expansion
Methodology Review and analyze publicly available data, including the Census, OSHPD, and the California Health Interview Survey (CHIS), among others Conduct targeted stakeholder interviews with major safety-net providers in Merced County, including Golden Valley Health Centers, Livingston Medical Group, Castle Family Health Centers, Mercy Medical Center, Los Baños Memorial Hospital, Central California Alliance for Health, Merced Health Department and Merced Human Services Agency Develop estimates of future eligibility for coverage among Merced s uninsured, including Medi-Cal, Covered California (with and without subsidies) and the remaining uninsured Model potential enrollment take-up rate and service demand changes for newly insured Merced residents
The Uninsured in Merced
Who are the uninsured in Merced? 51,700 Merced residents are uninsured (19.8%) 9 out of 10 uninsured are adults 18-64 Uninsured adults 18-64 (44,000), uninsured children <18 (6,000) More than 9 in 10 uninsured fall below 400% FPL 43% of the uninsured have income <138% FPL and 90% have income below 400% FPL 3 out of 4 uninsured residents are Latino, despite representing 54% of the population (34,000 uninsured Latinos) One-third of the uninsured are Non-Citizens (17,500) Source: 2009-2011 American Community Survey 3-Year Estimates, US Census Bureau
Merced s Safety-Net Delivery System
Major Safety-Net Providers In 2012, the four largest safety-net providers served up to 100,546 patients in Merced Co. Golden Valley Health Centers (8 medical sites, 4 dental) Castle Family Health Centers (3 medical sites) Mercy Medical Centers (3 medical sites) Livingston Medical Group (2 medical sites) Source: OSHPD 2012 Primary Care Utilization Reports
Patient Characteristics An estimated 31% of patients served by the four major safety-net providers are uninsured The vast majority of patients have income <100% FPL In all but one facility, Latinos represent two-thirds or more of the patient population Medi-Cal already represents the largest proportion of patients for each provider Two providers, Livingston and Golden Valley, serve a large number of agricultural workers
Services: Safety-Net Providers Comprehensive Primary Care for all ages are offered by each of the major safety-net providers Dental is only offered by Golden Valley at four sites (Merced, Los Baños, Planada, Le Grande) Mental/Behavioral Health services are offered by each of the providers, but limited Specialty services are offered on an extremely limited basis by three of four providers
Delivery System: Specialty Care Medi-Cal Limited network concentrated in Merced metropolitan area or out of county 67% of Merced Co. specialists contracted for Medi-Cal managed care, but overall number of specialists is low Uninsured - virtually no reliable referral destinations exist Safety-Net providers offer limited on-site specialty services for their patients Provider Golden Valley Castle Mercy Livingston On-Site Specialty Services Geriatrics, Podiatry, ENT, OB Allergy, Cardiology, Dermatology, ENT, Infectious Disease, Nephrology, Ortho, Pulmonology, General Surgery, Urology Ortho, Dermatology, GYN None Offered
Delivery System: Mental/Behavioral Health Effective 2014, CCAH will assume responsibility for low-severity Medi-Cal behavioral health services such as psychotherapy, medication management and psychiatric consults Co. Mental Health Services responsible for services for the severely mentally ill Safety-Net providers offer limited therapy/counseling and medication management services to their patients Provider Golden Valley Castle Mercy Livingston On-Site Mental/Behavioral Health Services - 15.0 FTE LCSW counseling/therapy services - Limited psychiatry/medication management - 4.0 FTE LCSW counseling/therapy services - Limited psychiatry/medication management ½ day/week counseling/therapy services (residents/county) - 2.0 FTE LCSW counseling/therapy services
Access and Barriers to Care
Access and Barriers to Care Access Provider perception of fairly reasonable access to primary care for Medi-Cal and uninsured patients Local specialist shortage contributes to limited local access to specialists for Medi-Cal patients (and long-distance travel to appointments) Local specialist shortage AND lack of willing providers contributes to extremely limited access to appointments for uninsured patients Limited counseling/therapy services offered by safety-net providers Providers have concerns about access to mental health services for severely mentally ill patients
Access and Barriers to Care Barriers Transportation Lack of accessible public transportation Travel to Merced metropolitan or out of county specialists for Medi-Cal patients (and uninsured) Addt l travel challenges for rural/southern Merced residents Cost Unknown/High specialty care costs for uninsured patients Long Waits Excessive wait times for specialty care among the uninsured Patient Behavior/Education Lack of patient awareness about provider resources and appropriate utilization of preventive health services
Access to Care: Primary Care Statewide data on the number of physicians serving Merced County suggests that there is limited capacity But
Access to Care: Primary Care Merced stakeholders report that there is fairly reasonable access to primary care services for Medi-Cal and uninsured patients According to CCAH, 80% of Merced PCPs are contracted for Medi-Cal managed care Provider A Provider B Provider C Provider D 3 rd Next Available Appointment (Non-Urgent) 3 Days 5-10 Days 11 Days 2-3 Weeks
Access to Care: Specialty Care Statewide data on number of physicians serving Merced Co. suggests that capacity is extremely limited number of practicing specialists at 33% of the overall California average And
Access to Care: Specialty Care Merced stakeholders agree that specialty capacity is limited for BOTH Medi-Cal and uninsured Medi-Cal patients often have to travel significant distances for care, particularly pediatric specialties Uninsured patients have little or no access (note: differences for hospitalaffiliated vs. FQHC/Look-Alike clinics) Top Barriers: Cost, Transportation, Specialist Shortage
Access to Care: Specialty Care Orthopedics, Dermatology, ENT, Endocrinology and Neurology are the most difficult to access specialties Specialty # of Providers Citing as Difficult to Access Orthopedics 5 Dermatology 4 ENT 4 Endocrinology 3 Neurology 3 According to CCAH, the most difficult specialties to secure adequate networks for include: ENT, Neurology, Dermatology, Hematology/Oncology, and Physical Medicine and Rehab
Access to Care: Specialty Care Provider Voices: It s not a question of more difficult. There is really no referral capacity for those that are uninsured. Some Medi-Cal referrals we can take care of internally where we have a referral source. We really do not have good referral sources [for uninsured patients]. For uninsured patients it is always an issue of cost. For all of our patients, especially pediatrics, transportation is a significant issues. Most specialists are not in the community.
Access to Care: Mental/Behavioral Health Service Need Counseling/Therapy to address anxiety, depression, co-occurrence with medical conditions (diabetes, cardiovascular disease) Stakeholder Perceptions on Access Safety-Net providers have developed capacity and expertise Services not sufficient, but a start Psychiatry/Medication Management to support patients on psychotropic medications, psychiatric consults Large safety-net providers can offer limited medication management Severe mental illness/advanced mental health needs requiring residential treatment or intensive intervention Concerns about access for Medi-Cal or uninsured patients
Access to Care: Mental/Behavioral Health Provider Voices: Mental health is a huge issue for the whole county all providers. It doesn t matter if you have insurance or not. Mental and behavioral health services will be something we struggle with for many many years.
Eligibility for Coverage under the ACA
Program Eligibility Changes Major coverage changes include the following: Medi-Cal expansion to include single adults, extend to 138% FPL Expected transition of all 1,400 MAP enrollees to Medi-Cal Covered California subsidies from 138-400% FPL
Uninsured Eligibility for Coverage Close to 30,000 uninsured citizens are almost certainly eligible for Medi- Cal or Covered California subsidies 7,500 of the 17,500 uninsured non-citizens are likely eligible for Medi- Cal or Covered California enrollment 10,000 uninsured non-citizens are likely to remain ineligible for any coverage programs ACA Coverage Eligibility Estimate Medi-Cal* 18,700 Covered CA Subsidy* 18,800 * Covered Include estimates CA of No both Subsidy* citizen and non-citizen eligibles 4,400 Remaining Uninsured Ineligible 10,000 * Include estimates of both citizen and non-citizen eligibles Source: 2009-11 ACS Community Survey
Impact of Coverage Expansion on Patient Demand and Access
Impact of Expansion on Demand How, will enrollment into coverage by the uninsured affect service demand and access in Merced? Changes in demand will be driven by several factors: 1) Enrollment Take-Up Rates by eligible uninsured 2) Additional demand by existing patients 3) New patients entering the system
Enrollment Take-Up Rates Too early to speculate on what proportion of the eligible will enroll in coverage, BUT several factors will influence enrollment Awareness/Perceptions of Coverage Options (Publicity/Outreach) Affordability Ease and Efficiency of Enrollment (Provider enrollment support) Linguistic and Cultural Access (Provider enrollment support) All providers interviewed anticipate a gradual increase in enrollment
Enrollment Take-Up Rates
Safety-Net Penetration Rate An estimated 6 in 10 uninsured Merced residents are already utilizing health services According to 2012 OSHPD data, up to 31K, or 58% of Merced uninsured already receive care from major safety-net providers According to the 2011-12 California Health Interview Survey (CHIS), 57.5% of uninsured Merced residents have a usual source of care
Demand Model: Assumptions At least 6 in 10 newly insured patients (and probably more) will already have a usual source of primary care Primary care utilization will increase incrementally for those with a usual source of care and more significantly for new patients Coverage Type Merced 2012 OSHPD Annual Visits Per Patient Sliding Scale/Self-Pay/Free 1.41 Medi-Cal 3.79 Private Insurance 2.61
Demand Model: Assumptions Since uninsured specialty access so limited, demand will increase significantly for all newly insured Sicker/Older residents will enroll first, so per patient increases in specialty demand will be higher if fewer residents enroll
Demand Model: Preliminary Findings 4,195 12,570 new patients in the system 5-15% increase in primary care utilization Proportional increases in specialty care utilization with more per patient utilization at lower take-up rates
Service Capacity Expansion All providers reported efforts to more efficiently utilize existing facilities and providers Repurposing non-clinical space to expand exam rooms Workflow efficiency improvements (e.g. Coleman) Most providers are actively recruiting physicians for a combination of existing and new positions (10.0 FTE) No providers are formally planning to add new facilities
Provider Recruitment Challenges Filling provider openings is a perpetual need and many remain unfilled for 12 months or more No physician residency pipeline in place for safety-net providers Competitive environment for limited pool of physicians pushes compensation demands higher Nurse Practitioner and Physician Assistant recruitment faces similar challenges Maintaining our provider staff has really been our biggest challenge- the top issue on our list is provider recruitment. It is becoming extremely competitive. The few [PCPs] here and there are now being heavily recruited by Kaiser, the hospital foundations and others. We can t compete.
Discussion Questions Based on your experiences in the community, do our findings resonate with your experiences and the experiences of your clients? Do you have ideas about other ways to measure access? What data/information could this group track to monitor outcomes and impacts?