Sacramento Region Health Care Partnership Market Analysis Data Presentation www.sierrahealth.org/healthcarepartnership
Sierra Health Foundation Health Program 2
Tom Meyer/Syndicated cartoonist 3
Study Partners 4
Study Team The Abaris Group Mike Williams, Project Lead Marsha Regenstein, PhD Alaina Dall Juliana Boyle Mark Zocchi Chuck Baucom Public Health Institute Carmen Nevarez, MD, MPH Project Lead Marisel Brown, MPH, MSBA Elaine Zahnd, PhD Nancy Shemick Amy Neuwelt, MPH Art Chen, MD Hatches Consulting Barrett Hatches, PhD 5
Impact of the ACA in the Region Increase insurance coverage 52% (117,947) are expected to receive Medi-Cal coverage and the remainder are expected to find insurance in the individual health insurance exchange. Sacramento Region Insurance Coverage 2009 and 2014 2014 Insurance 2009 Percent Movement 2014 Percent Employer 1,108,028 52.0% 1,108,028 52.0% Individual 103,973 4.9% 109,610 213,583 10.0% Medi Cal 369,057 17.3% 117,947 487,004 22.8% Medicare 248,432 11.6% 248,432 11.6% Uninsured 303,306 14.2% (227,557) 75,749 3.6% Total 2,132,796 2,132,796 Source: MCIC Chicago, 2012 6
CHC Visit Projections Projected (4) increase of community health center visits Projected CHC Visits, 2012 2016 800,000 680,745 700,000 646,842 600,000 500,000 472,662 400,000 300,000 Change due to ACA 200,000 Linear Increase 100,000 2010 Reference 0 2010 2012 2014 2016 Source: OSHPD Primary Care Clinic Utilization Data Files, 2006 2010; MCIC Chicago; The Abaris Group 2012 7
ACA MAPS Maps 1:7 Uninsured as a Percentage of the Population Sacramento County Within Zip Codes 2009 95691 95837 95691 1 95661 95626 95843 13% 95610 95621 958 42 95660 956 73 15% 15% 13% 13% 13% 95835 95652 95841 95628 95838 1 95834 16% 16% 16% 95 82 1 95608 95833 16 % 95822 956 91 15% 95822 1 15 % 95831 15% 19 % 95815 18% 16% 95825 95864 95816 95819 19% 19% 16% 18% 95827 95817 18% 95826 1 95820 18% 17 % 95670 17% 95655 958 24 17% 95828 95 82 9 95830 95823 17% 14 % 95 66 2 16% 95 74 2 95630 16% 956 83 Sacramento 16 % 95 83 2 95758 16% 95 62 4 956 93 16 % 956 39 95757 1 95 63 8 95690 956 32 1 95680 95690 Percentage of Uninsured by Zip Code Suppressed Zips 956 41 0.01% - 5.00% 5.01% - 10.00% 10.01% - 13.00% 945 71 13.01% - 15.00% 15.01% - 19.00% 8
ACA MAPS Maps 1:8 Uninsured as a Percentage of the Population Sacramento County Within Zip Codes Projected for 2014 95691 95837 95691 95626 95843 95660 3% 95842 95673 3% 3% 95835 3% 95652 95841 95838 95834 95 82 1 95608 95833 95815 5% 95825 95864 5% 5% 95816 95819 95827 95822 95817 95691 95826 95820 95822 95824 95831 95828 95829 95 82 3 3% 95661 95610 95621 95662 95628 3% 95670 95655 95830 95742 95630 3% 95683 Sacramento 95832 95758 95624 95693 95639 95 75 7 95 6 38 95690 95632 95680 95690 Percentage of Uninsured by Zip Code Suppressed Zips 95641 0.01% - 2.00% 2.01% - 3.00% 3.01% - 4.00% 94571 4.01% - 5.00% 9
Percentage of Low Income (<200% FPL) in Sacramento County, 2010 31.0% of Sacramento county residents (~430,000 people) are lowincome (<200% FPL) % Low Income Pop at or below 200% FPL, 05 09 (est.) < 15% 15 30% 30 45% Source: U.S. Census Bureau, American Community Survey 2005 2009 5 yr est www.udsmapper.org 45 60% >60% CHC (FQHC) FQHC Look Alike 10
Percentage of Low Income Population Using a Federally Funded CHC, 2010 Less than 10% of the lowincome population (<200% FPL) in Sacramento County visited a federally funded CHC in 2010 % of Low Income Using a Federally Funded CHC <20% 20 40% 40 60% 60 80% >80% Rural Health Clinic FQHC Look Alike CHC (FQHC) Source: U.S. Census Bureau, American Community Survey 2005 2009 5 yr estimate, Health Resources and Services Administration (HRSA) Uniform Data System (UDS); www.udsmapper.org 11
Change in Utilization of Federally Funded CHCs in Sacramento County, 2008 2010 Sacramento County saw a 65.8% increase in utilization of federally funded CHCs between 2008 and 2010 (~12,500 new patients) 2008 2010 % Change in Federally Funded CHC Patients 50 100% loss 10 50% loss <10% change 10 50% gain 50% or more gain Newly Served Rural Health Clinic FQHC Look Alike CHC (FQHC) Source: Health Resources and Services Administration (HRSA), Uniform Data System (UDS); www.udsmapper.org 12
CHC Visits per 1,000 Population Sacramento Region had considerably lower visits to community health centers than the statewide average (411) and several other key counties. CHC Visits per 1,000 Population, 2010 San Diego County Alameda County 567 616 California 411 Santa Clara County Sacramento region Contra Costa/Solano Counties Orange County 222 220 211 209 0 100 200 300 400 500 600 700 13 Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; 2010 U.S. Cens us
CA CHCs per 10,000 Population Comparison The Sacramento Region had the fewest CHCs, including fewer FQHCs in most regions studied. CHCs per 100,000 Population, 2010 Alameda County San Diego County California Contra Costa/Solano Counties Santa Clara County FQHCs FQHC Look Alikes Non FQHC Orange County Sacramento region 0.00 1.00 2.00 3.00 4.00 5.00 Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; 2010 U.S. Cens us 14
Demand: CHC Payer Mix Only 1.3% of all CHC visits are paid for by private insurance. Medi Cal is the largest payer group for CHCs in Sacramento County and now covers 43. of all CHC visits. Medicare visits have also grown from 4.3% of all visits in 2006 to 8.1% in 2010. Percentage of CHC Encounters by Payer Source, 2006 to 2010 2010 Medi Cal 2009 2008 2007 2006 0% 20% 40% 60% 80% 100% Sliding Scale, Self Pay & Free Indigent Other Medicare Private Sacramento County Primary Care Clinic Payer Mix, 2006 to 2010 Avg. Annual Payer Source 2006 2007 2008 2009 2010 % Change Medicare 4.3% 3.9% 8.1% 6.6% 8.1% 17. Medi Cal 24.2% 29. 35.3% 42.9% 43. 15.8% Indigent 1.0% 1.0% 1.3% 0.8% 0.7% 7.6% Private 1. 1.7% 1.5% 1.7% 1.3% 1.5% Self Pay & Free 10.7% 10.2% 6.8% 6.2% 9.8% 2.1% Other 58.5% 53.8% 47.0% 41.8% 36.6% 11.0% Source: OSHPD Primary Care Clinic Utilization Data Files, 2006 2010 Note: "Other" includes breast cancer, Child Health and Disability Prevention Program, Expanded Access to Primary Care, and Family PACT encounters. 15
Demand: Preventable/Avoidable ED Discharges 41.8% of all ED discharges were either nonemergent conditions or conditions that could have been treated in a primary care setting. Sacramento County Residents Emergency Department Visits, Estimates of Preventable/Avoidable Visits, 2010 Visit Classification: All Patients Total % Visits Classified as ED Care Not Needed: 89,005 41.8% Non emergent 45,073 21.2% Emergent/Primary Care Treatable 43,932 20.6% Visits Classified as ED Care Needed: 38,928 18.3% Emergent ED Care Needed Preventable/Avoidable 12,934 6.1% Emergent ED Care Needed Not Preventable/Avoidable 25,994 12.2% Other Categories Not Classified by Algorithm: 84,944 39.9% Drug/Alcohol 2,477 1.2% Psych 5,937 2.8% Injury 49,065 23.0% Unclassified 27,465 12.9% Source: OSHPD 2010 Emergency Department Data & NYU ED Algorithm Region Average 40. Definitions under ED Care Not Needed: Non emergent The patient s initial complaint, presenting symptoms, vital signs, medical history, and age indicated that immediate medical care was not required within 12 hours; Emergent/Primary Care Treatable Based on information in the record, treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation, and no procedures were performed or resources used that are not available in a primary care setting (e.g., CAT scan or certain lab tests); 16
Demand: Preventable/Avoidable ED Discharges by Payer Mix Compared with other payers, Medi Cal and self payers had a higher percentage of ED visits that were either non emergent or could have been seen in a primary care setting. Sacramento County Residents Emergency Department Visits, Estimates of Preventable/Avoidable Visits, 2010 Payer Visit Classification: Self Pay Medi Cal Commercial Medicare Total % Total % Total % Total % Visits Classified as ED Care Not Needed: 16,177 44.1% 30,042 46.9% 27,274 38.6% 13,456 37.3% Non emergent 8,412 23.0% 15,615 24. 13,513 19.1% 6,507 18.0% Emergent/Primary Care Treatable 7,764 21.2% 14,427 22.5% 13,761 19.5% 6,949 19.3% Visits Classified as ED Care Needed: 5,961 16.3% 10,617 16.6% 13,117 18.6% 8,278 23.0% Emergent ED Care Needed Preventable/Avoidable 2,276 6.2% 4,300 6.7% 3,520 5.0% 2,503 6.9% Emergent ED Care Needed Not Preventable/Avoidable 3,684 10.1% 6,317 9.9% 9,597 13.6% 5,775 16.0% Other Categories Not Classified by Algorithm: 14,514 39.6% 23,353 36.5% 30,276 42.8% 14,323 39.7% Drug/Alcohol 774 2.1% 590 0.9% 626 0.9% 340 0.9% Psych 1,130 3.1% 1,580 2.5% 1,676 2. 1,299 3.6% Injury 8,287 22.6% 12,412 19. 20,154 28.5% 6,829 18.9% Unclassified 4,323 11.8% 8,771 13.7% 7,820 11.1% 5,855 16.2% Source: OSHPD 2010 Emergency Department Data & NYU ED Algorithm Region Average 41.9% (Self Pay) 46.1% (Medi Cal) 17
Safety Net Capacity: CHC Financial Metrics In 2010, total expenses exceeded gross revenues by 10.6%. 43% (16) community clinic sites reported a loss (avg. = $1.2 million) 5 (20) community clinic sites reported a positive margin (avg. = $520,000) 3% (1) community clinic reported no loss/gain CHC Total Net Revenues, 2010 $15,000,000 $10,000,000 $5,000,000 e u $0 n v e e R $5,000,000 t e N l $10,000,000 ta T o $15,000,000 $20,000,000 $25,000,000 N=16 $20,333,464 Source: Note: OSHPD 1 community Primary clinic Care reported Clinic no Utilization loss/no profitdata file, 2010 $10,401,134 N=20 Total Net Revenues = $(9,932,000) Clinics with Loss Clinics with Positive Margins 18
CHC Total Net Revenues, 2006 2010 Since 2006, CHC losses have exceed revenues. In 2010, 19 CHC sites reported losses totaling $9.1 million and 18 CHC sites reported positive margins totaling $4.4 million. CHC Total Net Revenues, 2006 2010 2010 2009 $4,404,139 N=3 $7,267,579 $6,549,394 $9,130,472 2008 $4,034,838 $6,150,357 2007 $3,046,152 $3,044,701 N=4 2006 $3,598,061 Net Revenues 2006 2007 2008 2009 2010 Total CHC Margin 3. 0.0% 2.9% 0.9% 4.8% No. of clinics w/ + Margins 18 19 19 23 18 No. of clinics w/ Margins 13 8 13 10 19 Source: OSHPD Primary Care Clinic Utilization Data Files, 2006 2010 $5,840,320 Clinics with Negative Margins Clinics with Positive Margins 19
CHC Payer Mix Projections Medi Cal payers are projected to make up 61. of CHC visits by 2016. The percentage of uninsured visits is projected to decline from 15% in 2010 to 2.6% by 2016. Note: Projections are based on a decline in the uninsured population and increases in Medi Cal coverage and individuals that will purchase insurance through the health exchange. Projected CHC Payer Mix, 2012 to 2016 2016 Medi Cal 2014 2012 2010 0% 20% 40% 60% 80% 100% Sliding Scale, Self Pay & Free Indigent Other Medicare Private Projected CHC Payer Mix, 2012 2016 Payer Source 2010 2012 2014 2016 Medicare 9.0% 9.6% 9.7% 10.2% Medi Cal 40. 46.3% 58.6% 61. Indigent 4.5% 4.1% 3.5% 3.3% Private 4.8% 4.9% 7.0% 7.1% Self Pay & Free 15.0% 11.8% 2.7% 2.6% Other 26.3% 23.3% 18. 15. Total Visits 472,662 522,655 616,384 680,745 Source: OSHPD Primary Care Clinic Utilization Data Files, 2006 2010; MCIC Chicago; The Abaris Group 2012 Notes: "Other" includes breast cancer, Child Health and Disability Prevention Program, Expanded Access to Primary Care, and Family PACT encounters. 20
Major Themes Physicians Perspective Access to specialists is related to hospitals desire to avoid patient populations with health coverage that does not provide sufficient reimbursement for hospital based services. Geographic managed care definition of what constitutes a network contributes to patients not being able to access specialists within a reasonable distance. Health information exchange is needed across the region so health information systems can communicate.
Ten Key Data Observations 1. While the current safety net in the region has many challenges, the advent of ACA allows the community the opportunity to re-think its approach for primary care for the safety net. 2. Demand will grow and accelerate under ACA for the safety net population. 3. This newly insured population through a Medi-Cal product will likely be sicker and have a significantly higher level of chronic disease. 22
Ten Key Data Observations 4. The primary-care capacity (CHCs and EDs) to treat these patients has grown, but likely will reach capacity prior to full adoption of ACA. 5. The number of CHCs has grown, but falls short of many other similar size regions of the state. 6. Medi-Cal as a payer will accelerate under ACA and continue to be the largest payer source for CHCs. 23
Ten Key Data Observations 7. There is considerable overuse of expensive hospital services for the safety net and in particular EDs. 8. 50% of the region s CHCs are financially challenged and that number is growing. 24
Ten Key Data Observations 9. The number and location of FQHCs in the region are limited and many CHCs are not able to take advantage of a number of financial incentives afforded to FQHCs. 10.The healthcare safety net lacks a lead agency, coordination and integration. 25
Project Takeaways Capacity (physical and provider) is a present and continuing challenge to the safety net Current services are fragmented, fragile and financially not sustainable Stakeholders acknowledge that collaboration and leadership are the largest missing components There is a strong willingness to begin a process to solve these key issues 26
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