November 2008
Purpose of the Study This study analyzes short-term risks and provides recommendations on longer-term policy opportunities for the Marin County healthcare delivery system in general as well as Marin s healthcare safety net. The study was conducted by The Abaris Group under a contract with Marin County directed by the Marin County Department of Health and Human Services. Overview of Findings The study estimated the number of Marin County residents that are included in the healthcare safety net is based upon poverty levels and sustainable living income levels. The healthcare safety net includes those that are under insured or uninsured or have an income below the sustainable living level. The estimate of safety net residents ranges from 37,800 to 83,200 residents. The healthcare safety net was analyzed in the context of assessments of current and expected future availability of healthcare services. The project includes an assessment and projection of current and future healthcare utilization (projecting ahead 20 years). It calculates both local and regional community resources needed to provide healthcare safety net services, while considering potential changes to safety net providers as well to the health care environment. Finally, the study provides recommendations to the County of Marin on how to help ensure that necessary healthcare safety net services will continue to be available. 1 The principal findings of this report are: Current capacity is adequate for current demand but there is considerable uncertainty for the future: Marin County has sufficient current capacity to meet most of the healthcare demands for the total and safety net population today. There remain concerns regarding mental health, dental, women s health services and access to services in West Marin County Healthcare is undergoing considerable change which may inevitably jeopardize healthcare resources for both the general public and the safety-net population While there are several scenarios to suggest that this capacity will remain sufficient into the future there are others identified in the full report that suggest there could be a potential gap between the need for, and availability of outpatient and inpatient hospital services (e.g. potential changes at Marin General Hospital) Any major emergency will also likely place a major strain in emergency medical care capacity 1 This is supported by a comprehensive report and appendix with detailed analysis, calculations and data charts which can be found on The Abaris Group s web site at abarisgroup.com Page 1
Changes in demand are likely to occur as the payer mix changes: The healthcare payer mix in Marin County will change over time: The number of uninsured and underinsured (Medi-Cal) will rise The number of Medicare patients will rise consistent with the aging of the population in the county Employer-based insurance will decline but there will be an increase in direct-purchase insurance not necessarily keeping pace with the decline in employer-based insurance This change in payer mix will also require steps to be taken to mitigate the impacts of these changes, as outlined in the report, to improve capacity, efficiency and to leverage prevention and care management opportunities Declining health human resources at all levels (e.g. physician, nurse, public health, pharmacists, dentists, etc.) will continue to challenge Marin County s capability to manage healthcare in general and also for the safety net These special economic times may accelerate the health care delivery imperative: While Marin County may fare better than other communities during these incredibility difficult economic times: - Marin County is not immune from the symptoms of the economic crisis - Some health care systems have begun to cut back or slow growth plans which may affect Marin County hospitals - As individuals and businesses witness reductions in their own financial there will likely be an increase in the uninsured and under insured - The healthcare capital market has been dramatically affected by the crisis - There is a reported noticeable impact on philanthropic giving affecting all safety net providers The exact implications on Marin County are not known and may not be know for up to several years The economic crisis may hasten the need for Marin County stakeholders to initiate the recommendations in accompanying report Marin County is in a position that should permit to assist in addressing future needs: Calculating safety net outpatient and inpatient needs and comparing these needs to expected future capacity, without significant reductions in outpatient and inpatient capacity demonstrates that capacity is likely to be available to meet future demand through 20 years This is in the context of adequate funding being available and that many of the other threats to the healthcare delivery system will be addressed, as well as an alignment between quality and access. Other threats to the healthcare delivery system include: Declining healthcare human resources Declining levels of reimbursement for all payers Unfunded mandates, including seismic safety, nurse ratios, EMTALA, etc. Potential public policy changes, such as citizenship documentation requirements, immigration policy and the like Page 2
While the preference is for residents within Marin County to continue to get their healthcare in Marin County, there appears to be sufficient capacity in the entire region to close the capacity gaps should the report s worst-case scenarios occur There are a number of steps that the community and the County of Marin could take to mitigate most worst-case scenario risks especially in populations that have ethnic and income disparities with respect to chronic diseases and higher mortality rates Desired Long Term Goals The long-term goal for Marin County is to assure a high-performing, sustainable community healthcare safety net. A high-performing safety net is defined as one that: Maximizes efficiency and effectiveness through collaboration between individual providers in order to ensure timely care and follow up is provided especially across transitions (e.g. inpatient to outpatient) Delivers effective prevention, disease management and high-quality care to publicly insured and uninsured patients across institutional settings and longitudinally through each patient s life Considers regional resources and potential regional demand that would affect in-county demand Uses information technology to ensure the flow of clinical information between caregivers Is accountable and measures its performance and acts/adjusts accordingly To achieve this goal the report recommends a series of best practices for prevention and disease management efforts and proposes that the most suitable and promising of these be fully executed in the community. Further, the County of Marin should proactively and collaboratively plan with the community clinics, hospitals and other healthcare providers to assure there is a common vision of the safety net and that these best practices are deployed with a special emphasis on leveraging the outpatient services of the community clinics. Role of the County The County of Marin should continue in its leadership role to: Continue to provide forecasts regarding the future of the safety net population and its needs Reinforce its role on assisting with the transition of the governance of Marin General Hospital Strengthen its on-going partnership with safety-net providers such as the community clinics Continue to move towards the development of an integrated healthcare campus improving access for the safety-net consumer as well as emphasizing healthy living and health strategies such as continuing with open-space planning, nutrition programs and the role of volunteerism and non-profits in disease management and prevention Provide leadership and guidance on long-term planning for healthcare in the community particularly for the healthcare safety net Continue to monitor and plan for surge access to emergency health resources in the event of a major emergency Page 3
Continue to evaluate the trauma center requirements and assure that trauma center criteria are appropriate for the volume and acuity of the case load Recommended Next Steps (1) Over the long term, Marin County stakeholders (including the hospitals, outpatient services and others) should develop a countywide planning, goal setting and oversight process that uses a collaborative public/private model and strategically focuses on the identified healthcare challenges: Targeting the factors needed for a high-performance healthcare safety net Developing a countywide dashboard for the safety net s performance and to document improvements over time Promoting resources to respond to targeted goals (2) Marin County healthcare stakeholders should continue to study methods to leverage existing funding and solicit new funding for innovative best and promising healthcare safety net practices, these include: Targeting chronic disease management efforts Implementing prevention programs: Falls Injury Cardiac disease Other chronic diseases Linking hospital and community clinics (e.g. emergency department [ED] referral programs) Serving and tracking frequent users (emergency medical services [EMS] and ED) Expanding provider volunteerism and specialty coverage Providing information technology interfaces with all safety net providers (e.g. hospital ED referrals to the community clinics) Expanding after-hour inpatient surgery for the under and uninsured to further expand the existing outpatient model (Operation Access) (3) Marin County health safety net providers should continue to commit to a re-engineered patient care experience, such as: Enhancing coordination and collaboration between the community clinics and public health clinics Re-engineering the patient care experience with the goal of reducing waste, waiting times and enhancing capacity and access Using well-accepted industrial engineering and implementation tools (e.g. Toyota LEAN, high impact teams [HIT] and rapid cycle testing [RCT]) to accelerate the change process and the success of the initiative Page 4
(4) Marin County should continue to solicit additional input on potential mental health access and delivery issues by: Continuing to hold stakeholders input workshops Quantifying and targeting needs (5) The County of Marin should continue to monitor the Marin General Hospital (MGH)/Marin Healthcare District (MHD) transition by: Facilitating meetings between the MHD and Sutter Health Assuring continued solidification of existing inpatient safety net services (e.g. mental health, delivery and trauma services) Continuing to monitor the MHD s transition plan and providing assistance where appropriate Continuing to evaluate the trauma triage criteria for appropriateness for the volume and acuity of patients. Summary The Marin County Healthcare Safety Net Study is a comprehensive review of countywide healthcare in general and of its current and future safety net. There are many important strengths and opportunities with the current safety net delivery system but also many weaknesses and threats. By collaboratively developing a common vision of what the healthcare safety net should look like in the future and using leveraging tools (e.g. prevention, disease management and productivity strategies), the safety net is likely to be more stable and more accessible both now and well into the future. Page 5