• How a Health System Improved Access to Indigent Care

    Feb 18, 2011

    Sarah Benatar, Dana Hughes, Embry M. Howell, and Genevieve Kenney

    An overhaul of a county system resulted in substantial changes in care provision by safety-net providers, including implementation of team-based care, disease management, and an EMR.

    In early 2008, San Mateo County in California embarked on a comprehensive health system redesign initiative. It 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 (SMMC) delivery system.

    San Mateo County's health system includes SMMC, an integrated delivery system with a public hospital, 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, San Mateo County has a locally created coverage program, Access and Care for Everyone (ACE), that has been in place for two decades.

    Committed to Meeting Healthcare Needs

    Despite being one of the wealthiest counties in the United States, San Mateo County residents have experienced an erosion of employer-sponsored insurance, and patient cost-sharing (premiums and copays) responsibilities have risen. This has led to an increased reliance on the public healthcare 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.

    San Mateo County leaders set out to achieve the following goals for expanding coverage and improving access to health care:

    • 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 safety-net clinics.
    • 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 support, 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 (FPL).

    Although the ACE program provides financial support for qualified patients up to 200 percent, the policy of SMMC provides support on a sliding scale for patients whose incomes are at or below 100 percent FPL for charity care and ACE fee waiver, and at or below 400 percent FPL for discounted health care.

    The county continues 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, copayments, and care coordination 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, emergency room, and hospital; Ravenswood Family Health Center (RFHC), a private, federally qualified community health center in East Palo Alto; and physician practices and other hospitals that provide care unavailable at the SMMC.

    Revamping the Quality, Efficiency of Care Services

    The county and RFHC have launched ambitious efforts to redesign 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 clerical staff team each time they visit a clinic.
    • Disease management, primarily focusing on diabetes management, including an automated diabetes registry, group visits where diabetes patients learn about self-management, and the use of diabetes retinal cameras to do on-site screenings.
    • Electronic medical records (EMR), to increase efficiency and coordination of care.
    • Advanced access scheduling, a model that allows same-day scheduling, improves patient flow, and reduces wait times for appointments.

    Many of these changes have been piloted in the county's Innovative Care Clinic (ICC), located at the SMMC main campus. The ICC was originally intended as a specialized clinic focused on caring for adults with chronic conditions, but demands on the system have required that it serve all primary care adult patients located at the main campus. However, it continues to be a site for innovation, having implemented many initiatives ahead of other clinics in the county system.

    As of fall 2009, all primary care clinics had implemented EMR, most had transitioned to team-based care, and disease management programs were in place. The county did not have the resources to fully implement advanced access because of on-going demand for scheduled appointments.

    In addition, the county has contracted with the Health Plan of San Mateo (HPSM) to serve as the third-party administrator for the ACE and ACE County programs. As a result, a wide range of functions-such as member services, the availability of a 24-hour nurse advice line, a grievance and appeals process, and a quality assessment process-mirrors those offered to Medi-Cal enrollees.

    HPSM has also been able to negotiate contracts with many of the specialty physician practices and private hospitals at the same payment rates it has in place for Medi-Cal. In addition, since HPSM also administers Medi-Cal, the plan can identify patients who may qualify for Medi-Cal but are currently enrolled in ACE or ACE County to pursue conversion to Medi-Cal, resulting in savings to the county.

    Sarah Benatar is a research associate with the Urban Institute Health Policy Center, Washington, D.C. Dana Hughes is a professor of health policy at the University of California, San Francisco. Embry M. Howell and Genevieve Kenney are senior fellows at the Health Policy Center.

    This article is excerpted with permission from the following resource: Benatar, S., Hughes, D., Howell, E., and Kenney, G.,  Swimming Upstream: Improving Access to Indigent Health Care in the Midst of Major Economic Challenges, Urban Institute Health Policy Center, Washington, D.C., December 2010.