Monday, September 22 , 2014, 5:15 am | Fair 62.0º




Safety Net: Health-Care Providers Face Significant Challenges Serving Uninsured

Programs for low-income patients focus on primary care, outreach while attempting to move toward preventive help

Lab assistants Bobby Escobar and Marcos Cervantes work in the Westside Neighborhood Clinic’s small laboratory. The room is plastered in dolphin pictures and even a statue, since one of the staff members thinks it makes it more inviting for patients. (Lara Cooper / Noozhawk photo)
Lab assistants Bobby Escobar and Marcos Cervantes work in the Westside Neighborhood Clinic’s small laboratory. The room is plastered in dolphin pictures and even a statue, since one of the staff members thinks it makes it more inviting for patients. (Lara Cooper / Noozhawk photo)

By Giana Magnoli, Noozhawk Staff Writer | @magnoli |

[Noozhawk's note: This article is part of a Noozhawk special project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communcation & Journalism. On Tuesday, Day 5.]

[Click here for a gallery of photos from the series.]

The large population of uninsured and underinsured patients in Santa Barbara County is served mainly by what are called “safety net” providers such as the county’s Public Health Department clinics.

Santa Barbara County is relatively healthy, with higher life expectancy than the state average for California, but there are vast disparities based on race, ethnicity and socioeconomic status, said Dr. Takashi Wada, the county’s public health director.

               Santa Barbara County's Safety Net  |  About This Series  |

“For those who are uninsured or underinsured, the challenges are significant,” Wada said. “The safety net — our system of county health-care centers, community and private clinics and our hospitals — does what it can.”

Even with organizations meeting regularly and partnering to provide care, there are serious gaps in services.

The uninsured often delay or forego care altogether, which leads to preventable illness and premature years of life lost, Wada said.

He said there are serious gaps in the areas of obesity prevention, mental health and substance abuse services, and oral health care.

“When you’re uninsured, you don’t have comprehensive health benefits that include prevention and health maintenance,” he explained.

“You come in late with a disease or come to the emergency room with advanced conditions that could have been prevented, and they cost a lot more."

Wada said the impact of the challenge is widespread.

“The 70,000 uninsured people should go down to 20,000," Wada said. "And for those individuals who will be eligible and enroll in insurance, they’ll have that comprehensive benefit package.”

The county clinics see 31,000 patients — and field 120,000 visits — every year, and work closely with Cottage Health System’s three hospitals as well as Marian Regional Medical Center, Sansum Clinic and the Santa Barbara Neighborhood Clinics.

The three Santa Barbara Neighborhood Clinics have moved to electronic health records, an expensive requirement of the Patient Protection and Affordable Care Act. At a recent appointment, Dr. Charles Fenzi explains to patient Charles Condelos how his prescription can be sent paperless, and instantly, to the pharmacy of his choice. The system double-checks prescriptions against the patient’s age, other drugs and condition, asking the doctors if they’re sure. “We’re supposed to know that, but it’s a good reminder,” Fenzi says. (Lara Cooper / Noozhawk photo)
The three Santa Barbara Neighborhood Clinics have moved to electronic health records, an expensive requirement of the Patient Protection and Affordable Care Act. At a recent appointment, Dr. Charles Fenzi explains to patient Charles Condelos how his prescription can be sent paperless, and instantly, to the pharmacy of his choice. The system double-checks prescriptions against the patient’s age, other drugs and condition, asking the doctors if they’re sure. “We’re supposed to know that, but it’s a good reminder,” Fenzi says. (Lara Cooper / Noozhawk photo)

County clinics have specialists from Sansum come in regularly, get a few dozen Cottage Hospital residents to serve their patients, and split the safety-net population of patients in the South Coast with the Neighborhood Clinics.

Each organization ends up sharing patients — and information in the form of digital health records — when they can.

County officials expect at least 6,000 more people to be enrolled in Medi-Cal by Jan. 1, as part of the Medi-Cal expansion written into the Patient Protection and Affordable Care Act.

CenCal Health, which administers Medi-Cal for Santa Barbara and San Luis Obispo counties, expects 30,000 more people to join the program by mid-2014.

Safety-net providers like the county clinics rely on getting reimbursements for the care they give low-income or indigent patients, so they are working hard to make sure patients are signed up for Medi-Cal with pre-enrollment plans rolling out in October.

Even government-funded insurance pays more than uninsured patients, who usually pay nothing.

“Initially we’ll end up picking a lot of undiagnosed illnesses and a big demand on services, a surge, and I think over time we should see the benefits in terms of preventable illnesses,” Wada said.

Throughout the county, the biggest medical issue is women’s health, including obstetrics, gynecology and family planning.

The county receives a special category of “emergency” Medi-Cal that covers pregnant women regardless of immigration status, and that funding will not be expanded under the new health-care law, Wada said.

In Santa Maria, Marian Regional Medical Center has about 250 births a month, said Sue Andersen, chief financial officer for the hospital.

Of all obstetrics cases (pregnancy and childbirth), 70 percent to 75 percent of patients have Medi-Cal or are uninsured, and therefore are funded by emergency Medi-Cal, Andersen said.

The other major health issues in the county are diabetes, congestive heart failure and COPD: chronic obstructive pulmonary disease, a common lung ailment.

Many health issues are the result of poverty-related stress, which leads to serious disparities by area, Wada said.

Health-care providers make conscious efforts to have bilingual employees available to help the county's Spanish-speaking population.

The county only hires bilingual employees, as it has for years, and has specific outreach for Spanish-speaking and Mixteco people.

The Neighborhood Clinics have interpreters on hand to translate during appointments, and the Santa Barbara Cottage Hospital emergency room has interpreters until 10 p.m. and then uses a phone-in language service for any language that’s needed.

The Westside Neighborhood Clinic is one of three medical clinics operated by Santa Barbara Neighborhood Clinics on the South Coast. SBNC also runs a dental clinic on Santa Barbara's Eastside. (Lara Cooper / Noozhawk photo)
The Westside Neighborhood Clinic is one of three medical clinics operated by Santa Barbara Neighborhood Clinics on the South Coast. SBNC also runs a dental clinic on Santa Barbara's Eastside. (Lara Cooper / Noozhawk photo)

To serve the safety-net population, county providers try to be sensitive to cultural differences and realize some undocumented people are apprehensive about seeking help in government-funded clinics, Wada added.

With the current system, patients without insurance only go to the doctor when they’re sick, and they often choose the easiest, nearest option — the emergency room.

Marian gets about 6,000 patient visits a month in the ER (72,000 per year), which is more than all three Cottage hospitals combined.

Santa Barbara Cottage Hospital has the most, at about 43,000 per year, followed by Goleta Valley with 18,400 and Santa Ynez with 6,600.

There are no other after-hours options in Santa Barbara County.

Many parts of the Patient Protection and Affordable Care Act focus on better communication between doctors’ offices, like the mandated move to digital health records, in an attempt to keep people from using the emergency room like a doctor’s office.

Adding to that is the move toward a patient-centered medical home model, which focuses on preventative care and having a primary-care doctor linked to each patient. That way, every specialist that patients encounter can funnel information back to the primary doctor, who is a health case manager of sorts.

At the Westside Neighborhood Clinic, Dr. Charles Fenzi already works this way.

He takes on patient loads in addition to his work as chief medical officer, which he started last January. For much of his career, Fenzi has worked with the most vulnerable safety-net population.

During a recent appointment, he introduced himself to an older Latina woman who had come in with allergies and a cold. A young interpreter translated for her and brought her a box of tissues when she started to sniff.

The woman also has diabetes, and Fenzi asked her about her blood sugar levels while she was there. It’s important, he noted, to check ongoing medical issues even when someone comes in for a specific problem.

In this case, the woman had “fantastic” levels but doesn’t check her blood sugar at home, because she doesn’t know how to use the machine she was given at the pharmacy. Fenzi told her to bring it in anytime, and someone at the clinic would show her how to use it.

“We see a lot of diabetes, and it’s a combination of genetics and culture,” he said.

“It’s a storage disease; What helped people thrive 200 years ago, when they only ate occasionally, is now a hazard with Mickey D’s on every corner,” he said.

It’s difficult to get some people to come in for preventative care at all, since many workers have to decide between getting paid for a day or going to the doctor’s office, Fenzi said.

Integrated care will also require providers to give mental health and substance abuse care in primary-care clinics, once the reforms are implemented in January.

Most patients are referred to the county’s Department of Alcohol, Drug and Mental Health Services and other services.

Not only is frequent, preventative care better for patients, but health-care facilities are thinking about treating patients in the location with the lowest level of care to save money, Andersen said.

Clinics and health centers are much more efficient for covering everyday things like the cold and flu, so hospitals try to keep patients out of the ERs for nonemergency issues.

Marian Regional Medical Center is working with CenCal Health and its own emergency department to redirect people in the ER to the on-site Family Medicine Center if they have minor issues that can be treated by primary-care doctors, Andersen said.

Santa Barbara Cottage Hospital’s emergency department and case management program meets with community organizations every week for a “Monday huddle” to try to reduce the amount of frequent emergency room visitors.

Many of those patients are homeless, mentally ill or just have nowhere else to go, Cottage Health System CEO Ron Werft said. They work with Casa Esperanza, Parish Nursing (which is operated by Cottage and funded by the St. Francis Foundation of Santa Barbara) and other organizations to give proactive care.

It’s reduced the emergency department visits for that “frequent-flier” population significantly, Werft said. The first group of 700 people was reduced by 95 percent in just three years.

All safety-net health-care providers are focusing on outreach and patient education to move toward the preventive model.

To name just a few of its efforts, the Neighborhood Clinics has outreach workers who partner with Doctors Without Walls-Santa Barbara Street Medicine to help the homeless population and go to substance abuse meetings to educate people about free Hepatitis C and HIV testing.

At Marian, there are outreach workers for congestive heart failure patients to help the them remember to take their medication, make and keep appointments and help with any other issues that come up, Andersen said.

“It’s very successful at keeping people out of the hospital,” she said. “Our only problem right now with the system is we’re not paid for that. We’re paid if people come into the hospital. We hope with the reform that the government gets to a mechanism that pays for a program keeps people out of the hospital.”

Noozhawk staff writer Giana Magnoli can be reached at .(JavaScript must be enabled to view this email address). Follow Noozhawk on Twitter: @noozhawk, @NoozhawkNews and @NoozhawkBiz. Connect with Noozhawk on Facebook.

Other stories in the series:

» Patchwork of Clinics Struggles to Keep Santa Barbara County Healthy

» Without Health Insurance, Many Put Off Critical Treatment

» Poor Children May Have Most to Gain from Health-Care Changes

» Emergency Rooms Strained by Growing Load of Patients

» Mental Illness Places Escalating Burden on Emergency Rooms

» Demand for Services Expected to Jump with Affordable Care Act




comments powered by Disqus

» on 09.19.13 @ 12:53 PM

Too many illegal aliens and their gangster kids abusing the system. If your here illegally no free health care, no welfare money, no free food stamp money. and no more free section 8 housing. Prop 187 never should of been over-turned, the will of the people is being ignored and invalidated.

The Middle class cant afford it anymore,the dumb Dems are buying votes at your expense.

» on 09.22.13 @ 12:41 PM

Health insurance does not equal health care. Having an affordable plan that comes with a high deductible equals no health care (until the deductible is paid which is typically at least equal to the total of the monthly premiums). Since all that persons money is gone they don’t even have the option of paying cash, the cash has been stolen by the health insurance company.

The subsidies are a joke and require you to accurately guess your annual income, very difficult for self-employed or un-employed to do. If you guess too low you have to pay it back, guess too high and you don’t get the assistance. In addition people will have to report changes in their income each and every month it changes, which is every month for self-employed, and others. Medical forms require you to sign away your rights to privacy, give the state all of your information and constant access to your bank account, which they will be able to tap at will.

No guarantee is given to secure your personal data. If it gets out and results in ID theft you’re on your own, no help from the corporation that lost it or gave it away.

Obamacare is a scam designed to hide the true costs of health care from the paying public. Namely that the cost of healthcare is just like any other business, labor plus materials plus overhead. None of those factors are in the health care discussion, all of them are the direct reason for high health care costs, with the addition of profits for stockholders in the large hospital/insurance corps. Until that is addressed health care will continue to be out of reach for even well off people. No one wants to confront the doctors, the AMA or the medical workers about their sky high salaries. Bashing on teachers about their paltry wages is OK though.

Obamacare needs to be tossed and the doctors, hospitals, insurance companies, medical workers and equipment providers held to account for making huge money off of other peoples sickness. This why we need single payer and it’s why we don’t have single-payer.

» on 09.22.13 @ 03:09 PM

This is like the S.S scam in the 30s, it gave the Feds 15% of every dolar we make. They promised not to use it for other programs..liars!! The Federal departments exploded with over staffed over paid government servants. Obama care is another tax people.wake up.
The Feds want all of your paycheck..

Support Noozhawk Today

You are an important ally in our mission to deliver clear, objective, high-quality professional news reporting for Santa Barbara, Goleta and the rest of Santa Barbara County. Join the Hawks Club today to help keep Noozhawk soaring.

We offer four membership levels: $5 a month, $10 a month, $25 a month or $1 a week. Payments can be made through PayPal below, or click here for information on other options.

Thank you for your vital support.

 

Daily Noozhawk

Subscribe to Noozhawk's A.M. Report, our free e-Bulletin sent out every day at 4:15 a.m. with Noozhawk's top stories, hand-picked by the editors.