[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.]
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.
“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.
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.
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.
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.
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.”
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