Sacramento Region Health Care Partnership

Transcription

1 Sacramento Region Health Care Partnership Market Analysis Preliminary Data Presentation

2 Sacramento Region Health Care Partnership Sacramento County Market Analysis Preliminary Findings April 2, 2012 Presented by The Abaris Group + Public Health Institute tute

3 Study Partners Sierra Health Foundation The California i Endowment Sacramento Region Community Foundation 3

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 Amy Neuwelt, MPH Art Chen, MD Hatches Consulting Barrett Hatches, PhD 4

5 Study Overview and Progress The study is assessing El Dorado, Placer, Sacramento and Yolo counties primary care safety net. Combined these counties are referred to as the Sacramento Region. Two portions of the study: (1) Market Assessment (2) Strategic Planning Process 5

6 SRHCP Project Overview El Dorado County Planning Meeting Market Analysis Placer County Planning Meeting Sacramento County Planning Meeting Regional Strategic Planning Process Market Analysis Presentation Strategic Plan Yolo County Planning Meeting Dec 2011 Feb/Apr 2012 Apr/May 2012 Feb/May 2012 May

7 Study Methods Data from public sources California Health Interview Survey (CHIS) California Office of Statewide Health Planning & Development (OSHPD) HRSA Health Center Uniform Data System (UDS) US Census Interviews Community Health Centers (CHCs) Hospital Systems Counties Health Plans Other sources 7

8 Definitions of Terms Used Safety Net Uninsured Under-insured (Medi-Cal, Healthy Families, county indigent programs, low income health programs, etc.) Community Health Centers (CHC) Defined as a primary care clinic that is licensed by the California Department of Public Health Definition does not include county-run clinics (exempt from OSHPD reporting) Capacity Health care resources used to treat patients in the safety net: Community Health Centers (CHC) Emergency Departments (ED) Demand The number and rate at which people seek care in CHC and ED settings CHC Financial Data Margins = Net revenues total revenues Total revenues = Net patient revenue + other revenues (e.g. grants) Net revenues = total expenses total revenues 8

9 2010 Health System s Community Needs Assessment Three key findings on what is needed to help the underserved population : (1) Increase access to affordable healthcare and insurance (2) Improve quality of healthcare delivered in low or nocost settings (3) Provide more healthcare information and education 9

10 Health Reform

11 ACA or Health Reform: Implications for the Safety Net Medicaid (Medi-Cal) coverage expansions 16 million will be eligible for new Medicaid enrollees (up to 133% of the FPL) Newly insured likely to have chronic conditions and limited experience managing health Undocumented remain ineligible Private sector coverage expansions through health insurance exchanges (HIE) Doubling community health center (CHC) capacity 11

12 Impact of ACA in California Low Income Health Program will bridge coverage for uninsured adults under 200% FPL until Program Name El Dorado (CMSP Path2Health) Income Range Implementation Date 0-100% FPL January 1, 2012 Additional Covered by 2013 TBD Placer County Low Income Health Program Sacramento County Low Income Health Program 0-100% FPL February 1, 2012 Up to 4, % FPL February 1, 2012 Up to 15,000 Yolo County 0-100% FPL (CMSP Path2Health - New) July 1, 2012 Up to 3,200 12

13 Impact of ACA in the Sacramento Region 1 out of 3 people living under 138% FPL are currently uninsured in the Sacramento Region, but will be eligible for Medi-Cal under ACA * The effective FPL for ACA is 138% due to a 5% income disregard policy. Source: U.S. Census Bureau, 2009 ACS 13

14 Impact of the ACA in Sacramento County An estimated 167,257 uninsured individuals will obtain insurance in The majority (90,221or 53.9%) are expected to receive Medi-Cal coverage and the remainder (77,036 or 46.1%) are expected to find insurance in the individual health insurance exchange. Sacramento County Insurance Coverage 2009 and Insurance 2009 Percent Movement 2014 Percent Employer 696, % 696, % Individual 52, % 77, , % Medi Cal 289, % 90, , % Medicare 161, % 161, % Uninsured 222, % (167,257) 55, % Total 1,422,806 1,422,806 Source: MCIC Chicago,

15 Sacramento County Demographics

16 Population Data Sacramento County has a total population p of 1,391,431. (Sacramento Region = 2.1 million) 31.0% of individuals id earn incomes less than 200% of the Federal Poverty Level (FPL). 13.2% of individuals earn less than 100% of the FPL. Median household income = $56,799 (California average = $60,392) Source: U.S. Census Bureau, ACS 5-year estimates (poverty and income); 2010 ACS 1-year estimates (population). 16

17 Population Projections population projections estimate that Sacramento County will grow at a rate of 1% per year. Sacramento Region Population Projection Average Annual Percent Change, California 1.3% Sacramento Region 1.1% Yolo 1.4% Sacramento 1.0% Placer 1.4% El Dorado 0.6% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% Source: Sacramento Area Council of Governments, MTP/SCS 11/2011, CA Department of Finance Population Projections 7/

18 Safety Net Snapshot

19 Safety Net Population Sacramento 31.9% of the population p in Sacramento County is estimated to be under or uninsured (approximately 444,000 individuals). Safety Net Health Insurance Coverage, 2010 Insurance Type Sacramento Sacramento Region California No Health Insurance 13.9% 12.7% 18.5% Medicare & Medicaid 1.2% 1.1% 1.0% Medicaid (ages 18 64) 7.4% 6.1% 5.7% Medicaid (ages (g <18) 9.4% 7.9% 8.8% Total 31.9% 27.7% 34.0% Source: U.S. Census Bureau, 2010 American Community Survey 1 Year Estimates Note: Population = Civilian non institutionalized population 19

20 Percentage of Low Income (<200% FPL) in Sacramento County, % of Sacramento county residents (~430,000 people) are low-income (<200% FPL) Several zip codes within the metro Sacramento region have over 60% lowincome population % Low-Income Pop at or below 200% FPL, (est.) < 15% 15-30% 30-45% Source: U.S. Census Bureau, American Community Survey yr est % >60% CHC (FQHC) FQHC Look-Alike 20

21 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 Source: U.S. Census Bureau, American Community Survey yr estimate, Health Resources and Services Administration (HRSA) Uniform Data System (UDS); <20% 20-40% 40-60% 60-80% >80% Rural Health Clinic FQHC Look-Alike CHC (FQHC) 21

22 Sacramento County Conversely, over 90% of lowincome residents (~400,000 people) did not visit a federally-funded CHC in 2010 While a proportion of these low-income residents may use non-federally funded CHCs, a large number do not access care or rely on local EDs Low Income not Served by Federally-Funded CHC (Dot Density) Source: U.S. Census Bureau, American Community Survey yr est, Health Resources and Services Administration (HRSA) Uniform Data System (UDS); 1 dot=100 low-income people CHC (FQHC) Rural Health Clinic FQHC Look-Alike 22

23 Change in Utilization of Federally Funded CHCs in Sacramento County, Sacramento county saw a 65.8% increase in utilization of federally-funded ded CHCs Cs between 2008 and 2010 (~12,500 new patients) % Change in Federally-Funded CHC Patients Source: Health Resources and Services Administration (HRSA), Uniform Data System (UDS); % loss 10-50% loss <10% change 10-50% gain 50% or more gain Newly Served Rural Health Clinic FQHC Look-Alike CHC (FQHC) 23

24 Safety Net Capacity

25 Primary Care Health Professional Shortage Areas & Medically Underserved Areas in Sacramento County, 2011 The low income and homeless population of Del Paso Heights and the southern region of the county are federally designated health professional shortage areas (black stripes) Oak Park is a medically underserved areas (red stripes) Source: Health Resources and Services Administration (HRSA), Health Professional Shortage Areas (HPSA) Geographical Area Population Group Medically Underserved Areas/Populations (MUA) Medically Underserved Area Medically Underserved Population CHC (FQHC) FQHC Look-Alike 25

26 Mental Health and Dental Health Professional Shortage Areas (HPSA), 2011 There are no geographic HPSAs for mental or dental health in the county However, the following are facility-level mental health and dental HPSAs: Sacramento Community Clinic Folsom State Prison Sacramento County Department of Health Sacramento Native American Health Center, Inc. California Rural Indian Health Board, Inc. The Effort Health For All, Inc. Source: Health Resources and Services Administration (HRSA),

27 Capacity Sacramento Overview Outpatient 24 Community Health Centers (CHC) licensed primary care clinics 7 FQHCs 6 FQHC Look-Alikes 1 12 Non-FQHCs CHC Mental Health Services 6 CHCs staffed with psychologists 6 CHCs with licensed social workers 11 CHCs with substance abuse services CHC Dental Services 6 CHCs staffed with dentists (7.2 FTE) 1 county-run clinic* 1) MMC for Children and Families became an FQHC-Look Alike in 2011 *Note: county-run clinics do not report data to OSHPD. Source: OSHPD, 2010 Inpatient 22 General Acute Care Hospitals 273 ED Treatment Stations 1,779 ED visits/station 2,863 Staffed Beds % occupancy rate 2 Psychiatric Health Facilities & 3 Acute Psychiatric Hospitals 376 licensed psychiatric beds (70.6% occupancy) 1. Data does not include Shriners Hospital for Children - Northern California or Kindred Hospital Sacramento. Kaiser Foundation Hospital Sacramento/Roseville Eureka campus combined with Morse campus. 27

28 Sample of Safety Net Services + Resources Sacramento County Community Health Centers, 2010 FQHC or Look Clinic i Name Alike Alternatives Pregnancy Resource Center Neither Birth and Family Health Center FQHC Center for Aids Research, ED and Services Sac. Neither Feminist Womens Health Center Sacramento Neither Health for All Freeport Clinic FQHC Look Alike Health hfor All Las Pl Palmas Clinici FQHC Look Alike Health for All, Inc FQHC Look Alike MMC for Children and Families 1 Neither Planned Parenthood Capitol Plaza Neither Planned Parenthood Fruitridge Neither Planned Parenthood North Highlands Neither Planned Parenthood Mar Monte B Street Health Ctr. Neither Rancho Cordova Community Clinic Neither Sacramento Community Clinic Del Paso FQHC Look Alike Sacramento Community Clinic Southgate FQHC Look Alike Sacramento Life Center Neither Sacramento Native American Health Center, Inc. FQHC Society for the Blind, Inc. Neither Sutter Seniorcare FQHC Sutter Seniorcare Site Ii FQHC The Birthing Project Clinic Neither The Effort Medical Clinic FQHC The Effort Oak Park Community Health Center FQHC The Effort South Valley Center FQHC Sacramento County CHC Resources and Services, 2010 Primary Care Clinics i (N=24) Number of Clinicsi Percent of Total Staff Languages: Hmong % Russian % Spanish % Tagalog % Vietnamese % Transportation Services % Child Care Services 0 0.0% Substance Abuse Services % Homeless Services % Staffing (Number of Full Time Equivalents): Physicians 19.8 Nurse FP 26.7 Physician Assistants 11.2 Psychiatrist 9.7 Clinical Psychologist 0.2 Dentists 7.2 Source: OSHPD Primary Care Clinic Utilization Database, ) MMC for Children and Families became an FQHC Look Alike in 2011 Note: CHCs listed are primary care clinics as licensed by the California Department of Public Health. Clinics not licensed as primary care (e.g. a private medical office) and county-run clinics are not included in OSHPD data. 28

29 Sacramento County CHC Patient Volume by Facility Type, 2010 Sacramento County Community Health Center (CHC) Patient Volume (n=37), In 2010, there were ,960 patient t visits it at the primary care CHCs in Sacramento County 7814 PLANNEDPARENTHOOD PARENTHOOD CAPITOL PLAZA 7377 SALUD CLINIC % of visits were at CHCs that do not receive federal funding PLANNED PARENTHOOD MAR MONTE B STREET HEALTH CTR. BARTON MEMORIAL HOSPITAL FAMILY CLINIC PLANNED PARENTHOOD FRUITRIDGE PLANNED PARENTHOOD ROSEVILLE FEMINIST WOMENS HEALTH CENTER SACRAMENTO PLANNED PARENTHOOD NORTH HIGHLANDS DAVIS COMMUNITY CLINIC MMC FOR CHILDREN AND FAMILIES PETERSON CLINIC EL DORADO COUNTY COMMUNITY HEALTH CENTER EFFORT MEDICAL CLINIC, THE CHAPA DE INDIAN HEALTH PROGRAM, INC SHINGLE SPRINGS TRIBAL HEALTH PROGRAM SACRAMENTO COMMUNITY CLINIC SOUTHGATE THE EFFORT SOUTH VALLEY CENTER SACRAMENTO COMMUNITY CLINIC DEL PASO CENTER FOR AIDS RESEARCH, ED AND SERVICES SAC. PLANNED PARENTHOOD WOODLAND SACRAMENTO NATIVE AMERICAN HEALTH CENTER, INC. THE EFFORT OAK PARK COMMUNITY HEALTH CENTER WINTERS HEALTHCARE CLINIC CHAPA DE INDIAN HEALTH PROGRAM, INC MMC FOR CHILDREN AND FAMILIES PLACERVILLE HEALTH AND WELLNESS CENTER HEALTH FOR ALL LAS PALMAS CLINIC ALTERNATIVES PREGNANCY RESOURCE CENTER HEALTH FOR ALL, INC BIRTHING PROJECT CLINIC BIRTH AND FAMILY HEALTH CENTER SACRAMENTO LIFE CENTER HEALTH FOR ALL FREEPORT CLINIC SOCIETY FOR THE BLIND, INC. RANCHO CORDOVA COMMUNITY CLINIC SUTTER SENIORCARE SITE II SUTTER SENIORCARE SITE Primary Care CHC Patient Volume Source: OSHPD Primary Care Clinic Utilization Data File, 2010 Sacramento County Community Health Center (CHC) Patient Volume by Facility Type (n=37), Sacramento FQHC Look Alike Other CHC

30 High-Poverty Census Tracts and CHC Utilization Rates in California s 5 th Congressional District In the high poverty areas within metro Sacramento, the majority of high-volume CHCs do not receive federal funding g(yellow circles) & cater primarily to women and children* Federally funded CHC <1,000 1,000-5,000 5,000-10,000 10,000-15,000 % Population below 200% FPL Over 50% 25% to 50% Less than 25% *Planned Parenthoods, MMC for Children and Families, and the Birthing Project Clinic Sources: OSHPD Primary Care Clinic Utilization Data File, 2010 U.S. Census Bureau, ACS 5-year estimates FQHC Look-Alike Non federally funded CHC <1,000 <1,000 1,000-5,000 1,000-5,000 5,000-10,000 5,000-10,000 10,000-15,000 10,000-15,000 30

31 Primary Care Physician Capacity in Sacramento County, 2009 The ratio of residents to primary care physicians is slightly lower (better) in Sacramento county than California as a whole, but considerably higher (worse) than the national benchmark Ratio of Population to Primary Care Physicians Sacramento County 814:1 California 847:1 National Benchmark* 631:1 *90 th percentile among all U.S. counties Source: 2011 County Health Rankings, Health Resources and Services Administration s Area Resource File, 2009

32 Population Based Data

33 CHCs & County Health Rankings, 2011 Health Factors: Summary index of health behaviors, clinical care, social & economic factors, and physical environment) Sacramento County ranks 34 th among the 56 counties in CA for best population health factor measures. Source: University of Wisconsin County Health Rankings,

34 Sacramento County Highlights from California i Health Interview Survey 2009 Challenges: Sacramento County Health Measures, in 4: HBP 50% 32% overweight Over 1/4: obese 40% 16% asthma 30% % smokers Lower rate but of concern: 14.8% delayed or not get care 8% diabetic 20% 10% 0% Sacramento Source: California Health Interview Survey, 2009 State of California 34

35 Preventable Disease Rates in Sacramento County, 2009 Preventable hospitalization rates are the highest in the region and similar to statewide rates Prevention Quality Indicators (PQIs) in Sacramento County and California, 2009 Pre eventable Hosp pitalization Categori es Acute conditions Circulatory conditions Respiratory conditions Diabetes complications Sacramento County CA Risk-adjusted hospitalization rate per 100,000 Source: OSHPD, AHRQ Area-Level Prevention Quality Indicators Data File,

36 Mental Health Measures: Sacramento County and Region Serious Psychological Distress (SPD) Measure of serious, nonspecific MH distress ~ 8% County/Region Perceived need ~15% County/Region Got services ~ 12% County/Region Unmet Need among those adults who needed help Over 40% Did Not Get Needed MH/AOD Services Health Indicators Sacramento Sacramento State of County Region California Health Status, Adults 18 and Older, 2009 Est. N % Est. N % Est. N % Serious psychological ldistress (SPD) in past year Likely has distress Perceived need for MH or AOD services in past 12 months Needed help Utilization of MH or AOD services in past year Saw healthcare provider Unmet Need: Among Adults Needing Help, % Who Did Not Get Past Year Mental Health or Alcohol or Other Drug Services Source: California Health Interview Survey, , , m , , m , , m , , m 44.5

37 Dental Health Measures: Sacramento County and Region No past-year dental insurance Sac County One fourth of adults ~ 15% children, 2-17 years No past-year dental insurance Sac Region 26% adults ~16% children, 2-17 years Could not afford needed dental care Sac Region Less than 5% children, 2-17 years 24,000 children affected Health Indicators Sacramento County Sacramento Region State of California Health Status, Among Adults, and Among Children, 2007 Est. N % Est. N % Est. N % No Dental Insurance Adults ages 18 and over No Dental Insurance Children ages 2 17 years Could not afford needed dental care Children ages 2 17 years Source: California Health Interview Survey, , , m , , m , ,

38 Safety Net Demand

39 Community Clinic Patients + Visits Sacramento County Primary Care Visits and Patients, As seen in the rise in 300, total visits and 250, patients, CHC 200, demand has 150, increased 100, significantly in 50, Sacramento County tal Tot In 2010, there were over 100, unique Primary Care Clinics & Visits, Sacramento Region, 2010 patients visits to Sacramento County CHCs. Total Patients Total Visits Visits per Patient County Total Clinics Total Visits Total Patients Visits/Patient El Dorado 4 69,840 26, Placer 2 43,632 16, Sacramento , , Yolo 7 117, , Total , , Source: OSHPD Primary Care Clinic Utilization Data File, 2010 r Patient Visits per 39

40 Demand: CHC Payer Mix Only 1.3% of all CHC visits are paid for by private insurance. Medi-Cal is the largest 2008 payer group for CHCs in 2007 Sacramento County and now covers 43.4% of all 2006 CHC visits. it Medicare visits have also grown from 4.3% of all visits it in 2006 to 8.1% in Percentage of CHC Encounters by Payer Source, 2006 to Medi Cal % 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 % Change Medicare 4.3% 3.9% 8.1% 6.6% 8.1% 17.4% Medi Cal 24.2% 29.4% 35.3% 42.9% 43.4% 15.8% Indigent 1.0% 1.0% 1.3% 0.8% 0.7% 7.6% Private 1.4% 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, Note: "Other" includes breast cancer, Child Health and Disability Prevention Program, Expanded Access to Primary Care, and Family PACT encounters. 40

41 Demand: CHC Payer Mix Revenue Sacramento County Percent of CHC Net Patient Revenue by Payer Source, 2006 to 2010 In 2010, CHC net 2010 patient revenues in Sacramento County 2009 totaled $45 million The largest payer 2007 source comes from 2006 Medicare, which 0% 20% 40% 60% 80% 100% accounted for 37.9% of all net patient Source, 2006 to 2010 revenues in Payer Source Medi Cal Self Pay County Indigent Other Medicare Private Sacramento County Percent of CHC Net Patient Revenue by Payer Avg. Annual % Change Medicare 19.4% 21.4% 16.9% 41.4% 37.9% 18.3% Medi Cal 40.5% 37.5% 44.3% 24.5% 27.5% 9.2% Indigent 0.9% 0.9% 0.7% 0.7% 0.5% 14.3% Private 0.3% 0.9% 0.8% 0.7% 0.6% 15.0% Self Pay 4.3% 3.6% 3.3% 3.4% 3.6% 4.5% Other 34.6% 35.7% 34.0% 29.4% 30.0% 3.5% Source: OSHPD Primary Care Clinic Utilization Data Files, Notes: "Other" includes breast cancer, Chi ld Health and Disability Prevention Program, Expanded Access to Primary Care, and Family PACT encounters. 41

42 Sacramento County ED Discharges The number of ED discharges by Sacramento County residents has grown over the last 5 years at an average annual rate of 8.1%. Per population, ED utilization for Sacramento County residents increased from 218 per 1,000 in 2006 to 288 per 1,000 in Sacramento County ED Discharges, , ,000, 350, , , , , ,000 50, , , , , , ED Utilization Rates per 1,000 population. Visits per 1,000 Pop California Sacramento County Source: OSHPD Emergency Department Encounters, County Frequencies by Patient Source: OSHPD Emergency Department Visits: Frequencies by County & EMS utilization County of Residence trends, ; 2010; CA Department of Finance, Dec Notes: The ED visit data only includes residents of Sacramento County discharged Note: ED utilization rates do not include ED visits that resulted in hospital admission. from an ED (does not include ED admissions). ED

43 ED Discharges Payer Mix The percentage of ED visits by 2009 Sacramento County residents 2008 with private 2007 insurance has 2006 declined while self- payers and Medi- Cal payers have increased Sacramento County Percent of ED Visits by Payer Source, Medi Cal 0% 20% 40% 60% 80% 100% Self Pay Commercial Medicare Other Non Federal Other Sacramento County Percent of ED Visits by Payer Source, Avg. Annual Payer Source % Change increased. Medicare 16.4% 15.9% 16.5% 15.8% 15.9% 0.8% Medi Cal 24.8% 25.5% 27.2% 28.4% 29.9% 4.8% Commercial 40.7% 39.0% 37.3% 36.1% 33.5% 4.8% Self Pay 13.0% 14.6% 14.5% 16.3% 17.8% 8.3% Other Non Federal 3.2% 3.5% 3.4% 2.6% 2.0% 11.8% Other 1.8% 1.5% 1.1% 0.8% 0.8% 17.6% Source: OSHPD Emergency Department Encounters, County Frequencies by Patient County of Residence Notes: The ED visit data represents the residents of the county discharged from an ED (does not include admissions). 43

44 Sacramento County ED Admissions Total ED visits (discharges + admissions) in Sacramento County increased from 358,000 to 485,000 between The ED patient hospital admission rate declined during this time period from 17.4% to 14.7%. Sacramento County ED Visits and Admissions, Vis sits 600, % 18.0% 500, % 400, % 12.0% 300, % 8.0% 200, % 100, % 2.0% 0 0.0% Total Discharged Total Admitted Percent Admitted Percent Ad dmitted 44 Source: OSHPD Annual Utilization Database,

45 Demand: ED Visit Acuity Almost a third (32.3%) of all ED visits seen in Sacramento County were classified as either minor or low/moderate severity. Acuity of ED Visits in Sacramento County Hospitals, 2010 (N=485,837) 16.6% 1.2% 14.8% 21.2% 17.6% Minor Low/Moderate Moderate Severe w/o Threat Severe w/ Threat Unknown 28.7% Source: OSHPD Annual Utilization Database,

46 Demand: Preventable/Avoidable ED Discharges 41.8% of all ED discharges were either non- emergent 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, % Non emergent 45, % Emergent/Primary Care Treatable 43, % Visits Classified as ED Care Needed: 38, % Emergent ED Care Needed Preventable/Avoidable 12, % Emergent ED Care Needed Not Preventable/Avoidableentable/A 25, % 2% Other Categories Not Classified by Algorithm: 84, % Drug/Alcohol 2, % Psych 5, % Injury 49, % Unclassified 27, % Source: OSHPD 2010 Emergency Department Data & NYU ED Algorithm Region Average 40.4% 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); 46

47 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, % 30, % 27, % 13, % Non emergent 8, % 15, % 13, % 6, % Emergent/Primary Care Treatable 7, % 14, % 13, % 6, % Visits Classified as ED Care Needed: 5, % 10, % 13, % 8, % Emergent ED Care Needed Preventable/Avoidable 2, % 4, % 3, % 2, % Emergent ED Care Needed Not Preventable/Avoidable 3, % 6, % 9, % 5, % Other Categories Not Classified by Algorithm: 14, % 23, % 30, % 14, % Drug/Alcohol % % % % Psych 1, % 1, % 1, % 1, % Injury 8, % 12, % 20, % 6, % Unclassified 4, % 8, % 7, % 5, % Source: OSHPD 2010 Emergency Department Data & NYU ED Algorithm Region Average 41.9% (Self Pay) 46.1% (Medi Cal) 47

48 Mental Health and Substance Abuse Sacramento County Residents (2010): 15,645 ED discharges for a mental health or substance abuse (MHSA)-related diagnosis (3.8% of all ED discharges). 91.6% of these discharges occurred in Sacramento County EDs. ED Discharges & Hospital Admissions for a MHSA Related Diagnosis, ,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, ,317 14,328 ED Discharges 3,169 6,799 Out of County In County Hosptial Admissions An additional 9,968 individuals Source: OSHPD Emergency Department and Patient Discharge Data, 2010 were hospitalized with a MHSA- related diagnosis (7.2% of all hospital admissions). Note: Data Includes patients hospitalized at both general acute care and psychiatric hospitals. Classification of mental health or substance abuse based off of primary discharge diagnosis. 68.2% of these hospitalizations occurred in Sacramento County hospitals. 48

49 Safety Net Demand Projections

50 Projected CHC Visits Using historical growth trends and anticipated changes in payer mix, CHC demand in Sacramento County is projected to grow to 414,254 visits by Sacramento County Projected CHC Visits, , , , , , , , , , , , ,000 50, Source: OSHPD Primary Care Clinic Utilization Data Files, ; MCIC Chicago; The Abaris Group

51 Demand: CHC Payer Mix Projections Medi-Cal payers are projected to make up 64.5% of CHC visits by Self-payers are projected to decline from 9.8% in 2010 to 1.6% by 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. Sacramento County Projected CHC Payer Mix, 2012 to Medi Cal % 20% 40% 60% 80% 100% Sliding Scale, Self Pay & Free Indigent Other Medicare Private Sacramento County Projected CHC Payer Mix, Payer Source Medicare 8.1% 9.1% 8.9% 9.5% Medi Cal 43.4% 49.8% 62.2% 64.5% Indigent 0.7% 0.7% 0.6% 0.6% Private 1.3% 1.4% 2.1% 2.1% Self Pay & Free 9.8% 7.5% 1.6% 1.6% Other 36.6% 31.4% 24.6% 21.8% Total Visits 241, , , ,254 Source: OSHPD Primary Care Clinic Utilization Data Files, ; 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. 51

52 Demand: ED Visit Projections Based on historical growth trends, Sacramento County residents are projected to make 579,381 visits the ED by Sacramento County Projected ED Visits, , , , , , , , , , , , Source: OSHPD ED Encounters, Frequencies by Patient County of Residence, ; MCIC Chicago; The Abaris Group 2012 Note: The ED visit projections includes residents El Dorado County discharged from an ED (does not include ED admissions). 52

53 Demand: ED Payer Mix Projections Self pay patients are projected to drop to 5.2% of ED discharges by Medi-Cal is projected to be the dominate payer in the ED, with 42.3% of total discharges by Note: Projections are based on a decline in the uninsured population and increases in Medi-Cal coverage and individuals id that t will purchase insurance through the health exchange. Sacramento County Projected ED Payer Mix, % 20% 40% 60% 80% 100% Medi Cal Self Pay Private Medicare Other Sacramento County Projected ED Payer Mix, Payer Source Medicare 15.9% 15.7% 15.6% 15.5% Medi Cal 29.9% 9% 31.4% 40.8% 42.3% Private 33.5% 31.8% 36.9% 35.8% Self Pay 17.8% 18.9% 5.1% 5.3% Other Non Federal 2.0% 1.8% 1.4% 1.1% Other 0.8% 0.4% 0.1% 0% Total Visits 408, , , ,381 Source: OSHPD Hospital Annual Utilization Data Files, 2010; MCIC Chicago; The Abaris Group 2012 Note: The ED visit projections includes residents of Sacramento County discharged from an ED (does not include ED admissions). 53

54 CHC Financial Metrics 54

55 Safety Net Capacity: CHC Financial Metrics In 2010, total expenses exceed total revenues with a margin of -4.1%. 13 CHCs reported a loss totaling $5.7 million. 11 CHCs reported a positive margin totaling $3.4 million. Sacramento County CHC Total Net Revenues, $1,480,052 $1,366,484, $2,627,686 Net Revenues N=4 $3,453,149 ($3,692,066) N=3 $5,004,060 ($5,747,751) Clinics with Negative Margins Clinics with Positive Margins Total CHC Margin 7.8% 4.1% 4.7% 2.7% 4.1% No. of clinics w/ + Margins No. of clinics w/ Margins Source: OSHPD Primary Care Clinic Utilization Data Files,

56 CHC Net Patient Revenues per Encounter, Net revenues per CHC encounter declined from $214 in 2006 to $187 in 2010 Sacramento County Net Revenue Per Encounter, $250 $214 $200 $182 $183 $200 $187 $150 $100 $50 $ Source: OSHPD Primary Care Clinic Utilization Data Files, ; Bureau of Labor Statistics CPI Inflation Calculator Notes: Adjusted to 2010 dollars. 56

57 Key Data Observations - Preliminary 1. The safety-net population will continue to grow with the advent of faca. 2. Medi-Cal as a payer will accelerate under ACA thus continue to be the largest payer source for CHCs. 3. There is considerable overuse of expensive hospital services for the safety net and in particular EDs. 4. Most CHCs are financially challenged and their margin of losses has continued to grow. 5. The number and array of FQHCs in the region are limited and thus many CHCs Cs are not able to take advantage a of a number of financial incentives afforded to FQHCs. 57

58 Study: Additional Assessments Data Available or Underway Additional workforce issues Additional capacity measures Added financial metrics CHC site survey results CHC client focus groups Medical group input session Innovations and promising practices Other stakeholder interviews i (i.e. health plan, hospitals, etc) Transportation issues Other issues 58

59 THANK YOU! 59

60 Breakout Question Based on information shared earlier in this meeting and your experiences with this county s safety net, what is required to successfully implement health care reform and does not apparently exist right now?